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HomeMy WebLinkAbout22-EB028 256 Route 6A ApprovedRECEIVED MAR 14 2022 YAHMOu'l n APPROVED MAR 14 2022 YARMOUTH iv n ieJK1r1--C wlf-"kvgAy EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: (Cj ASSESSOR'S INFORMATION: Map: (7 7 _ Parcel: f 1 Office Use Only Perntit# Amount Permit expires 180 days from issue date CONTRACTOR: t<W U -i D NVt>-- l� b r 2 NAME Uv1A1LING ADDRESS�t �, TEL. # V-11 Residential ❑ Commercial / Est. Cost of Construction S Home Improvement Contractor Lie. # W7 n Construction Supervisor Lic. Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor g I have Worker's Compensation Insurance Insurance Company Name: `�TPSG { Worker's Comp. Policy#_ WORK TO BE PERFORMED Tent F Duration (Fire Retardant Certificate attached?) Wood Stove Siding: # of Squares Replacement windows: # Replacement doors: # Roofing: # of Squares — (®J Remove existing* (max. 2 layers) InsuIation� Old Kings Highway/Historic Dist. 00 Replacing like for like Pool fencing *The debris will be disposed of at: IV 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) will be just cause for denial or revocation of my license and for prosecution under M.G.L. Ch. 268, Section 1. Applicant's Signature: Date: Owners Signature (or attachment) Date: Approved By: Date: Building Official (or designee) £MAIL ADDRESS: Zoning District: Historical District: Yes No Water Resource Protection District: - Yes No Flood Plain Zone: -- Yes _. No Within 100 ft. of Wetlands: Yes No 2� Sherman, Lisa From: RICHARD GEGENWARTH <r.gegenwarth@comcast.net> Sent: Monday, March 14, 2022 1:37 PM To: Sherman, Lisa Subject: Re: 22-EB028 256 Route 6A Attention!: This email originates outside of the organization. Do not open attachments or click links unless you are sure this email is from a known sender and you know the content is safe. Call the sender to verify if unsure. Otherwise delete this email. L Perfect match. I approve. Richard On 03/14/2022 1:05 PM Sherman, Lisa <lsherman@yarmouth.ma.us> wrote: Hi Richard, APPRO D MAR 1 4 2022 Request to replace the roof at 256 Route 6A. Like for like; new color is CertainTeed Pewterwood. Please let me know if you need any additional information. Thanks Richard, Lisa Lisa Sherman Office Administrator Old Kings Highway Committee/Yarmouth Historical Commission Town of Yarmouth 508-398-2231, ext. 1292 YARiviUu ; KING'S H!GI RECF i� The C mmonwealth o Massachusetts'' f APPS MAR 14 202bepartment oflndustrialAccidents I Congress Street, Suite 100 MAR 14 ° , YtiriiY,ti�,J t r+ s" 1 OLD KING'S HIGHWAY Boston, MA 02114-2017 • www.mass.gov/dig Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Apiolicant Information Please Print Le ibI Name (Business/Organization/Individual): B[�na" VLu(-, 3E�6 L�z�lrl X04- �L, Address: City/State/Zip: Are you an employer? CheEk the appropriate box: 173 Phone ##:_ � 2 D I.R1 am a employer with _1� employees (full and/or part-time).* 2.F-11 am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp_ insurance required.] t 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. [ will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. ST] I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t fi.❑GVe 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.] Type of project (required): 7. []New construction 8. ❑ Remodeling 9. ❑ Demolition 10 ❑ Building addition 11. Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13. Roof repairs 14. gOther -F *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t 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:_ --:>TAP, Policy # or Self -ins. Lic. #: W& G i�6AExpiration Date: Z Job Site Address: -25 City/State/Zip:H&a7V75 Attach a copy of the workers' compensation policy declaration page (showing the policy n tuber and expirati n 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 the pains and penalties ofperjury that the information provided above is true and correct. 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 b. Other ACOR" CERTIFICATE OF LIABILITY INSURANCE aATE(MMroorYYYY) CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 2/11/2022 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: AHT Insurance, A Baldwin Risk Partner PHONE FAX 458 South Ave Arc No Ext : 800-648-4807 AIC No): 781-447-7230 E-MAIL ADDRESS: W �� R Whitman MA 02382FR_Ecr1­-iV E E) EACHOCCURRENCE $1,000,000 INSURERIS) AFFORDING COVERAGE NAIC # INSURERA : Main Street America Assurance 29939 icense#: CA#0858748 INSURED MAR 1 4 _L FINEBUI-01 INSURER 8: National Grange Mutual Instlran 14788 - Fine Building &Finish, Inc. DREMAMAE T RENTED PREMISES Ea occurrence $ 500,OOp 79D Mid Tech Dr. INSURER C : Star Insurance Company 18023 INSURER D : West Yarmouth MA 02673 t Ah(v,vu i ; LOD KWG'S HIGHWAY INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 164054059 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 LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MMIDDlYYYY POLICY EXP MMIDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY MPP3982T 51112021 511/2022 EACHOCCURRENCE $1,000,000 CLAIMS -MADE � OCCUR DREMAMAE T RENTED PREMISES Ea occurrence $ 500,OOp MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER GENERALAGGREGATE $2,000,900 POLICY ❑ PRO ❑LOC JECT PRODUCTS - COMPIOP AGG $ 2,000,000 $ OTHER. B AUTOMOBILE LIABILITY M2P1273N 511/2021 5!1!2022 COMBINED SINGLE LIMIT $1,000,000 Ea accident BODILY INJURY (Per person) $ 250,000 ANY AUTO OWNEDX AUTOS SCHEDULED AUTOS ONLY BODILY INJURY (Per accident) $ 500,000 X HIREDX NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE S1,p00,000 Per accident $ UMBRELLA LIABOCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN WC0869558 1/24/2022 1/24/2023 X STER ATUTE FRH EACH ACCIDENT $ 500,000 ANYPROPRIETORIPARTNERIEXECUTIVEEL- OFFICE EMBER EXCLUDED? N r A E.L. DISEASE - EA EMPLOYEE $ 500,000 (Mandataryory in NH) in if yes, describe under E.L DISEASE - POLICYLIMIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is requlred) i MAR 14 2022 i OLD KING'S HIGHWAY CERTIFICATE Evidence of Insurance SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 4-,A 0,L ©1988-2015 ACORD CORPORATION. All rights reserved. Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards ConstructiontSupervisor CS -093441 Etpires: 05107/2023 STEPHEN KLUG 79 MID TECH -DR WEST YARMOUTH MA=673 ` Commissioner . 71bffrC�4ttL65i'f(1ri4iFfll Eaf}s�& �aSrf�e�� 4i�g4!`�ffon HOME IMPROVEMENT CONTRACTOR TYPE. Individual Registration Expiration 156270 06/1812023 STEPHEN KLUG DIBIA STEPHEN KLUG FINE BUILDING & FINISH STEPHEN KLUG ;7 79 D MIDTECH DRIVE!<7�G t'J� W YARMOUTH, MA 02673 Undersecretary ECEIVE-0 MAR 14 2022 Y rknivi"JU 1 1, QPPOVE6 MAR 1 4 2022 YAR ivs, u i s; -e��Upk