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HomeMy WebLinkAboutBLD-23-005916 • 01.v- ,t �t e g'2 Office Use Only t;w! 0 �/�-I wa iPermit# e'id _ •'0 . 1.4 . H ,Amount /QQiV46) MATTA M CSEJ� I �� `°�."'.� !Permit expires 180 days from j issue date 13 GD - g3 --CIO 5 0 I EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department R ,C E 1 V E D 1146 Route 28 - South Yarmouth, MA 02664 APR 21 2023 (508) 398-2231 Ext. 1261 � BUILDING DEPARTMENT CONSTRUCTION ADDRESS: I �-A DD LJ' 1 By ---- ASSESSOR'S INFORMATION: ` Map: Parcel:� C� OWNER: L-b\t4 ty_scp C'kv 3 --t62- S)c 2 5 ?- 5. 36 -)I0) NAME PRESENT ��'' M ADDRESSt TEL. # CONTRACTOR: - -OS C�c e4`A L-' 'I p'Z(-Y i 1E3e ) .ist\KkT ci i ti? vo-ke_.L( NAME MAILING ADDRESS TEL.# '--7 _C7'-55_.(& Residential ❑Commercial Est.Cost of Construction$ '55 14-"' Home Improvement Contractor Lic.# /63 O '2- / Construction Supervisor Lic.# 656>0 .D--- Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor have Worker's Compensation Insurance �q' Insurance Company Name: (COC'iNT�7 EA/gU�'(d7 Worker's Comp.Policy# C— Div`.5-01(1?3-451v '� WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove i Siding: #of Squares 5 Replacement windows: # I 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: )r- e-S‘ "e.-\yz-xo c-u_! --Tez Location of Facility I declare under penalties of perjury that the statements herein contained 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 o vocation of my license o rosecution under M.G.L.Ch.268,Section I. Applicant's Signature: , , `/j i ? Date: / Owners Signature(or attach II e0 Date: Approved By: Date: el;___ � Building Official(o icr EMAIL ADD :�,EO VIZI C,, :,,30v..° � e — �l Cam. Cal Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft. of Wetlands: ❑ Yes 0 No 0 Yes ❑ No • The Commonwealth of Massachusetts Department of Industrial Accidents 7:111 1 Congress Street, Suite 100 r- Boston, MA 02114-2017 . IIMI •• www.mass.gov/dia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): —Z 53,J (mac Jtn\� _T S-r15Z.0% C S Address: t--1 J Lxv'\ '5 S� City/State/Zip: Z ''�`�>>Zl�l- ' phone #: • �3—o�cl S Are you an employer?Check the appropriate box: Type of project(required): l. m a employer with t 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. r; Remodeling any capacity.[No workers'comp.insurance required.] ` 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.] 9. emolltiori I am a homeowner and will be hiring contractors to conduct all work on my10 Building❑ addition 4. ❑ 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 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractprs have employees and have workers'comp. insurance.; 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: (A- e RJ?Lo i j S Policy#or Self-ins.Lic. #: S61 j1 Expiration Date: CP-��?l Job Site Address: (3 ( ` S City/State/Zip: ()e71,6.9( 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 perjury that the information provided above is true'and correct. Signature: Date: Lif J�( J Phone#: 7f— 9''S3—i)dS • 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#: ACCORD® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 04/21/2023 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 Robert W.Parker Charles G.Jordan Insurance Agency PHONE FAX 17 Front Street INC,No,E,t); 781-337-0427 (A/C,No): 781-335-6897 Weymouth,MA 02188 ADDRESS: rparker@cgjordaninsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: Western World Insurance Co. 13196 INSURED Joso Contract Services Inc. INSURER B: Associated Employers Insurance Company A0234 24 Holmes Street INSURER C: Safety Indemnity Insurance Company 33618 Braintree,MA 02184 Nautilus Insurance Company INSURER D: P y 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) • COMMERCIAL GENERAL LIABILITY NPP8016210 09/18/2022 09/18/2023 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE <>' OCCUR PREMISES(Ea occurrence) $ 50,000 MED EXP(Any one person) $ 1,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JE a LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: _... $ AUTOMOBILE LIABILITY 6234616 08/07/2022 08/07/2023 COMBINED SINGLE LIMIT $ 1,000,000 (`, (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED j SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY • ,AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) D UMBRELLA LIAB I ';OCCUR AN1263746 09/18/2022 09/18/2023 EACH OCCURRENCE $ 5,000,000 EXCESS LIAB 'CLAIMS-MADE AGGREGATE $ 5,000,000 DED RETENTION$ 10,000 $ g WORKERS COMPENSATION WCC-500-5011123-2022A 06/27/2022 06/27/2023 1/ PER OTH- AND EMPLOYERS'LIABILITY STATUTE `ER Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBEREXCLUDED? N N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 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. 1146 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD COMMONWE A LTH OF MASSACHUSETTS THE COMMONWEALTH OF MASSACHUSETTS DIVISION OF OCCUPATIONAL LICENSURE Office of Consumer Affairs&Business Regulation BOARD or HOME IMPROVE ,NT CONTRACTOR ELECTRICIANS .. ,. TYPE:Co7poration ISSUES THE FOLLOWING LICENSE Registration. , Ex4tiration REG JOURNEYMAN ELECTRICIAN «a+'i, 1i32877 x .,0�1t32t2024 JOSO CONTRACT SERt/(C INC JOSEPH E OBRIEN `.' {HOLMES ST ,,—,, BRAINTREE,MA 02184-1707 ,,or 't JOSEPH E.O'BRIEN �)� 24 HOLMES STREET � -���• BRAINTREE,MA 02184 00s*---' I Undersecretary 25501 E . 07/3112025 266237 iitt LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER Commonwealth of Massachusetts C•MMON LTH OF 'SSACHUS S Division of Professional Licensure DIVISION OF OCCUPATIONAL LICENSURI Board of Building Regulations and Standards BOARD OF Conskrodt4444§tipervisor ELECTRICIANS ISSUES THE FOLLOWING LICENSE CS-030702 65pires: 10/06/2023 REGISTERED MASTER ELECTRICIAN 1'm JOSEPH E O RIEN l JOSEPH E OBRIEN 414 , ' 24 HOLMES$d ,,. BRAINTREE NIA 02y; `24 HOLMES ST. , a , BRAINTREE,MA 02184-1707 ,Of ' r i' =lt 40 Commissioner ✓+ .a. , J_./41{.IJA., 9911 A; 07131/2025 267897rb LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER