HomeMy WebLinkAboutBLD-23-005974 64:Y`qR e e!i ® 4.v /�_ OOffiice Use Only
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MATTACM ESE S.: Amount
,1_ 4.o..«o°,,d; APR 2`� 2023 ��
:• I' Permit expires 180 days from
UE,cf T !issue date
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: ./0 Ai.'--) M r T C(f
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: rittfRCo46ZET FPdrBO /O t !CItiCUNsc,1 OjQ `78I- ?6 (o — •Zd13
NAME PRESENT ADDRESS TEL. #
CONTRACTOR: T P°�(.�O iJ a 3. COS ICJ`/ ylv Eo Uie JE SOS- 36 0 -a t'v(o
N.Ai IE MAILING ADDRESS TEL.#
1
liZ esidential ❑Commercial >. / Est.Cost of Construction$ cal .2.So , 00
Home Improvement Contractor Lic.# Construction Supervisor Lic.# 9 5j'7
Workman's Compensation Insurance: (check one)
❑ I am the homeowner ❑ I am the sole proprietor cll.-have Worker's Compensation Insurance
Insurance Company Name: .0/8E1?7V /McO7 ' 9L Worker's Comp.Policy# AJCta..- 3(S -36 31 o'3O 3 /
WORK TO BE PERFORMED /
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares Replacement windows: # Replacement doors: #
Roofing: #of Squares %Lc— ( Remove existing* (max. 2 layers) Insulation
Old Kings Highway/Historic Dist. (t/)ieplacing like for like Pool fencing
r56 6 Dif— It ke 4✓11re.• 4027/2 3 ,o-. S -1
*The debris will be disposed of at: Su[711.1?jw(C/4- 0041 1e
Location of Facility
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: 4,, 4,a,Q4� �
Date: /
'w /.2'?/oZ 3
Owners Signature(or attachment)
Ef — Date:Date:
Approved By: 2" 3
Building Official(or ign
EMAIL ADDRE
Zoning District:
Historical District: 0 Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No
Water Resource Protection District: Within 100 ft. of Wetlands:
❑ Yes ❑ No 0 Yes U No
`" \ •
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
•`mow v Boston, MA 02114-2017
y,:
:.5'• 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):
Address:
City/State/Zip: Phone #:
Are you an 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.❑I am a sole proprietor or partnership and have no employees working for me in
any capacity.[No workers'comp.insurance required.] 8• ❑ Remodeling
3.0 I am a homeowner doing all work myself [No workers'comp.insurance required.]t 9. Demolition
4.0 I am a homeowner and will be hiring contractors to conduct all work on mYProP �1'•
e I will 10 Building addition
ensure that all contractors either have workers'compensation insurance or are sole
proprietors with no employees. 11.❑ Electrical repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.❑Plumbing repairs or additions
These sub-contractors have employees and have workers'comp. insurance.: 13.❑Roof repairs
6.0 We 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.
r 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:
Policy#or Self-ins.Lic. #: Expiration Date:
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 certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature:
Date:
Phone#:
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#:
ACc CERTIFICATE OF LIABILITY INSURANCE DATE
"'"'°°' `'
k.....-- 08/08/22
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 pollcy(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 CONTAt.r
NAME:
PHONE
United
edM n InStrance n Agency,Inc. r No.Exe►: 508-759-6595 I i .No): 508-759-3822
19P.O.Box 1013 nooREss:
Buzzards Bay,MA 02532 INSURER(s)AFFORDING COVERAGE NAIC I
INSURER A: Liberty Mutual Ins Co
INSURED
INSURER B:
Persson Construction Inc INSURER C:
Kent Persson
22 Colony Ave D'
Boume,MA 02532 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 POUCY 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.
L INSR TYPE OF INSURANCE "OD MD POLICY NUMBER CExP
LRNTS
COMMERCIAL GENERAL LIABILITY
EACH OCDAMAGETCyRREIIDW.qNNCE $
CLAIMS-MADE OCCUR PREMISES(Ea axu�ED rrence) $
MED EXP(Any one person) $
—
PERSONAL&ADV INJURY $
GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
POLICY❑PRE LAC
PRODUCTS-COMP/OP AGG $
OTHER
AUTOMOBLE LIABIJTY COMBINED SINGLE LIMIT $
—
ANY AUTO
(Ea accident)
BODLY INJURY(Per person) $
OWNED SCHEDULED
AUTOS ONLY _ AUTOS BODLY INJURY(Per accident) $
HIRED NON-OWNED PROPERTY DAMAGE
_ AUTOS ONLY _ AUTOS ONLY (Per accident) $
— 1>MBRELJ.A LIAR H OCCUR
EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE
AGGREGATE $
BED I I RETENTION$
WORKERS COMPENSATION $
AND 'LOYERS'LIABILITY Y/N XI S ATUTE I I ER
EI
A ANY PROPRIE EXCLUDED?R/DCECUTNE❑ N/A WC5-31 S�6310 E.L.EACH ACCIDENT $ 500,000
(Merry In MI) 3-031 08/07/22 08/07/23
Iyes describe under EL.DISEASE-EA EMPLOYEE $ 500,000
DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LRAIT $ 500,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Residential Builder
Email: mpresby@piymouth-ma.gov
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Town of Plymouth ACCORDANCE WITH THE POLICY PROVISIONS.
26 Court St
Plymouth,Ma 02360 AUTHORIZED REPRESENTATIVE
Kris Dexter
1
ACORD 25(2016/03) The ®1988-2015 ACORD CORPORATION. All rights reserved,
ACORD name and logo are registered marks of ACORD
3/28/23,6:55 AM Mail-Kent Persson-Outlook
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Persson Construction,Inc.
22 Colony Ave.
Baas.MA 02532
Phone:(508)360-2906
www.perssonremodeiing.com
perssonwindOW hotmail.cam
PWZOSAL St BIE TED Trk PHONE: Ou�TE
Margaret Falbo 781-956-2238 3/17/23
STREET: JOB NAkIE: ARCHITECT:
10 Keix msett Cir
Car.antis Aram CODE: JOB LOCATION: DATE OF MANS:
Yarmouth,MA
We hereby submit specifications he:
Strip off old roof shingj/from entire roof and remove to the dump. Inspect roof deck.Re-nail
all loose boards.Use tarps to protect all shrubs and walls from damage.
Build a cricket behind ihe chimney to divert the water properly.
Apply 2 coats of clear water proofing to the chi.
I ll new 8"white aluminum drip edge on all eaves,new flanges on all plumbing vents.
Install 3'of Owe ns Corning Ice and Water Barrier on all eaves and in all valleys.
Install a layer of 30 lb.felt paper on entire roof deck.
Install Owens Coming sir shingles on all eaves.
Install new Owens Cawing Duration arch tect style roof shingles on eta roof.
sbmgke• will be fitstalied using 6 i =roofing to ensure 130 mph wind ratmg.*
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Division of Occupational Licensure
Board of Building Regulations and Standards
Office of Consumer Affairs&Business Regulation upi T,
eg Construct uper Specialty
HOME IMPROVEMENT CONTRACTOR p
TYPE Corporation CSSL-099507 licpires:01/02/2024
•1E '` KENT E PERSON tC
22 COLONY AVEN
PERSSON coNist
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KENT E.PERSSON. �lIX,T,t rt.l�`
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BOURNE,MA 02532 Commissioner ()ca 1i. r7Frncll�a
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3/28123,6:55 AM Mail-Kent Persson-Outlook
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Persson Construction,Inc.
22 Colony Ave.
Bourne.MA 02532
Phone:(508)360-2906
wmv.pesssonremodelina.com
pa'ssonwindovrs@hotmaiLcom
PROPOSAL stnearizoTo: PRONE:
Margaret Falbo 781-956 2238
3/17/23
10 Imsett Cir
crrv,srA7's AND ZIP CODE: XXI'NAME:
JOB LOCATION: nwi16 OF PLANS:
$:
Yarmouth,MA
We attt specifications ,
Strip off old roof shingles from entire roof and move to the dump.Inspect roof deck.Re-nail
all loose boards.Use tarps to protect all shrubs and walls from damage.
Build a cricket behind the chimney to divert the water properly.
Apply 2 coats of clear water proofing to the chimney.
Install new 8"white aluminum drip edge on all eaves,new flanges on all plumbing vents.
Install 3'of Owens Coming Ice and Water Barrier on all eaves and in all valleys.
Install a layer of 30 lb.felt paper on entire roof deck.
Install Owens C 'shies on all eaves.
Install new Owens Corni �on ng architect
style roof shingles on entire roof
S • will be fastened usin&45Teeemg x is to ensure 130 mph wind rating.
Color will be -;,c 1'- s; ~
h ista ridge veits on alb iidgesi and Owe bsRanking
I and Ridge shingles.
lob site will be cep,,a s!i? be; sa o d tithe d .
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HIC Registration Complaints
Registration # 173732
Registrant PERSSON CONSTRUCTION INC.
Name Kent Persson
Address 22 COLONY AVE.
City, State Zip BOURNE, MA 02532
Expiration Date 11/05/2024
Complaints Details
No complaints found for this registrant.
You can also view arbitration and Guaranty Fund history.
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