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Home My WebLink AboutBLD-22-007129 01.y,, Office Use Only ,} p C��.. It l/S)� Permit#&tire"/6'3O I 11\` .i S-o, )) Amount .`O""'" c Permit expires 180 days from issue date Ott- ao2-MTi 24 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department RECEIVED 1146 Route 28 South Yarmouth, MA 02664 JUN 08 2022 (508) 398-2231 Ext. 1261 B ILDING DEPARTMENT CONSTRUCTION ADDRESS: ' $ j idle, i. • ,` .cam — ASSESSOR'S INFORMATION: Map: Parcel: OWNER: „le✓l#lies "Tr-exki slew g ar 44 e m ei..1 $ SL4.44K4itc Si Sock z7,1 .9903 NNAMS 1 u� �+ PRESENT ADDRESS TEL. # CONTRACTOR:3 +\ 3�N�10 '!7 diti 4cr'e• 1h. ck )L, mil. �6 j n 7� , I`1- 1- 9 0 77 NAME (I MAILING ADDRESS TEL.# esidential ❑Commercial Est.Cost of Construction$ IS Ow �j Home Improvement Contractor L .# 1q�06.5° Construction Supervisor Lic.# 65-l T n Workman's Compensation Insurance: (check one) 0 I am the homeowner ❑ I am the sole proprietor I have Worker's Compensation Insurance �1�} R �r �j'1 Insurance Company Name: 1`cai'G 'Th S• Worker's Comp.Policy#�j , i g 17 0 ll 'J 1(/„L WORK TO BE PERFORMED Tent J: Duration (Fire Retardant Certificate attached?) Wood Stove El Siding: #of Squares Replacement windows:# Replacement doors: # [[�� Roofing: #of Squares !O Remove existing*(max.2 layers) Insulation 17 Old Kings Highway/Historic Dist. Replacing like for like Pool fencing 11 e`a t,),;,t Z If .tell (11 g e T C)(G*The debris wbe disposed of at: V 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: i At .. (F�'+R`-,�.�L_ Date: O Owners Signature(or attachment) Date: p V / Approved By: L- Date: !/'' G—G Building Official(or de ee EMAIL ADDRES • Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No , The Commonwealth of Massachusetts 1- - / Department of Industrial Accidents tif ='itmi= 1 Congress Street, Suite 100 %,44 _'l:_t Boston, MA. 02114-2017 ,,_, 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): 411 Cc lie C0 5'-1u-16n Address: Li(, S} C 2 Ads try. City/State/Zip:Ck1)-rh, /"4. c%13 Phone#: 9' 1-1-922 ) 1/ Are you an employer?Check the a proprieate box: Type of project(required): 1. 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. I am a homeowner doingall work myself. t 9. ❑Demolition ❑ ys [No workers'comp.insurance required.] 4.0I am a homeowner and will be hiring contractors to conduct all work on mY property. I wilt 10❑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 5.0I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.t 13. Roof repairs n 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. OtherQ ` �� 152,§I(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: (r`wiltr S 115, Policy#or Self-ins.Lie.#: /16 b' 140119 ; Expiration Date: Li/1 9J Job Site Address: 16 6 r'`e-- 9, City/State/Zip:/'rr 'A1i Ou l') /1,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 verification. I do hereby c tify under a pains and penalties of perjury that the information provided above is true and correct. WSignature: Date: 0/J 0 g Phone#: ?lilt 929- )9911 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#: c R ,accr tom-- CERTIFICATE OF LIABILITY INSURANCE I DATE(MM/DD/YYYy) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS2 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 Broker PHONE 771- -8381 34 Main Street Est); 508 FAX No 508-771-0663 West Yarmouth,MA 02673 ADDRESS: schlegelinsurance@gmaii.com INSURER(S)AFFORDING COVERAGE NAIC I! INSURER A: TRAVELERS INSURED INSURER B: ALL CAPE CONSTRUCTION INC INSURER C: ' 27 DANCING BROOK ROAD SOUTH YARMOUTH,MA 02664 INSURER D 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. )L R TYPE OF INSURANCE AODL SUBit ,(MM/DDY EIYY1 UMM POLICY LIMITS Atil5 WVD_ POLICY NUMBER COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 ACLAIMS-MADE n OCCUR DAM (Eaoccurrrrence) $ 500,000 MED EXP(Any one person) $ 10,000 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY[ jE a LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: _ $ AUTOMOBILE LIABIUTY COMBINED SINGLE LIMIT $ ' (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED _AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $_ AUTOS ONLY AUTOS ONLY (Per accident#_ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I RETENTION$ 11 I $ WORKERS COMPENSATION I STA UTE J ERH AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE EXECUTIVE Y'N N!A 6HUB8H02859922 04/14/22 04/14/23 E.L.EACH ACCIDENT $ 100,000 B OFFICER/MEMBER EXCLUDED? y (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 It 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 It mare space Is required) CORPORATE OFFICERS HAVE ELECTED NOT TO BE COVERED UNDER THEIR WORKERS COMPENSTION 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 YARMOUTH MA 02673 AUTHORIZED REPRESENTATIVE J� ' � `� I 01968.2015 ACO D ORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD of Consumer i & usinees, LlaGon ° ty,Ac nnwais,a►w e Registration valid for individual use only TYPE:Corporation before the expiration date.If found return to: Registration. Expiration Office 0c aConsumer ton Affairs Street Suite B7usiness Regulation ALL CAPE CONS_TlttJGfi1ON16806,8 INC 6iuy20Z3 1Boston,MA 02118 JUSTIN M.JAC `i , 46 SHADY ACRiit �.�»�"^ Not valid without signature CHATHAM,MA Oi3..r Undersecretary - J Cornmonweatth of Massachusetts Gliti Division of Professional Licefwure Board of Building Regulations and Standards CofS , ' vi3or CS-102675 � , tires:.05/06/2023 m JUSTIN MJA0I 46 SHADY MORE tS , tt CHATHAM M/.4 0< •.::. i l Y.` Commissioner du / . Y670,4 1 Sherman, Lisa From: RICHARD GEGENWARTH <r.gegenwarth@comcast.net> Sent: Thursday,June 9, 2022 4:38 PM To: Sherman, Lisa Subject: Re:22-EB076 46 Summer Street 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. We will miss the red roof. The new color will invite a change in the front door. I approve. Richard On 06/09/2022 3:38 PM Sherman,Lisa<Isherman@yarmouth.ma.us>wrote: Hi Richard, Resident would like to replace the roof with CertainTeed Pewterwood at 46 Summer Street. Please let me know if you need any additional information. Thanks Richard, St 1 11 Lisa JUN 0 9 2022 YARMOUTH OLD KING'S HIGHWAY Lisa Sherman Office Administrator Old Kings Highway Committee/Yarmouth Historical Commission Town of Yarmouth 508-398-2231,ext. 1292 23,, u �� : a S �. s as rev ... ,, .'• .�try .. F r €�. ,• r ..fir " �A z, .4 k+j, r� r l• 0:'• ' -1,1! 1„1:'''• ...'1' 0,••:.:.;..:. v•• ••••0v. • kr-• .11 0 . 1 RECEIVED • - fly s 2022 i I ;r'rkiviuuEri r—ppROVED OLD KINGS HI" 31� A`r` 4 1 JUN 0 9 2022 i t 1LO KING'KING'S HIGHWAY k E ui/ +�s s `�c xi a f / . �a /� FT^�axi- � 4, f�� / n / a � �� " �l i.A f J as �g .x ;r, �g �, '!'rl -�' Ip h �r+ �1 ' "-' Vic : ' „x+ --`*4 " /if �`3 mikkolligifit'-'4,11„,,,,, 3! Aiisa:M3t,lf \;'::'''lt;.:„'j;::i:„:' ,� F 'i . Via- j}j f '3F. .; :ice " fi ,10 7 s g ,',::':':',:ii:J,'.]:,..-:]::E,::::.„-_ ,,J ...,:..:.:, ::::, :-::::,;.,tiE,i4t!,,::.:„.:..„,.„:„.„:„,:::::::::.:::!.": cb .. i�g.. a 8 'six D-.., dill 9 222 BAR f OLD i `S HIGHWAY k