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Home My WebLink AboutBLD-23-006047 Unit 25 �pF•YRR Office Use Only O H ri Permit# q Es' .�' f uc fd 9 Amount Permit expires 180 days from i issue date 517D-°,3—m&®Y7 EXPRESS BUILDING PERMI T APPLICATION TOWN OF YARMOUTH Yarmouth Building Department R C E J V E' D 1146 Route 28 "T �-�- — South Yarmouth, MA 02664 APR 18 2023 (508) 398-2231 Ext. 1261 t CONSTRUCTION ADDRESS: (QL1 1Ij? \ • ,� /�,/ 1�A e,u�� oiv0 r� PARTMT �.J /u 777 OiI-� ---- ASSESSOR'S INFORMATION: Map: Parcel: I (7 OWNER: &Al—VA 1�i' KO 6 NAME `l !�I ,/mot it- ��.u' ()NOY �y✓ PRESENT ADDRESS TEL. # � k640101/ TEL. #CONTRACTOR: g'3b0�� NAI IE MAILING ADDRESS y TEL.# ❑Residential rcial Est.Cost of Construction$ J0Oe,01) Home Improvement Contractor Lic.# / .9 d FCS —/O 2/ /�fiConstruction Supervisor Lic.# )U( Workman's Compensation Insurance: (check one) 0 I am the homeowner ❑ I am the sole proprietor 7(I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares I Y Replacement windows:# Replacement / doors: # Roofing: #of Squares / ( Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. O Replacing like for like Pool fencing *The debris will be disposed of at: S 5-ty6-0 Location of Facility I declare under penalties of rjury that the to p rein 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 r revocation i ens d for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: / Date: / d Owners Signature(or attachment) Date: Approved By: % Build or desibe E Date: S DRESS: r� u Zoning District: Historical District: 0 Yes ir No Flood Plain Zone: 0 Yes .13V No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes u- No 0 Yes No DATE(MM/DD/YYYY)CERTIFICATE OF LIABILITY INSURANCE 03/27/23 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 AME::` JIMMY HINDMAN Schlegel&Schlegel Ins Broker (a/CNN,Ext): 508-771-8381 FAX No): 508-771-0663 34 Main Street E-MAIL West Yarmouth,MA 02673 ADDRESS: schlegelinsurance@gmail.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: INSURED INSURER B: TRAVELERS ILYA LAVRENOV INSURER C: DBA A GRADE EXTERIOR SOLUTIONS 393 BUCKSKIN PATH INSURER D CENTERVILLE,MA 02632 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 ADDLBUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO REN I EU CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY _ AUTOS ONLY (Per accident) UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY B OFFICER/MEMBER ER EXCLUDED?XECUTIVE Y N/A 7PJUB6R08057122 09/23/22 09/23/23 E.L.EACH ACCIDENT $ 100,000 (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 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) ILYA LAVRENOV HAS ELECTED NOT TO BE COVERED UNDER HIS CURRENT WORKERS COMPENSATION POLICY INSURANCE COVERAGE IS LIMITED TO THE TERMS,CONDITIONS,EXCLUSIONS,OTHER LIMITATIONS AND ENDORSEMENTS OF THE POLICY 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. BUILDING DEPARTMENT w YARMOUTH MA AUTHOR! D RI;'-ES NTATIVE" ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department oflndustrialAccidents 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): /L..'(1' C 1 " n e..noi Address: City/State/Zip: Phone #: 5t) &e)D.:35 Are yo n employer? Check the appropriate box: Type of project(required): 1. I am a employer with employees(full and/or part-time).* 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑ em delinruction R any capacity.[No workers'comp. insurance required.] g• Remodeling 3.0 I 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. 11.0 Electrical repairs or additions 5.❑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•Q Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El 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 isprovi�workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: / le/1� , Policy#or Self-ins. Lic.#: (2 / 2 0 Expiration Date: l 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 verification. I do hereby certi nder tli pai and penalties of perjury that the information provided above is true and correct. Signature: Y f� / Date: /PS( 4e097 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#: Commonwealth of Massachusetts Division of Professional Licensure and Standards Board of Building Regulations ConstrU l �ISp rvisor CS-107181 2 spires 05127I2023 ILYA LAVRENOV ram' " . 13 BIRCH STREET HYANNIS MAl38Q1 ,il j l()iss.I lil-'�` 4, Commissioner 1. t E Vz cc m o c c `. m N m G �o 0 a co is DI ul 0 0 - 0,- CC ++ m +� ::: m = ao47 QN N r c 1 N7 -.`4 'O 11 M m.� 1r U y�• I8o dal 2 'a u) c a et.'`,�, I L 5 c "r o c t� "< Ts� O c>sN o �°oc "� I N U (,� 8 Bg i- ` o `� �' " III Q ZEc>sOo , O m > v) c- 5`• C o o ~- d U ," E 01 0 W 0 0 N d O c W I _ e0 S w v ~ aGo - Q am ov 0 • V W c k.-coo 'a 2.. Zi_a Wa � m am >10) gyaa co co o Q C 1'c3