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HomeMy WebLinkAboutBLD-22-007284 Office Use Only ti'©I Y .er, Permit* ( f.b" 2II< yak ' *� H Amount /00 •f .p. cM Parrett expires I80 days from .. issue date /3LM— d2-9- - dd'7� t-/ EXPRESS BUILDING PERMIT APPLICA'J'1 C E i V E D TOWN OF YARMOUTH -�-----_--- Yarmouth Building Department J U N 17 2622 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 B y�( T NT CONSTRUCTION ADDRESS: 153 Wood Rd. ASSESSOR'S INFORMATION: Map: Parcel: OWNER'_ Jean Kinkead 508-280-8554 NAME PRESENT ADDRESS TEL if CONTRA CToR: Richard Buckley P.O. Box 734, Orleans, MA 508-648-6553 t Ce,....sLiz NAME MAILING ADDRESS TEL.ii laResidential 0Commercial Est.Cost of Construction$30,000 Home Improvement Contractor Lie.#177174 Construction Supervisor Lie.#CS-061145 Workman's Compensation Insurance: check one) 0 I am the homeowner Pr I am the sole proprietor 0'I have Worker's Compensation Insurance Insurance Company Name: Liberty Mutual Worker's Comp.Policy#WC531 S385048032 WORK TO BE PERFORMED Tent El Duration (Fire Retardant Certificate attached?) Wood Stove ❑ Siding; #of Squares 12 Replacement windows:#3 Replacement doors: #1 Roofing: #of Squares (❑)Remove existing*(max.2 layers) Insulation 1 ! El Old Kings Highway/Historic Dist, C3)Replacing like for like Pool fencing El *The debris;will be disposed ofat: Daniels:Recycling, Orleans, MA 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 answers) will be just cause for denial or revocation of�1m'Iii//�nnss�and ford o; under M.G.L.Ch.268,Section I. 1 /i Applicant's signature: �/I �' t Date: 0�/7/ 2Z Ouvaers tore(or attachment) / Dane:/ Approved By: ''~ Date: Building Official(or desi EMAIL ADDRESS: Zoning District: Historical District: [3 Yes " No Flood Plain Zone: t 1 Yes [' No Water Resource Protection District: Within 100 ft.of Wetlands: El Yes G No_ C Yes 0 No P .lie Wrnrno2urPA 0/./ o��ac�uusedi Office of Consumer Affairs&Business Regulation HOME IMPROVEMENNTid ONTRACTOR • R I ' xir In F 11/07/2023 RICHARD B , ! krr 43 RICHARD BUM. '.-a 4,1 r �a,�wGk' 60 CIRCLE DR";� p,0 j EASTHAM,MA 0 .-w,f'" Undersecretary Commonwealth of Massachusetts Division of Professional and Standards Board of Building ,�Isor Conal 'it_''"� i Tres 0612712023 RICHARD ElK 60 CIRCLE °' ar } EAS I11AM i' ' �p , r Commissioner eic,4. • The Commonwealth of Massachusetts = Department of Industrial Accidents : � a 1 Congress Street,Suite 100 ,1 if Boston, MA 02114-2017 www.mass.gov/dia J`4+7 Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lezibly Name (Business/OrganizationfIndividual): Buckley & Sons Carpentry Address:3 Giddiah Hill Rd., P.O. Box 734 City/State/Zip:Orleans, MA 02653 Phone#: 508-648-6553 Are you an employer?Check the appropriate box: Type of project(required): 1.01 am a employer with 2 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. (l Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall work t 9. ❑Demolition ❑ myself.(No workers'comp.insurance required.] 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will I O❑Building addition ensure that ail contractors either have workers'compensation insurance or are sole 11.QElectrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.01 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.* 6.0We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q✓ Other 3 windows.1 door and siding 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy iutvLutation. 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: Liberty Mutual Ins. Policy#or Self-ins.Lie.#: WC531 S385048032 Expiration Date: 4/1/23 Job Site Address:153 Wood Rd. City/State/Zip: S.Yarmouth,MA 02664 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 an pen 'es of perjury that the information provided above is true and correct Signature: j Si f / Date: 6/8/22 Phone#: 508-648-6553 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 CIerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: • C�® DATE(MMIDDIYYYY) A CG CERTIFICATE OF LIABILITY INSURANCE 03/01/2022 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(les)must 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: Mary Clare McGraw BENSON YOUNG&DOWNS INSURANCE AGENCY LLC ,E, : (781)820-4606 FAX (A/C.No): ADDRESS: maryclare@byandd.com 56 HOWLAND ST INSURER(S)AFFORDING COVERAGE NAIL PROVINCETOWN MA 02657 INSURER A; LM INS CORP 33600 INSURED INSURER B RICHARD BUCKLEY INSURER C DBA BUCKLEY&SONS CARPENTRY INSURERD: PO BOX 734 INSURER E: ORLEANS MA 02653 INSURER F COVERAGES CERTIFICATE NUMBER: 748871 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. IN.TR TYPE OF INSURANCE IADDL SUER POLICY EFF [ POLICY EXP ID LIMITS INSD WVD POLICY NUMBER (MMD/YYYY) (MM/DDIYYYYI I COMMERCIAL GENERAL LIABSJ Y EACH OCCURRENCE fI$ CLAIMS-MADE I I OCCUR DAMAGE AMA SET(Ea RENTED arcs) $ • MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GENt AGGREGATE LIMIt APPLIES PER: GENERAL AGGREGATE $ POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED 'AUTOS SCHEDULED AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS I (Per accident) I UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE N/A AGGREGATE $ DED I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY X STATUTE ER A OFF ICEOR/MEIWEREXXCLUD D?ECUTNE NIA WA WA WC531S385048032 04/01/2022 04/01/2023 E.L EACH ACCIDENT $ 100,000 If yes,describe under Mandat InnNH) I E.L.DISEASE-EA EAPLOYEE $ 100,000 DESCRIPTION OF OPERATIONS below I E.L DISEASE-POLICY LIMIT C$ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached It more space le 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/Iwdtworkers-compensation/Investigations/. Sole proprietor has not elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Wel(fleet ACCORDANCE WITH THE POLICY PROVISIONS. 300 Main St AUTHORED REPRESENTATIVE Wellfleet MA 02667 Daniel Cr•W'-y,CPCU,Vice President—Residual Market—WCRIBMA ®1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD - Clarke, Kristin From: kinkead j.m <kinkead j.m@gmail.com> Sent: Friday,June 17, 2022 4:15 PM To: Clarke, Kristin Cc: Rick Subject: Approval of work covered in permit Attention!:This email originates outside of the organization. Do not open attachments or click links unless you are sure this email is from a known sender and you know the content is safe. Call the sender to verify if unsure. Otherwise delete this email. Hello, I Jean Kinkead of 153 Wood Road in South Yarmouth give permission to Richard Buckley to do the work outlined in the permit. Thank you, Jean Kinkead ph 508-280-8554 1