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HomeMy WebLinkAboutBLD-23-005866 I R E C E l V r D Office Use Only �r Y! gRli .Permit#2023 Amount BUILDING DEPART E Permit expires 180 days from p. ..:_.: ., By. issue date 13 I./ - 3 -66 52I & EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508)398-2231 Ext. 1261 ( CONSTRUCTION ADDRESS: T�rI\�C 1l.0 kpad eg- I CL 1 ' toU MA- OW)-7 3 ASSESSOR'S INFORMATION: Map: Parcel: OWNER: © vx x4 ctDAS(A ` f- 3 S ^ a t9 NAME PRESENT ADDRES TEL. # CONTRACTOR: ?,.)SSe-k lJ x 7JCQUL(-- [O') Halo_S'\. ` J 1 lQ VI/l1 S b$-42g•-I 17 7 NAME MAILING ADDRESS TEL.# esidential 0 Commercial Est.Cost of Construction$ `'(` 'J(J o" Home Improvement Contractor Lic.# 051 1 Li Construction Supervisor Lic.# 1, S —1 v- I c Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor (Q'I have Worker's Compensation Insurance/� 2 Q Insurance Company Name: 1_,l_Qi0l�l�1.� -1 V11,a' IIlls° Q n Worker's Comp.Policy \k)(' Js&D f I WORK TO BE PERFORMED Tent L Duration (Fire Retardant Certificate attached?) Wood Stove El Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares (j Remove existing*(max.2 layers) Insulation I I l l Old Kings Highway/Historic Dist. a)Replacing like for like Pool fencing I I *The debris will be disposed of at: I VOA reK ( c '/Location of Flity 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 den' revocation of my lice d for prosecution under M.G.L.Ch.268,Section 1. /p Applicant's Signature: V� /'' Date: L/((1 �- Owners Signature(or attachment) J Date: "Z 7'(J -. 3 Approved By: Date: Building Offici d ee) EMAIL AD SS: Zoning District: Historical District: ❑ Yes U No Flood Plain Zone: C Yes T. No Water Resource Protection District: Within 100 ft.of Wetlands: U Yes U No ❑ Yes ❑ No • PAUL J. cti:Ctity OL uC( , SONS Owner Affidavit Property Owner Must Complete & Sign This Form If Using a Roofer/ Builder I (print) T© u`ra"'t , as Owner/ Agent of the subject property, hereby authorize Paul J. Cazeault & Sons Roofing Inc. to act on my behalf in all matters relative to work authorized by this building permit application for: 10v . �J. wymott.-4, Address of Job �S ��'� kI Signature of Owner9vc(Jut-4,- 1'U%i/1/&1- 3' -j- Mailing Address of Owner LK 1 l AMA.) . ipuvywy,o-t, Telephone # ( 1'7 .. .TL 1, c9.)e r( Date • GI 1 1,d Please return this form to Paul J. Cazeault Roofing along with your signedn contract. t It is needed for us to obtain the building permit required by your tow plate your roofing project Fax: 508-420-4555 Email: office@cazeault.com The Commonwealth of Massachusetts �, tr/ Department of Industrial Accidents 1- 1 Congress Street,Suite 100 W ►= Boston,MA 02114-2017 r,„144' www.massgovldia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly. Name(Business/Organization/Individual): p -L J ( 4j F 3 0 ru S Address: /08( Ala g'N City/State/Zip: C i u t /V4 Q,1Q25 Phone#: 6)38 'a8 ! iAre yea an employer?Check the appropriate box: �- Type of project(required): I Own anm a employer with J5 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 any capacity.[No workers'comp.insurance 8. Remodeling required.] 3. I am a homeowner doingall work 9. ❑Demolition Qmyself.[No workers'comp.insurance required.]t 4.0I am a homeowner and will be hiring contractors to conduct all work on my property. I will ID Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0I ant a general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance.: 13.QRt)of repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.QOther 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 subcontractors and state whether or not those entities have employees.If the sub-contractors have employees,they must provide their workers'comp.policy number. Iam an employer that is providing workers'compensation insurance for nay employee Below is the policy and job site information.Insurance Company Name: t6 i LA Pj I /�(,(`1� rt.. /kis U.._W J C !o'ZPOQ CLc!O A) �`�� Policy#or Self-ins.Lic.#: //UCH✓3 P S 3 8 QQ'1/44..2.q Expiration Date: 3/l 4/ i'ô 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 certri under the pains and pe ' ofperjuiy that he information provided above is true and correct Signature: alaa Date: Phone*: 5O ''.213 l 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#: Aco!e J CERTIFICATE OF LIABILITY INSURANCE DATe(MM@DIYYYY) Q8/0512022 THIS CERTIFICATE 15 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 OP INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING )NSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANTt If the certificate holder Is an ADDITIONAL INSURED,the polioy(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 "Linda Sullivan • - NAME: PRONE 508 957-4239 THE HILB GROUP OF NEW ENGLAND LLC ROVE No.EA: ( ? LFAArXc.Na); ADDRESS: isullivan@dolns.com 120 Turnpike Rd INSURER(S)AFFORDING COVERAGE NAIL# Southborough MA 01772 INSURER A: LM INS CORP 33600 INSURED INSURER B: • PAUL J CAZEAULT&SONS INC INSURER c: INSURER o: 1031 MAIN ST . INSURERS: • OSTERVILLE MA 02655 INSURER P: • COVERAGES CERTIFICATE NUMBER: 801276 REVISION NUMBER; ' INDICATED.TO CNOTWITIFY HSTANDINO ANYT THE IES'OF REQUIREMENT,TERM OR CONDINCE LISTED TION OF ANY CONTRACT OR OTHER DOCUMENT WI HAVE BEEN ISSUED TO THE INSURED NAMED DVE FOR THE TH RESPECTTOLICY WHICH PERIOD CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEROIN IS SUBJECT TO ALL THE TERMS, • EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, ADDLSUER POLICY EPF� POLICYEXP LIMITS IN TYPE INSO WWI POLICY NUMBER ,.IMMIDDNYYYI IMM@DIPNY} • COMMERFIALGENERALLIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED • CLAIMS-MADE El OCCUR PREMISES(Eanocnrtence) $ • MED EXP(Any one person) $ • NIA PERSONAL&ADV INJURY $ GEM AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLIO? SECT LOC • PRODUCTS-COMP/OP AGG 8 OTHER: COMBINED SINGLELIMIT $ AUTOMOBILE LIABILITY (Ea accldann ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED UTOS N/A BODILY INJURY(Per enoldent) $ AUTOS ONLY ANON-OWNED PROPERTYPROPERTYDAMAGE $ HIRED (Per occident) _ALl fOS ONLY — AUUTTOSS ONLY $ UMBRELLALIAS }OCCUR _ EACH OCCURRENCE $ EXCESS LIAR ,CLAIMS-MADE N/A AGGREGATE $ CEO RETENTIONS $ �/ ER WORKERS COMPENSATION X STATUTE ER AND EMPLOYERS'LIABILITY YIN EL EACH ACCIDENT $ 1,000,000 ANYPROPRIETORIPARTNERIEXECUTNE A OFFICER IMEMBEREXCLUDED? NIA` NIA NIA WC531S388670022 08/10/2022 08/10/2023 E.L.DIStASE.EAEMPLOYEE $ 1,000,000 (Mesta#ory In NH) . If yes,describe under E.L DISEASE•POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS bairn? £ I N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Sohadute,may b.pltanheU If core apace Is required) to dorsement WC 20 03 Workers' for benefits toton empt employees In stat be es otheaid r than Massachusett Massachusetts s If the Insees ured hires,or has nhlred Those employees outside of Massachusetts.no authorization Is to pay This certificate of insurance shows the policy in force on the date that this certificate was Issued(unless the expiration date on the above policy precedes the Issue date of this certificate of Insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification • Search tool at wWw.nrass.gcv/iwd/workers-compensailonMvestlgatlonsl, CERTIFICATE HOLDER CANCELLATION ' SHOULD ANY OF THE ABOVE-DESCRIBED POLICIES BE 0ANOELLEt7 BEFORE • THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, ' AUTHORIZED REPRESENTATIVE I 1 Daniel M.CroJby,CPCU,Vice President--Residual Market—WCRIRMA I 01988-2015 ACORD CORPORATION, All rights reserved, I • ACORD 26(2018/03) The ACORD name and logo are registered marks of ACORD 1 A`oR® • CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YWY) 04/29/2022 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). CONTACT Tina Reeves • PRODUCER NAME: Dowling&O'Neil Insurance Agency PHONE (800)640-1620 (A/C,No,Extl: (A/C,No): 973 lyannough Road ADDAILESS: treeves@doins.com INSURER(S)AFFORDING COVERAGE NAIC# Hyannis MA 02601 INSURER A: James River Insurance Company INSURED INSURER B: Safety Indemnity Insurance Company 33618 Paul J.Cazeault&Sons,Inc. INSURER C: QBE Insurance Corporation 1031 Main Street INSURER D: • INSURER E: Osterville • MA 02655 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2242909764 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 ADUL SUER POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DDIYYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 • DAMAGE TO RENTED 50,000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 1,000 A Y Y 000715306 04/30/2022 04/30/2023 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY 1 XI Tar- LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY CEO Ma ccNEDtSINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ B OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS PROPERTY DAMAGE HIRED NON-OWNED $ AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ C EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- • STATUTE ER AND EMPLOYERS'LIABILITY• Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE N/A EL.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED?(Mandatory in NH) EL.DISEASE-EA EMPLOYEE $ If yes,describe under EL..DISEASE-POLICY LIMIT $ , DESCRIPTION OF OPERATIONS below 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 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. — - ---- AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD • • I I v o 0 .0) a) O C _- . .0 lii C 0 CO d O N CVN O 0 a)m N H O OH O C C)) C H C Q O C C W nN/CD a d a7 '^ vJ LL O O.O O Q• O 2 m-- ,~, 1 (f) 1.,... op (/) '411.,. H CI. CZ = 3 c.3 IL Q C -- - f O W ,. g, C 0c...Ts y QC �- dye •� m ) 4� 1, 0 7' E C 2 id a, �� II . CC ors d: N 2 N t+ a O•-Q m ' VI 'fa L f ,J o. , i m•�._c N W Q .�< • P � ", m m O o m �. cn 1 - E `' o o. Oom 1-1 o 4 .. I• C 0 w5ce a) W O I c. ? = d so -a Z 2� U D d) Q w ,O _� °�¢3. O C 1:„..-x:i.i ,,,1 b z-, • Z +`O Lo Q 3O y 11 I . I—I—O 0 Z� t ,0" LNLI I-ul w `- =g' .rn, U z Z ° ~N` F N w J w o � Q Qom U o = w �ui a ,-O w m 0 J I-- U -IQ> 0 -'i WgK -J Cl)M W 03 CC.- 0 0 oGiWAT1O4, ' '111 SNO1S2WWIN fir 4- :N 82131XV8£96 . ' , a, rA 3 ll3SSn21 no ; ziii:saiidi$1 LS6801. SO los�ti� t suoO spJepue4s pue suol;eln a>J 6ulplln9 j.o pleas ainsuaoll leuoPedn33O uolslnl( ' ' spasnyaessew to Lpleaenuounuo0' WI 'l