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HomeMy WebLinkAboutBLD-23-001527 Pt 4')2 zI e2 1 Office Use Only O�.YAR`7 I Permit# j (.� 11) Amount `c' MATrI.Cr1 e,f; {Permit expires 180 days from �O"�°RAl{0a�'Cad issue date 13 LA) -9.3 -Otir.3 ,7 EXPRESS BUILDING PERMIT APPLICATI i V p TOWN OF YARMOUTH — -�---- Yarmouth Building Department SEP 2 ��22 1146 Route 28 South Yarmouth, MA 02664 BUILDING DEPARTMENT (508) 398-2231 Ext. 1261 ay _ ---- 14. 's/4 CONSTRUCTION ADDRESS: ki fop rs 6°Preen i 553 So 0 ft428, Y a , ASSESSOR'S INFORMATION: >;'r(gIcfien P a r4 't Pei. gMap: Parcel: O\ ER: E" IS PO 61- 6C JelliliFe Ir 1elk, Dr! Atik el.or0 11- 211-903 NAME PRESENT ADDRESS M A) o zi 03 TEL. # � ) M®re. DV) CQ>n 11 " .7 CONTRACTOR: �' NAME goin po lo n MAILING ADDRESS 02 TEL.# Commercial /1/)5-g Est. � loft 0 Residential Cost of Construction$ r Home Improvement Contractor Lie.# . i + 0 •' Construction Supervisor Lic.# p td34ifr Workman's Compensation Insurance: (check one) I] I am the homeowner D I am the sole proprietor �I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED f 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: 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 arid"` cation of my license and for prosecution under M.G.L.Ch.268,Section 1. :" Date: l ° /ate Applicant's Signature: ^ Owners Signature(or attachment) Date: .� Approved By: / Date: '✓ - ''L Building ial esignee) EMAI DRESS: Zoning District: Historical District: a Yes C No Flood Plain Zone: C, Yes 2 No Water Resource Protection District: Within 100 ft. of Wetlands: ❑ Yes ❑ No G Yes 2 No Department of Industrial Accidents aft= 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.nnas's.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): C-j.s T-L M Rr Ny�AI-i a S Q�`c-�;�f d N Address: D ie City/State/Zip: 3AoGU s OA O I9Uld Phone #: `7 1?'( • 2.3 ( • SL`( S•S Are you an employer? Check the appropriate box: Type of project (required): I am a employer with employees(full and/or part-time).* 7. E New construction 2' I am a sole proprietor or partnershipand have no employees working for me in g•;_( P P �" 8. Remodeling any capacity.[No workers'comp. insurance required.] 9. Demolition 3.�I am a homeowner doing all work myself. [No workers'comp.insurance required.] 10 Building addition 4.[1:1 I am a homeowner and win 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-contactors listed on the attached sheet13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance: 5. We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] 'Any appl icant that checks box nl must also fill out the section below showing their workers'compensation policy information. 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: C /A friA 4 c /h Policy#or Seli ins.Lic.#: Expiration Date: Job Site Address: 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 51,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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 nde i 4naities of perjury that the information provided above is true and correct. Signature: Date: Phone#: T R-b• Z 3 I • 5-4-( �; 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. ElectricaI Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: co Ar CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) l r, 09/13/2022 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). CONTACT Emily LeBlanc PRODUCER NAME: Cross Insurance-Wakefield PHONE (781)914-1000 FAX,No: (781)224-5777 (A/C,No,Ext): ( ) 401 Edgewater Place Suite 220 ADDRESS: emily.leblanc@crossagency.com INSURER(S)AFFORDING COVERAGE NAIC# Wakefield MA 01880 INSURER A: Selective Insurance Co.of SC 19259 INSURED INSURER B: Custom Renovation Services Inc INSURER C: 1 Foliage Drive INSURER D: INSURER E: Saugus MA 01096 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2231889978 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. ADDL SUBR POLICY EFF POLICY EXP INSR LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 500,000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 15,000 A S2377948 11/20/2021 11/20/2022 PERSONAL&ADVINJURY $ 1,000'000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X PROT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 JEC OTHER: AUTOMOBILE LIABILITY Ea aBINEDtSINGLE LIMIT $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ A OWNED X SCHEDULED A9107394 11/20/2021 11/20/2022 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS PROPERTY DAMAGE HIRED X AUTOS ONLY (Per(Per accident) $ X AUTOS ONLY $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS-MADE S2377948 11/20/2021 11/20/2022 AGGREGATE $ 5,000,000 DED X RETENTION $ O $ WORKERS COMPENSATION X STATUTE ER AND EMPLOYERS'LIABILITY YIN 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE NIA WC9082496 03/23/2022 03/23/2023 E.L.EACH ACCIDENT $ A (Mandatory in 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Evidence of Coverage Only CERTIFICATE HOLDER CANCELLATION ISHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Evidence of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE "1-- 1 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD THIS COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation 47040. HOME IMPROVEMENTcONTRACTOR TYPE11t ual,:, Rea ;i..e + 1l15ii . 024 JOHN G,DILLON A xx JOHN G.DILLON 7 1 FOLIAGE DR. ;i , j.4;4r t" Mitiintti SAUGI!S,MA 01906 ' . L1nders cretary Commonwealth of Massachusetts Division of Professional License e AppogYr Board of Bu!ding Regulations and Standards C G_ £ff3faf Expires: 3gft3rt JOHN G D1LLC N 9 SHORE DRi1 E �� 9,10.01' CANTON MA r1201-__ ` ,fittaitsiiiiilitiiii 6, `w.* f o.g.istr:atd<sn vatto for indtvldttal use on! gz exX rratian date. Xf found return tn: Qft7ce of ty Y e3rsvrr f-i:e f00n ontsuntsrgffalrs suite 7/sdtaes e axX74ian Boston,/WA 0 11 itreet •uudte 710 MA 0 #f1X I if) 0L t C f 3' Construction Sup ervisor 4,4 ; Unrestricted-Buildines of any use group which contain ,1 less than 35,000 cubic Feet(991 cubic meters)of enclosed space. INN Failure to possess a cuircnt edition of the Massachusetts WItiti State Building Code is cruse for revocation of this license ledr,i4 tore For intarrnatiun about this license Call(617)727-320C or visit www.Xraass,govv`dpi in;