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HomeMy WebLinkAboutBLD-20-4011 y j ottice Use Only ,O , `4R mow• • t�! �0' Pennit# • 1 •0,• „ �l t. -x. :Amount `�MATTACM LS[e_� ' �`°""' gyp •' ,Permit expires 180 days from f issue date ey,,,i)-- D-- ii Di I EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department S JA _o ;2, 1146 Route 28 South Yarmouth, MA 02664 z (508) 398-2231 Ext. 1261 ?_ . CONSTRUCTION ADDRESS: 5 0`7 1g1,c4. c6a d /it/ ASSESSOR'S INFORMATION: Map: Parcel: OWNER: a{ NAME PRESENT ADDRESS / TEL. # T— -F i_ CONTRACTOR: 6(A) _fp1( /Ziv .�3ih .s/ e. L is/7Y4 4`�,01?t f-7'-x NAME MAILiti G ADDRESS TEL.# ❑Residential XI Commercial Est.Cost of Construction$ $s/C Home Improvement Contractor Lic.# Construction Supervisor Lic.# 6 S - Jill i-3 Workman's Compensation Insurance: (check one) , I am the homeowner ❑ I am the sole proprietor X I have Worker's Compensation Insurance Insurance Company Name: 41-(7,,J 44 u,l (-4:my Worker's Comp.Policy# I'uZL(4 WORK TO BE PERFORMED Tent Duration /5;0 (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows: # Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: Cl11 1 o c ]O71 T ra I (ell. )(32 Location of Facility I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) iVbe just cause for denial or revs ati. o y •cense and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Sign. re: j/r •II � Date: /—J 267•E2 Owners Sign. ure(or a achmen�el��./ /� ' Date: f�ia%+ f v Approved By: j��� Date: I -/7 . /.0o0 Bui ., 6• ici. .- ee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No 44, The Commonwealth of Massachusetts r Department oflndustrialAccidents i , 1 Congress Street, Suite 100 Boston, MA 02114-2017 ,,, - •`' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/Individual): &j UW SAc. Address: 12 a? ot.r'Jil1 Jv S City/State/Zip: LE t3OS/U� 12ZI7 Phone #: 1-0 7- '5 b'7- 60-00 Are you an employer?Check the appropriate box: Type of project(required): 1.X I am a employer with 75 employees(full and/or part-time).* 7. _New construction 2.E I am a sole proprietor or partnership and have no employees working for me in 8. n Remodeling any capacity. [No workers'comp.insurance required.] 3. I am a homeowner all work myself. 9. _ Demolition ❑ doing y [No workers'comp. insurance required.] 10 ❑ Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions proprietors with no employees. 12._Plumbing repairs or additions 5.—I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.= 14.jj/ Other "it:wit) 0 FT•iee 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees. [No workers'comp. insurance required.] Jreti le✓• *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 4(v- y illuite4/ Z.,t 9.6,'1,'J-i 43, ,f_ _ Policy#or Self-ins. Lic. #: (qzit it Expiration Date: l iii/LiMt Job Site Address: _So 7 erit,k trSltle d iv City/State/Zip: ?3 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under tl e pains and penalties of perjury that the information provided above is true and correct. Signature: Date: /-/O- Z.WZ6 Phone#: i-1fc17- 2117 iroill 7 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other ' Contact Person: Phone#: / ® DATE(MMIDD/YYYY) A 0 CERTIFICATE OF LIABILITY INSURANCE 1/10/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Rogers&Gray Ins.-Kingston Branch PHONE 508-746-3311 N,No):877-816-2156 63 Smith Lane (A/C.No.Extl: Kingston MA 02364 ADDRESS: mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Selective Insurance Company of America 12572 INSURED GVWINCO-01 INSURER B:Travelers Property Casualty Company of America 25674 c. 1200 200 Bennington St INSURER C:Illinois Union Insurance Company 27960 East Boston MA 02128 INSURER D:Arrow Mutual Liability Insurance Company 13374 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER:1367181860 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP W LIMITS LTRINSD VD POLICY NUMBER (MM/DDIYYYY) (MM/DD/YYYYI A X COMMERCIAL GENERAL LIABILITY S2336444 6/18/2019 6/18/2020 EACH OCCURRENCE $1,000,000 DAMAGE TED CLAIMS-MADE X OCCUR PREMISESO(Ea occurrence) $500,000 MED EXP(Any one person) $15,000 Ciontractual Lia PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY X JECT LOC PRODUCTS-COMP/OPAGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY A9106736 6/18/2019 6/18/2020 COMaccBINEidenUDSINGLELIMIT $1,000,000 (Ea ANY AUTO BODILY INJURY(Per person) $ OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED (Per ieDAMAGE $ AUTOS ONLY _AUTOS ONLY $ B X UMBRELLA LIAB X OCCUR ZUP-71M58445-19-NF 6/18/2019 6/18/2020 EACH OCCURRENCE $20,000,000 EXCESS LIAB CLAIMS-MADE - AGGREGATE $20,000,000 DED X RETENTION$in( ill $ D WORKERS COMPENSATION 1924A 1/1/2020 1/1/2021 X STATUTE OERH AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE N N/A (Mandatory N in NH) E.L.EACH ACCIDENT $1,000,000 aR/MEMEREXCLUDED7 E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 A Leased/Rented S2336444 6/18/2019 6/18/2020 Limit 500,000 C Pollution CPY G71535204 001 7/1/2019 7/1/2021 Aggregate 3,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) RE:Project:Contract#417-New Department of Public Works Building,located at 507 Buck Island road&74 Town Brook Rd,West Yarmouth Ma 02673. The Town of Yarmouth and Weston&Sampson are included as additional insureds for Automobile Liability on a Primary and Non-Contributory Basis for the conduct of the(Named)Insured,but only to the extent of that liability. The Town of Yarmouth and Weston&Sampson are included as Additional Insured for General Liability and Excess(Umbrella)Liability,for ongoing and completed operations on a primary,non-contributory basis,as required by a signed written contract or agreement with the Named Insured. See Attached... CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth 1146 Route 128 AU DREPRESENTATIVE South Yarmouth MA 02664 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD • \ c' Commonwealth of.Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constir rilti1 rvisor !�• , CS-111283 I �fq Ocpires 01/11/2021 MARK A FRAZIER 31 ;It , 8 BROOKVALE ST U • DORCHESTERCNTER'SMA021z4 g • a Commissioner