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HomeMy WebLinkAboutBLDX-23-15520 Office Use Oni %off•'�`qk '5 x-G3/'S 0 O•, i ermit# ' '° ; RECEIVED r D 'amount r.) •'-It'A MATTAGM CSEJ4"' [--- --'M"-'-w`•--� 1 Permit expires 180 days from _ r issue date .f 02 EXPRESS BUILDING P idlit Lti. kie • TION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 3i I(‘vfr St c-c e f ASSESSOR'S INFORMATION: Map: Parcel:OWNER: DArI VO6eC. f v-1ttN/" PRESENT ttt, r5+reC� 7 R 1, oc^ � b�/3 NAME CONTRACTOR: M JM yagleAgetficlac.ADD kenS 1n� (Ave s GtTst .t A((k 6 D545 N ME MAILING7'.7 'i Li$% f611 Vt.esidential ❑Commercial Est.Cost of Construction$ d 7,�j 17 , 50 Home Improvement Contractor Lic.# i Cr ( 70 7 Construction Supervisor Lic.# Cc l i r -3 410 Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor I have Worker's Compensation Insurance yK� Insurance Company Name: 'RC I-it (Arm m � A-6cn cd, Worker's Comp.Policy# 6� 601 U�S / /`V / ?Q r 55 23 Oe Co WORK TO BE PERFORMED 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 *The debris will be disposed of at: e—V Pea-1,4 t;1` (,J '-$1 e, S VFW` i,p( C4 !v 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. ` ,x Applicant's Signature: r,if Ji "' 'fir. ,,G Date: D X542o kwners Signa . e(or attac 1 AlO ,✓`IRt-'t C._. h 1-11,-;; Date: ir Approved By: i% /�� % � Date: 0,/f•�� B 6 it i•f if 'al . . EMAIL ADDRESS: — /� Zoning District: Historical District: ❑ Yes 0 No Flood Plain Zone: u Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No 0 Yes 7 No —* k 6 roky4rro+r,(.ow L . coin \ The Commonwealth of Massachusetts =WE11 1 p II Department of Industrial Accidents 1 Congress Street, Suite 100 ' Boston, MA 02114-2017 �;s.•'' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERi`r1ITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): K 4 ro`y ljW PAk( .,- I t/t/t.„ Address: 2 D -tASil --o,1 Dr1 . ' City/State/Zip: $6no(2);(k fi/f ( SC3 Phone #: 7 7 y 15 y 6/7 Are you an employer?Check the appropriate box: Type of project(required): 1. m a employer with t employees(full and/or part-time).* 7. _New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. n Remodeling any capacity. [No workers'comp.insurance required.] 3._I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. ❑ 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.❑ Electrical 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 14. Other "�' �� 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 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. j Insurance Company Name: Thy 'Tn5J(An . A •P cyr F Pc_- C 01. • C- Policy#or Self-ins. Lic. #: 6 _S 1 1-V J 1 1(8,7 0 e SS 1-3 Expiration Date: 2)2-C ig. d? Job Site Address: Se. gi-Je1 5fif,k,8 f City/State/Zip: Y6kfrtcx4-4 friA- 0 a‘ y 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true'and correct. Signature: 34 Date: 2 0 / )6/a.3 Phone#: 77ge gi,5' 96fJ7 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: {{Office Use Only ',O�`Y' I Permit# ~ 'tl ! 0.- i Amount O i A;�i ,.��: Permit expires 180 days from pMyp��yd;` ;issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 3o kJ� 5t��e ASSESSOR'S INFORMATION: Map: Parcel: OWNER: Vv el Ns. A UogjeC- 3P f(ii.er S#fet. ' i y NAME PRESENT ADDRESS TEL. # CONTRACTOR: �NB� v t CK � * ,,d/Gl$a ensifl PKV ie .5�•1 0Jic Li,k. Lt 14 6 )5C3 NA1vtE ,� s MAILING ADDRESS TEL.#7 f J S l fa? Vitesidential 0 Commercial Est.Cost of Construction$ 6 ( 17 e 5 4u I I if 70 7 Construction Supervisor Lic.# CS I X3 L a Home Improvement Contractor Lie.# Workman's Compensation Insurance: (check one) I am the homeowner 0 I am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: i -�&t .M S U((,t4((l,, +r,�� A-eoi Worker's Comp.Policy# t O aU IS[ K /70 r 55s13 Off cod.- WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove P Re lacement windows:#____._,.__ Replacement doors: # Siding: #of Squares Remove existing* 2 layers) Insulation Roofing: #of Squares ( ) g { Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing IVM. 0cd'k�tc1"- 0 e.Sfie S�Li)is Ci *The debris will be disposed of at: 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 arts'serts} will be just cause for denial or revocation of my license and for prosecution under M.G.L.Ch.268,Section I.f Date )/.- o A) Applicant's Signature: —' kwners Signature tar attachment) Date: Date: _._..._. Approved 13y Building Official for designee) EMAIL ADDRESS: i Zoning District: Historical District: 0 Yes GI No Flood Plain Zone: :I Yes 1.: No Water Resource Protection District: Within l00 it,of Wetlands: 0 Yes CI No 0 Yes :1 No A DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 10/25/2023 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 Ellysia Moreis THE INSURANCE AGENCY OF CAPE COD INC PHONE la 508c.No.Extf: ( )888-2766 FAX No): E-MAIL Do ESS: ellysia@insuranceofcapecod.com P 0 BOX 1053 INSURER(S)AFFORDING COVERAGE NAIL N SANDWICH MA 02563 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: K BRAY CARPENTRY INC INSURER C: INSURER D: 20 KENSINGTON DRIVE INSURER E: SANDWICH MA 02563 INSURER F: COVERAGES CERTIFICATE NUMBER: 944096 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 LIMITS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER JMMIDDIYYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE 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 $ PRO- POLICY PRO- LOC PRODUCTS-COMP/OP AGG $ JECT $ OTHER: COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY (Ea accident) BODILY INJURY(Per person) $ ANY AUTO — OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ (Per accident) AUTOS ONLY AUTOS ONLY $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE N/A AGGREGATE ,$ DED I RETENTION$ WORKERS COMPENSATION X I $ STATUTE I ERH AND EMPLOYERS'LIABILITY Y I N E.L.EACH ACCIDENT $ 500,000 ANOFFICERJM MBR/PARTNER/EXECUTIVE 500,000 A (Mandatory NH) CLUDED? NIA NIA NIA 6S62UB1 K8700:523 02/26I2023 OZ/26/2 E.L.DISEASE-EA EMPLOYEE $ (Mandatory In NH) 500,000 If yes,describe under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below 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 ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth 1146 Route 28 AUTHORIZED REPRESENTATIVE Yarmouth MA 02664 Daniel M.Croy,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD co zxm x D D0 m 0 O ZxW Na m m = c *zD w< , , v, 3 z u20 rt .O CD m 20D AFT �37 .x 9 .. g.� )4 D Z iv jj au 1 v ' wm-2 ;s .. o xiCD > 7 ny0 = n -1 33 c CAD I m �cm m I o m -1.. nw1 m ` co nO ,'ti = CDoo Po oo o D .--' i I o ocn K low 3 )13 ' Oo < 3 > m co O(0 .3 Y , -fl 6 m , . , ,.5 I_. .' D y i 8 \i J F.; gait ii hi m * 0_' a s " m m 0 -: D O = , c w.w - Cb - Cn 2 C fpa7fa S v o' o - ' pDJ C U0 -4C°C y 1 m > > CD CD cc o c CD ! CT o co m N (Dp fD C 0 N OOP 0 / n N C7 y O N p. 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