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HomeMy WebLinkAboutBLD-23-006017 i ^ DY'YAR$ ����r /// / /d Office Use Only ",14 ` 3-/�/ ;Permit# n a�7� (� ;Amount 5D.D�j M SE AT,,I,, E Permit expires 180 days from j issue date EXPRESS BUILDING PERMIT APPLICATION 02,3 3 - 6� �/7 TOWN OF YARMOUTH Yarmouth Building Department RECEIVED 1146 Route 28 South Yarmouth, MA 02664 MAY 01 1023 (508) 398-2231 Ext. 1261 BUILDING P DEPARTMENT CONSTRUCTION ADDRESS: 7 Gp Po✓►npc ri.0 By _ ASSESSOR'S INFORMATION: Map: Parcel: 33q- 993 -05.99 OWNER: _FV e \�..ki SWIf4V\ 6O 1)c*k 7 Apavlo n at. yeAr nit a 4\ .C3Za NAME / " PRESENT ADDRESS 1 TEL. # � CONTRACTOR: Cam- &1'S,e J%�vci dok el 'S D C�Gtv1 ~j'J t Ray r ain4 $o - ! 22-S-t(0 �� NAME ✓ MAILING ADDRESS / TEL.# Residential ❑Commercial Est. Cost of Construction$ /O f enD d Home Improvement Contractor Lic.# l'p,2 g 6 2. Construction Supervisor Lic.# CS 07/ r,.2- Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor : I have Worker's Compensation Insurance Insurance Company Name: Set ec,T: 1-n 5. Worker's Comp.Policy# 5-00 5 O 22 6 9c'/ WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows: # Replacement doors: # Roofing: #of Squares 305, . ( R �ve esistin_�* (max.2 layers) Insulation Old Kings Highway/Historic Dist. (e,/S Replacing like for like Pool fencing o? L rt. 1 I lu- w"1 rl? 8- 114/14 f'/2 *The debris will be disposed of at: /VIP FrA4 i 6T 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 or revoca'on of m license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: 5 /A0 Owners Signature(or attachment) ,f' Date: Approved By: i J �j,'� 3 Date: Building Official(or designee) E ADORES Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft. of Wetlands: Ei Yes 0 No 0 Yes _ No The Commonwealth of Massachusetts • u, = L Department of Industrial Accidents L/11= 1 Congress Street, Suite 100 f= Boston, MA 02114-2017 .•`'� www.mass.c'ov/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): c IP, �c njt,11�2.c S Address: 421 C V> -1 City/State/Zip: A// 2 ka,vtAt 1 V\\ per-?b7 Phone #: cog-- 0 Are you an employer?Check theappropriate box: Type of project(required): 1. I am a employer with tg 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. 9. ❑ Demolition ❑ y [No workers'comp. insurance required.] 4.❑I am a homeowner and will be hiring contractors to conduct all work on mYProPrtY• e I will 10 Building addition 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. 1-, [ oOf repairs These sub-contractors 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 ��� j�Gl C 2tti(C8)) 152,§1(4),and we have no employees. [No workers'comp.insurance required.] f *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: '7� E'( «rIL iSiA<-0mAce Policy#or Self-ins. Lic. #: 5O050 2 (o k/ Expiration Date: 7/2//2 3 Job Site Address: 7 6 t7otvk pow 0 f ot< City/State/Zip: y41r ctt)''_P?Ai, { I 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 o perjury that the information provided above is true'and correct. Signature: -l Date: 4� 0'2—5 � Phone#: 50% 12 Z 57(0 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#: SUPEBUI-01 KMALLELA ACOREY DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 4/28/2023 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 NAME: FBinsure,LLC 128 Dean Street (A"Ic°,No,Est):(508)824-8666 FAX No):(508)880-0142 Taunton,MA 02780 E-MAIL info@fbinsure.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Selective Insurance Company of America 12572 INSURED INSURER B:Associated Employers Ins.Co. 11104 Superior Builders Inc INSURER C: 95 Dean St INSURER D: Raynham,MA 02767 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 WVD IMM/DDIYYYY) (MM/DD/YYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR S 2440154 12/24/2022 12/24/2023 DAMAGE TO RENTED 500,000 PREMISES(Ea occurrence) $ X Blkt Add'I Ins MED EXP(Any one person) $ 15,000 x Blkt Waiver PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY X JECQT LOC PRODUCTS-COMP/OP AGG $ 3,000,000 OTHER: $ AUTOMOBILECOMBINED SINGLE LIMIT LIABILITY (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOSSp BODILY INJURYp (Per accident) $ AUTOS ONLY AUUTOS ONLDY (Per acaGent)DAMAGE UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY Y/N WCC5005022694 7/21/2022 7/21/2023 STATUTE ER 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ )FFICER/MEMBER EXCLUDED? N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 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 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE (Re444 0110.4 O/H ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD • • Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Corporation . . Registration, { Expiration 192862 7., 1 0/31/2023 • SUPERIOR BUILD ,4N / ill GEORGE SILVEIRA r ' 95 DEAN ST 1 ,h•CL.��aGGfri RAYNHAM,MA 02767 Underse cretaty_ Commonwealth of Massachusetts s Division of Occupational L,censure f Board of Building Re i lations and Standards Cons ton Srvisor �w ,y S-071620 x 4pires:01/20/2024 GEORGE-M VLVEI 95 DEAN ST RAYNHAM NOS 02757. Commissioner d f'' t1&ncf�a •