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HomeMy WebLinkAboutBLD-23-000110 C,OJ t . U t /l O /7Q Office Use Only Permit# grgq 0 �H Amount 1� cO, MATT M f Permit expires 180 days from issue date £L'i) —03 —OOD 11 EXPRESS BUILDING PERMIT APPLICATIOI4 R E C E I V E D TOWN OF YARMOUTH Yarmouth Building Department JUL 07 2022 1146 Route 28 _ South Yarmouth, MA 02664 BUI T AENT By. '/�J� (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS:do i CIVIL p & ya,m4,1), ASSESSOR'S INFORMATION: Map: Parcel: I, G6 3' 5°5 ,, OWNER:&eu( e.- ? ( I4 rU 0 3 60 CCAO , ( Htidct" lU N, o2051 l� 3s! . NAME PRESENT ADDRESS TEL. # e CONTRACTOR:'vJI, .. V` (W 6 /Iat Imo. d )vP', /h� v961 � ,ry riti-?))-0 9,1 NAME AILING ADDRESS TEL.# Residential 0 Commercial Est.Cost of Construction$ dGG Home Improvement Contractor Lie.# IRG15-O Construction Supervisor Lic.# G J' (q4 )? Workman's Compensation Insurance: (check one) \, 0 I am the homeowner 0 I am the sole proprietor ® I have Worker's Compensation Insurance Insurance Company Name:frat.i`rS iv"' Worker's Comp.Policy C% U(MT Hai v ` / ?c WORK TO BE PERFORMED Tent E Duration (Fire Retardant Certificate attached?) Wood Stove LEI Siding: #of Squares ,g Replacement windows:# t l Replacement doors: # Roofing: #of Squares (❑)Remove existing* (max.2 layers) Insulation ri 1 1 Old Kings Highway/Historic Dist. Replacing like for like Pool fencing 7 *The debris will be disposed of at: C 4v i xeo 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� ocationo y license and for prosecution under M.G.L.Ch.268,Section 1. 7/3//9 Applicant's Signature: ► �� � / Date:Owners Signature(or attachment) 7/9/9/ ']Date: jl�9 Approved By: L-4 Date: � �� Building Official(or design: Z. EMAIL ADDRESS: Zoning District: Historical District: Li Yes No Flood Plain Zone: L- Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes LI No ❑ Yes LI No . The Commonwealth of Massachusetts 'Er_ L Department of Industrial Accidents ;E,lll` 1 Congress Street, Suite 100 vii_4 Boston, MA 02114-2017 ..'' wwrv.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information L Please Print Legibly Name (Business/Organization/individual): AlA l Cc n C Ir hh'r. Address:(16 'A ccil� Acrt tn. C/i c`{'Acr , AA, 0)633 City/State/Zip: Phone #: ??4- 99?-- 0941 Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with employees(full and/or part-time).* 7. 0 New construction 2.IJI am a sole proprietor or partnership and have no employees working for me in 8. []Remodeling any capacity.[No workers'comp.insurance required.] 3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition 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 11.0Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑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.t civil/ 0 et'CL 5 6.�We 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.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. ,, c Insurance Company Name: l ' 1`l5 cn J Policy#or Self-ins.Lic.#: £ I9V) HO 0 6'l cl d 2 Expiration Date: Vil q/a J Job Site Address: 04' Pejty , Rd Ya."-441\`Mk, 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 c rtify under the pains and penalties of perjury that the information provided above is true and correct Signature: � Date: ?/ Vag Phone#: /'r.Lj' r ' i/T,y 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#: QF yam A message from the • • � , y yarmouth Water Department 99 Buck Island Road• West Yarmouth, MA 02673 •508-771-7921 ATTENTION HOME OWNERS AND CONTRACTORS!! Please note that the box shown below is property of the Yarmouth Water Department and is an important part of the drinking water metering system. The Yarmouth Water Department utilizes these "End Points" to collect water usage readings from our 1t itM<3tPaitotrwited i aAT R Y customer's water meters. PLEASE DO NOT REMOVE THEM FROM YOUR HOME OR BUSINESS!! If work is being done in the vicinity of the End Point, please take care to maintain the wiring and securely reinstall the End Point. If the End Point is damaged or lost, or the wires are broken, the Water — -- Department will charge the property owner for any necessary labor and equipment needed to make the repairs. Please call the Water Department at 508-771-7921 with any questions or to schedule a repair. Thank you for your assistance in keeping our water system running smoothly! THANK YOU FOR YOUR HELP! For more information visit: • www.yarmouth.ma.us/139/Water ACCORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 04/20122 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 CONTACT JIM HINDMAN Schlegel&Schlegel Ins Broker (NCC,NNo,E■t): 508-771-8381 FAX 34 Main Street E-MAIL (ac,No): 508-771-0663 West Yarmouth,MA 02673 ADDREss: schlegellnsurance@gmail.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: TRAVELERS INSURED INSURER B ALL CAPE CONSTRUCTION INC INSURER C: 27 DANCING BROOK ROAD INSURER D SOUTH YARMOUTH,MA 02664 INSURER E: INSURER F: _ COVERAGES CERTIFICATE NUMBER: 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. INSRL TYPE OF INSURANCE �Up wv POLICY NUMBER _jMM/DDNYVY)(MF M POLICY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE 10 EN['ED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) S 500,000 MED EXP(Any one person) S 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 POLICY JECT PRO LOC PRODUCTS-COMP/OP AGG S 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S (Ea accident) ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Per accident) $ _ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE S DEO RETENTIONS WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR/PARTNERIEXECUTIVE Y/N E.L.EACH ACCIDENT $ 100,000 B OFFICER/MEMBER EXCLUDED? I y I N/A 6HUB8H02859922 04/14/22 04/14/23 ' (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,AddltIonal Remarks Schedule,may be attached II more space Is required) CORPORATE OFFICERS HAVE ELECTED NOT TO BE COVERED UNDER THEIR WORKERS COMPENSTION POLICY 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. TOWN OF YARMOUTH BUILDING DEPARTMENT YARMOUTH MA 02673 AUTHORIZED REPRESENTATIVE �r 11/ l - 1 ©1966•2015 ACOI�D f�ORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD �J + _ mer� airs& uslnese RegulationJfeOY'-"o RS1GfiECeo Pu4 mttrrootafkCmPR Registration valid for individual use only TYPE:Corporation before the expiration date.If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 188058 06/12/2023 1000 Washington Street•Suite 710 ALL CAPE CONSTRUCTION INC Boston,MA 02118 JUSTIN M.JACINTO 46 SHADY ACRE DR '^''°` Not valid without signature CHATHAM,MA.02633 Undersecretary • Commonwealth of Massachusetts Divisiofon ofding Pesoa Board Buil Regulations rofsi no Licensure and Standards ConstrU tfffi UpRrvisor CS-102675 65,pires:05/06/2023 JUSTIN M JACI j 46 SHADY ACRE mi CHATHAM MAD j Commissioner drP kI7Lrrr&�A