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HomeMy WebLinkAboutBLD-23-001557 Office Use Only ,o *Y' R. PIA �'1 z 1 z� ,k C `t,+'. Permit# r 4 r'' p 0 :4 y, Amount 7 /)/) MATT IM $ 4 , -d Permit expires 180 days from issue date etP A3 -eidiS5 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 SEP 212022 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT n By. -- CONSTRUCTION ADDRESS: t q _f D IA(\ i 'J -. S. yAQmou ASSESSOR'S INFORMATION: Map: Parcel:OWNER: Sotvit'rQs' R P3n-f-at‘N2. if-10i'ane 144,4 .JC •$te-MIwth 978*-$7O -(4L 3 I NAME PRESENT ADDRESS TEL. # CONTRACTOR: .3010 % 1dV CI t) 51in 1 DI 5 I- HYMN') 50 B 36 9 SBJ 6 NAME MAILING ADDRESS TEL.# CAL AV.:, {jvrrD 4 (E, UC 1 in c Residential 0 Commercial Est.Cost of Construction$ I . 000 Home Improvement Contractor Lic.# 19 1 Il 3 1 Construction Supervisor Lic.# C 3 ` t O c CI 8 i Workman's Compensation Insurance: (check one) El I am the homeowner 0 I am the sole proprietor rim have Worker's Compensation Insurance Insurance Company Name: L to 1' 3 0 4(A'na. Worker's Comp.Policy# WC- 1 I`S a WORK TO BE PERFORMED Tent n Duration (Fire Retardant Certificate attached?) Wood Stove U Siding: #of Squares :).5 Replacement windows:# Replacement doors: # Roofing: #of Squares 19 (❑)Remove existing* (max.2 layers) Insulation n I I Old Kings Highway/Historic Dist. (0)Replacing like for like Pool fencing n *The debris will be disposed of at: 101.On O( Pit iou 71 D 15fosAI (AC I I t rf Location of Facility I declare under penalties of perj t t 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 r o ti of my license and for prosecution under M.G.L.Ch.268,Section 1. aa Applicant's Signature: •, Date: �-',,,,-1 )el 0 )a)rl. a- Owners Signature(or atta ent 4 Date: -1 /o2I c1O e7A Approved By: Date: / '2—_ Building Official(or gnee) EMAIL ADDRESS: Zoning District: Historical District: C Yes No Flood Plain Zone: I Yes I No Water Resource Protection District: Within 100 ft.of Wetlands: Yes C No Yes _. No -" 4 I t • I 1 _ _ _ The Commonwealth of Massachusetts *—., 1 Department of Industrial Accidents _AK_ 1 Congress Street, Suite 100 .. Boston, MA 02114-2017 Sv.,'v www.mass.gov/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 (EJ--E, t)V 1\ (o 4 ItiEfn0 O I ) n C `.ic A ) f)e)_1 oUI A Address: as S vY1 i DI ST City/State/Zip: J lA;nf 1 S M 0 .bo Phone#: SCY8 36 9 8 836 Are you an employer?Check the appropriate box: Type of project(required): 1.0I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.1=iI 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 3.01 am a homeowner doing all work myself. [No workers'comp. insurance required.]t 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.❑Plumbing repairs or additions 5.N1I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.atr'oof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.1=1We 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— / \ \('\5)Ptf)C�, Policy#or Self-ins.Lic. #: W C — 13 0 1\ S g3 Expiration Date: Og 137 l do;3 Job Site Address: \Ol':1 1)IA fl . A\( , City/State/Zip: 5- '/A`Pro'W.H 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 certi Wider the pains andpenalties of perjury that the information provided above is true and correct Signature: 3' Date: O CIA J ate )<::Dz) Phone#: 508 36 L/ 8856 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#: A O or CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 09/13/22 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: JIM HINDMAN Schlegel&Schlegel Ins Brokers,Inc. (A/C.N Enr 508-771-8381 ONE FAX No): 508-771-0663 34 Main Street E-MAILDSS: Schlegelinsurance@gmail.com West Yarmouth,MA 02673 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: NGM INSURANCE COMPANY 14788 INSURED INSURER B: LM INSURANCE COAST CARPENTRY HOME IMPROVEMENT INC INSURER C: 250 SUDBURY LANE INSURER D HYANNIS,MA 02601 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 CONDIT ON 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. ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DDIYYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 500,000 MED EXP(Any one person) $ 10,000 A MPJ5180E 08/30/22 08/30/23 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 O- POLICY JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY , AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER YIN 100,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ B OFFICER/MEMBER EXCLUDED? N/A WC-1301152 08/31/22 08/31/23 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under 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) COPORATE OFFICERS HAVE ELEXTED TO BE COVERED UN THEIR CURRET WORKERS COMPENSATION POLICY INSURANCE COVERAGE IS LIMITED TO THE TERMS,CONDITIONS,EXCLUSIONS,OTHER LIMITATIONS AND ENDORSEMENTS OF THE POLICY 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. BUILDING DEPARTMENT WEST YARMOUTH MA 02673 AUTHORIZED REPRESENTATIVE WILLIANA CASTRO ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts Division of Occupational Licensure Construction Supervisor Board of Building Regulations and Standards Unrestricted -Buildings of any use group which contain !qI r' 11 less than 35,000 cubic feet(991 cubic meters) of enclosed Const ion$ (visor space. , CS-109981 —� ca.gpires: 12/22/2023 e JOAO DEMORA , ,-_ j 22 SMITH STREET HYANNIS MAt02601 , • i !f'�.0LLv,I'.13'.- ,��.�/ Failure to possess a current edition of the Massachusetts , Commissioner i la K. rV&niira State Building Code is cause for revocation of this license. O For information about this license I Call(617)727-3200 or visit www.mass.gov/dpl THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Corporation Registration Expiration 197431 12/10/2023 Registration valid for individual use only before the CREATE BUILD&REMODEL INC expiration date. If found return to: 1+ Office of Consumer Affairs and Business Regulation V1 1000 Washington Street -Suite 710 JOAO DE MOURA E� 'Y"` • Boston,MA 02118 22 SMITH ST x �� HYANNIS, MA 02601 Undersecretary J Not valid without signature i