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HomeMy WebLinkAboutBLD-23-005490 X; Ot e Use Only ,,�t /l O ` `' ip- Z 3- 065Yyf/ rmit O . y i H Amount /00 sap 'N Mr TA n'c�sr• : Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATIMX E ! V E D TOWN OF YARMOUTH -"-`V_ Yarmouth Building Department APR 04 2023 1146 Route 28 South Yarmouth, MA 02664 B -►-- 2VM�trT (508) 398-2231 Ext. 1261 tilt_ — �'7� CONSTRUCTION ADDRESS: 35 Monroe Ln., West Yarmouth, MA ASSESSOR'S INFORMATION: Map: Parcel: OWNER: Tom Conroy 35 Monroe Ln NAME PRESENT ADDRESS TEL. # CONTRACTOR: Charles Baniukie 4 Nathan Henry Rd, W Hary 508-868-3829 f NAME MAILING ADDRESS TEL.# El Residential 0 Commercial Est.Cost of Construction$ 16,000 Home Improvement Contractor Lic.# 192608 Construction Supervisor Lic.#CS-067057 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: Worker's Comp.Policy# WORK TO BE PERFORMED Tent E Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 4 Replacement windows: # 1 Replacement doors: # Roofing: #of Squares (0)Remove existing*(max.2 layers) Insulation u Old Kings Highway/Historic Dist. (0))Replacing like for like Pool fencing *The debris will be disposed of at: S & J, South Dennis Location of Facility I declare under penalties of perju• I . t , tate ents ere .' .• • are true :•• orrect to the best of my knowledge and belief. 1 understand that any false answer(s) will be just cause for denial • ••voc .r oe license •••.•• •• ution u,:•�4.G.L.Ch.268,Section 1. Applicant's Signature: AO /' %r 40, Date: / _ ,,Awnera Signature(or a' ehn►ent)� - Date: 4/, a Approved By: Date: / �'Z3 Building Official(or design ' / EMAIL ADD Zoning District: Historical District: LJ Yes J No Flood Plain Zone: F Yes L> No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No ❑ Yes Li No • ESUS i1 9 C, • The Commonwealth of Massachusetts -,ff/ Department of Industrial Accidents Ma1';= I Congress Street,Suite 100 „VI Boston,MA 02114-2017 www.massgov/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): Cho...r Je.s 1?:)414.1.1 Address: t v t jkrbr City/State/Zip: Yv v.D� �'�'A Phone#: og io 2 Are you an employer?Cheek the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. ❑New construction 1 I am a sole proprietor or partnership and have no employees wort:ing for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.0I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 Q 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 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions . 5E11 am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.n Roof rep irs These sub-contractors have employees and have workers'comp.insurance.: I ' 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other dud / 152,§1(4),and we have no employees.[No workers'comp.insurance required.] ��IVYWW *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. tContractors 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: • Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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 veritication. I do hereby ce un r th poi penal ' of Iu that t information provided above is true and correct. Si r • Date: Phone • Official use only. Do not write in this area,to be comph'ted 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#: Commonwealth of Massachusetts V` C Division of Occupational Licensure j Board of Building Re ulations and Standards Cons - ionr ,rvisor -, .f CS-067057 -k t spires 1212012023 CHARLES P pANIUKIEWICZ,JR F "..' 4 NATHAN HENRY RD ._ - 11-klie`i, . , WEST HARWPCH MA 02671 y 'V:, i 5, ; i Commissioner dtuda A. UAnii. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Im•rovement Contractor Re istration ^� ��'4. Type: LLC C BANKS BUILDERS, LLC M egtstration: 192608 4 NATHAN HENRY RD ` = Expiration: 02/07/2025 WEST HARWICH, MA 02671 � *i i ,/fj `r+ Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE: LLC Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street •Suite 710 192608 02/07/2025 Boston,MA 02118 \NKS BUILDERS, LLC I,RLES P. BANIUKIEWICZ JR �CTHAN HENRY RD >T HARWICH, MA 02671 Tay . . . . ! : • . • ' . , i • '••:. ) • . ......1 '' • i ) • ,....... •ZI .‘,.. . . . . 1.!: ..... —.. ..._ ,.... `s-,.• f, - . , .., .•.;;;,-,f • ;it I f ' t •••-•3 n ; " , . nti. -• r.r. ' ; ; • • li !.•- '.; :L.; . . . ;,.• •:, .,-...: k ,. • ._ • •;.,• .‘ . N : I.:, . :-4 5 . . . :-..; 'a,' 4 ,,....... . -...'„," - —,..... • .-. --- 7 0 ri • — -- ',--,p ..*..... •z 7 ..... -. •-.n . • to n"1'.t„i-- ',. ..„, .4._,• , ,-;;;. no ' )...) r•;••• , :1-.• ...: . ft *.?,nn.7.:... -,; ;.••• 0 *:•B n'X ;:t, -,.; ••• 4;1:: .,."..' ',,,,.: i,.... . .- (, ;: ;. ."...' `..--,' '''. 17.;" •••: ,•-••• ;,:-.:".. ,7: '' ,'4,1 . "," --„ r•nk (1,," , ,; •-n ;*,!, .-.; .-• -„,. , , , • , ...... .. .,, •fnt,.• , _.... .• , . ...7„. 75 ii al/ . 32 f•itel t ,,,,,,n4 (-) — ' ....) • % . . 0 ,..." . , ..- ... ".:0 -„.•-I% 1.-.'.. -, ., ---, tt^ '-,.,.. •- v)le ..0, -. -4„ . ... 1:: i aa,a:.' •„;.. :*/1.-. ;:i 4: „,,; - ' * , •: • -,?T. 7:- ,,1 k, , • . . ..1. '4D • —. 2:. Ui .,.• n'. "t, ... 4 U4 Si -4 _ .... ..,.... _ . BANIUKI OP ID: KF ACCP/?L] CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 01/10/2023 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 508-398-6060 CONTACT Bryden&Sullivan Insurance Bryden &Sullivan Ins Agency PHONE 508-398-6060 IFAX No):508-394-2267 of Dennis Inc. (NC,No,Eat): 485 Route 134, PO Box 1497 E-MAIL So. Dennis, MA 02660 ADDRESS Bryden&Sullivan Insurance INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Associated Employers Insurance INSURED INSURER B:NGM Insurance Company 14788 Theodore C. Baniukiewicz QUALITY CRAFTMANSHIP INSURER C: 4 Nathan Henry Rd West Harwich,MA 02671 INSURER D 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 NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD wvQ (MM/DD/YYYY) IMM/DD/YYYYI B COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR MPP2225C 05/25/2022 05/25/2023 PREMISES(Ea occu encel $ 500,000 x Business Owners MED EXP(Anyone person) $ 10,000 PERSONAL&ADV INJURY $ I,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 PRO-OTHER: $ AUTOMOBILECOMBINED SINGLE LIMIT LIABILITY jEa accident) $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ AUTOS ONLY NON-OWNEDUUT (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y/N WCC-500-5018201-2022A 12/21/2022 12/21/2023 100,000 ANY PROPRIETOR/PARTNER/EXECUTIVE N N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION TOWN-02 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. TOWN OF YARMOUTH 1146 ROUTE 28 S.YARMOUTH,MA 02664 AUTHORIZED REPRESENTATIVE Bryden&Sullivan Insurance ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD j) — Of°Ktc--WIT.3 cto rant .r Es_GkuJ ALS WD ?�1&Aip oOrNicP -70 I c/