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HomeMy WebLinkAboutBLD-23-002158 l• Ak,d�( )6/ Z-t(/z Og;Y;4 Office Use Only ; Permit# eye q3 O Amount Sd, Permit expires 180 days from issue date &D 023— ,D02-I5S EXPRESS BUILDING PERMIT APPLICATI1 E !/ E D TOWN OF YARMOUTH .-.._.__ Yarmouth Building Department [-OCT 202022 1146 Route 28 South Yarmouth, MA 02664 ._" BUILDiNCa C)cRF�F�Tfl/7ENT (508) 398-2231 Ext. 1261 BY:-- CONSTRUCTION ADDRESS: /3 /1/ YAC,re- �//�C(�� á',7/*// ASSESSOR'S INFORMATION: Map 5 07 a?a© Parcel:e)7 OWNER: ,J >V !//Chards bid 01110 21/7 1I)es?I4e f / 9/3 CP369 NAME PRESENT ADDRES TEL.) CONTRACTOR: i///2 vi'/w. (,%l tiT -�e' i 9/3`f . .�f‘ NAME MAILIN ADDR SP TE #jam ❑Residential BBCommercial Est.Cost of Construction$ CJ/ /e i) . Home Improvement Contractor Lic.#r74?Cf7 Construction Supervisor Lic.#�JC 097// Workman's Compensation Insurance: (check one) 01 am the homeowner 0 I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent Et Duration 'lLe' ; " (Fire Retardant Certificate attached?) Wood Stove ij Siding: #of Squares 0 Replacement windows:# / Replacement doors: # 0 Roofing: #of Squares 0 (I1)Remove existing*(max.2 layers) Insulation Fl 151 Old Kings Highway/Historic Dist. 3 Replacing like for like Pool fencing M *The debris will be disposed of at: /h L-ro J>4 `lJ UJ 4,/ _ Diva 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 -cense and for prosecution under M.C.L.Ch.268,Section 1. 7 Applicant's Signature: _1�� 4% Date: /////% - Owners Signature(or atta ent) Date: Approved By: ✓/ Date: Building Official deli e) EMAIL ADDR • piw��e Q�Q6�CpQ� z. Zoning District: Historical District: C Yes No Flood Plain Zone: 7 Yes r_ No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No . The Commonwealth of Massachusetts _g/, Department of Industrial Accidents iW t. 1 Congress Street, Suite 100 . Boston, MA 02114-2017 ' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plu ,ers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information j Ple:.e Print Legibly Name (Business/Organizatio dividual) Cf i c.7 Se),A Address: c4?_/,/ � City/State/Zip: c BRA_ /ej j -- Phone #: /�3 %Z '(g0 Are you an employer?Check the appropriate box: Type of project(required): I.❑1 am a employer with employees(full and/or part-time).* 7. Ei New construction 2.1 am a sole proprietor or partnership and have no employees working for me in 8. 2 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 0 Q Building addition 4.0I am a homeowner and will be hiring contractors to conduct all work on my property I will 1 ensure that all contractors either have workers'compensation insurance or are sole 11.[]Electrical repairs or additions proprietors with no employees. 12.ElPlumbing repairs or additions 5.01 am a general contractor and I have hired the sub-contractors listed on the: ched sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.$` 6.0We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[]Other 152,§I(4),and we have no employees. [No workers'comp.insurancevrequired.] *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. tContractors 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'comp hsation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' com nsation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as rep' d under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as ell 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 tl e p ' s and penalties of perjury that the information provided above is true and correct. Signature: Date: /-//7A-� Phone#: •-)1-6 67,4 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#: co U) c rt L' = m V) e= 2 N 0 a, a m e = ``d ...I _ ,Q�� ypI- r 1(,3 6- Q Y (DI o > U > p v .— o ato0 w • o6. ��� o MI co za ;7 E (I) m 0 0 0 �d 3 E m c m — e e 0 $ e 0 -0� 1 a o r go a a to CO = c 000 w ,, . oc acc$ o U to t& 0 ,c�'; l'Z'a v_ I u ; TO §—t a � 2 SC r S Yl Jrt C pit itill Icg; E g 0 OAS}� 4 .,,i @ = r c N co 2 O , E g In W O I O:CC 'lc yr�at, g m s co 0 it 5o Li%°r - LLu, cc cc,2 8s x % 1>'0 W nn Y CV 7i WTY Q (C?...,—u� al r s 5 tU§ W Y '"` The Commonwealth of Massachusetts �t _._,_, ge Department oflndustrialAcciderzts ' :1�l 1g 1 Boston Congress 02114-201 Q0 . - `—. www.rnassgov/din '..RECEIVEDry Workers' Compensation Insurance Afftdavit: Builders/Contractors/Electricians/Plumb'rs. TO BE FILED WITH THE PERMITTING AUTHORITY. j SEP 2 6 2022 ADDlicant Information Please P • t Legibly Name (Business/Organization/ a'vi ' { (fj f1/ «j^ " /Z16.4i ,,_ v DEPARTMENT Y Address: `') 7- F //ecte JZi,/.1,-', .. City/State/Zi 4-L /01 Phone#: 4t/3 ' ;'1�'') �, Are you an employer?Check the ap 'ropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.1 1 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 doingall work myselft 9. ❑Demolition ' ❑ ys [No workers'comp.insurance required.] 1.0 [] Building addition 4.0 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 11.0 Electrical repairs or additions proprietors with no employees. , 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 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. tContractors that check this box must attached an additional sheet showing tile 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: Policy#or Self-ins.Lic.#: Expiration Date: 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 Signature 7 Date: Phone#• -4,� ` J� l/ 1.�' 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#: ha ItA Farm Family Casualty AMERIC:AN Insurance Company NATIONAL An American National Company 344 ROUTE 9W I GLENMONT, NEW YORK 12207-2910 SELECT BUSINESS PACKAGE DECLARATION PAGE Policy Number: 2007X0395 Portfolio Number: Account Number: Name and Mailing Address of First Named Insured: KR CONSTRUCTION LLC 254 FALLEY DR WESTFIELD, MA, 01085-4914 Agent: 3761 TIMOTHY F VILES 55B N MAIN ST S DEERFIELD MA, 01373-1059 Agent Phone: 413-665-8200 Business Description: CONSTRUCTION Form of Business: Limited Liability Corporation Transaction Type: Renew Policy Period: From 07-20-2022 To 07-20-2023 12:01 A.M. Standard Time at your mailing address shown above IN RETURN FOR THE PAYMENT OF THE PREMIUM,AND SUBJECT TO ALL THE TERMS OF THE POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY PROPERTY COVERAGE TOTAL LIMITS OF INSURANCE Buildings $0 Business Personal Property $5,000 Business Income & Extra Expense Actual Loss Sustained Not Exceeding 12 Months Other Endorsements See Schedules LIABILITY COVERAGE General Aggregate Limit(Other than Products-Completed Ops.) $2,000,000 Products-Completed Operations Aggregate Limit $2,000,000 Personal &Advertising Injury $1,000,000 EACH PERSON/ORGANIZATION Each Occurrence Limit $1,000,000 Medical Expenses $ 5,000 EACH PERSON Other Endorsements See Schedules PREMIUM Premium shown is payable at inception Total Premium $987.00 POLICY SUBJECT TO ANNUAL AUDIT: Yes The Declarations, Schedules and Forms and Endorsements Make Up Your Complete Policy. Refer to Schedule Of Forms and Endorsements. Process Date: 05-31-2022 W rn X-3842 0319 Page 1 of 5 RECEIVED *hug ��� Farm Family Casualty _�_._,_,_._......_.... AI/� C'+ Insurance Company SAP 12022 �* ��' ! � An American National Company NATIONAL BUILDING DEPARTMENT By; 344 ROUTE 9W I GLENMONT, NEWYORK 12207-2910 SELECT BUSINESS PACKAGE DECLARATION PAGE Policy Number: 2007X0395 Portfolio Number: Account Number: Name and Mailing Address of First Named Insured: KR CONSTRUCTION LLC 254 FALLEY DR WESTFIELD, MA, 01085-4914 Agent: 3761 TIMOTHY F VILES 55B N MAIN ST S DEERFIELD MA, 01373-1059 Agent Phone: 413-665-8200 Business Description: CONSTRUCTION Form of Business:Limited Liability Corporation Transaction Type: Renew Policy Period: From 07-20-2022 To 07-20-2023 12:01 A.M. Standard Time at your mailing address shown above IN RETURN FOR THE PAYMENT OF THE PREMIUM,AND SUBJECT TO ALL THE TERMS OF THE POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY PROPERTY COVERAGE TOTAL LIMITS OF INSURANCE Buildings $0 Business Personal Property $5,000 Business Income & Extra Expense Actual Loss Sustained Not Exceeding 12 Months Other Endorsements See Schedules LIABILITY COVERAGE General Aggregate Limit(Other than Products-Completed Ops.) $2,000,000 Products-Completed Operations Aggregate Limit $2,000,000 Personal &Advertising Injury $1,000,000 EACH PERSON/ORGANIZATION Each Occurrence Limit $1,000,000 Medical Expenses - - $ 5,000 EACH PERSON Other Endorsements See Schedules 0 PREMIUM Premium shown is payable at inception Total Premium $987.00 POLICY SUBJECT TO ANNUAL AUDIT:Yes The Declarations, Schedules and Forms and Endorsements Make Up Your Complete Policy. Refer to Schedule Of Forms and Endorsements. Process Date: 05-31-2022 iP iP a cc W O O X-3842 0319 Page 1 of 5 ,nmxmoa SELECT BUSINESS PACKAGE DECLARATION PAGE Policy Number: 2007X0395 Named Insured: KR CONSTRUCTION LLC CLASSIFICATION SCHEDULE ,., Classification Code Premium Basis Exposure Premium ''A Carpentry - Construction of Residential Property - 74171 Payroll 28,600 $742 Not exceeding 3 stories in height - Shop Building No Description Class Code Deductible Limit of Insurance Premium LOCATION OF DESCRIBED PREMISES #: 1 254 FALLEY DR , WESTFIELD,MA 01085-4914 1 Business Pers Prop 74171 $500 $5,000 $73 Protection Class: 3 Protective Safeguards: Not Applicable Personal Property Rating Basis: Replacement Cost BUILDING SPECIFIC COVERAGES Accounts Receivable • On Premises Limit $15,000 Included • Off Premises Limit $5,000 Included Business Income from Dependent Property $10,000 Included Damage to Premises Rented to You $100,000 Included Outdoor Property $15,000 Included ' Valuable Papers & Records • On Premises Limit $25,000 Included • Off Premises Limit $5,000 Included LOCATION SPECIFIC COVERAGES Fire Department Service Charge $5,000 Included Money and Securities Included • On Premises $10,000 • Off Premises $5,000 Outdoor Signs $5,000 Included Water Backup & Sump Overflow • Water Backup Limit $5,000 Included • Business Income/Extra Expense Limit $5,000 Included OTHER ENDORSEMENTS Electronic Data $15,000 Included Employee Dishonesty $15,000 Included Forgery or Alteration $15,000 $Included Fungi Rot Bacteria Liability $25,000 $50 X-3842 0214 Page 2 of 5 2007X0395