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HomeMy WebLinkAboutBLD-23-006061 p /�// 3 � Office Use Only Permit* " Q ,. Amount *44* m c Permit expires 180 days from issue date h— a3 -- ,41e0dZel_I EXPRESS BUILDING PERMIT APPLICATI E C E I V E D TOWN OF YARMOUTH Yarmouth Building Department MAY 0 2 2023 1146 Route 28 South Yarmouth, MA 02664 B U I L ! R (508) 398-2231 Ext. 1261 BY CONSTRUCTION ADDRESS: t Sop Pth,1 ul� y 4 of/U ASSESSOR'S INFORMATION: Map: Parcel: OWNER: dy`!_' i`i Nut-ray L f Q, 4S 0aaa 1 NAM PRESENT ADDRESS TEL. # CONTRACTOR: v k h (frvq/1(,D 8#(, �✓ �t t'�"c.'I r !i" ?ire e 'Z° l/ ) AME MAILING ADDRESS I TEL.# Residential CI Commercial Est.Cost of Construction$ 3, 300 Home Improvement Contractor Lie.# a (II Construction Supervisor Lie.# (.pis Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 111 have Worker's Compensation Insurance Insurance Company Name: 4XIQ ihte,fro wed Worker's Comp.Policy#( 2V 8 '/N K j'),3 ii WORK TO BE PERFORMED Tent ,C Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares ?p ( )Remove existing*(max.2 layers) Insulation El Old Kings Highway/Historic Dist. ( D Replacing like for like Pool fencing ri *The debris will be disposed of at 14A,T : cox I / API/53i4r. Location of Facility I declare under penalties of perjury 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 rev t' n of my I' se and f prosecution under M.G.L.Ch.268,Section I. nn Applicant's Signature: Date: /��IGI'N i 0`6 1�3 Owners Signature(or a eat) Date: .[[ Approved By: s f Date: 5 Building Offici or ` ee) EMAIL ADD'litO ' t/ '/ Zoning District: Historical District: CI Yes U No Flood Plain Zone: U Yes No Water Resource Protection District: Within 100 ft.of Wetlands: El Yes 0 No U Yes 7] No 4 / :: -' 7 1 Proposal PROPOSAL NO. DATE �w �/ BID NO. ARCHITECT tT0 PHONE NO. DATE OF PLANS f ADDRESS WORK TO BE PERFORMED AT: Lk) • .,t C/t-it ilr-i 1, 1,_, .... :ter°—73 We hereby propose to furnish the materials and perform the labor necessary for the completion of PC')41 p---1741/ 74/Z-41:/01411tAr- Area below for additional description and/or drawings: - E `� IS < . , 4 . , f14 ", . ,rft e r :.- fps 1 ...... ` _ E , 14 c4 , holf � r ) V -1 /,A a tov (-4 °. yf 4 0 ` ` ` iektitio4. ,,,,,i6 c i i. _ , . r faults.. _7,w,,,/_.. i',. cy,,,teftyLiz,4 6,64t14. r ff u .5.4 cep" �ur , - All material is guaranteed to be as specified,and the above work to be performed i;r`•ccordance with the drawings and specifications submitted for above work and completed in a substantial workmanlike manner for the sum of Dollars ($ <i< f,r )with payments to be made as follows. ,k, ibt,,,,,,, acirv, 4/..",....2,,, ) 3/..,--, ,„ef.„,, ,,,,,,,,,,,, ,,,,,42;) i , ....,_ ACCEPTANCE OF PROPOSAL 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 4 Date t r} t,- . / Signature "i °' „A \ i r J i scions.NC3818-50 11-12 The Commonwealth of Massachusetts Department of Industrial Accidents _ /1I= 1 Congress Street, Suite 100 toP4 °- - _ "07, Boston, MA 02114-2017 www.mass aov/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):Cite1/q`lM /. Address: Qua 5evc ke - j1 City/State/Zip:grtwd'icv-I 11/14 ©a&3► Phone#: ?'i Lao telf Are you an employer?Check the appropriate box: Type of project(required): 1.01 am a employer with employees(full and/or part-time).* 7. ❑New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.1:1I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑Building addition 4.0I 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.dam a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[Loof repairs These sub-contractors have employees and have workers'comp.insurance.* 14.DOther 6.1=1We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§I(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#I 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: 4o1a o b LAME Policy#or Self-ins.Lie.#: 661e.2 U 6 — Lip/if 43-- 4 —2 - Expiration Date: 81/7 ..)o2 3 Job Site Address: 113 /'/ Ad-4 City/State/Zip: Vita-Attach a copy of the workers compensation policy declaration page(showing the policy number ayitri414/1)/4 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 c der t/e pains and penalties of perjury that the information provided above is true and correct. Signature: ' Date: I f( 9d !"/ 3' Phone#: / I q79 - UG iq 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 CIerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: ■ LCTCONS-01 KLEBLANC MM/D ACC/W L° DATE( D/YYYY) CERTIFICATE OF LIABILITY INSURANCE DATE 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: AXiA MetroWest nC PHONE / , o,Ext):(413)788-9000 FAX WC,No):(413)886-0190 E-MAIL info@axiagroup.net INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Kinsale Insurance Company INSURED INSURER B:ACE American Insurance Co. LCT Construction&Service Inc. INSURER C: 4 Evergreen Lane INSURER D: Hopedale,MA 01747 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 SUER POLICY NUMBER M/POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MDD/YYYYI (MM/DD/YYYY) 1,000,000 A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE X OCCUR 0100058934-4 11/21/2021 11/21/2022 DAMAGE TO RENTED 100,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X 5ECOT- X LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: COMBIN $ AUTOMOBILE LIABILITY Ea accient SINGLE LIMIT ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED _ AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE - AUTOS ONLY AUTOS ONLY (Per accident) $ _ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS X PER H ND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N 6S62UB-4N44123-A-22 8/17/2022 8/17/2023 E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N/A SOO,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 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) 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 ACCORDANCE WITH THE POLICY PROVISIONS. 866 Satucket Road Brewster,MA 02631 AUTHORIZED REPRESENTATIVE I I ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. 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