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HomeMy WebLinkAboutBLD-23-005109 , , • • Of'YHR BUILDING PERMIT APPLICATION . APPLICATION TO CONSTRUCT, REPAIR, RENOVATE , CHANGE THE USE, OCCUPANCY OF, • 0 C OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING. M..TT�.cn[[y• Town of Yarmouth Building Department s^.- 1 146 Route 28 . Yarmouth, MA 02664-1492 Tel: 508-398-2231 ext. 1261 Fax 508-398-0836 ������ Office Use Only Planning Board Information Assessors Department Information: rf flo Pe . Z 3 60 / ( ate Plan Type_ Map Lot I►U/!3 Permit Fee Sd; Endorsement Date / O/�2�e ..). g Date New T'�1�, Deposit Rec's $ P Ca i V 0 �' 1.4 Property Dimensions: MP-" ' a $j2LILD Net Due (�,,„ +Otn.r I Lot Area(sf) Frontage(ft) Lot Coverage • (� Z. %' (JJCf ��.� Th Section for Office Use Only C Building Pe i iiiii84i':'r 'bN r Date Issued: 63p(0 J V Signature: -7-.--r' - '3 '/6-o . Certificate of Occupancy Buil. ng Official Date- is Is not required Section 1 - Site Information 1.1 Property Address: 1.2 Zoning Information: C Ul_\N�� Cab kkD - /6 I / Zoning District Proposed Use 1.3 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required I Provided Required Provided 1.4 Water Supply(M.a.L c.40.S 54) 1.5 Flood Zone Information: Comments Public Private Zone: BFE Section 2 - Property Ownership/Authorized Agent I 2.1 Owner of Record: ---TG "I_1 \r ci 17 (,r< _ S kpi n Pc\o i rf.l-La( Name(print) Mailing Address: Signature 6 t r` 9 �� 9.. .3 ' . 9 Telephone Telephone / Email Address: 2.2 Authorized Agent: A! ac PEeesR ociciciDC- _AG c�1 v.P < r ICJ ul.'a�ir. �rx� Name (print) Mailing Address: Signature Telephone Fax Email address: ! Section 3 - Construction Services 3.1 Licensed Construction Supervisor: Not Applicable W 3., L a C l P \tr\f Ar- {J - 3 G 7- 1 )_ (7,F,`-16 License Number 19 2) C ,nee ST ),..Pr J- (Al , Is4 \1\Aurri.-4 C),_-)6 73 _ Address J-c,7/Qc 9/o1C-)Q..6 ` ?g,\0"-_"• 9.,-p,6_'-N 5c)k -R,a) S C_i Expiration Date -t` (\.) Signature Telephone Email Address: C) p\j ' )) e 00 .-n i-i I o — 1 o,ig -.) 3.2 Registered Home Improvement Contractor. ' Company Mame Not Applicable ❑ • r ss se- i''�n. R ;'kJ 1 J C Avv.� G s� ►\p- S 't Registration Number Address a) ,1 5 u \t.-,21'Q� * cC..)cc "-6 C>5 1..1-G Expiration Date Signature Telephone U7- //.0-1 aQ a Section 4- Workers' Compensation Insurance Affidavit (M.G.L c. 152 S 25C(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes .... No Section 5 - Professional Design and Construction Services-for Buildings and Structures Subject to Construction Control Pursuant to 780 CMR 116(containing more than 35,000 c.f. of enclosed space) Section 5.1 Registered Architect: Not Applicable ❑ Name (Registrant): ' Registration Number Address Expiration Date Signature Telephone Section 5.2 Registered Professional Engineer(s) Name Area of Responsibility Address Registration Number • Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Hama Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address • Registration Number Signature Telephone Expiration Date Section 5.3 General Contractor t___ La€ C ` , c Not Applicable ❑ Company Name N W (_Rrr Z -Pe R£ 1 < .0 h A Person Responsible for Construction �� (r p c 3 ,V— Z iA), � ,,AQA--r Y It.. GQ6 : Address Signature Telephone , Section 6 - Description of Proposed Work (check all applicable) . New Construction ❑ (for multiple family only) No.cf Bedrooms (for multiple family only) No_of Bathrooms Existing Bldg. ❑ Repair(s) Q Alterations ❑ Addition ❑ Accessory Bldg. ❑ Type Demolition Other Specify: P fY: 1 Brief Description of Proposed Work: Re_Fca T .r-,C,v, kGa R.-SS Section 7- Use Group and Construction Type I Building Use Group (Check as applicapable) Construction Type A ASSEMBLY ❑ A-1 ❑ A-2 ❑ A-3 ❑ IA ❑ A-4 ❑ A-5 ❑ 1B ❑ B BUSINESS ❑ 2A ❑ — E EDUCATIONAL ❑ ❑ F FACTORY ❑ F-1 ❑ F-2 ❑ 2C ❑ H HIGH HAZARD ❑ 3A ❑ I INSTITUTIONAL ❑ I-1 ❑ 1-2 ❑ 1.3 ❑ 3B ❑ M MERCHANTILE D4 ❑ R RESIDENTIAL ❑ R-1 ❑ R-2 ❑ R-3 ❑ SA ❑ S STORAGE ❑ S-1 ❑ S-2 ❑ 58 ❑ U UTILITY ❑ SPECIFY: M MIXED USE 0 SPECIFY: S SPECIAL USE ❑ SPECIFY: - Complete this section if existing building undergoing renovations; additions and/or change In use. Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34 Proposed Hazard Index 780 CMR 34 Section 8 Building Height and Area I Building Area Existing if applicable) Proposed Number of floors or stories include basement levels Floor Area per Floor(sf) Total Area All Floors (sf) Total Height (ft) Section 9 - STRUCTURAL PEER REVIEW (780CMR 110 11) Independent Structural Engineering Structural Peer Review Required Yes No SECTION 10a OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, , as Owner of the subject property, hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 10b OWNER/AUTHORIZED AGENT DECLARATION , as Owner/Authorized Agent hereby declare that the statements and information on the forgoing application are true and acurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name Signature of Owner/Agent Date Section 11 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be completed by permit applicant 1.Building 2.Electrical 3.Plumbing/Gas 4.Mechanical(HVAC) 5.Fire Protection 6.Total=(1+2+3+4+5) 7.Total Square FL(tornew smcaaes&aedth a) Check Below ❑ Conservation-Commission Filing (if applicable) ❑ Old Kings Highway& Historical Commission approval (if applicable) . The Commonwealth of Massachusetts of "illy Department of Industrial.Accidents 1` 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 Please Print Legibly Name (Business/Organization/Individual): PL.._ cat R.k::'F'.\f\--rR.ks q•0 c. Address: 6()it. P_1'f Gt-ke, .S wa(6 City/State/Zip:N1a�Y, � �n�A. Oa6•cj Phone `5o g 3 _,,Stic) Are you an employer?Check the appropriate box: Type of project (required): In I am a employer with of employees(full and/or part-time).* 7. i� 2.0 I am a sole proprietor or partnership and have no employees working for me in ❑Rev construction any capacity.[No workers'comp. insurance required.] 8• ePnodeling 3.01 am a homeowner doing all work myself. [No workers'comp.insurance required.]t 9. ❑ Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. I 1.0 BlectricaI repairs or additions 5.O I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12'❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.: 13.0 Roof repairs 6.0 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 I 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 ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ,Yovp(Z 1kSSt1 RA\h.,ce I\ G'IJ Ci d LI (- Policy#or Self-ins.Lic.#: pJG/1Cjr,rip 39,6 R20 o a A Expiration Date:� P' O 41aVaoQ3 Job Site Address:`5 c,i a' PeNA n \Fru.a City/State/Zip:s,c. aR‘,,y-it1--(j.4 YA A, Attach a copy of the workers' compensation policy declaration page(showing the policy numr 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. l'do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: S c, .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#: §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-22311 ext.-1261 Fax 508-398-0836 Office of the Building Commissioner BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G.L. Ch. 40, §54 and 780 CMR- Section 105.3.1. #4. I hereby certify that the debris resulting from the proposed work/demolition to be conducted at ,SurAN. CZ)NI J1,LLa61 \v‘. 1� . Work Address Is to be disposed of oat the following location: y a Rw\t,t fl N Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. Signature of Application Date Permit No. • Commonwealth of Massachusetts �F Division of Occupational Licensure Board of Building Re utations and Standards Cons ronI rftf5,rvisor • CS-116646 Spires: 12/29/2025 WALACI P MACHADO m 193 CAMP STD APT J5 WEST YARMO JTH MA 02673 • �- . Commissioner do.? K. bjE,lifi a, THE COMMONWEALTH of MASSACHUSETTS • Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE: Individual Registration Expiration 201015 02/22/2025 WALACI PEREIRA MACHADO WALACI MACHADO 193 CAMP ST APT J-5 WEST YARMOUTH,MA 02673 Undersecretary Registration valid for individual use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 1000 Washington Street -Suite 710 Boston,MA 02118 Not valid without signature ACORD Client#: DATE TM CERTIFICATE OF LIABILITY INSURANCE 06/06/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHT 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 RAPHAEL OLIVEIRA MAKAG• PHONE (508)771-4600 DISCOVERY INSURANCE AGENCY LLC (NC,No,EXI): 668 MAIN ST-UNIT A EMAIL raphaeldiscovery@gmail.com ADDRESS: HYANNIS,MA 02601 INSURER(S)AFFORDING COVERAGE NAIC INSURED INSURER A: Atlantic Casualty Insurance Company INSURER B: PLJ CARPENTRY INC INSURER C: 661 PITCHERS WAY INSURER D:AIM MUTUAL INS CO HYANNIS - 02601 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED 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 TALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRL ADDLI SUBR POLIL`VEI-F POLICY EXP TR TYPE OF INSURANCE NSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS A GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES(Ea acurrence) $ 100,000.00 CLAIMS-MADE I I OCCUR /� MED EXP(Any one person) $ 5,000.00 L261004216-1 8/11/2021 8/11/2022 PERSONAL&AOV INJURY $ 1,000,000.00 GENERAL AGGREGATE $ 1,000,000.00 PRODUCTS-COMP/OP AGG GENT AGGREGATE ILIM�IT APPLIES PER 2,000,000.00 POLICY ' I PROJECT I K $ ILOC B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) ALL OWNED _ 'SCHEDULED BODILY INJURY(Per accident) AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) • UMBRELLA UAB OCCUR EACH OCCURRENCE EXCESS LIAR CLAIMS-MADE AGGREGATE DEO RETENTION S D WORKERS COMPENSATION WC STATUTORY OTH AND EMPLOYERS'LIABILITY VM LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT OFFICER/MEMBER EXCLUDED? N AWC40070395842022A 6/3/2022 6/3/2023 $ 1,000,000.00 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000.00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000.00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEF ICLES(Attach ACORO 101,Additional Remarks Scledule,If more space Is required) CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE IT IS THE CUSTOMER'S RESPONSABILITY TO INFORME ANY CHANGES OR CANCELATIONS. RAPHAEL OLIVEIRA 1/1 ©1988-2010 ACORD CORPORATION.All rights reserved. Contract PIA CARPENTRY Date Contract 128 West Main St, Unit 1 E Hyannis - MA 02601 03/01/2023 760 (774) 487 - 8089 contact©pljcarpentryinc.com Name/Address Ray Kenneally Project Swan Pond Village, South Yarmouth, MA Swan Pond Village, South Yarmouth, MA Description PAYMENT: Full payment at the job completion *A signed proposal must be received prior to the start of any work, upon accordance to PLJ Carpentry Inc terms and policies* Date: 3/1/2023 Total $16,900.00 Signature: ?i_ i_ 74/iatia_c_. ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department o ....r 1146 Route 28, South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508-398-0836 • Massachusetts State Building Code,780 CMR Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only RECEIVED Building Permit Number: 0IA) co1,A Date Applied: MAR 14 2023 Building Official(Print Name) Signature BUR NG nFPA TMENT tp a q DOn(1 R.d SECTION 1:SITE INFORMATION BY 1.1 Property Address: u6it ioli 1.2 Assessors Map&Parcel Numbers .s vjai. cb v LLace S.�ca.R'nnotj1H 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,Q 54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: — Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: -7C)/-1 'NY\a-rL a c K SQ i u*'h 4&1muutk, Name(Print) City,State,ZIP 3 w G,n Pond V; 1)a aje l Ol: • 63 9-a13635 No.and Street r resit efl+ Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied 0 1 Repairs(s) 0 Alteration(s) 0 I Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other tiff Specify:6fc3 re raC.,r Brief Description of Proposed Work'': {�p P '� l,� art"e R „Da a& Rty Inn a t' z� Pr p e . ,D% L-L ANC ►lS d_I-ATE ' SECTION 4: ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building C�$ 1. Building Permit Fee:$ Indicate how fee is determined: '6 r lam' c,V ❑Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: y 0 UU e.-a2 41 5.Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 'er,,9oo, p0 Cl Paid in Full 0 Outstanding Balance Due: t egO - nLj- g)0_ 1081 .-i ••3...' -•ail. T g. E .E . _. f • R 3.'f a. ..� l ... ) .. ter.. .. - i L. SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) C,5--U ( W a 1 C.'� a_ (-, 3 License Number Expiration ate Name of CSL Holder List CSL Type(see below) UJ G a v.,, i I.P-r J- No.and Street Type Description e3—I taRv\,,ou—ft—iY� C U) Unrestricted(Buildings up to 35,000 cu.R) ' A ' R Restricted 1&2 Family Dwelling City/Town,State, M Masonry a6 RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 583 6J31,-(_c�CI)0n _Hal3.4)aziry,.,.. I Insulation Telephone Email adcress D Demolition 5.2 Registered Home Improvement Contractor(HIC) ('-) 2 L-a f.r_ PP.R t R I 1rv‘a(' N a.t\C, HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 15:I:3 ST NPt -_ (A1ck1-1_a \pr. `�i�j4l'Ti tnnat, No.and Street Email address t� Uj . ` IR U-t \tiN.►a,C36 73 ,5cc�('c_5_I.1d City/To ,State,ZIP Telephone SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c.152.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes ISE No ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize 'kJ to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date • SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. lohln Mak-tacK 03`Y-1`23 Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program), will not have access to the arbitration program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.aov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" ' The Commonwealth of Massachusetts Department of Industrial A cc idents 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): PL,J (-AR ETA - sic. Address: 6( L PST L NP,Rs liJak6 City/State/Zip:{-{cl Rv c S ,a• aacc,A Phone #:,_5o4 3��`,;Qo Are you an employer?Check the appropriate box: Type of project (required): LE 1 am a employer with employees(full and/or part-time).* 7. E New construction 2.E i am a sole proprietor or partnership and have no employees working for me in 8. J Remodeling any capacity.[No workers'comp. insurance required.] 3. I am a homeowner doingall work myself. r 9. ❑ Demolition ❑ y (No workers'comp. insurance required.] 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will t0 E Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.E Electrical repairs or additions proprietors with no emoioyees. 12.❑Plumbing repairs or additions 5.E 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 13.0 Roof repairs 6.E We are a corporation and its officers have exercised their right of exemption per MGL c. 1 ®Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box R I 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: Yr)l10.% 1.,h\ 11 KAN,,ce E.?0 C-,d LL(- Policy or Self-ins.Lic.#: QjGtycic\%.3 5R2Q0as A Expiration Date: Q AL-Vapa Job Site Address: t,)av\ PCNn r> \I-rLL& City/State/Zip:S. aR d-1 111,A, Attach a copy of the workers' compensation policy declaration page(showing the policy numr 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. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: t e Jts9oc,. P sz,. \..., Date: p 3/ft Ic�c,7 Phone#: S 3r6c, .c 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 S. Plumbing Inspector 6.Other Contact Person: Phone#: §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261 Fax 508-398-0836 Office of the Building Commissioner BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G.L. Ch. 40, §54 and 780 CMR- Section 105.3.1. #4. I hereby certify that the debris resulting from the proposed work/demolition to be conducted at 5u)3.\(. t \Ae`. la . Work Address Is to be disposed of oat the following location: y a R cN 0r(N >>rs Pc,S"LL— Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. Signature of Application Date Permit No. Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Re ulations and Standards Cons 'ionrS ,rvisor CS-116646 spires: 12/29/2025 WALACI P MACHADO 193 CAMP STD a APT J5 WEST YARMOUTH MA 02673 >>, Commissioner )'401• 1&c & THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration 201015 02/22/2025 WALACI PEREIRA MACHADO WALACI MACHADO 193 CAMP ST APT J-5 ��f i Vic' WEST YARMOUTH,MA 02673 Undersecretary Registration valid for individual use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 1000 Washington Street -Suite 710 Boston,MA 02118 Not valid without signature • ACORD Client#: DATE TM CERTIFICATE OF LIABILITY INSURANCE 06/06/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHT 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 RAPHAEL OLIVEIRA MARAP• PHONE (508)771-4600 DISCOVERY INSURANCE AGENCY LLC (NC,No,Ext): 668 MAIN ST UNIT A EMAIL raphaeldlscoveryi9gmail.corn ADDRESS: HYANNIS,MA 02601 INSURER(S)AFFORDING COVERAGE NAIC INSURED INSURER A: Atlantic Casualty Insurance Company INSURER B: PLJ CARPENTRY INC INSURER C: 661 PITCHERS WAY INSURER D:AIM MUTUAL INS CO INSURER E: HYANNIS - 02601 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED 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 TALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRL ADDLI SUBR POLICY EFF POLICY EXP TR TYPE OF INSURANCE NSR WVD POLICY NUMBER (MM/DDTYYYY) (MM/DD/YYYV) LIMITS A GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES(Ea orvrrence) $ 100,000.00 CLAIMS-MADE CCCUR MED EXP(Any coe person) $ 5,000.00 L261004216-1 8/11/2021 8/11/2022 PERSONAL&ADVINJURY $ 1,000,000.00 GENERAL AGGREGATE $ 1,000,000.00 GENL AGGREGATE LIMIT APPLIES PER PRODUCTS-CCMP/OP EGG $ 2,000,000.00 POLICY n PROJECT I K ILOC B COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea&cadent) _• BODILY INJURY(Per person) ANY AUTO ALL OWNED SCHEDULED BODILY INJURY(Per ac''dent) AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per scads[) C UMBRELLA LIAR OCCUR EACH OCCURRENCE EXCESS LIAR CLAIMS-MADE AGGREGATE DED RETENTION$ D WORKERS COMPENSATION YM WC STATUTORY OTH AND EMPLOYERS'LIABILITY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE �^ OFFICEA/MEMBER EXCLUDED? N E L.EACH ACCIDENT $ 1,000,000.00 AWC40070395842022A 6/3/2022 6/3/2023 (Mandatory in NH) E L DISEASE-EA EMPLOYEE $ 1,000,000.00 If yes.descnbe under DESCRIPTION OF OPERATIONS bNre EL.DISEASE-POLICY LIMIT $ 1,000,000.00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES Attach ACO RD 101,Additional Remarks Scledule,if more space Is required) CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE IT IS THE CUSTOMER'S RESPONSABILITY TO INFORME ANY CHANGES OR CANCELATIONS. RAPHAEL OLIVEIRA 1/1 ©1988-2010 ACORD CORPORATION.All rights reserved. Contract 4,11k PU CARPENTRY Date Contract 128 West Main St, Unit 1E Hyannis - MA 02601 03/01/2023 760 (774) 487 - 8089 contact@pljcarpentryinc.corn Name /Address Ray Kenneally Project Swan Pond Village, South Yarmouth, MA Swan Pond Village, South Yarmouth, MA Description PAYMENT: Full payment at the job completion *A signed proposal must be received prior to the start of any work, upon accordance to PLJ Carpentry Inc terms and policies* Date: 3/1/2023 Total $16,900.00 Signature: 24,i,-7,gadeLeA