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HomeMy WebLinkAboutBLD-23-000939 #324 .ygR e�y t tt ,� ITtd owes L ) do Office Use Only +! O I`^r �°� �s G pj 7 Jn /��y Permit# G MATTACf CSC, �`°°°°"°"°"Q c —_ n n Permit expires 180 days from (x�C_J� i issue date t) Ak_ r c` c( RECEIVED EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH AUG 19 2022 Yarmouth Building Department _�, ,���p____ 1146 Route 28 BUILFIN TM By: , South Yarmouth, MA 02664 • (508) 398-2231 Ext. 1261 '/U Do G'' /&fJ3 CONSTRUCTION ADDRESS: J / ©a f/ l /'ii s - , S 0 a_ & Ktr'j/1,1 0 a 4 t ASSESSOR'S INFORMATION: Map: Parcel: 1�,� QQ -CO u �,p�,crt1 au ^( IA. j S, V LC 220.E -Lt-0-4,2J„OWNER: /�'lg.tADc�%,-f CX�t,rG Li i'� a`� moan s�`4 t�if.�r-�-i� NAME PRESENT ADDRESS TEL. # CONTRACTOR:AL 7' Coesr° ' rueG``I c ii ( ,tz � e, Pond d c �n-64/,t7 a1L Mil 0Z 6 43 NAME MAILING ADDRESS J TEL.# _cog_ 2 6 0 - i 2 Dg- Residential L�J Commercial Est.Cost of Construction$ la 2, p9` 0 0 /✓o Home Improvement Contractor Lic.# J✓ y 40.2 Construction Supervisor Lic.# ii:26- -161,9 Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor a I have Worker's Compensation Insurance Insurance CompanyName:t&S'4rs'1 _Lisa.t &x Ce 61-0xa Worker's Comp.Policy#VV/V01q.2.V 111:23 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 'e'k ( /)Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing 6 6 ,rapt s Lrd 1 We - f s 0ct44. J *The debris will be disposed of at: TO wa/ii O !,.Lr 1pp, 0 st `i 4 pi %74,='d- ( (e 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 revo i n of my license and for prosecution under M.G.L.Ch.268,Section I. Applicant's Signature: 4 Date: ®e7 '11�/ 2 Owners Signature(or attachm A P_ Date: e / / / O 2.. G. Approved By: Date: 'g - 3-_ Building Official(or design L ADDRESS: Zoning District: 110 11\ 1 1Pn C Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No 1„t,A(Ice,h ow Water Resource Protection District:- Within 100 ft.of Wetlands: al ill).?- 1-tdvt,- . 0 Yes 0 No 0 Yes Ll No 41/11441 ''� The Commonwealth of Massachusetts 1-11106.4211111 L Department of Industrial Accidents Ew- WI 1 Congress Street, Suite 100 Illjp, Boston, MA 02114-2017 o, —M wps,, www.mass.gov/dia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information _ �' Please Print Legibly �f Name (Business/Organization/Individual): ,.�7 f r (�O1/j Ii�G(c1/�o,' . Z e Address: PJ PIS f o Cl t� City/State/Zip: id Ifs r/ 2oa,-(`. MA O.)6-'22Phone #: 5ov` 360 /3 PS Are you an employer?Check the appropriate box: Type of project(required): 1.E 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. I am a homeowner doing all work myself. [No workers'comp. insurance required.]t _ 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.E Electrical repairs or additions proprietors with no employees. - 12._Plumbing repairs or additions 5.E I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 1-,.yRoof repairs These sub-contractors have employees and have workers'comp. insurance.t 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. 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: t c2 S-{ec 4 —i it C t-L ra ioe 61 0 u(J Z 4 C. Policy#or Self-ins. Lic. #: WC V 01g 2-01I0-2 Expiration Date: 1 d+./ 0l y -e_ . A.._ Job Site Address: Z"l 0 lof no_ / i' ..: ? City/State/Zip: C :Va.(A4 016-1it /7 4 0 ZOO l 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 ' nd enalties of perjury that the information provided above is true and correct. Signature: '`' Date: 05/ f g/ L7 0 2 Phone#: 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 Phone#: Contact Person: N r r >S D -1 �3�J[A 0 0 D c-o� -4 W m �IvD �3] 33 Soo Nr C p-� -i oc 0 mom DOc� s O w C n N -I� D -IOC D Z mZ m`SO D3O n-4 N T N r nm3 m r w Z m w n 0 y. N» m mtn D C a 0 m n -I N S m m 2 0 m ay 3 � n 0 3 CD 0 0 cu \ CO0 0 ai 0 C -` o O 3 z ,---" CD_ 7-(Dc' m 0 x " s CD D)as D \ o m N a O No.,mm " n 0 {gyp ca- ,,m m»Igo - O w0 to R gi. a. 0 C - CO f :� =aa Xco 0 j� D ��c� mii3 -i w co v(n 2 --Im op C C >>N v 0 U) ow m p CD.-' m 5 o m D CC --I W D o r _ N `G C A co r 0) C g a W 0 r-f t 9 m U W coRo-N Q Cr N A s a Na o m 9 rt c 3 O m n 0 n A. } r 3 V»f \ co ƒ k§xco \ o0 ; kj \o— kk / %), °k cc5 2c: Z \ 22 §>^-4cotp;H a - ; 32lg k0 \ Acna ; ) £ ( ) 7 »«+ a 4 ` « -'. » z- - .2 . DD/Y REP® CERTIFICATE OF LIABILITY INSURANCE DATE(MMl1vo7/DONYYY) 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 Kelly Smith EASTERN INSURANCE GROUP LLC PHONE N Exry: FAX (508)620 3447 No): E-MAIL ADDRESS: kesmlth@easteminsurance.com 233 WEST CENTRAL ST INSURER(S)AFFORDING COVERAGE NAIC tl NATICK MA 01760 INSURER A: ATLANTIC CHARTER INS CO 44326 INSURED INSURER B: ALT CONSTRUCTION LLC INSURER C: INSURER D: 22 HORSE POND ROAD INSURER E: WEST YARMOUTH MA 02673 INSURER F: COVERAGES CERTIFICATE NUMBER: 723258 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. TR TYPE OF INSURANCE I NSD ISWVD POLICY NUMBER UBR I MM/DO/YYYY)I(MM(DDIYYYYI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED 1 CLAIMS-MADE ( OCCUR PREMISESJEa occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY_ $ GEN'L AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE $ POLICY ECOT t_— LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMB (Ea accident) ANY AUTO ((BODILY INJURY(Per person) $ ALL OWNED -- AUTOS SCHEDULED AUTOS N/A I BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) i I $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATEI $ DED RETENTION$ I$ WORKERS COMPENSATION I X I STATUTE I I OTH- AND EMPLOYERS'UABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y!N EL EACH ACCIDENT $ 1,000,000 A OFRCER/MEMBEREXCLUDED? N/A N/A N/A WCV01420403 12/04/2021 12/04/2022 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under i DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Norkers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay Maims 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 ssue 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/. :ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ELT Construction LLC ACCORDANCE WITH THE POLICY PROVISIONS. ?2 Horse Pond Road AUTHORIZED REPRESENTATIVE —1 (. N MA 02673 Yarmouth Daniel M.Croy,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. CORD 25(2014/01) The ACORD name and logo are registered marks of ACORD • THIS I"^RTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CER". `.CATE 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 CONTACT Eastern Insurance Group LLC PHONE FAX 233 West Central St (A/C,No.Ext):800-333-7234 _lac,No):781-586-8244 Natick MA 01760 ADDREss: CSR24CL@easteminsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Arbella Protection Insurance Co 41360 INSURED ALTCONS-01 INSURER B:Merchants Mutual Insurance Company 23329 ALT Construction LLC 22 Horse Pond Road INSURER C: W Yarmouth MA 02673 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:662655047 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 POLICY EFF POLICY EXP TYPE OF INSURANCE LTR INSD I WVD POLICY NUMBER (MM/DDIYYYY) (MM/DD/YYYYL LIMITS A X COMMERCIAL GENERAL LIABILITY 9520049457 12/1/2021 12/1/2022 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $100,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $2,000,000 X POLICY JECT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: B AUTOMOBILE LJABIUTY MCAI002609 6/2/2021 6/2/2022 COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $20,000 OWNED X SCHEDULED BODILY INJURY(Per accident) $40,000 AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY , AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ • WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETORIPARTNERIEXECUTIVE EL EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? N/A (Mandatory in NH) E.L DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached It more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Display Purposes Only AUTHO RIZED REPRESENTATIVE urt-ervic) ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD