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HomeMy WebLinkAboutBLD-22-007286 OY.Y`9R n 1 Office Use Only JJJ J / 0 i Permit#y 0/zj/Z2 4/0.0- 'Amount I) *WOOML`''E Permit expires 180 days from 'issue date -ai -L07 EXPRESS BUILDING PERMIT APPLICATI I E TOWN OF YARMOUTH Yarmouth Building Department JUN 17 2022 1146 Route 28 South Yarmouth, MA 02664 BU...20 TMENT By' (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: � 4 l/eL L 6-) vV 2 ,11-1,,, or // ASSESSOR'S INFORMATION: Q / � Map: Parcel: OWNERkiJ�trAe Yd— L - /`cL/ o1 "- iL Z ,O r ir_rvi2 7 7 7.1) .1 -13 NAME PRESENT ADIESS TEL. # CONTRACTOR: cS/L � /e_4 Vd_.)-:-n/ioz/---t. ���t'" 7'j?D -- ,Pdf- NAMEJ ING ADDRESS TEL.# esidential ❑Commercial Est.Cost of Construction$ /d D o Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# No Qs)deb /✓e hill %the-4 "r Pc - RIC UV 6D)(` 7 ..Tune.4 4`ap BE PERFORMED Tent Duration .7-3 d4 y.S (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows: # Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: 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. O Applicant's Signature: Q Date: .(,� Owners Signature(or attachment) „....e___ _ 7_� Date: — Approved By: , , I/ Buildi ffici r d ',nee) EMAIL ADDRE S: Date: -77 Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes D No vIc CERTIFICATE OF LIABILITY INSURANCE . . DAIS"'""°°"""'' 05(23/2022 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 INSURERS).AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER IMPORTANT: If the certilcets holder is an ADDITIONAL INSURED,the policy(lees)must have ADDCIIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the bras end conditions of the policy,certain policies may require an endorsement. A statement on this certificate doss not confer rights to the certificate holder In lieu of such endorsemengs). c2NrAe, Joseph Dupuis Mc8hea Insurance Agency.Inc Lis,* ( M.2o-colt ( uc.►►,*(501040 1645 Falmouth Road,Rt 28 BLDG D joeSpncehesinsurance.com Centerville,MA 02632 IMMUNE) NAIL/ -- +MERA: PENNAMERICA INSURED imam a: progressive Casualty 11770 Bayside Tent&Table,Inc. comus.c: AIM Mutual 40c Whites Path INSURER 0: South Yarmouth,MA 02664 MUM II: wpm P: COVERAGES CERTIFICATE NUMBER: 00002179-0 REVISION NUMBER: 1 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,TERN 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, is AND CONDITIONS OF SUCH POLICES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IiTIR rnEOFeaWRANCBArousurer POLICY POLICY ESP P9 JssOnanYM,SIOLSOIrtrn_ LIMITS A X 001011ERCIAL GENERAL LIABILITY PAV0380864 0W17!2022 0511712023 EACH OCCURRENCE • 1.000,000 DAMPAieC AIMS , X OCCURES°iEaoea $ 50,000 — ,MED ECP(Am ererperson) $ 5,000 PERSONAL Amy swRY s 1.000,000 aE n AGGREGATE LUST APPMES PER GENERAL AOOREOATE $ 2,000,000 X. POUCY❑JI cr Li LOc PRooucrs-cou OPAoo $ INC OTHER • ^B AII� TOSO'LIASIUTY 02711576■6 101 2021 101261� c a2 LIMIT $ ANY AUTO BODILY INJURY(P.,person) $ 100.000 OVSIE*urns .L SCHEDULED E0 BODILY INJURY(Per aoetdwe) $ 300.000 ONLY HIRED NOLLOVIIE0 _.. AmosoLY AUTOS ONLY Wei : �MPROPERTY DAMAGE r + - ' $ lxX� — MOREL LA UM OCCUR EACH OCCURRENCE $ EXCESS Las CLAIMS40A0EAGGREGATE ___.3 OED I I ssycs ION$ s C LOY MI WORNINIS COMPENSATION Vt WCC-600✓Btt1S t!-2022A 0sr7�2022 062212023_xl ,re I 1 W. Wand/delEMBER E70p.LDED?ANY PROPRIETOISPARREREXEctITIVE r r r N 1 A EL EACH ACCIDENT $ 500,000 NM � Q�TiONa below EL DISEASE-fiA EMPLOYEE $ 500,000 SP E L.DISEASE-POLICY UNIT $ 500,000 DBIanPTIOM OPOPaRATIDNS,LOCATIONS IMMURE(AEONS 101,Addelenei Ramada an,&4 m a b 062060 B man um*N 1011100$14 Workers Comp:Corporation owner Ryan Gil.Is not Included for coverage under the Workers Compensation policy CERTIFICATE HOLDER CANCELLATION ' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE . Town of Yarmouth THE EXPIRATION DATE THEREOF,NOTICE WILL SE DELIVERED IN 1146 Route 28 ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE I .. .• ..,1 aL• . •1JFD) ACORD 26 tm1NT/03) The01988-2015 ACORD CORPORATION. All rights reserved ACORO name and loco are marks of ACORD Printed by JFD on 05123/2022 al 01:62PM O y y y w n n c� C" w oo Ha _ o c a r+ p� feir a. t� x ,0 -. a 0 cr rD rD rD ,n-.7'.. el:15)n ,<...<----,u ,,(9- rz,H gu"4 cfr .-:__-- cr A a el z � oo 0b n on rD c•C .-- ..tribSt: c oe51111 El 0 0<...‹.<7_ , y cyW z w n .• v' a yc. rpa G , J nr b o A mn Y " p a z '-' .0 bO . o� et ro © < O e slob .,-: o d c o o DU n y w C _ O r� .d• �] w V n o a eln0cng' y r o Cr' o yL'I o ►� o o y ' n , m cc t EP M. 6- E y v, o 1, bdtz X 0- Cr CI N p 127 rD XI 1=1 a' et) . a. f.,,, a tTi = A F.L. U Z a H R. --0. = is< .c +01- rev w p �, w u, w 'oz o y , F -1 el) , CA y ti ro DJ0oc, Cy n pa91 CA w m °' A- rn '� by cs 5 N �" r� co (41;41) 'CZ $11111 n n Nei tr.] 0 E g fq ,..% = a ro 2 y a (' rD rn+ .1 T....7.--0-7 is:zi C3 < C m rt e, . ,;,:.., . w H fp er) N 5,c ...-a... • The Commonwealth of Massachusetts — �1_ t Department of Industrial Accidents , 1 Congress Street, Suite 100 _. Boston, MA 02114-2017 y �Y www.mass.gov/dia \Porkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly • Name(Business/Organization/Individual): I&!'A,Ve Address: -2-fet_)---ni ei&--/-11 City/State/Zip: iLld✓ Phone#: -c-W-- 7�.e's —4 oa1--‘ Are you an employer?Check the appropriate box: Type of project(required): 1.[D I am a employer with employees(full and/or part-time).* 2.0 I am a sole proprietor or partnership and have no employees working for me in 8.. 0 Rem construction any capacity.[No workers'comp.insurance required.) ❑ eodeling '.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 my property. 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 P ogees. 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet- 12.0 Plumbing repairs or additions Th sub-contractors have employees and have workers'comp.insurance.: 13.El Roof repairs 6. are a corporation and its officers have exercised their right of exemption 14• Other 152,§1(4),and we have.no employees. .i Pti ui per.MGL c. ❑ [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. p Insurance Company Name: T C y/,-) rat.-- Policy#or Self-ins.Lic.#:VVCC —�OD '' '-;-3 Q / ---',.4d6?---e- Expiration Date: J~—d d• '-d-_3 *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 S is:nature: 6 lti -w Date: Ca -!7 - 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#: rr. SHALL F,. �r :jO FEET • a- ;AND A PLOT PLAN >!i)FS AND FOR LOT it Indicate Imatice .• Additions w airaccessory build, ng - ----__ Sewerage disposal Well xi 42) rear)I I Abutter's Name I "� Lot* REAR YARD Abutter's If this is a Name corner lot, K Lot* write in If this is a name of street. ....... ..�. corner lot, ), • write in name of street. •0. To �8 YARD / 4r HOUSE YARD • - • • • • • • • • • SST BACK : • • •..-ft. 1 • (lot..................ft f ) I . \ (NAME OF STREET) ""/7 / \ mation Supplied by