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HomeMy WebLinkAboutBLD-23-005939 L rn Ella-T7/02-3 .6 ''.w Office Use Only1 A,'� '�s Permit* r++\'S ki Amount 5 2 c� Permit expires 180 days from issue date bL-b-of3-605C139 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department RECEIVED 1146 Route 28 South Yarmouth,MA 02664 APR 2 6 2Q23 (508) 398-2231 Ext, 1261 CONSTRUCTION ADDRESS: 14 COUNTRY CLUB DR, SO YARMOUTH BUILDING DEPARTMENT By- ASSESSOR'S INFORMATION: TOWN OF YARMOUTH Map:90 Parcel:45 OWNER: ALBERT MERCADO 16 ADRIENNE DR, SO YAF 978-870-0734 NAME PRESENT ADDRESS TEL. # CONTRACTOR: MARK MULLEN 7 CONNEMARA WY, SO Yd 508-221-8591 NAME MAILING ADDRESS TEL.# 0 Residential 0 Commercial Est.Cost of Construction$4- /56®,0 Home Improvement Contractor Lie.#167281 Construction Supervisor Lic.#104076 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: AMERICAN ZURICH INS CO Worker's Comp.Policy#6ZZUB6R48878522 WORK TO BE PERFORMED Tent II Duration (Fire Retardant Certificate attached?) Wood Stove El Siding: #of Squares 40 Replacement windows:# Replacement doors: # Roofing: #of Squares (❑)Remove existing*(max.2 layers) Insulation I I I I Old Kings Highway/Historic Dist. a)Replacing like for like Pool fencing El 'The debris will be disposes of at: TOWN OF YARMOUTH DISPOSAL Location of Facility I declare under penalties of perjury that the statements herein contained are true and orrect 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 lice and for prosecution under . .L.Ch.268,Section 1. Applicant's Signature: Date: 4/25/2023 Owners Signature(or attachme Data,4/25/2023 Approved By: Date: 4/25/2023 Building Official(o i EMAIL ADD . Zoning District:r �Mb/a �j 11'�am Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes G No G Water Resource Protection District: Within 100 ft.of Wetlands: 50S-gold -L/07-07D ❑ Yes 0 No 3 Yes 0 No The Commonwealth of Massachusetts jok -��, Department of Industrial Accidents 4 1 Congress Street,Suite 100 14 Boston, MA 02114-2017 wwn.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Annlicant Information Please Print Legibly Name (Business/Organization/Individual): MULLEN ROOFING AND SIDING Address:7 CONNEMARA WAY City/State/Zip:WEST YARMOUTH, MA phone#: 508-221-8591 Are you an employer?Check the appropriate box: Type of project(required): 1.01 am a employer with 4 employees(full and/or part-time).* 7. ❑New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. Q Remodeling any capacity.[No workers'comp.insurance required.) 93.01 am a homeowner doing all work myself[No workers'comp,insurance required.]t Demolition 4.0I 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 arc sole 11.❑Electrical repairs or additions proprietors with no employees. 12.OPlumbing repairs or additions 5.0I 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. ght of exemption per MGL c a are a corporation and its officers have exercised their ri 14.Q 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. '1 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: American Zurich Insurance Co Policy#or Self ins.Lic.#: 6ZZUB6R48878522 Expiration Date: 07/09/23 Job Site Address:14 COUNTRY CLUB DR City/State/Zip: S YARMOUTH 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 certify under the pains and penalties of r' ry that the information provided above is true and correct Signature: ��% � Date: 04/25/2023 Phone#: 508-2 1-8591 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#: ACCORDCERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 08/01/2022 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: Debra Grassi MARGARET J GRASSI INSURANCE AGENCY INC PHONNo.Eat): (508)295-2007 Na): ADDRESS: Grassi-ins@comcast.net 1188 MAIN ST INSURER(S)AFFORDING COVERAGE NAIC# W WAREHAM MA 02576 INSURERA: AMERICAN ZURICH INSURANCE COMPANY 40142 INSURED INSURER B: MULLIN ROOFING &SIDING INC INSURERC: INSURER D: 7 CONNEMARA WAY INSURER E: W YARMOUTH MA 02673 INSURER F: COVERAGES CERTIFICATE NUMBER: 799923 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 ADDL SUBR POLICY EFF POLICY EXP LTRINSD WVD POLICY NUMBER (MM/DDIYYYY) (MMIDDIYYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO- POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS N/A BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE OTH- ER AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBER EXCLUDED? N/A N/A N/A 6ZZUB6R48878522 07/09/2022 07/09/2023 (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/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 Mullin Roofing & Siding Inc ACCORDANCE WITH THE POLICY PROVISIONS. 7 Connemara Way AUTHORIZED REPRESENTATIVE West Yarmouth MA 02673 Daniel'" k niel M.Cro: y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD - F • iwY =a'a ..S.Y4.. k 5 A C� r. }.„-- 4tc she $4 5! .&°{. y :� aka .F._ _- - ii 4.---',i,-;:. -•.• .• --_,,-.. ,- -:-',i,-, -.2,1.,-i.,,,-74,--, -,--,- :,,,:s\ --: .,-,-.:,'-,14.. %.,,,;,•„1,-,z,--.,-.--,----....-—,..._.-,-,y,..:,,,,-,*„...,..-_,,i,k.-i i j i _ ` .-. 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