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HomeMy WebLinkAboutBLD-23-001396 ,_.. ., , .0-.1..7.444- ,_ ea,aid-- Office Use Only O 9 1 m /Z Permit# eL /h27 p 1 *i Amount 5D_ Kam/ •'! MAI.- 1'. . 4. -, "1n."a+'�g : Permit expires 180 days from issue date 6teD 023 _& /3 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department R E C E I V E D 1146 Route 28 South Yarmouth,MA 02664 SEP 14 2022 (508) 398-2231 Ext. 1261 Don( '� ` BUILDING DEPARTMENT CONSTRUCTION ADDRESS: 191 ,�J�.�n C Ay( . �V V Ti.4 yq&rnoLra- By -_ ASSESSOR'S INFORMATION: Map: /� (� Parcel: qy p OWNER:I f`t.�� -t t!1- �G>`,t�` � / l sp lit/vvt2 // ,, l l O 7-D SC 4)— N E AA PRESENT ADDRE n ` TEL. # �^ �/ p Q CONTRACTOR: NTO1\ ) 9e 'vl cf I TI' S yllnor. TEL.# �o a b f l7 V 'MEE MAILING ADDRESS G e c-PII. Bvh ID 4 tCrmo9c 1 l v1 C. # Residential 0 Commercial Est.Cost of Construction$ p 5O0 0 �jp Home Improvement Contractor Lic.# 1 CH LI 23 I Construction Supervisor Lic.# 6$ - 1 07 /8 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 4 1 have Worker's Compensation Insurance T' 1 Insurance Company Name: L I A5.)Q,A( C,i Worker's Comp.Policy# lW,C - i 30 1 159. WORK TO BE PERFORMED Tent n Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# lc) Replacement doors: # Roofing: #of Squares (❑)Remove existing*(max.2 layers) Insulation I I F1 Old Kings Highway/Historic Dist. CI)Replacing like for like Pool fencing I I *The debris will be disposed of at: 1CILL)0 0' YA h(W U 1 c DI Si20, 1 I Location of Facility I declare under penalties of perjury 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 revs+:ti • +f my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: ©q I Ic) Owners Signature(or attac i ) . , ; I 1 . "�Date: i -/ �/y ' Approved By: ./ Date: "'�//y '.2.2.- Building O'> ial(o •esignee) EMAIL •_P4.y SS: ' Zoning District: Historical District: Yes r No Flood Plain Zone: -: Yes E No Water Resource Protection District: Within 100 ft.of Wetlands: i 1 Yes L No : Yes �." No The Commonwealth of Massachusetts 1 ='=crilli_ /, Department of Industrial Accidents _n = 1 Congress Street, Suite 100 _�alif=_ ' Boston, MA 02114-2017 Y,�tog www.mass.gov/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): CQrc �_ U1 1 ()1 ► r ( . Ve 10 Address: 4 SO) i-04 5 1 City/State/Zip: )iiikAY11 S NI 09-60 l Phone#: 505 369 B b S6 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 2.0I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself. [No workers'comp.insurance required.]t 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 El Building addition 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.L I� am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t _ 6.0We are a corporation and its officers have exercised their right of exemption per MGL c. 14.��'•then u}6�fl�O Ul) r i,IC Y l��►q 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: /...AA in SOW C E — Policy#or Self-ins.Lic.#: kk)C^ 1_2,O I 1 5 a Expiration Date: 0 8 J 3 1j _,X),43 Job Site Address: I q-i 1)1A fC A'if[ City/State/Zip: _5.. /A k_Yf OL)TH - /A 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 verificati n. I do hereby cer ' er the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: o'J 10 ) 0)-g Phone#: 50 8 36 11 8 FS6 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#: t`i ." DATE(MM/DD/YYYY) ' CERTIFICATE OF LIABILITY INSURANCE 4114 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). CONTACT PRODUCER NAME: JIM HINDMAN PHONE 508-771-8381 FAX No): 508-771-0663 Schlegel&Schlegel Ins Brokers,Inc. A/C,No.Ext): 34 Main Street ADDRESS: schlegelinsurance@gmail.com West Yarmouth,MA 02673 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: 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 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. ILTR TYPE OF INSURANCEADDLSUBR POLICY EFF POLICY EXP LIMITS INSD WVD POLICY NUMBER (MM/DD/YY YY) (MM/DDIYYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 500,000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 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 PRO- LOC PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY JECT $ OTHER: COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY (Ea accident) ANY AUTO BODILY INJURY(Per person) $ — OWNED SCHEDULED BODILY INJURY(Per accident) $ _ AUTOS ONLY _ AUTOS PROPERTY HIRED NON-OWNED PRO(Per P accident)ERTY DAMAGE $ AUTOS ONLY AUTOS ONLY $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ $ DED RETENTION$ PER OTH- WORKERS COMPENSATION STATUTE ER AND EMPLOYERS'LIABILITY Y I N 100,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ B OFFICER/MEMBER EXCLUDED? N/A WC-1301152 08/31/22 08/31/23 100,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS I 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 ACCORDANCE WITH THE POLICY PROVISIONS. TOWN OF YARMOUTH BUILDING DEPARTMENT AUTHORIZED REPRESENTATIVE WEST YARMOUTH MA 02673 WILLIANA CASTRO I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD IICommonwealth of Massachusetts Division of Occupational Licensure Construction Supervisor Board of Building ulations and Standatids Unrestricted -Buildings of any use group which contain Constonf Isor less than 35,000 cubic feet(991 cubic meters)of enclosed .4 space. CS-109981 .� kpires: 1212212023 JOAO DEMO14RA 7, 22 SMITH STREET ' HYANNIS MA 02601 ; :i �'.JJ Failure to possess a current edition of the Massachusetts Commissioner r1.A"I t7Cv» U. State Building Code is cause for revocation of this license. 4 For information about this license Call(617)727-3200 or visit www.mass.govldpl THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affaiff.,d&Business Regulation 4 HOMEIMPROV-'i j CONTRACTOR TYR w.,r-,o anon ir- 9 w j i'17,- Registration valid for individual use only before the CREATE BUILD&RE. C expiration date, if found return to: Office of Consumer Affairs and Business Regulation r, 1000 Washington Street -Suite 710 JOAO DE MOURA -'i Boston,MA 02118 22 SMITH ST �,„„,,,,,.a.`, ,,,4• HYANNIS,MA 02601 ', Undersecretary /644________, 1 i. Not valid without signature i