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HomeMy WebLinkAboutBLD-23-003266 �, `., l Office Use Only Y RO Permit#C,iE,.'t7 ") 4., 0 cia,guL i.j /02 /3/2 qp O� ,'� , y • ;Amount MATTAC M Ezr ` „..,, 'P, SPermit expires 180 days from I issue date 6uy-(9-3-603zith EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department ."._-- 1146 Route 28 DEC 0 9 2022 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT /�, f CONSTRUCTION ADDRESS: 3.6' �/4�l e ,/ ,9 t''e $/ / a6 d' Sri I Ox I A fr. P ASSESSOR'S INFORMATION: Map: Parcel: OWNER: •.�17nj`7 A , D en'h e h� I y/3 6's©y NAME PRESENT ADDRESS TEL. #� !'f CONTRACTOR: SWF) cat, <� SAekD� 9"7'J 1/- al S1 u/�D /0 NAME ✓ MAILING ADDRESS TEL.# ($`Residential 0 Commercial Est.Cost of Construction$ 1 DD®,00 Home Improvement Contractor Lic.# /1 ?3 25-/ Construction Supervisor Lic.# 61, r 9 / 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: :41C-�/e L e V'j Worker's Comp.Policy# 2 3-4 6 6 WORK TO BE PERFORMED 9i.ri4 J 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: S i-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 revocation of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: • ,Owners Signature(or attachment Date: �j Approved By: 1(2 Date: �2'"- � ` u. g ial r designee) L ADDRESS: J i ell Zoning District: bil-CP ta"f Historical District: 0 Yes 0 No Flood Plain Zone: ❑ Yes ❑ No +/ Water Resource Protection District: Within 100 ft.of Wetlands: l� ❑ Yes ❑ No ❑ Yes ❑ No Ctem j al tadiA tr`,/1/ i i/ic/tdn 44 hErn0 . '".! j L 1 Gam_ ON --- f,� The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 • Boston, MA 02114-2017 5,,ss.4` www.mass oov/dia v. \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): ,S y,'-o / 11 fx-7 /e1z 0v c i d 5 e_ov fr Address: 127 /3 aity e-k- S /lire e v� City/State/Zip: Senc_ 1 Dew�l�`S t1i a 264ghone #: • — .25 / ' 7 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.E1 am a sole proprietor or partnership and have no employees working for me in 8. _ Remodeling any capacity. [No workers'comp.insurance required.] 3.❑I am a homeowner doing all work myself. [No workers'comp.insurance required.]' 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 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El 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: Policy#or Self-ins. Lic. #: Expiration Date: Job Site Address: 3 E' ,3? //e / w-e S p� �/yt City/State/Zip: YOrvY�i 0 tit-D `j /� I,- Attach a copyof the workers' com enSation policydeclaration page (showing the policynumber and expiration date). P 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: Date: /2-/0 /20 22-- Phone#: p a �-��� `.2�� 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: Commonwealth of Massachusetts Division of Professional Licensure 1\-.91 Board of Building Regulations and Standards ConstVitt Wilpskrvisor CS-073981 „ pires: 11/11/2022 MICHAEL F DRiscou. 2 CHRISTOPIR HALL WAY 0 YARMOUTH P9RT MA 02675 •:;•.! Commissioner ?kill K. • 12/9/22, 10:25 AM Details Licensee Details Demographic Information �_ mry rFull Name: Michael F Driscoll Owner Name: License Address Information City: Yarmouth Port State: MA Zipcode: 02675 Country: United States License Information 'License No: CS-073981 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 12/5/2022 Issue Date: 11/11/2010 Expiration Date: 11/11/2024 License Status: Active Today's Date: 12/9/2022 Secondary License Type: IDoing Business As: Driscoll Building Status Change Reason License Renewal Prerequisite Information No Prerequisite Infformaorma. tion No Available Documents _... https://madpl.mylicense.comNerification/Details.aspx?result=456c4c76-a231-42a5-a941-40ffea691025 1/1 a 0 u c 3 dY ar o 0 .roN a .2m d 11 O o op M ` - L ('J — a 2 r_ o t e - co so a).c -o c d tds W DI a r in 01 "r m c c In . 33mr N U) W p 'm oo aT R c�Y — I c a nrt ,-... j \ p 11011 0 it d3 • /• WN \,,,, d o ,To r II 1. t1il O W t 141 r'iimtinu'u' v ,,< ar9 atO m 2 C O m N m O Uoo y ti , d 0 .— E oz �o : � W O = U =re U i" U O Q m ga GN _ M O F NyZ `O -tea > imt3EK ce Z• O la-ad d- oOUWa E o e)= Ld11-• ° -I O 0CQ L<aoaI ¢ O t 3 at re AM > = FW-- Z cn aa, co z O O H g 0 W dY • Z s 0 W r eV CC d V O O 2 �cAQ =�dn W m = O Yre2 F u > 0 „�"2 dY -)cc W Q Z h.8 • U)-(.J) I DATE(MMIDD/YYYY) R CERTIFICATE OF LIABILITY INSURANCE 12/05/2022 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 co endorsement(s). PRODUCER NTACT NAME: Sandy Marchant PHONE 508 238-0056 I 1 FAX(A/C,No): MORSE INSURANCE AGENCY INC INC.No. ( ) ADDRESS: sandymarchant@morseins.com INSURER(S)AFFORDING COVERAGE NAIC# 285 WASHINGTON ST NORTH EASTON MA 02356 INSURER A: TRAVELERS INDEMNITY CO OF AMERICA 25666 INSURED INSURER B: USAROV HOME RENOVATIONS CORP INSURER C: INSURER D: 127 BAXTER ST INSURER E: S DENNIS MA 02660 INSURER F: COVERAGES CERTIFICATE NUMBER: 840690 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE PO WHICH THIS LICY PERIOD INDICATED. YE RITERM OR CONDIT ION O IS OCUMENT WITH TTO CERTFICATE MAY ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED ISSUBEC TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BPOLICYF Y PAID CL EI M LTR TYPE OF INSURANCE INSD WVD S INSR LIMITS EACH OCCURRENCE $ ADDL SUBR POLICY NUMBER (MMIDD/YYYY) (MMIDD/YYYYI COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES(Ea occurrence) $ CLAIMS-MADE I I OCCUR MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER:POLICY JECT PRODUCTS-COMP/OP AGG $ PRO- I I LOC $ OTHER: COMBINED SINGLE LIMIT $ (Ea accident) AUTOMOBILELIABILITY BODILY INJURY(Per person) $ ANY AUTO BODILY INJURY(Per accident) $ OWNED SCHEDULED AUTOS AU ONLY NN-O N/A PROPERTY DAMAGE $ HIRED NEY (Per accident) AUTOS ONLY AUTOOSS ONLY $ EACH OCCURRENCE $ UMBRELLA LIAB OCCUR N/A AGGREGATE $ EXCESS LIAB CLAIMS-MADE �/ $ DED I I RETENTION$ /�I STATUTE I I ERH WORKERS COMPENSATION 100 000 AND EMPLOYERS'LIABILITY Y I N E.L.EACH ACCIDENT $ ANYPROPRIETORIPARTNER/EXECUTIVE 09/23/2022 09/23/2023 E.L.DISEASE-EA EMPLOYEE $ 100,000 A (Mandatory in EREXCLUDEDZ I NIA I NIA NIA 6HUB6R08627422 in NH) If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) t to Work 'sr o benefit to iemployees nlstates of hed �thanan Massachusetts Massachusetts )f the insured hires,oyees only. nor h snh ed those employeedorsement WC 20 03s outtside of Massa6 B,no tchusettts. to pay claims f T is cate was ssued certificate of certificate of nsurahe nce)policy lcThe status of this coverage can befmonito monitored daily byunless the access accessing the)ration date on the Proof of Coverage above Coverage Verification he issue date of this ce Search tool at www.mass.gov/Iwd/workers-compensation/investigations/. CANCELLATION CERTIFICATE HOLDER ULD ANY OF HE DATTEVE DESCRIBED THEREOF, NOTICE ES WILL LE WILLCBECELLED DELIVERED BEFORE THE EXPIRATIONIN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouthport 1146 MA-28 AUTHORIZED REPRESENTATIVE MA 02664 � . South Yarmouth 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