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HomeMy WebLinkAboutBLDX-23-15513 Y ',�� R - :Office Use Only ,> .. • -1 9: Z3-/ss 3 O f;,i C 1 mu # '� nwrr�ln cscJd '. _{Amount �1) ; O+aaatoa9 r' ' ". ;:-• ' `Permit expires 180 days from j issue date EXPRESS BUILDING PERMIT APPLICATI I IV E C E 1 V E TOWN OF YARMOUTH Yarmouth Building Department OCT 24 2023 1146 Route 28 South Yarmouth, MA 02664 [BUIF9RT (508) 398-2231 Ext. 1261 ey l CONSTRUCTION ADDRESS: l Lis rho„. L►q CA..) p rah. _.nl_ O : b n ASSESSOR'S INFORMATION: `i l�l Map: i Parcel: OWNER: ebeovel C , rY Dh+ t LJSrmcu-.c LN,Lo"yAry.0 i 432643 hp, 613- 8 aisgf NAME PRESENT ADDRESS TEL. # CONTRACTOR" r UM' w A 4 ,3 NAME MAILING ADDRESS TEL.# 'Residential ❑Commercial Est.Cost of Construction$ t L1, 980 .( ti.,., Home Improvement Contractor Lic.# I -t t4"I 1 Construction Supervisor Lic.# (Q 61 Set Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: 5 C hIjl 145 u rot()c. . Worker's Comp.Policy# 1 OLS9 WORK TO BE PERFORMED 6S60Ug6 63tizaaaz Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows: # Replacement doors: # Roofing: #of Squares ) 8 ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: 1 h nn t�r'Cl}5ur- f-D j „.,'Jo c� 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 lic se and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Cd..C.c1,44 Date: JO 1.14 1 Owners Signature(or attachment) (l 1' `-� Date: Approved By: Date: ZG j c , Building 0 (or ignee) EMAIL ADD Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No ❑ Yes 0 No - 1(/)Cti.J•-1 ' (i.-1 GA-e..(-- 4-i(6h} \c0 G\Ac, a cvrl The Commonwealth of Massachusetts N' L Department of Industrial Accidents 1 Congress Street, Suite 100 :, Boston, MA 02114-2017 :.5••' www.mass.gov/dia \pt. Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual) ;...t0 , —t1 / t ,,r• i + in( Address: 54 (., 11 1--6 tkcAA t JG� City/State/Zip: Nye-,s hr\ C -6U1 Phone #: 5 - 34,(4 --$3Q3 Are you an employer?Check the appropriate box: Type of project (required): 1.—_ I am a employer with employees(full and/or part-time).* — 7. New construction 2._I am a sole proprietor or partnership and have no employees working for me in — any capacity.[No workers'comp. insurance required.] 8. Remodeling 3. I am a homeowner doing all work myself 9. Demolition y [No workers'comp. insurance required.]t 4._I am a homeowner and will be hiring contractors to conduct all work on my property. I.will 10 n Building addition ensure that all contractors either have workers'compensation insurance or are sole 1 1.El Electrical repairs or additions proprietors with no employees. - 5.[]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.[I]Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance.$ 13.E]Roof repairs 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. Insurance Company Name: t G- M in St ie-a 2C_i. Policy#or Self-ins. Lic. #: G S 60 U Q 6 R.C. 34 . .13,3 Expiration Date: / P C'' 06'� Job Site Address: I 1 i S I (U ;,, �(G,,.�r�� �y,Ci /State/Zi '' _ "' �' P:CJN.IGcr,,A1,-. MA oa6"4-3 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. CI-Signature: Date: 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 Contact Person: Phone#: ACc RKY CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 10/24/23 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 NAMEACT JIM HINDMAN WORLD INSURANCE ASSOCIATES LLC (q/CONNo,Ext): 508-771-8381 FAX No): 508-771-0663 34 Main Street E-MAIL West Yarmouth,MA 02673 ADDRESS: schlegelinsurance@gmail.com INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: NGM INSURANCE 14788 INSURED INSURER B: THE HARTFORD WATER TIGHT INC INSURER C: 54 WHITEHALL WAY INSURER D: HYANNIS,MA 02601 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. INSR TYPE OF INSURANCE ADDLSUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 500,000 MED EXP(Any one person) $ 10,000 A MPJ3911B 04/12/23 04/12/24 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PET LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ 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 $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY B OFFICER/MEMBER/EXCLUDEDXECUTIVE N N/A 6S60UB6R63422223 10/06/23 10/06/24 E.L.EACH ACCIDENT $ 100,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CORPORATE OFFICERS HAVE ELECTED TO BE COVERED UNDER THEIR WORKERS COMPENSATION POLICY INSURANCE COVERAGE IS LIMITED TO THE TERMS,CONDITIONS,EXCLUSIONS AND OTHER LIMITATIONS AND ENDORSEMENTS OF THE POLICY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town Of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth,Ma 02664 AUTHORIZED RI4PEENTATIVE 508-398-2365 Fax, ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Re ulations and Standards Constructiq pee or Specialty ry CSSL-106159 63)aires:01/06/2025 JORGE L RO)IEI •r p , 577 MAIN ST . HYANNIS Mk p2601=;', Commissioner dia a / C7&mica_ zcG0) m 97 Z_nm X Q A m DDm -i 0 O D (AD ivo m0 z xi m o._ ZCm 0 0 co _ N % Z %f] c Z Cn -I J 4 • m,DrD- 1 o <-' Ills 8 ° y= rn m Z.� a, Z p o (7 ';' 11111 rx! t•p Wag '°„'ate t' ° '+,,P Z vi_N + a {- 3 Hn O -I c ' CD I �� • f° m ; 2 O ffl n w 0 �, C� 13 0) I 0 0 z �` 3oocn S 1 �i.' aoop %hi J; ll b _,. °�:d . vo '" 1TI r C y A '<0. ' i u s w""(Q CD (I) c a� � 1 C m m� t �-- � � I 3 1 N • 2A (.0 O co -,'N a .coo _+C 73 N pivvm ND O C D d r' # a o t 7 fD X yi N i C 7 d a 1 3 ., , -,---i t i r ICIIl�fl( CONTRACT FORM Client Information Name: j & k C o r ± w r 0 lI i Address: r L/ S /14 o r-e L.N City: W T a-r/M cv1` Postai code 02 (e"7 3 Estate /14 A Phone# ('/ ? e y? Z Zv T Description of services to be provided: ep(61€ -HAR foOF on 411,e e arm cr,wci 44c41, 1 fig v Q [ K 1 (e p(&ce # rC e ot.st�'.� OC.d 4-►. ►;e4 re ;ec4 .J4 e (oof i et 4-hc ba,,ct'( c, . _ ok � p4 © &4y TOTAL: I q, go OCR DEPOSIT: 2,57D F.®1 r �--5 / {AJkeh (,t,� �trel f i joh DUE ON COMPLETION: , 50 f A Wiley! Ws . '►i 31,1 Accepted on behalf of client: We understand the above project will be to the terms and conditions as stated with the client. NAME: 0xV\ C cam-i'-f-W r -ii - DATE: /0 ' lc - 23 SIGNATURE: -"f Accepted on behalt of contractor NAME: Iar ~e P44Ci'D beAllet (II't, /j146 D -:, /Q- ij. 43 SiGNA E UF_ /11r ' r