The URL can be used to link to this page

Home My WebLink AboutBLD-23-001995 Gt l to 1,llq/z2_ RECEIVED OCT 1 3 2022 Office Use Only 46 --— Permit#CO it I C BUI aIr 2�� /BENT O O H By._ _ ens _ Amount/to•' 6 MATT M[s 4. 4«.,.,,co•4 r.� Permit expires 180 days from issue date 60 -023 EXPRESS BUILDING PERMIT APPLICATION q a.5 TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 J (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: c2 `l G a\/vim p ,S T (A). (t ,c'w c U T I-4 ASSESSOR'S INFORMATION: Map: Parcel: OWNER: 3 e:1-T C.{/ 0-8 V_ _.)e.S �. /dR\ \c irN Ym.�.c��6"i� ( T k. RC,3k ADDRESS 0 PRESENT TEL. # CONTRACTOR: (.J a L 1 C j \Y 14 d,1X� I` C,a S kF i c-5 )",‘ CA‘"'7,1 .50 6c,,5-4-10 NAME MAILING ADDRESS TEL.# ❑Residential tkommercial Est.Cost of Construction$ 61 4 0 .0 Home Improvement Contractor Lic.# 2c,J..c31 s Construction Supervisor Lic.# - I` c Li 6 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 1 am the sole proprietor '1 have Worker's Compensation Insurance Insurance Company Name: e� Worker's Comp.Policy# IY tr,)C✓ 1`i 413 WORK TO BE PERFORMED n Tent 11 Duration (Fire Retardant Certificate attached?) Wood Stove I I Siding: #of Squares Replacement windows:# S Replacement doors: # Roofing: #of Squares (❑)Remove existing*(max.2 layers) Insulation I I I I Old Kings Highway/Historic Dist. (Q)Replacing like for like Pool fencing *The debris will be disposed of at: e7 R)or\Cc T I-1 at L. 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 Signature:�j j _ � �w_.e . `r X Date: I /o S/3 a Owners Signature(or attachment) Date _/ Approved By: � � Date: Building Official(or desig EMAIL ADDRESS: Zoning District: Historical District: Yes No Flood Plain Zone: Yes L No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No ® DATE(MM/DDM'YY) ACc REP CERTIFICATE OF LIABILITY INSURANCE 10/05/2022 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 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 NAME: BIBERK HONK ExtY 844-472-0967 FAX Not, 203-654_3613 P.O. Box 113247 E-MAIL customerservice@biBERK.com Stamford, CT 06911 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:National Liability&Fire Insurance Company 20052 INSURED INSURER B: Walaci Machado INSURER C: 193 camp st apt j5 INSURER D: West Yarmouth, MA 02673 INSURERE: 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. INSRPOLICY EFF POLICY EXP LT ADDLTYPE OF INSURANCE IN5D WVDSUBR POLICY NUMBER (MM/DDIYYYY) (MMIDD/YYYY) LIMITS LTR INSD WVD COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE I$ 0 DAMAGE TO RENTED CLAIMS-MADE I OCCUR I PREMISES(Ea occu ence) $ 0 I MED EXP(Any one person) i$ 0 I PERSONAL&ADM INJURY I$ 0 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 0 POLICY I 1 SECT LOC PRODUCTS-COMP/OP AGG i$ 0 I $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT I$ (Ea accident) I ANY AUTO BODILY INJURY(Per person) -.$ 'OWNED 'SCHEDULED BODILY INJURY(Per accident)I$ H H ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE 1$ AUTOS ONLY AUTOS ONLY (Per accident) $ I UMBRELLA LIAB OCCUR EACH OCCURRENCE i$ EXCESS LIAB CLAIMS-MADE IAGGREGATE I$ DED 1 RETENTION$ I $ WORKERS COMPENSATION X STATUTE ERH ' AND EMPLOYERS LIABILITY Y I N ANYPROPRIEfOR/PARTNERJEXECUTIVE NIA N9WC772492 09/09/2022 09/09/2023 E.L.EACH ACCIDENT $100,000 A OFFICER/MEMBEREXCLUDED? N (Mandatory in NH) EL.DISEASE-EA EMPLOYEE$100,000 If yes,describe under DESCRIPTION OF OPERATIONS below _ E.L.DISEASE-POLICY LIMIT {$500,000 ' Professional Liability(Errors & Per Occurrence/ i Omissions): Claims-Made Aggregate DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if 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 Betty Jacovides ACCORDANCE WITH THE POLICY PROVISIONS. 248 Camp St B5 AUTHORIZED REPRESENTATIVE ,•^ South Yarmouth, MA 02673 fi' ..31--, " at O 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD • . The Commonwealth of Massachusetts '�� _ J. Department of Industrial Accidents __ Ivrar 1 Congress Street,Suite 100 �L_f Boston, MA 02114-2017 ,\ ......zir sv.�'' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print LeeibIy Name (Business/Organization/Individual): (d1/4 R 1 a -C, \-\,N ac l-b R Dc, Address:) 9'3 C,G\,,,,P 5,1- f,PT -5 City/State/Zip: cj;c.K,7 \t„\c,LL-�i i- U, ccBPhone#: .5c,a . 6o.61 L( Are you an employer?Check a appropriate box: Type of project(required): 1.121 am a employer with --L employees(full and/or part-time).* 7. D New construction 2.111 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 3.0I 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.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.nI am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0 Roof 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. Other �-r y . 152,§1(4),and we have no employees. [No workers'comp.insurance required.] *Any applicant that cheeks 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'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: L.R .F,p,R I Policy#or Self-ins.Lic.#: Y'3cIJ c`1i v2 4. u.8 Expiration Date: 0q /c 9/Dc.3a3 Job Site Address: ( q g C.at,,,..1F) �T City/State/Zip: 14. 1 fCNrvtit-v f.-1 ,K. 0:3 13 Attach a copy of the workers' compensation policy declaration page(showing the policy numbiai 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: 6) Po..o,..� \,.,,,,,r.R. 0 Date: Jr-,/o S/ao D3 Phone#: 5c;C. rc;.51 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#: Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Regulations and Standards Const ionTS rvisor CS-116646 v tpires: 12/29/2025 WALACI P MACHADO 193 CAMP ST! APT J5 _ WEST YARMOSJTH MA 02673 Commissioner cw Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE: Individual Registration Expiration 201015 02/22/2023 WALACI PEREIRA MACHADO WALACI MACHADO- 193 CAMP ST APT J-5 WEST YARMOUTH,MA 02673 Undersecretary Registration valid for individual use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 1000 Washington Street -Suite 710 Boston,MA 02118 Not valid without signature Fox Wood a... • .. .r • Mf 3 248 Camp Street West Yarmouth Mass. 02673 October 6, 2022 Betty Jacovides Foxwood Unit B-5 248 Camp Street West Yarmouth, MA 02673 Dear Betty, The Board of Trustees is in receipt of your request to replace / perform work within your unit at Foxwood Condominium in accordance with the rules and regulations or by-laws of the condominium association. After reviewing the work requested,the following is provided: WORK TO BE COMPLETED: • 7—Double-Hung Windows (new construction) • 1— Bay window DOCUMENTATION: 1. A copy of the Contractor's PROFESSIONAL license HAS been received. 2. Copy of the building permit HAS NOT been received. 3. A copy of the certificate insurance naming FOXWOOD CONDOMINIUM as an additional insured HAS been received. 4. Proof of workman's compensation HAS been received. CONDITIONS 1. Copy of Certificate of Insurance listing Foxwood Condominium Association as an additional insured. (must be received 3 days prior to work start date) 2. Copy of building permit(can be provided the work start date) 3. Trim to be Azek or equivalent 4. Trim to ae face nailed with stainless steel nails OR counter sunk screwed with plugs. 5. Two business day advance notice of work start date. 6. Carpenters ID verification (done at start of work) 7. Windowsills must be installed on finished work. 8. Work area to be left in free of debris. 3. All materials to be taken off the property and not placed in dumpsters on the property STATUS: .., s s iONA I Y -`.OV T ubiect to . 3 Should the work completed and/or item installed not conform to this submission, the board of trustees will require removal/correction to comply with this approval. If you have any questions, please contact Shaun Horan at 508.775.6880 or John Pupa at 508.420.0047. Cordially, John J. Pupa Business / Financial Manager Foxwood Condominium