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HomeMy WebLinkAboutBLD-23-005543 :Y. O ice Use Only O .. _ y ]Amount _�('���n.,a�,rrr�cn csc �. 1 *SQL°*�,tea' 'Permit expires 180 days from *;; -•"" l issue date EI EXPRESS BUILDING PERMIT APPLICA V E D A /4 TOWN OF YARMOUTH O 5 2023 Yarmouth Building Department �p 1146 Route 28 BUILDING DEPA t�TIf71ENT South Yarmouth, MA 02664 By: (508) 398-2231 Ext. 1261 t� CONSTRUCTION ADDRESS: eJ f-66r- Ave ASSESSOR'S INFORMATION: Map: Parcel: I OWNER: atiltoi_ 1:/ N P SENT/� E/ �� ADDRESSG _( TEL. # / CON TOR: V` -611:7 ((le ea 1�'T I440 5,, -5 SQ"7 ✓ NAME MAILING ADDRESS TE IS [} Residential 0 Commercial Est.Est.Cost of Construction$ 7,�j O-(1 I./Home Improvement Contractor Lic.# 11,60 lit 1 Construction Supervisor Lic.# 0..('T/ �/ 7 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I�am the soleproprietor I have Worker's Compensation Insurance / Company ��cv`' P Policy# ( I 4 i3 '1 ?3 II J Insurance Com an Name: Worker's Comp. WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) 30418Elatusze Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares ( ) Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Poo fe tng frtc‘145 I.t-k cE CE '(E('( C,�ir wir% *The debris will be disposed of at: fGF (t N u- v P f1tsi (� Location of Facility N 1,,Q k I declare under penalties of perju t 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 or r-voi.• . • se d for prosecution under M.G.L.Ch.268,Section 1. r Applicant's Signature: 114111P116. y _Date: i ),.. Owners Signatur or attachmen` Date: Approved By: ` Date: / . -----;:.Z Building Official(or desi e) EMAIL ADDRE : Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No ''� The Commonwealth of Massachusetts c*c, = /, Department of Industrial Accidents _n/11= 1 Congress Street, Suite 100 =•r`= Boston, MA 02114-2017 www.mass.aov/dia ..5" o Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): 5 (C f itOlsol.7 .../ Address: (ki (S j ✓ '— 6 City/State/Zip: f``5 itsC�2,5 �� -k!' Phone #. `s --5 v Are you n employer?Check the appropriate box: Type of project(required): 1. I am a employer with 7, 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.[No workers'comp. insurance required.]t 9. [I] Demolition 10 ❑ Building addition 4.0 I 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 are sole 11.❑ Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.1]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.; 6.❑We are a corporation and itsofficers 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. (� 'L Insurance Company Name: TAkI/C41~4J Policy#or Self-ins. Lic. #: () ff45?l7 73) I la Expiration Date: S— 1?-- 3,1 k/ Job Site Address: 2 J rkr lilt City/State/Zip: c 5'-' 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 er the •cs ndpenalti of perjury that the information provided above istrue'and correct. Signature: , -4 Date: `J`u' (,1 ✓ Phone#: • 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." • An employer is defined as "an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a Iicense or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s)name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia Steven Kady Phone: 508-563-2515 Ma. Licensed Construction Supervisor#059847 Toll free: 800-567-9787 MA. HIC Contractors License#126014 Fax: 508-563-2516 P.0 Box 493 Falmouth. Ma 02541 Cell: 508-566-5087 Fax: 508-563-2516 Email: Steve@SteveKadvMasonry.com www.SteveKadyMasonry.com PROPOSAL March 17,2023 Donna Shaw 21 Frost Ave. West Yarmouth, Ma. 02673 804-774-6914 DLShaw2@comcast.net WORK TO BE PERFORMED: • Construct ground staging • Construct roof staging • Remove center chimney down to roof line • Chatham pan flash • Re-construct chimney using Glen-Gerry Antique brick • With detailed crown • Re-set chimney cap TOTAL: *Labor, Material &Disposal: $7,500.00 *Unforeseen circumstances may arise and would be billed additionally at time*&material z 6 t o 2oZ-.3 50% to Schedule, balance due upon completion A`o DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 09/15/2022 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 NAME: CONTACT Sharen Rabesa —AX PHONE 508 289-4160 _AA/C,No): MURRAY&MACDONALD INSURANCE SERVICES INC E-MAIL ONo.ExU: (508) ADDRESS: sharen@riskadvice.com 550 MACARTHUR BLVD INSURER(S)AFFORDING COVERAGE _ NAIC* BOURNE MA 02532 INSURERA: TRAVELERS INDEMNITY CO OF AMERICA 25666 INSURED INSURER B: KADY STEVEN INSURER c: - DBA STEVEN KADY&SON MASONRY CONSTRUCTION INSURER D: P 0 BOX 493 INSURER E: FALMOUTH MA 025410493 INSURER F: COVERAGES CERTIFICATE NUMBER: 814753 REVISION NUMBER: THIS IS TO THAT THE THE NDICATED.CNOTWITHSTANDING ANY IREQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH REES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVEOR PECT TOLICY 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. IADDL SUBR POLICY EFF POLICY EXP LIMITS LTRIRI TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDD/YYYY) (MDorrrYYI MI COMMERCIAL GENERAL LIABILITY EACHOCCURRENCE DAMAGETO RENTED J CLAIMS-MADE I OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY I PE O- I LOC $ OTHER: COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY (Ea accident) BODILY INJURY(Per person) $ ANY AUTO OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ HIRED NON-OWNED H ONLY AUTOSPROPERTY DAMAGE $ (Per accident) AUTOS ONLY AUTOS ONLY $ EACH OCCURRENCE $ _- UMBRELLA UAB _ OCCUR EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ X STATUTE OTH- ER WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN E.L.EACH ACCIDENT $ 500,000 A FFICERJM MBER XCL DED? CUTIVE A O(Mandatory InNH)EXCLUDED? NIA N/A N/A 6HUB931X732122 08/29/2022 08/29/2023 E.L.DISEASE-EAEMPLOYEE $ 500,000 (Mandatory NH) E.L.DISEASE-POLICY LIMIT $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If mom 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.govilwd/workers-compensation/investigations/. Sole proprietor has not elected coverage. CERTIFICATE HOLDER CANCELLATION SHOES BE THEUEXPIRATIIONHDATE E VTHEREOF, NOTICEE DESCRIBED I WILL CANCELLED BEFORE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth 1146 Route 28 AUTHORIZED REPRESENTATIVE Cjip MA 02664 _',. South Yarmouth Daniel M.Crot*i,CPCU,Vice President-Residual Market-WCRIBMA I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Division of Occupational Licensure Board of Building Regulations and Standards ConstructiQupe44 i Specialty CSSL-059847 ,� E,Cpires: 10/03/2024 STEVEN L KAD PO BOX 493 v. , FALMOUTH ? ,33 PA, Commissioner dam Office of Consumer Affairs b Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration 126014 04/07/2024 STEVE KADY • STEVE L.KADY 200 ASHUMET RD 1,0""1+'4(/ E.FALMOUTH,MA 02536 Undersecretary