BLD-23-000823 .
` jam. '
• of•'y'i,q, BUILDING PERMIT APPLICATION
,; ''tr' APPLICATION TO CONSTRUCT,REPAIR,RENOVATEUSE,• O CHANGE THE OCCUPANCY OF,
et.. ef OR'DEMOUSH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLWNG.
O �� 'may Town af'Ytrnrnttth Building Department
csA,t"..... a- . I 146 Route 28 • Yiirmcouth, MA I/2664-1•49`2
". Tel:
508-398-2131 eat. 1261 Fax 508-398-0836
Office Use Only Planning Board Information Assessors Department Information:'"
Permit No. � Date Plan Type Ma l 'µ'. " '�° l
1 i
Permit Fee $ Endorsemerd Date_,_ . I
- Recording Date New f • 4
Deposit Rec'd. $ Date ,
Plan Na 1.q Property Dimensions' i
Net Due $ ,,,, ; Nr
Other , ;
Lot Area(sf) Frontage(ft) '.,a. . :,.._(1rt,Da---pe....
This Sectbn for Ottice Use Only
Building Permit Number: l Date Issued:
Signatura: .�,., ° ,.4. �' '�l<o.r � Certificate ofIs Occupancy
Buikilttg Official Date` is
required
Section 1 Site Information I
1.1 Proper address:
6 a 'G^`G5iL fL / 1.2 Zoning tnfortrsation
A r
Zoning District Proposed Use
1.3 Braiding Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required
Provided Required Provided
1.4 Water Supply(ILQ.L c.40.S 154) 1.5 Flood Zone k,fuL.►uatiut,
comnenes
Public Private Zone: _.� BFE:
Section 2-Property ClwnershiplAuthorized Agent
2,1 Owner of
Ror°
� 7 ///twi mi,: ytr,A rat o'✓/L`� • �� I Jw� ,,teyK
Name(Print)
Mailing Address:
Si gnature act//S A,1�1hlitila s u, ',`,�%� A...,,
Telephone
Telephone
Ernai!Address:,/ 1 1/
2.2 Authorized.Agent 1
A&i 1 /G,:4.6 AA, '{• 013F(LQ W►ttz ea- s"- '1al Gtvw 1 / �j �•
Harm riot l J'Yiri/'� /`�
Ip l , y ,�.-•, ..-,, ► .• i IN, Mailing Address:
may- J,,.�'"' V r,✓" _'---.....To11
Signature Telepiaohe" Fax
Email Address.:
3-Construction Services
3.1 License cti
d Construon Supervisor: Not Applicable 0
RA Nrl.,,,;,-1-001
4 Cowl wb•v^G1. U C.4,^1./`C•� /// ' G Z 3)if Licen/s'ey Number /�
Address �`j ( C./ 1 O - I b V
Signature " �i S — /l 3 Expiration Date
Telephone �,j Email Addre/ss:: )l 1 / I ..a 2- 3
I3a , r7M^'t ®t//-obliI rit),
cP/iiii
3.2 Registered Home Improvement Contractor.
Company Name dtici Not Applicable ❑
Addres Registraatio
'7�! - S� - � a 3 ' oz3 � �' ���d
ISignature Telephone g /f 2 3
• Section 4 Workers'Compensation Insurance Affidavit(MMA,G.L c.152 S 25C(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure
to provide this affidavit will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes No
Section 5 Professional Design and Construction Services-for Buildings and Structures Subject
to Construction Control Pursuant to 780 CMR 116(containing more than 35,000 c.f. of enclosed space)
Section 5.1 Registered Architect:
Not Applicable
Name(Registrant): !ff'���
i Registration Number
Address
Expiration Date
Signature Telephone
Section 5.2 Registered Professionat Engineer(s)
Name Area of Responstility
Address Registration Number
Signature Telephone Expiration Date
•
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiation Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Section 5.3 General Contractor
Not Applicable
Company Name
Person Responsible for Construction
Address
Signature Telephone
SECTION .Z Ob OWNERf AUTHORIZED AGENT DECLARATION
I,, 1awK c'r Yll"wIbati_
as Owner/Authorized Agent
hereby declare that the statements and information on the forgoing application are true and acurate,to
the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
O EfZT (,c ').toJ(7.- . "T.a..�►-� A-Pt-titrsTR- tZ
Print Name /
%sue .r + •'� �/ t �r
•
Signature of Owner/Agent
' '' Date
Section 11 - ESTIMATED CONSTRUCTION COSTS
Item • Estimated Cost(Dollars)to be
completed by petrol applicant
1.Building
2.Electrical
3.Plumbing/Gas
4.MechaNgt(F{VAC)
5.Fire Protection
6.Total=(1+2+3 4+5) •
T.Total Square Ft.lter flwr seuewns&aasbzes)
Check Below
El Conservation-Commission Piing
(if applicable)
❑ Old Kings Highway&Historical •
Commission approval
(if appliicable)
•
The Commonwealth of Massachusetts
A=*,= i._�fQ1 Department of Industrial Accidents
f$1= 1 Congress Street,Suite 100
c=1.=1t= Boston,MA 02114-2017
r4, „-1 www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH TUE PERMITTING AUTHORITY.
Applicant Information (AlPlease Print Legibly
Name (Business/Organization/Individual): /3`., A j/1-),,.�5 rtri-y,. ii , 6 eht t, eC GIG- C
Address: CGvi ,N,..,.e.,4 t:.4
City/State/Zip: tc,iv.,., i// c)7_330 Phone#: /70 — S ( '3 — `-// 0 3
Are you an employer?Check the appropriate box:
Type of project(required):
l.al I am a employer with 3 d employees(full and/or part-time).*
7. ID New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in
any capacity.[No workers'comp.insurance required.)
8. 0 Remodeling
3.0I 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 property. 10 ❑Building addition
ensure that all contractors either have workers'compensation insurance or�are sl I will
Pl l.❑ Electrical repairs or additions
Proprietors with no employees.
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.i 13.Q Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL a 14. Oth ��� �, ��h
i 52,§I(4),and we have no employees.[No workers'comp.insurance required.)
*Any applicant that checks box 4I 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: 2 V h,`6,11 411,4
41„,','tee A TO S, Co,
Policy#or Self-ins_Lic.#: WC 3 G Z ?LT 3/�/Z- Expiration Date: 4I f/ / ZG 2 3
Job Site Address: 6,6 IC'^,t $1- 4 City/State/Zip: Ycr•vi 4(
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 certi under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date: �S� /�.o 2- 2
Phone#: �45 l ,)_( 3 - l a
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):
I.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
§TOWN OF YARMOUTH
1146 Route 28, South Yarmouth, MA 02664
•
508-398-22311 ext.-1261 Fax 508-398-0836
Office of the Building Commissioner
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
Pursuant to M.G.L. Ch. 40, §54 and 780 CMR- Section 105.3.1. #4.
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at 6 GC
Work Address
Is to be disposed of oat the following location: V vwrp si rt-^ v i'Ct i Z 10,S/9 S w I
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. 111, §150A.
051/ Z�zz
Signature o ppiication Date
Permit No.
Al CERTIFICATE OF LIABILITY INSURANCE DATE(MMDD2YYYY)
o4/oa2022
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 8
certificate does not confer rights to the certificate holder In lieu of such endorsement(s).
PRODUCER CONTACT Ey
Aon Risk Insurance Services west, Inc. O
Denver Co Office PHONEFAX 1900 16th Street, Suite 1000 (EMAILNC. .Erct): (303) 758-7688 I(NC.No.): (303) 758-9458
a
Denver CO 80202 USA A'�E
ADDRESS:
INSURER(S)AFFORDING COVERAGE NAIC C
INSURED INSURER A: Zurich American ins CO
Blusky Restoration Contractors, LLC 16535
9110 East Nichols Avenue Suite 180 INSURER a: Lloyd's Syndicate No. 1458 AA1120102
centennial Co 80112 USA INSURER C:
INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:570092531210 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 ADDL SUBR Limits shown are as requested
LTR TYPE OF INSURANCE IUD p pOLICy NUMBER (POLICY EFF 91 j POLICY EXP
B X COMMERCIAL GENERALL UABILnY ENVP000024822 04/01/20 04/01/7p7 EACH OCCURRENCE LINTS $1,000,000
ICLAIMS-MADE I I OCCUR DAMAGE TO RENTED $100,000
PREMISES(Ea occurrence)
MED EXP(Any one Person) $5,000
PERSONAL&ADV INJURY $1,000,000 C
GEN'LAOGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 a
POLICY �JEC ❑X LOC
PRODUCTS-COMP/OP AGG $2,000,000 m
OTHER:
A AUTOMOBILE LIABILrrY BAP 3029532-02 04/01/2022 04/01/2023 COMBINED SINGLE LIMITin
(Ea accident) E 5,000,000
X ANY AUTO
BODILY INJURY(Per person) O
X OWNED —SCHEDULED Z
AUTOS ONLY AUTOS_ BODILY INJURY(Per accident)
01
X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE
—ONLY _AUTOS ONLY (Per accident) I0
B t
X UMBRELLA LIAR X OCCUR ENVX000020022 04/01/2022 04/01/2023 EACH OCCURRENCE $15,000,000 0
EXCESS UAB CLAIMS-MADE AGGREGATE $15,000,000
DEG' 'RETENTION
A WORKERS COMPENSATION AND wC302953102 04/01/2022 04 01/2023 X IPERSTATUTE I I
EMPLOYERS'LIABILITY / ER
ANY PROPRIETOR/PARTNER!EXECUTIVE rY/NN
OFFICER/MEMBER EXCLUDED? I 1 N/A E.L.EACH ACCIDENT $1,000,000
(Mandatory In NH) 11
(yea describe under E.L.DISEASE-EA EMPLOYEE $1,000,000
DESCRIPTION OF OPERATIONS below
B Env CPL/Prof E.L.DISEASE-POLICY LIMIT $1,000,000—�
ENVP000024822 04/01/2022 04/01/2023 Per occurrence 51,000,000 a
Pollution Liab
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required)
Evidence of Coverage.
n
b
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN ACCORDANCE WITH THE
POLICY PROVISIONS.
Blusky Restoration Contractors, LLC AUTHORIZED REPRESENTATIVE ==
9110 East Nichols Avenue suite 180 ��
Centennial CO 80112 USA
Ribeffigatarseas Yetviase Xai9lGet
a
ACORD 25(2018/03) The ACORD name and logo are 01988-2015 ACORD CORPORATION.All rights reserved.
9 registered marks of ACORD
COMMERCIAL ONLY,- BULDING PERMIT
' APPLICATION REGULATORY APPROVALS NOTICE
Address of Proposed Work:( G6 i L
yNA
r.
Scope of Proposed Work: i3.c C'V c:v,r,/ t A AL vyr .oC 04
Date: ! 9/ 2- 2-
Based on the scope of work described above,the applicant is required to obtain approval sin-
offs from the following departments as checked-of below: g
Health Dept.508-398-2231 ext. 1241
Conservation--508-398-2231 ext. 1288
.Water Dept.--99 Buck island Road, 508-771-7921
Old Kings HWY. Hist. Comm. -508-398-22631 ext. 1292
Engineering Dept.-508-398-2231 ext. 1250
Fire Dept.—Kevin Huck/Scott Smith,96 Old Main Street,SY
Note: Please call Fire Department for an appointment. 508-398-2212
Other
Appropriate plans and/or application shall be provided to each departments checked-off above.
Each of these regulatory authorities has their own requirements outside the jurisdiction of the
Building Department. All applicable approvals shall be obtained prior to submitting a building
permit application to the Building Dept.
Thank you for your cooperation.
Receipt Acknowledgement:
Applicant's Signatue
Date'
Rev.Jan. 2019
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Office of Consumer Affairs and Business Regulation
1000 Washington Street- Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
Type: LLC
BLUSKY RESTORATION CONTRACTORS,LLC. Registration: 98476
0
9110 E.NICHOLS AVE,SUITE 180 Expiration: 9/05/2023
CENTENNIAL,CO 80112
Update Address and Return Card.
SCA 1 0 20M-05//117
.7%ii infeiMMififelAt4iliestemaiaapelbtion
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:LLC before the expiration date. If found return to:
Registration Expiration Office of Consumer Affairs and Business Regulation
188476 09/05/2023 1000 Washington Street -Suite 710
BLUSKY RESTORATION CONTRACTORS,LLC. Boston,MA 02118
DREW BISPING
9767 EASTER AVE
CENTENNIAL,CO 80112 Not valid wit signature
Undersecretary