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Home My WebLink AboutBLD-23-006059 0a ,/it/ �y ,1+q Office Use Only "4 Q _ Permit# 11P 0 Ni: Amount L ' Permit expires 180 :: days from issue date BC.L -c23 -.dO to 0S9 EXPRESS BUILDING PERMIT APPLICA ION C E I V P D TOWN OF YARMOUTH Yarmouth Building Department MAY 02 2023V 1146 Route 28 .�South Yarmouth, MA 02664 B U I L :,,a• - (508) 398.2231 Ext. 1261 BY - _ CONSTRUCTION ADDRESS: c✓ 6l/,S l....r/ri tc, rizatiaro i 62, ASSESSOR'S INFORMATION: Map: Parcel: A t/o G Q ) 77 y �l� ?% OWNER: T PRESENT/ ADDRESS �/�� j f TEL. #(� Q U� ,g CONTRACTOR: N Jdf Lq (4 'Vd s (J(KO '/t# ke /, & ihi,. et / f ZD Ato epo/ AME MAILING ADDRESS I TEL.# QResidential 0 Commercial Est.Cost of Construction$ fop Home Improvement Contractor Lie.# aOJ 9/9 Construction Supervisor Lie.# CS 0/41 y2 Workman's Compensation Insurance: ftCheck one) D I am the homeowner k am the sole proprietor L� I have Worker's Compensation /� „ Insurance. . Insurance Company Name: Ax(l fl t f►0 VkitSt Worker's Comp.Policy# G S(!d v6 If N N4(23 A-1,1 WORK TO BE PERFORMED Tent II Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofin • #of S uares l q (Er)Remove existing*(max.2 layers) Insulation 1-1 Old Kings Highway/Historic tg way/Htstortc Dist. Replacing like for lie Pool fencing El Ik Y.� tNK.L (iY C6 6\1-r a l /33 *The debris will be disposed of at: giCce /,( /�� I Location of Facility r" l� I declare under penalties of perj a e 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 of my r se and for prosecution under M.G.L.eh.268,Section I. Applicant's Signature: Date: 7/fi /s 23 ,,-- Owners Signature(or a meat) ��e Date. Approved By: Bate Building Official(o •f:1:t: TF , a a'1 •�- t . / Zoning District: Historical District: 0 Yes ': No Flood Plain Zone: 01 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: CI Yes '1 No i0 Yes 0 No It L opoIJa Page# of pages <7 )p p t p .. S Y,.,P9,�.v f^ ''� ,-�.j7.^"' { 0^2p_ 'Y F.�'F,�.,,, )j�i`-yam i _ rq - `p t PROPOSAL SUBMITTED TO: JOB NAME JOB# r 6 w 9 ADDRESS 1� w> / 66 t JOB LOCATION 1/444VVIA -_ DATE DATE OF PLANS PHONE# 1a�% t'"� 4A , FAX# 'ARCHITECT 71 ii ;1D ?lye hereby submit specifications and estimates for: r i - svie re-er of- j.,,,, ,,6:;-'Al _)/ii-11,457,Li<frkitf opt"-, 00.'', -41"/ ow . 0. S ( Al cx" e a �t t i3 t — ( u t,r ,,i zs , 4,054407 04 leirdfize , To , , V _ //tea • ?lye propose hereby to furnish material and labor—complete in accordance with the above specifications for the sum of: $ r'' '470 Dollars with payments to be made as follows: �s f Any alteration or deviation from above sp ecifications involving extra costs Respectfully f =`fq will be executed only upon written order,and will become an extra charge is over and above the estimate. All agreements contingent upon strikes, submitted ; t t accidents,or delays beyond our control. Note—this proposal may be withdrawn by us if not accepted within days. / C.,' Zicceptottce of Vropo5a l The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payments will be made as outlined above. Signature „'ref '. ' ' s Date of Acceptance Signature / 19/T-3850 09-11 ( +ter iI The Commonwealth of Massachusetts 1F----- 1 Department of Industrial Accidents �,=l 1 Congress Street, Suite 100 * ''° _ r�. Boston, MA 02114-2017 :. wwmass.Q oov/dta Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): C4r.val14 emiS� C, Address: 9 t/(,1 6 / . City/State/Zip: R rewit,,1 NA( pace 3/ Phone#: ??e ,&l q Are you au employer?Check the appropriate box: Type of project(required): 1.0I am a employer with employees(full and/or part-time).* 7. El New construction 2.01 am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] 8. Remodeling 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t g El Demolition 4.0I am a homeowner and will be hiring contractors to conduct all work on my property. I will 14 El Building addition ensure that all contractors either have workers'compensation insurance or are sol • •prietorswith no employees. 11,QElectrical repairs or additions 5.FAI am a general contractor and I have hired the sub-contractors listed on the attached sheet 12.❑Pl Bing repairs or additions These sub-contractors have employees and have workers'comp.insurance.: 13•Iffroof repairs 6.0We 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: 1�/4 d(( Wei- Policy#or Self-ins.Lie.#:(p ,vg,— '/vitas -A--}I- / lo3 Expiration Date: P!(� Job Site Address: 7 'I6' �j City/State/Zip: yy Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration O). 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 i,r the ains and penalties of perjury that the information provided above is true and correct. Signature: I Date: / Aoa3 Phone#: III IN kepi 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: Q R LCTCONS-01 KLEBLANC CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 9/8/2022 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 CONTACT AMA MetroWest NAME: PHONE (A/C,No,Ext):(413)788-9000 FAX No 41 E-MAIL info@axia rou net (A/C, )°( 3)886-0190 ADDRESS: g p. INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A:Kinsale Insurance Company INSURER B:ACE American Insurance Co. LCT Construction&Service Inc. INSURER C: 4 Evergreen Lane Hopedale,MA 01747 INSURER D INSURER E: COVERAGES INSURER F: 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 ADDL SUBR LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF POLICY EXP A X COMMERCIAL GENERAL LIABILITY (MM/DDnYYYI (MDNYYY1 LIMITS CLAIMS MADE X OCCUR EACH OCCURRENCE $ 1,000,000 0100058934-4 11/21/2021 11/21/2022 DAMAGE SET Ea occu RENTED $ 100,000 MED EXP(Any one person) $ PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY X JE I X LOC GENERAL AGGREGATE $ 2,000,000 OTHER: PRODUCTS-COMP/OP AGG $ 2,000,000 AUTOMOBILE LIABILITY $ COMBINED SINGLE LIMIT _ ANY AUTO (Ea accident) $ OWNED SCHEDULED BODILY INJURY(Per person) $ _ AUTOS ONLY AUTOS HI RTOS ONLY NON-OWNED BODILY INJURY(Per accident) $ AUTOS ONLY PROPERTY DAMAGE (Per accident) $ UMBRELLA LIAB OCCUR $ EXCESS LIAB CLAIMS-MADE EACH OCCURRENCE $ DED I RETENTION$ AGGREGATE $ B WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY ER OTH- ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N 6S62UB-4N44123-A-22 8/17/2022 8/17/2023 X I STATUTE ER OFFICER/MEMBER EXCLUDED? I I N/A E.L.EACH ACCIDENT $ 500,000 (Mandatory in NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 500,000 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) Green Company CERTIFICATE HOLDER CANCELLATION — SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Carvalho Construction Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 866 Satucket Road ACCORDANCE WITH THE POLICY PROVISIONS. Brewster,MA 02631 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) The ACORD name and logo are registered ma ks9of ACORD CORPORATION. All rights reserved. • :, � "" �4-zb ,"�� ,, »;�-,',.. :. c ^3 > • 4. h s a • i' .' .% :T ' ' i ,!> ,. `' s # Y,, , ,;'.i. � ; `„,, " ' �=w� �°'«„ :° < _.Y „ ' d ,,; /-,A,g,;/, ,wtr' ' �„',,� '�.'.� , 1sb.�s� � '4 f, xi, � .�,,;, �7< ./ , ,4* K. ..;'"3 �s , .' — _ � , ^ : •z l a T :> .t ; �. 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