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HomeMy WebLinkAboutBLD-23-001295 Lin q hz im, !Office Use Only -,,,,.., 4k. • ..-.. 0 Pertnit-# by.# )6,i5 110,4t0+4.0041;ct, ;Permit expires 180 days from issue date 131--i) - e3 -61)1245 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH r Yarmouth Building Department IRECEIVED 1146 Route 28South Yarmouth, MA 02664 1 SEP 09 2022 (508) 398-2231 Ext. 1261 A UILDING DEP ARTMEN tXONSTRUCTION ADDRESS: 33 -1 .-r ?-ric 0 - cfLAAAA:, "-Ai,4A,--- it-1 F-N °Y T i ASSESSOR'S INFORMATION: Map: 3(4 I Parcel: q 3 1 , OWNER: a c9 C Lk C 6-1\4tit,.) L,te,..C. 1"k-AW INN.0;s vs, - N:1.-i••:•.,5 ,1/4.41\ 3D't -ILA t-5.?IA NAME ' PRESENT ADDRESS TEL. # R b dc. IrS, 6 oil._ .) iti A Yt--eQ 0 vXONTRACTOR. 0 -C. 1/44._ ,..—..... .)....1.- 4.A.,....-- _ j .. „01.,..pvirvILL 4 tvA NAME ' MAILING ADDRESS ta # .5-0 P 556 0 Residential 1,1..e‹--/runercial Est.Cost of Construction S d7°f 0 0 0 i....•••• Home Improvement Contractor Lie.# Construction Supervisor Lie.#CZ'CPI--aco I Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 111/(have Worker's Compensation Insurance Insurance Co.mpany Narrie: r 1 c rvtavi`..s *7-1:vt c.. Co. e...i -c „E_.--,.._ Worker's Comp.Policy# il\ M 0.3 I(.,,.7 til WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Viding: #of Squares .2.(. > vItaacement windows:# q tygiament doors: # ,..aoofing: #of Squares 3 0 ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: rYS. CVC.-0 i , , i A 1 Location of Facility I declare under penalties of perjury th. the statements herein contai4 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 r el a,' n cf my license. 41 pr•;, •tion under M.G.L.Ch.268,Section 1 IVApplicant's Signature: lb I ' Date: 9).-) 1 Za L22"wners Signature(or attachment) 0 P/3111‘?61 141--- Date: 9- i- 2-Z. Approved By:By: Date: Building Offic or d e EMAIL ADD- . Zoning District: I DO — Historical District: 0 Yes 72 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No N. Commonwealth of Massachusetts I 9) ula Division of P Regulations n ons ad Standards Board of Building } visor Consti!it N�pires:06/03/2023 CS-092761 ABIGAIL O ROSE -- 24 GREAT WESTERN ROAD HARWICH MA 02645 Commissioner u,c. mil&disk.- Construction Supervisor Unrestricted -Bui(tlings of any use group which contain less than 35,000 cubic feet(991 cubic meters) of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Call(617)727-3200 or visit www.mass.gov/dpl o • x EAST ROUTE 28 MAi 2 "."--LOCUS LOCA11ON MAP STATE HIGHWAY - ROUTE 28 '59.24• _ .00; a. • 1 h c hew . Oc O / , , I ' 'tl k ''' -3F-----------(— '''' t•It` r J / - //¢ IAn - i / 4 2 i" / IQ 4ti{ Al. t p l'S Q \ e'(,, �I 1;/ q� ��r 1 1 R i HI ,,} - 1r 1 1:/ 1 r PLAN OF LAND IN WEST YARMOUTH, MASSACHUSETTS t 1 f/' AS PREPARED FOR / DRIVE—0—RAMA, INC: `3'¢i?A•- SCALE 1' = 30' MAY 4, 1498 ,.,,, j/� / / 0 15 30 60 90 120 t J/; ` f — i r SWEETSER ENGINEERING I� J( \,is • 235 GREAT WESTERN ROAD 7 i `' P.O. BOX 713 /// / SOUTH DENNIS, MASS. / s 02660• FAX (508)9398 53063 415 6-0 0 AGENCY CUSTOMER ID:ROBEBOU-01 MVERTENTES ACORE Loc#: 0 ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY License#1780862 NAMED INSURED HUB International New England Robert B Our Co.,Inc. POLICY NUMBER 24 Great Western Road P.O.Box 1539 SEE PAGE 1 Harwich,MA 02645 CARRIER NAIC CODE SEE PAGE 1 SEE P 1 EFFECTIVE DATE: ADDITIONAL REMARKS SEE PAGE 1 THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance ***Additional Policies*** Contractors Pollution Carrier: Illinois Union NAIC#33667 Policy#CPYG27416676004 Term: 12/01/2021-12/01/2023 $2,000,000 Each Occ/$2,000,000 Aggregate- Motor Truck Cargo Acadia Insurance Co Policy#CIM5182149 term: 12/01/2021-12/01/2022 Limit$500,000 Per Conveyance Installation Floater Acadia Insurance Co Policy#CIM5182149 term: 12/01/2021-12/01/2022 Limit$300,000 Per Jobsite Deductible$5,000 Professional Liability Ironshore Specialty Insurance Co Policy#DCP7BABOPFQ002 term : 12/01/2021-12/01/2022 $2,000,000 Each Claim/$2,000,000 Aggregate ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AC w ROBEBOU-01 MVERTENTES 41011.... CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/30/2021 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 License#1780862 CONTACTNAME: Catherine Lawrence HUB International New England PHONE 222 Milliken Boulevard (A/C,No,Eat):(508)235-2207 I FAX Fall River,MA 02721 E-MAILES (A/C,No): ADDRS:catherine.Iawrence@hubinternational.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Firemen's Insurance Company of Washington,D.C. 21784 INSURED INSURER B:Acadia Insurance Company 31325 Robert B Our Co.,Inc. 24 Great Western Road INSURER C:Navigators Insurance Company 42307 P.O.Box 1539 INSURER D: Harwich,MA 02645 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 CONTRACTOR 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 SUER LTR TYPE OF INSURANCE INSD VD POLICY NUMBER POLICY EFF POLICY EXP W A (MM/DD/YYYY) IMM/DDlYYYYI_ LIMITS X COMMERCIAL GENERAL LIABILITY _ CLAIMS-MADE X OCCUR EACH OCCURRENCE $ 1,000,000 X CPA1301428-30 12/1/2021 12/1/2022 DAMAGETO(Ea NT Dnce) $ 1,000,000 MED EXP(Any one person) $ 20,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY JECT LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: A AUTOMOBILE LIABILITY $ COMBINED SINGLE LIMIT 1,000,000 X ANY AUTO (Ea accident) $ OWNED MAA1301440-30 12/1/2021 12/1/2022 BODILY INJURY(Per person) $ AUTOS ONLY SCHEDULED AUTOS HIRED NON-OWNED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE (Per accident) $ B X UMBRELLA LIAR X OCCUR $ EXCESS LIAB CLAIMS-MADE CUA 5460543-11 EACH OCCURRENCE $ 7,000,000 12/1/2021 12/1/2022 DED I I RETENTION$ AGGREGATE $ A WORKERS COMPENSATION aggregate $ 7,000,000 AND EMPLOYERS'LIABILITY X PER OTH- ANYPROPRIETOR/PARTNER/EXECUTIVE1/1/2023 STATUTE ER YIN WPA0316767-22 1/1/2022 OFFICER/MEMBER EXCLUDED? N N/A E.L.EACH ACCIDENT $ 500,000 (Mandatory in NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 500,000 DESCRIPTION OF OPERATIONS below C Commercial Umbrella GA21EXC8887101V E.L.DISEASE-POLICY LIMIT $ 500,000 12/1/2021 12/1/2022 each occ/aggregate 9,000,000 B Equipment Floater CIM5182149-17 12/1/2021 12/1/2022 Each occ/aggregate 500,000 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 Town of Yarmouth. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1146 Route 28 ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE I 1�`s •7 ACORD 25(2016/03) 1988-2015 The ACORD name and logo are registered marks of ACORD CORPORATION. All rights reserved. ACORD