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Home My WebLink AboutBLD-23-000580 i Office Use Only �ERR Pu 8J ' / Permit# /1 ,,' - o, ( C gd.0 am(6 l O . y ;Amount C•G MATTA n 7/4 -; *a+......^°,,; IPermit expires 180 days from .*;;::••••' i issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146Route28 RECEIVED South Yarmouth, MA 02664 311- A (508) 398-2231 Ext. 1261 AUGif 0 3 2022 CONSTRUCTION ADDRESS: 56 taN*14 ST UILDING DEPARTMENT By.--_— ASSESSOR'S INFORMATION: Map: Parcel: OWNER: bit/1_1 ' Si'(_: 3I ye '( NAME PRESENT ADDRESS �} TEL. #CONTRACTOR: SR'/1. ((o o 6F4jkWJLcO S tr_st..7 NAME r MAILING ADDRESS TEL. j Residential ❑Commercial Est.Cost of Construction$ 7 ,) 1✓ ✓ Home Improvement Contractor Lie.# I zA !4" onstruction Supervisor Lic.# CS1I7 Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor ' I have Worker's Compensation Insurance ✓Insurance Company Name: T614d S Worker's Comp.Policy,# WORK TO BE PERFORMED b e/'1�® d �' I yri- to -th Tent Duration (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 CCP ✓*The debris will be disposed of at: Location of Facility I declare under penalties of perju at 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 rev ion y cense and for prosecution under M.G.L.Ch.268,Section 1. f 7, ✓Applicant's Signature: n Date: 0 p/3ICJ� n Owners Signature(or attachment) see C / Date: Approved By: . Date: 8 �� Building cial esig e) EMAIL SS: 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 ❑ No The Commonwealth of Massachusetts Department of Industrial Accidents 1 lr• 1 Congress Street, Suite 100 „ 11 Boston, MA 02114-2017 www.mass aov/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): /Address: City/State Zip: IPp61 Phone #: 6'S — CS" Are you n employer?Check the appropriate box: Type of project(required): I. I am a employer with ) employees(full and/or part-time).* 7. ❑New construction 2.E I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑ Demolition ` 3.E I am a homeowner doing all work myself.[No workers'comp.insurance required.] 10 ❑ Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions proprietors with no employees. - 12.0 Plumbing repairs or additions 5.E 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.E We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E Other 152,§1(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. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. lithe sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. ��..//�� Insurance Company Name: -;�=�A S Policy#or Self-ins.Lic. #: L R(930F'73), ( - Z( Expiration Date: T-1711 Job Site Address: 3$ 4(49? T City/State/Zip: \Ales!`""'' 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 verificatio . I do hereby certify u pain nd penalties of perjury that the information provided above is true and correct. /Signature: Date: Phone#: —Sp\ — ,S 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#: BM Steven Kady Phone: 508-563-2515 Ma. Licensed Construction Supervisor#059847 Toll free:800-567-9787 MA. HIC Contractors License#126014 Fax: 508-563-2516 P.0 Box 493 Falmouth. Ma 02541 Cell: 508-566-5087 Fax: 508-563-2516 Email: Steve@SteveKadyMasonry.com www.SteveKadyMasonry.com PROPOSAL August 2,2022 Kathlene Sage 38 River St. S.Yarmouth, Ma. 860-334-8781 Coastal Kathlene(a.icloud.com WORK TO BE PERFORMED: • Construct ground staging • Construct roof staging • Rem e center chimne down to first floor TOTAL: £ZZt eea *Labor, Material, Disposal: $7,000.00 WNW* -; aMaYMO lintisUildbebahligkiNOnaily at time*%maal 50% to Schedule, balance due upon completion ACCORD CERTIFICATE OF LIABILITY INSURANCE DATE`M"I°°""YY) 08/27/2021 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 CWITACT Zachary Tonello Murray&MacDonald Insurance Services,Inc. PHONE fC�Eoo. (508)540-2400 ' ,No): (508)289-4111 550 MacArthur Blvd. Exth o Fss: zach@riskadvice.com INSURER(S)AFFORDING COVERAGE NAIC S Boume MA 02532 INSURER A: Arbella Protection Insurance 41360 INSURED INSURERS: Travelers Indemnity Co.Of America 25666 Steve Kady Masonry,DBA:Steven Kady&Son INSURER C: P.O.Box 493 INSURER D: INSURER E: Falmouth MA 02541-0493 INSURER F: COVERAGES CERTIFICATE NUMBER: 21-22 Master REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDffION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POUCIES 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 INSD w�vo POLICY NUMBER iMMIDDIYYWJ_,!avoorrYYY) UNITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1.000,000 DAMAGE To RENTED CLAIMS-MADE OCCUR Pip aocrareoce) $ 300,000 — MED EXP(Any one Person) $ 5'� A 85000285/36 08/14/2021 08/14/2022 PERSONAL&ADV INJURY $ 1,000,000 GEMLAGGREGATE UNITAPPUES PER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS $ 2'�'�POLICY J�ECT LOC OTHER Are Legal $ 200,000 AUTOMOBILE LIABILITY COMBINED SINGLE UMIT j 1,000,000 (Ea accident) ANY AUTO - BODILY INJURY(Per person) $ A — OWNED SCHEDULED 1020018068 03/24/2021 03/24/2022 BODILY INJURY(Per accident) $ AUTOS AUTOS ONLYPROPERTY X At1TOS XAUTOS ONLY X AUTOS (Per EYY accident)DAMAGE Medical payments $ 10,000 _ UlIMRELLAUAB _ OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS-MADE AGGREGATE DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'UABIUTY I STATUTE I ER B ANY PROPRIETo�CUTIVE Y❑ NIA 6HU8831X7321-21 08/29/2021 08/29/2022 EL EACH ACCIDENT $ 500,000 OFFIC E'RIMEM BER OCCLUDED? (Mandatory in NH) EL DISEASE-EA EMPLOYEE $ 500'CIDD If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POUCY UMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101.Additional Remarks Sdudule,may be attached If more space 1$required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORMED REPRESENTATIVE • South Yarmouth MA 02664 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2018/03) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Co nstructfpgkii$Fir Specialty CSSL-059847 N5pires: 10/03/2022 STEVEN L KOY PO BOX 493 FALMOUTH 9OjçCc Commissioner clail YEknal;k, .OL F iii/ ce,),saa/heJe/4. Offlon of Canammar Maks&iluahwes Itagulailen • HOME IMPROMMIMMT CONTRACTOR TYPE,4,•Individual • lisaMen. • 124/07/2024 STEVE KADY STEVE L.KADY 200 ASHUMET RD E.FALMOUTH,MA 0253S: Undorsecretary - - • •