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Home My WebLink AboutBLD-23-002562 CamScanner 11-07-2022 19.00-ACFrOgCbD6Pqi9NBurMKaxoCr... https://doc-Ok-18-apps-viewer.googleusercontent.com/viewer/secure/p... the O4y •O Y-.� Penal // E .rc.,. C Ate_ • titlS�• s paudt opine ISOthist an issue data 6LD _ 2-3-G)025602_ EXPRESS BUILDING PERMIT APPLICATIONE C E f V E D TOWN OF YARMOUTH _._�_ Yarmouth Building Department 1146 Route 28 NOV 08 2022 South Yarmouth,MA 02664 (508)398-2231 Ext.1261 _ - - _ r— /� '/� BUILDING DEPARTMENT CONSTRUCTION ADDRESS: *'t 2, 13 Ci reL LOL 1)(i U C By ASSESSOR'S INFORMATION: KO -S1M �^"P11.1g, M' c.Oiq-a Pam: lc J, 71f- OWNER: s i�G L-- AlK tp.iS PRESENT 6107,991,E g-9?-9 CONTRACTOR: 110 De MORA- as 5 P, 1-4 sT 11p4115 5°t ,36L/ 8856 NAME MAILING ADDRESS TEL I rilesideatird O Cowsercia��l]] Est Cost of Construction 10, Oa-1 mpnrea C eat Carats Lk.# 1 9 -1 113 I Constriction Supervisor lie.# ;5 1 o'I 9 8 1 Woskmea's Compensation his t«: (check one) 0 tam the homeowner 0 I am the sole proprietor 41 have Worker's Coon Insurance lesso nce Company Name: L M 1 fl .S()t A n GC worker's Comp.policy# W C - 1 3 3 115 4' WORK TO BE PERFORMED Teat D Duration (Fire Retardant Certificate attached?) Wood Stove ❑ Siding: #of Squares nn Repiaeemeawindows:# Replacement doors: # ofing:Ro #of Squares (Q) (0)Remove ems*(max.2 layers) Insulation 11 _ Old Kings Diet. 00 Replacing like for like Pool fencing El t »sp �m 1 go a-' Moe dadswinbe disposed dot Tow n or raeatloidF dYq)O 0-p4 ®15p05A i I declare mdei peodtia of -d i .,_the statanals basin combed art Ina ad meet to the beat duty imowledsa sad belief I mdenuod that my this answers) will bust came for denial Cr ; ,- of my license and for psaaatioa undo M.O.L C11.26B,Section 1. Appltaat's z , Datc )1 0 - N lior, lek Data 1) '�I-- APProved BY: ,�.�- � Buddies,,, or; ) EMAIL . Zoning District: Historical District 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District Within 100 R.of Wetlands: ❑ Yet ❑ No 0 Yes 0 No 1 of 1 11/7/22,9:21 PM i it • _, _ Commonwealth of Massachusetts Division of OccupationalLicensure Construction Supervisor Board of Building Re ul and StandaYfds Unrestricted-Buildings of any use group which contain I r less than 35,000 cubic feet(991 cubic meters)of enclosed Cons i ni a visor space. CS-109981 r spires: 12/22/2023 JOAO DEM�RA ��:,� i 22 SMITH STREET° I&ilr HYANNIS MAfi2601 ,; r t.v��l,Lt'd 3` Failure to possess a current edition of the Massachusetts Commissioneru. fi. t7Cimr Um� State Building Code is cause for revocation of this license. For information about this license Call(617)727.3200 or visit www.mass.gov/dpl THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Aff &Business Regulation IMPROV I�Ap HOME ONTRACTOR 11 r , Registration valid for Individual use only before the CREATE BUILD&R c,A �b t " • expiration date. B found return to: e` I Office of Consumer Affairs and Business Regulation 1000 Washington Street -Suite 710 • JOAO DE MOURA Y `fit Boston,MA 02118 22 SMITH ST 1 ,,,,,Ya.,,r.(404. HYANNIS,MA 02601 , Undersecretary • Not valid without signature • t CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDMNY)09/13/22 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 CONTACT NAME: HINDMAN Schlegel&Schlegel Ins Brokers,Inc. PHONE o E,th 508-771-8381 FAX ,No): 508-771-0663 34 Main Street E-MAIL West Yarmouth,MA 02673 ADDREss: schlegelinsurance@gmail.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: NGM INSURANCE COMPANY 14788 INSURED INSURER B: LM INSURANCE COAST CARPENTRY HOME IMPROVEMENT INC INSURER C: 250 SUDBURY LANE INSURER D HYANNIS,MA 02601 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. )VTR TYPE OF INSURANCE NSD 6y.UVD POLICY NUMBER PU!DD YYF POLICY-IMPYLIMITS (MM/DD/VYY1t1 SMM/DDIYYY1r1. X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 GE TO RENTED CLAIMS-MADE n OCCUR PREMISES(Ea occurrence) $ 500,000 _ MED EXP(Any one person) $ 10,000 A 'MPJ5180E 08/30/22 08/30/23 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY n ECOT- n LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) 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 EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ TH- $ WORKERS COMPENSATION PER AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVEY/N E.L.EACH ACCIDENT $ 100,000 B OFFICER/MEMBER EXCLUDED? N/A WC-1301152 08/31/22 08/31/23 100,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) COPORATE OFFICERS HAVE ELEXTED TO BE COVERED UN THEIR CURRET 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 POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN TOWN OF YARMOUTH ACCORDANCE WITH THE POLICY PROVISIONS. BUILDING DEPARTMENT WEST YARMOUTH MA 02673 AUTHORIZED REPRESENTATIVE WILLIANA CASTRO ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts 0/1111 '_f 1„r l Department oflndustrialAccidents :nil•,:. 1 Congress Street, Suite 100 _L 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 Please Print Legibly Name (Business/Organization/Individual): 150A0 �(2)QuhA C 1 A t B u d o 4 £&70 Off, l Address: 9c s ilY t City/State/Zip: 1-11,tno Is f' ' 6O I Phone #: AB 3( I 8656 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 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. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all work myself. 9. ❑ Demolition ❑ y [No workers'comp. insurance required.] I am a homeowner and will be hiring contractors to conduct all work on my10 Building addition 4. ❑ o 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 512(1 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.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑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: L m 1 yl Su Min CC Policy#or Self-ins. Lic. #: 1. ` 1 50' Expiration Date: O$ 3 //c)ba Job Site Address: If a L- G FC I)OU.) pit City/State/Zip: )(fig /no y Po'Zr 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 certi . o-r the pains and penalties of perjury that the information provided above is true and correct. Signature: �� Date: f 1 / 6 lola Phone#: 508 36y 8856 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#: