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HomeMy WebLinkAboutBLD-23-002508 O °YRR fi #k- 9 ;Office Use Only �/ ' 0 /`,, Permit# C N / /1) O� . H L� /' -�-zZ Iot7 `"°°'°`°gyp j Permit expires 180 days from j issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 rNov 0 4 2022 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 ___ __.._._. J/� BUILDING DEPARTMENT i CONSTRUCTION ADDRESS: /(/7z . Shore �� By: ASSESSOR'S INFORMATION: —T' T Map: Parcel: OWNER: 3—lA SA-►n J.. r1q O `(I ‘63' s •Sho�2 - • 5a8 39 q 8 q 30 NAME J/� PRESENT ADDRESS / TEL. # CONTRACTOR,# j/51 �-(rl9 r/-(.&Ci�tcG4/ /C -61.41leteG /XS/me: (� fa y033 NAME MAI ING ADDRESS TEL.# �s cz-b ❑Residential Commercial Est.Cost of Construction$ t j eft-CV Home Improvement Contractor Lic.# / PS^(‘Y Construction Supervisor Lic.# 9J ' .!8 Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor ,'I have Worker's Compensation Insurance Insurance Company Name:L/�i AtS24/'4/kC'e.- CD . Worker's Comp.Policy* 6()C53l5 ^ Pp Y7D/2 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Ruurarg. #uP juntea ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: ei/t,(7 67'ei t9 Tie Location of Facility I declare under penalties of perjury that the statements herei ontained 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 license and r prosecution under M.G esti I. �7 Applicant's Signature: ate: //• z• c 0 00 Owners Signature(or attachment) Vili ` 1 Date: l i- a - ab a a Approved By: Date: ,;----- Building Official(or desi�:° EMAIL ADDRESS: i Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: ❑ Yes 0 No O ' S` 75'(�J ,�T Water Resource Protection District: Within 100 ft.of Wetlands: !�t 0 Yes 0 No 0 Yes ❑ No , commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constt16/ jSpfArvisor CS-093798 Aires:07/07/2023 ALEKSANDR?V B KONSTANTIN PO BOX 842 r. WEST YARMOUTH MA 026730 y()/ssAticf6 Commissioner Baia fi t7fim�Qta rye Ke492,eoszurend%o�.A.o i�ruln Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE;Corporation Regis x iration 195669 05/20/2023 KREATIVE BARNS INC. KONSTANTINB.ALEKSANDROV 159 OLD MAIN STREET :aG(.6c SOUTH YARMOUTH,MA 02664 inriaraarratani a - The Commonwealth of Massachusetts , �t!l, Department of lsutustriai. t adent 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BEETLED WITH THE PERMITTING AUTHORITY.. Applicant Information Please Print Legibly Name(Business/Organization/Individual): Kreative Barns Inc. Address:159 Old Main Street Erty/St<ate/Zi r:Sattth lfarx cloth MA 02664 Phone#:508-904-0539 Are you an employer?Check the appropriate box: Type of project(required): LS I am a employer with 8 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. El Remodeling any capacity.fNo workers'comp.insurance required.] 9.. a Demolition 11 am a homeowner doing all work myself.[No workers'comp.insurance required.] 10 ✓©Building addition 4.01 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 arc sole 11.0 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. 13.0Roof repairs These sub-contractors have employees andhave workers'comp:insurance? 6.ElWe are a corporation and its officers have exercised their right of exemption per MGL c. 14.DOther 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box 141 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 esttpioycies.:Vale s actors have employees,they must provide their workers'comp.policy-ember. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Liberty Mutual Pommy# #WG531 S619892012 08/29/2023 Expiration Date: Job Site Address:107 South Shore Drive City/State/Zip:S.Yarmouth. MA 02664 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 D1A for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: _ ___ Date: 11/02/2022 Phone##:5 8- g 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#: (a DATE(MM/DD/YYYY) ACORL, CERTIFICATE OF LIABILITY INSURANCE `..----- 09/15/22 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 NAMEACI JIM HINDMAN PHONE FAX 508-771-8381 A/C,No): 508-771-0663 Schlegel&Schlegel Ins Brokers, Inc. LAIC,No.Extl 34 Main Street E-MAIL I ADDRESS: schlegelinsurance@gmail.com West Yarmouth,MA 02673 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: NGM INSURANCE INSURED INSURERS: LM INSURANCE COMPANY KREATIVE BARNS INC INSURER C: 159 OLD MAIN STREET INSURER D: SOUTH YARMOUTH,MA 02664 INSURER E: )INSURER F: COVERAGES CERTIFICATE NUMBER: 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 ADDL6UBR PPOLICY NUMBER 1JMMIOtY EFYV POLICY EXP /YYYY) LIMITS LTR tNSD wvo, �r�'�r'r�1 X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 500,000 I CLAIMS-MADE XI OCCUR PREMISES Ea occurrence) $ MED EXP(Any one person) $ 10,000 A MPP5983J I 08128l22 I 08/28/23 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 PRO- I LOC PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY JECTPRO- $ OTHER AUTOMOBILE LIABILITY a acca IN eDtSINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ OWNED ^SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAB _ OCCUR f EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ ~—WORKERS COMPENSATION X MUTE ER AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ _ 100,000+ B OFFICER/MEMBER EXCLUDED? N l N/A WC 531 S619892012 08/29/22 08/29/23 (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 — DESCRIPTION OF OPERATIONS;LOCATIONS/VEHICLES IACORD 101.Additional Remarks Schedule,may be attached If more space Is required) CORPORATE OFFIERS HAVE ELECTED TO BE COVERED UNDER THEIR CURRENT WORKERS COMPENSATION POLICY INSURANCE COVERAGE IS LIMITED TO THE TERMS,CONDITIONS,EXCLUSIONS,OTHER LIMITATIONS AND ENDORSEMENTS OF THE POLICY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF.NOTICE WILL BE DELIVERED IN TOWN OF YARMOUTH ACCORDANCE WITH THE POLICY PROVISIONS. BUILDING DEPARTMENT YARMOUTH MA AUTHORIZED REPRESENTATIVE KBARNSINC@GMAIL.COM, \I 1988-2015 ACOR_CORPORATION. All rights reserved ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD