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HomeMy WebLinkAboutBLDX-23-15131- 01•Y.qR lOffice Use Only .4 RECEIVED l >(- z3- /513/ H (Amount t.NATTA n 5, d AUG O 9 2023 1<w.,.��,.p Permit expires 180 days from ---- . _- . - 'issue date BUILDING DEPARTMENT By EXPRESS BUILDING PERMIT APPLICATION . e ,,, TOWN OF YARMOUTH /7to.6e „si � •O Yarmouth Building Department , 4 1146 Route 28 '' ^.. U� Og 2 %r� Yarmouth, MA 02664 , -ly,''`D/------ South (508) 398-2231 Ext. 1261 -�� p`�Rry Z 5r ST ) L 1 .S Q(l '� r CONSTRUCTION ADDRESS: S � u 7"' C.�(�N�'f ASSESSOR'S INFORMATION: ,yame Map: Parcel: �r- OWNER: I`'/1�� " ive (/" Dd 1�/iu601.4 2� .S" ct.s �,J J 2,6Z- 3vv- 5`2,6 NAME j PRESENT ADDRESS TEL. # 1TME' CONTRACTOR: 1 Z elkl ik orl s t S, 4.rve. 43 k46em'wMhi.2 no r).-- 9 s-3- .5-2.0 b NAME MAILING ADDRESS IQ U 17 / TEL.# Residential ❑Commercial Est. Cost of Constructio� 3 U 1)0.�� Home Improvement Contractor Lie.# 1 3 2 N Construction Supervisor Lic.# C 5— ) )3-3- VC Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor X I have Worker's Compensation Insurance1 Insurance Company Name: 244/L.1 l'Aa• Worker's Comp.Policy# (9c.Z u 01 q i 1 O lC'92 —. WORK TO BE PERFORMED t/I7E P 4 � "' /17ler7o,� ol oh 717 an Tent Duration (Fire Retardant Certificate attached?) o 17 Wood Se Se�s, 7L Siding: #of Squares Replacement windows: # Replacement doors: # ite_94/i/GE4, Roofing: #of Squaresexisting* /ca2 BA/ — q ( )Remove (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: Qbc lsTh 5o CAL N n.27 1.9 v'4 , iP'J „}t-sme-4, YL4-..9 Location of Facility I declare under penalties of jury 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 deni o re c no of y ense and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: n 2 3 /''/1(".s 11)W,�." �Date: 9- Owners Signature(or attachment) Date: Approved By: Date: *f:7___ 2. Building tc. r esignee) E DRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No ❑ Yes ❑ No 2 9L . 6 evcvn-et.A. 0 , 9g4.b1g1/►s. (11/1/7 �. a • The Commonwealth of Massachusetts 1_,�,11 W. Department of Industrial Accidents C 1 Congress Street, Suite 100 _ �=s Boston, MA 02114-2017 �5.•°' 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): /, 3 eArneellS1-3 n/ Address: 1e3 . Okij ii- L 1cL City/State/Zip: PL1mi'ir2 rnq a23 () Phone #: )' �1 S^-3 5--24) 6 Are you an employer?Check the appropriate box: Type of project(required): 1• am a employer with S employees(full and/or part-time).* 7. New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all work myself. 9. ❑ Demolition ❑ y [No workers'comp.insurance required.]' 4.0 I am a homeowner and will be hiring contractors to conduct all work on property.mY I will 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.❑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.: 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.] Demo *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: �u 2'1 4 Policy#or Self-ins. Lic. #: W? 4 ay 3 rf nj U Co ?ZZ Expiration Date: / 2-f 2. 3 Job Site Address: 2 5 -ir7f(rs. /1"1 City/State/Zip: 7t)4141 '' A444-J7669 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 cer ' u er the pa' a penalties of perjury that the information provided above is true'and correct. Signature: c� Date: 1_ZT Phone#: ? 8�) ` I b S.2 vC 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#: ' 7 A UL)A RECOVER * RECONSTRUCT, RESTORE EMERGENCY REPAIRS AUTHORIZATION I, the undersigned property owner or manager hereby authorize Paul Davis Emergency Services of the South Shore ("Contractor") to make emergency repairs in the form of mitigation due to 1/1/1776-41. damage to my property located at (address) 2-5 SI I L? 12,-) (city) Y/7 ' .j , (state))2 (zip) (the "Property„) I acknowledge that I am responsible for the cost of these emergency repairs. I also acknowledge that temporary repairs do not carry any guarantee. If such repairs are covered under my insurance with Ai / ("my Insurance Company"), then I hereby authorize my Insurance Company to pay Contractor directly for such repairs upon my execution of the Completion Certificate below. I further request that any applicable deductible be withheld from such payment and I will pay such deductible amount directly to the contractor. I hereby represent and warrant that I have all necessary power and authority to execute this Authorization as a legally binding instrument. fi By: Property Owner or Li Manager: , , -- f j, 1/ 1' e3Print Name: `Y �'. ., 1 .-;,t, , � ,,, a'\,e `-- , , , ,, t Dater By: Paul Davis Emergency Services Representative: Print Name: Joseph O'Connell Date: it"" 1-- COMPLETION CERTIFICATE The Contractor has completed the authorized emergency repairs. If applicable I herby direct my Insurance Company to pay Contractor for such repairs. General description of work done: Property❑ Owner or ❑ Manager: Print Name: Date: PDES-S02006-0509 Commonwealth of Massachusetts Division of Occupational Licensure Board of Building R ulations and Standards Consstt rS isor CS-113746 ,21' Ett4pires:03/24/2025 JOSEPH W • 63 WAGON EL PLYMOUTH Cor7572issioncr x r. ��' ',A. tmtrTHE COMMONWEALTH OF MASSACHUSETtS Office of Consumer r &Business Regulation HOME IMP � ,i4 oNTRACTOR r ( t HBR ENTERPRISES, tf�� D/B/A PAUL DAVIS _•--OF THE SOUTH SHORE JOSEPH OCONNELL 63 WAGON WHEEL R® , p:=' '' ,..(4 .• PLYMOUTH,MA 02360 ' Undersecretary A► D CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 08/08/2023 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). PRODUCER NAME: Karyn Stauss BURGIN PLATNER &COMPANY LLC PHONE FAX (A/C.No.Ext): (617)691-2622 (A/C.No): amass: ks©bphins.com 14 FRANKLIN ST INSURER(S)AFFORDING COVERAGE NAIC# QUINCY MA 02169 INSURERA: AMERICAN ZURICH INSURANCE COMPANY 40142 INSURED INSURER B HBR ENTERPRISES INC INSURERC: DBA PAUL DAVIS EMERGENCY SERVICES OF INSURERD: 63 WAGON WHEEL RD INSURER E: PLYMOUTH MA 02360 INSURER F: COVERAGES CERTIFICATE NUMBER: 919537 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY ECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS N/A BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE DED RETENTION$ $ WORKERS COMPENSATION PER _ AND EMPLOYERS'LIABILITY Y/N X STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBEREXCLUDED? N/A N/A N/A 6ZZUB9981A06722 12/01/2022 12/01/2023 (Mandatory in NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is 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/Iwd/workers-compensationfinvestigations/. .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. 1146 MA 28 AUTHORIZED REPRESENTATIVE S Yarmouth MA 02664 D C, Daniel M.Cro nr y,CPCU,Vice President—Residual Market—WGRIBMA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD