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HomeMy WebLinkAboutBLD-23-001268 y L Office Use Only ,OY.YgR in q C�/ /Z� /� �j �. n^1 ''. Permit# (�>F� f�o2 //'f ' G, Amount /d �(O OI H; �t.`�4Tr n.-s.fix; Permit expires 180 days from ate cam: issue date &1.-,0- 3-X/tee EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department RECEIVED 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 SEP 0 7 2022 r BUILDING DEPARTMENT CONSTRUCTION ADDRESS: (,/��`y( �,9/L L ❑f ASSESSOR'S INFORMATION: Map: Parcel: OWNER: SAMc� 14 a a1 N 11-2Le,o R,& oi:i ith0004,� dr cl l 5 qq4 NAME PRE ADDRESS TEL. # CONTRACTOR: f i MAILIN ADD S TEL.# CO esidential El Commercial Est.Cost of Construction$ Ck C 4.5, Home Improvement Contractor Lic.# 1 C1 ,S D1Lt Construction Supervisor Lic.#(qq ll...A Workman's Compensation Insurance: (check one) ❑ I am the homeowner ElI am the sole proprietor j '1 have Worker's Compensation Insurance Insurance Company Name: II&4 y/ Mold 4 L Worker's Comp.Policy# tee,2;3 i,j 4,t g y J r) II- WORK TO BE PERFORMED Tent E. Duration (Fire Retardant Certificate attached?) Wood Stove El Siding: #of Squares Replacement windows: # Replacement doors: # Roofing: #of Squares R.c? ( „r Remove existing*(max.2 layers) Insulation 1 I I Old Kings Highway/Historic Dist. a)Replacing like for like Pool fencing I I *The debris will be disposed of at:_ 14, i(CD De..-Ny dS /144- 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 Signa QV:" - ? Date: g - C., — 12- Owners Signature(or attachment) _ Date: f Approved By: Date: / ?v,� Building 0 (or ignee) EMAIL AD SS: Zoning District: Historical District: Yes [_ No Flood Plain Zone: " Yes r No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No Jim Heneghan 114 Talcott Ridge Rd. South Windsor,CT 06074 (860)913-6986 September 6,2022 SEASIDE ROOFING &SIDING LLC Jay Jacinto 23 Ridgewood Rd. Orleans Ma.02653 Dear Mr.Jacinto I wish to confirm that I am retaining you to replace the roof at 9 Town Hall Ave,South Yarmouth. Sincerely, ,L 4. / James Heneghan DATE(MM/DpIYYYY) ActiUR® CERTIFICATE OF LIABILITY INSURANCE `,�,• 04/18/2022 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 INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must 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 CONTNAME ACT Craig Vokey CRAIG S VOKEY DBA MARK T VOKEY INSURANCE WC,No,Ext): (508)945-3535 'FAX No): EMAIL i cra voke ADDRESS: oraig@vokeyinsurance.com Y P 0 BOX 1247 INSURER(S)AFFORDING COVERAGE NAIC# WEST CHATHAM MA 02669-1247 INSURER A: LIBERTY MUTUAL FIRE INS CO 23035 INSURED INSURER B: SEASIDE ROOFING AND SIDING LLC INSURER C: INSURER D: 23 RIDGEWOOD ROAD INSURER E: ORLEANS MA 02653 INSURER F: COVERAGES CERTIFICATE NUMBER: 765450 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 �ADOL SUBR POLICY EFF POLICY EXP TYPE OF INSURANCE LIMITS LTR INSO WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO RENTED $ CLAIMS-MADE OCCUR PREMISES Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO-JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT I$ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ NON-OWNED AUTOS PROPERTY DAMAGE HIRED AUTOS AUTOS $ (Per accident) UMBRELLA LIAB _ OCCNIR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ I _ DED RETENTION$ �/ $ WORKERS COMPENSATION X STATUTE ER 0TH- AND EMPLOYERS'LIABILITY A OF CER/MEMBER EXCLUDED? N/A N/A NIA N/A WC231S615989012 04/26/2022 04/26/2023 E.L EACH ACCIDENT $ 100,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 tf yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT ,$ 500,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS I 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-compensation/investigations/. 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 Building Inspector ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 Daniel M.Cry,CPCU,Vice President—Residual Market—WCRIBMA I ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD QOr "'fl -a A i0 a N Z `i 12 %71n3 61 crU Op w J t. �'� i o. su o 0-.: io � o 0M mFJ \v,Z 0 .N to , ... C io W C N O 07' s W� 3 O O' l.. N a Cg' it }-0O o E .c � Zoo , h o O E v0� O >�- ca 5 \: d O W cc -)W U) U 0 II C S(W� 2 0 i �� 0 � Q m ';, cn W W N 4 co GL-.I cC m p OMB ca ��0 J -)NO U)U U f, • The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 a y v, www.mass'b ov/daa Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly st''Name (Business/Organization/Individual): f;L1r'. i/�oc-T,A,, /^,del S A t Address: ), `'t . , 1i�12)1,,. ,. , Y P: C I '. �'> Phone#: . G /- i , ? Li Cit /State/Zi r� �;'� r;' ; ���� Are you an employer?Check the appropriate box: Type of project(required): l.9 am a employer with employees(full and/or part-time).* 7. ❑New construction 2.0I 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.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑Building addition 4.0I 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.QElectrical repairs or additions proprietors with no employees. 12.0Plumbing repairs or additions 5.0I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. 00f repairs These sub-contractors have employees and have workers'comp.insurance.t 6.0We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El 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. 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: 1-- Policy#or Self-ins. Lic.#: f C,_21.1\ /n _5€ 0 ! Z Expiration Date: '/f 2L!`Z 3 Job Site Address: ID())N, 1/4 L/_640 e City/State/Zip:/ J4 m..tf4 14J, 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. Signature — .� 1`d jd,,, Date:C -(v- Li" Phone#: , 'r/ LI �. l 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#: