Loading...
HomeMy WebLinkAboutBLD-23-002292 ��/�//�� Office Use Only $OF.YA'4 i Permit# l�/`� O p y sd i !Amount AO MATTACn ESE `.t.+,,.tit,', (Permit expires 180 days from issue date 6LP —c23 — a-- EXPRESS BUILDING PERMIT APPLICATIO C E i V D TOWN OF YARMOUTH .. _.___.__..__.. Yarmouth Building Department OCT 27 2022 1146 Route 28 South Yarmouth, MA 02664 gg BUILDING `EPgRTME(VT (508) 398-2231 Ext. 1261 t BY CONSTRUCTION ADDRESS: .20 \V-e'6G"` -•-c , - A Q 1v - .)4 ASSESSOR'S INFORMATION: rMap: Parcel: n L}Vv"........—....sej 0 �v 2- 4OWNER: "� � � C 1-(eit-4. � f N \ e'DRESS TEL. # '�f j/,�(� CONTRACTOR: Kw., 4—e\ N \.....\ s o 7 / 7�✓t� NAME MAIL 1 SS TEL.# ' .kesidential ❑Commercial vvv Est.Cost of Construction$ [ D'_cS�'1> !!Home Improvement Contractor Lic.# F 73 p 2p Construction Supervisor Lic.# C S 6 Q 2.5.E Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am t sole proprietor a I have Worker's Compensation Insurance t. Insurance Company Name: Worker's Comp.Policy# 6 S b(Jtlir N.4,S722 WORK TO BE PERFORMED .. Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows: # 7 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: 11 (Iy_vi44,1 L il—c,-- Fc/7 Location of Facility I declare under penalties of perjury -.t ,-state ,ems herei on ` ed are , e and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or r,•ocati,,n of m ice,se. for.osec •.n under M.G.L.Ch.268,Section 1. Applicant's Signature: / Date: 2,7 04—% ,2�2 -.wooillp"' Date: `O O'er 1-r l�Owners Signature(or attachment) �r�•: � Approved By: /&...-- �� A'I Date: 7®" 9 Building Offici.,r de,fie) S'ti' L ADDRESS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft. of Wetlands: 0 Yes 0 No 0 Yes 0 No f- 1 The Commonwealth of Massachusetts • ='e _ L Department of Industrial Accidents eI Congress Street, Suite 100 _: _ Boston, MA 02114-2017 www.mass.gov/dia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information w J� r Please Print Legibly Name (Business/Organization/Individual): N(j �-XJ 1 Address: 7,2 aa A4 `6' City/State/Zip: H �16/ Phone #;_ ' b Are you an employer?Check the appropriate box: Type of project(required): I NI am a employer with 3. employees(full and/or part-time).* 7. New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. gi Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑ Demolition 3.0 I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 10 0 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. • 12.0 Plumbing repairs or additions 5.0 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.; 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other 152,§1(4),and we have no employees. [No workers'comp. insurance required.] *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: 7 # Policy#or Self-ins.Lic.#: 6 6 6(i 1 T ?- 2-Expiration Date: `2 Job Site Address: ;2-O !]r—�\1 '��' City/State/Zip: C - ( n Attach a copy of the workers' compensation policy declaration page(showing the policy number a 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 un he p s an pen of perjury that the information provided above is true'and correct. Sig ) nature: Date: ,did 2 - 7 Phone#: 61 7 71- 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#: ACC CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDrfYYY) 05/25/2022 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 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 Marshall Lovelette MARSHALL K LOVELETTE INSURANCE AGENCY INC (NCNo,Ext►: (508)775-4559 FAX (A/C. E-MAIL ADDRESS: marshall@loveletteins.com 396 MAIN ST INSURER(S)AFFORDING COVERAGE NAIC U WEST YARMOUTH MA 02673 INSURERA: HARTFORD UNDERWRITERS INS CO 30104 INSURED INSURER B: HEALY BROTHERS CONSTRUCTION CORP INSURERC: INSURER D 72 OLD MAIN ST INSURER E: SOUTH YARMOUTH MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: 778513 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. IL SR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS TR INSD WVD POLICY NUMBER (MM/DDIYYYY) (MM/DDIYYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO RENTED $ CLAIMS-MADE OCCUR PREMISES(Es occurrence) $ _ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATEPO- $ POLICY El JET LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED S N/A BODILY INJURY(Per accident) $ _ AUTOS NAON-OWNED PROPERTY DAMAGE $ HIRED AUTOS _ AUTOS (Per accident) $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ FF $ WORKERS COMPENSATION �X STAATUTE ERR- AND EMPLOYERS'LIABILITY Y I N A OFFICER/MEMBEREXCLUDED?ECUTIVE N/A NIA N/A 6S60UB4N38257422 05/29/2022 05/29/2023 E.L.EACH ACCIDENT $ 100,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www,mass.gov/Iwd/workers-compensation/investigations/. 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 28 AUTHORIZEDAUTHORIZED REPRESENTATIVE C� South Yarmouth Daniel M.CroWey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD HOME IMPROVEMENT CONTRACTOR TYPE:Individual Reglstcation Expiration 173878 , 04/22/2023 ,, MICHAEL HEALY MICHAEL A.I I 72 OLD MAIN ST .' SOUTH YARRk14:MA 4)2664 Undersecretary . o f . Commonwealth of Massachusetts toi Division of Professional Licensure Board of Building Regulations and Standards - Const,ru t iCitt.ipp,,rvisor • • CS-060855 it spires:11/22/2022 MICHAEL A FJEALY 4 72 OLD MAIN5T I I • SOUTH YARP45)UTH 64 r C 'voiss•110'` • Commissioner c K. Z7&C:14a • r