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HomeMy WebLinkAboutBLD-23-005846 Li IA Li )2123 5;0 . •- Office Use Only Og.Y; �+ a `' . ' 'v "3�; R C E 5 V C D Permit#Cam*070V .ior�( Amount ._ ,.$�y�,: APR 19 2023 wit exp ei�ys from issue date EXPRESS BUILDING PERMIT APPLICATL. N TOWN OFYARMOUTH i RECE@VPD Yarmouth Building Department I r-".-_- 1146 Route 28 2 4 South Yarmouth,MA 02664 2023 i (508)398-2231 Ext. 1261 4APR OF_ aRTnn �/ ' f' Q�, 6y CONSTRUCTION ADDRESS: —j I) LA i/1S 1 SLYL �,(1 ASSESSOR'S INFORMATION: Map: 5 3 Parcel: -3a 1 OWNER: A lj 1 Alin �C: t� I `7 i 1 �,i!l S (blA.) 31S F. t� '7D/ !Yi y. 07 toAME PRESENT ADDRESS TEL, # CONTRA' CTOR 31'r ciZei r / ,U &)( 2 ty 7 t0 6✓1- 4_ LS/4D Dzip,S 5-be 9 yO-3O crl i NAME MA INd ADDRESS TEL.# es dential 0 Commercial Est.Cost of Construction$ /6"1 Da Home Improvement Contractor Lic.# J3 0 5/ Construction Supervisor Lic.# 1e.)//45 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietorhave Worker's Compensation Insurance //,,, Insurance Company Name:Alkyl in(, /a_Q Worker's Comp.Policy Vat'/ 4 Q 2 //I Z02 ' WORK TO BE PERFORMED Tent II Duration (Fire Retardant Certificate attached?) Wood Stove E Siding: #of Squares b Replacement windows:# Replacement doors: # Roofing: #of Squares /1 /2-. ( ) emove existing*(max.2 layers) Insulation n I I Old Kings Highway/Historic Dist. Replacing like for like Pool fencing El *The debris will be disposed of at: ( lis '"1� �--1�f^1 cation of acility 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 revocation of my license and for prosecution under M.G.L.Ch.268,Section 1. (� Applicant's Signature: \� Date: ia �� Owners Signature(or attachment) Date:Approved By: Date: 9 2�j/ —2 Building Offi (or gne EMAIL ADD SS: Zoning Di ct:1j Historical District: a Yes 7I No Flood Plain Zone: I Yes Z'No Water Resource Protect i District: Within 100 ft.of Wet ds: 0 Yes No Cl Yes No The Commonwealth of Massachusetts 49, Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA.02114-2017 .�`t wwx.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. ADalicant Information ' G Please Print Legibly Name (Business/Organization/Individual): r -h 1y1..Q,, m ei(011-ei/Y1P-rl r Address:j, V, ?DUX Z City/State/Zip: 19i"/-ta l2b53 Phone#: SDI( �6 3DS'I Are yo n employer?Check the appropriate box: Type of project(required): I. I 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.] 3.01 am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. El Demolition 10❑Building addition 4.01 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.❑Pl bang repairs or additions 5.01 am a general contractor and I have hired the sub-contractors listed on the attached sheet 13. of repairs These sub-contractors have employees and have workers'comp.insurance.* 6.0We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Others 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. f 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: 4►� m 121) Policy#or Self-ins.Lic.#: V 100.. 1 b1) j 211 d!20z3 >4' Expiration Date: Job Site Address: 44 1 U-r1S I Ot,t.7 -40+1 & City/State/Zip: (� Y YY1 O 1 - 024 73 Attach a copy of the workers' compensation po icy declaration page(showing the policy n ber 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 of perjury that the information provided above is true and correct. Signature: Date: i / 23 Phone#: cL + ' 2 `ID' 8� 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 Board of Building Regulations and Standards construct 11144 specialty CSSL-101185jcpires:1012612023 MARK D NICKERSON . 1 PO BOX 2476' ORLEANS M02658 �- Commissioner dad2t trZ -1`22/220-,410.8ead ae)e)acitecie/4- Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: LLC Registration: 133851 MCAS LLC Expiration: 08/16/2023 D/B/A NICKERSON HOME IMPROVEMENT PO BOX 2476 ORLEANS,MA 02653 Update Address and Return Card. SCA 1 0 20M-05/17 63ebftseifR +ISi a a- tiretaritacjal*tlon HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:LLC before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 133851 08/16/2023 1000 Washington Street -Suite 710 MCAS LW Boston,MA 02118 D/B/A NICKERSON i1OMEIMPROVEMENT MARK D.NICKERSON- - /2 12 COMMERCE DRIVE _ --fit 1/• .4 ORLEANS,MA 02653 Not valid without signature Undersecretary °" 0496 - PROPOSAL MCAS, LLC NICKERSON HOME IMPROVEMENT •ROOFING •SCREEN PORCHES Z40�3081 P.O.BOX 2476 •DECK •RENOVATIONSEO STORIES �107 FAX ORLEANS,MA 02663 •ADDiGS • TERIOR/EXT www.nldcersorthornelmprovement.com srsonhomelmprovement.com •ADDCflONS •INTERIOR/EXTERIOR PANTING •SKYLIGHTS •WiNDOWS/DOORS E-Mall nta rk1202653lyahoo.aom •GARAGES •KITCHEN&BATH REMODELING 12 Commerce Drive PHONE 2768 3/13/2023 Ill William Redmond JOB t i LOGIBION 411 Winslow Gray Road -r Pkc46E./la kOt/XE West Yarmouth,MA 02673 Nv / co diem redmondwfir@icloud.com SAME JOB MASER JOB rye We hereby submit specifications and estimates for: Strip double layer of shingles off entire roof and bay window roof - Nail all loose plywood roof sheathing where needed install Sp heavy duty white aluminum drip edge on all lower edges and new flanges around vent pipes install 36 WinterGuard ice and Water protector on all lower edges,around all openings,in ail valleys and over bay window roof complete install Roof Runner high performance synthetic underlayment on remaining stripped areas install roof shingles listed below on stripped area-hurricane nailed(6 nails per shingle) Supply all labor,materials,debris removal and del fees GOOD-Landmark Lifetime architectural roof shingles-235lbs./sq.,10-year algae resistance and 110 MPH wind warranty estimated at. BETTER-Landmark Lifetime Pro architectural roof shingles-250 lbs./sq,maximum definition colors ,15- year algae resistance and 120 MPH wind warranty estimated at, OPTION-install ridge vent at$10 per lineai foot Remove and dispose sidewall from left side of house and right side of main house gable end Nail ail loose sheathing install new side flashing an chimney install TYVEK or equivalent house wrap Supply and install new natural white cedarsidewall shingles on left side and right side of main house gable ends Supply all labor,materials and debris removal estimated at; We Propose hereby to tunes material and tabor—complete In accordance with the above moons,for the sum of: doleus($ )• Payment to be made as follows: lollars requested with signed proposal Progress payments on request balance on completion Ad material le guaranteed to be es sponged.All work to be completed In a professional manner acccafing tostondmdpack...Anyeftadonordade9ar from above specIltadons Authorized �• involving extra costs erg be exuded only upon vetten orders,and wadi become en eft due charge over and abate the estimate.At adreent Win Gawk acddar s or delays beyond our control.osier to*mina tornado,end other necessary tessonne.Our Now . may be drawn acted n QdaYs- worlwrsae Mt/covered rcareredb y►worlat►toCompensation . Acceptance of Proposal—The above price,specifications and 4/47,' E, more are sesmaatary and we hereby acoaMed.You am suUrod5ed to do the workSignature=�f t as speed.Payment w E be made as outlined above. Signature Date of Acceptence: 9n '1t1�^ - V ; , ® A`�o CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 04/12/2023 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 Rogers and Gray Processing BALDWIN KRYSTYN SHERMAN PARTNERS LLC ,ate No ExUc (508)398-7980 A/,No): ADDRESS: mail©rogersgray.com 4211 West Boy Scout Blvd Suite 800 INSURER(S)AFFORDING COVERAGE NAIC# Tampa FL 33607 INSURERA: AIM MUTUAL INS CO 33758 INSURED INSURER B: MCAS LLC INSURERC: NICKERSON HOME IMPROVEMENT INSURERD: P 0 BOX 2476 INSURER E: ORLEANS MA 02653 INSURER F: COVERAGES CERTIFICATE NUMBER: 880831 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 ADADMMMISUBR POLICY EFF POLICY EXP LIMITS LTR !NMVD POLICY NUMBER ( DD/YYYY) IMMIDDIYYYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO RENTED $ CLAIMS-MADE OCCUR PREMISES Ea occurrence) $ MED EXP(Any one person) $ N/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 AUTOS ONLY AUTOS N/A BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE _ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA UAB _ OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ - $ WORKERS COMPENSATION X PER AND EMPLOYERS'UABIUTY X STATUTE ERH Y ANYPROPRIETOR/PARTNER/EXECUTIVE /N E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBEREXCLUDED? N/A N/A N/A VWC10060211892023A 03/01/2023 03/01/2024 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If es,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. 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.mass.gov/Iwd/workers-compensation/investigations/. 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. 1146 MA 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 Daniel M.Crowjey,CPCU,Vice President—Residual Market—WCRIBMA I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD 7 ® DATE(MMIDD/YYYY) ACCORD CERTIFICATE OF LIABILITY INSURANCE 04/18/2023 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 REI3RESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to -7 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: Jen Davis Mark Sylvia Insurance Agency (P��HICNN Ext): (508)957-2125 FAX No): (508)957-2781 404 Main Street ADDRESS: markImarksylviainsurance.com INSURER(S)AFFORDING COVERAGE NAIC# Centerville MA 02632 INSURER A: Farm Family Casualty Insurance INSURED INSURER B: MCAS,LLC DBA Nickerson Home Improvement INSURER C: PO Box 2476 INSURER D: Orleans,MA 02653 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. ILICY EXP NSR TYPE OF INSURANCE ADDLN SUBR POUCY NUMBER POLICY D YD/YYl Y1 (M MIDDIYYYYI UMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ 100,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 5,000 A 2001 L6307 2/21/2023 2/21/202 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 XPOLICY 78 LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y I N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Carpentry-Residential Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN William Redmond ACCORDANCE WITH THE POLICY PROVISIONS. 411 Winslow Gray Rd AUTHORIZED REPRESENTATIVE Yarmouth MA 02637 ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION.All rights reserved. The ACORD name and logo are registered marks of ACORD