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Home My WebLink AboutBLD-23-001720 ' C t )L e 4 11. b Office Use Only L y�i j 0 ' ..0i•YgR-, 4�U . 'C} Permit# O k 6' /Ai t Vie C' Amount SD oj •O -R+i ,Te .u�rr n s �. IL '� g. Permit expires 180 days from ��'" "` �" issue date l? u1) Z3 _66r7Zb EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department -- -1146 Route 28 SEP 2 9 2022 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT By: CONSTRUCTION ADDRESS: 15 Conservation Dr. Yarmouthport --- ASSESSOR'S INFORMATION: Map: 134 Parcel: 27 OWNER: John McBride 15 Conservation Dr 860-214-4980 NAME PRESENT ADDRESS TEL. # CONTRACTOR: Nickerson Home PO Box 2476 Orleans Ma 101/eI3508-240-3081 NAME MAILING ADDRESS TEL.# El Residential ❑Commercial Est.Cost of Construction$4575.00 133851 Construction Supervisor Lic.#101-185 Home Improvement Contractor Lic.# p Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor El I have Worker's Compensation Insurance Insurance Company Name: Aim Mutural Worker's Comp.Policy#VWC10060211892022A WORK TO BE PERFORMED Tent L Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:#1 Replacement doors: # Roofing: #of Squares (❑)Remove existing*(max.2 layers) Insulation I I I i 1 Old Kings Highway/Historic Dist. O Replacing like for like Pool fencing *The debris will be disposed of at: Daniels Recycling 7 Finlay Rd. Orleans, Ma 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. �` Date: 9/29/2022 � Applicant's Signature: '' _ °^ Date:see contract Owners Signature(or attachment) J C et��f ,A,Le.G l d Approved By: - _ Date: � . Building Officia r d ee) EMAIL RESS: Zoning District: Historical District: . Yes No Flood Plain Zone: - Yes = No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No 1 Yes 7 No $6f� Office Use Only Si:1E a- Permit 41011 c'. py i Amount !IC` «err In s Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 15 Conservation Dr. Yarmouthport ASSESSOR'S INFORMATION: Map: 134 Parcel:27 OWNER: John McBride 15 Conservation Dr 860-214-4980 NAME PRESENT ADDRESS TEL. # CONTRACTOR: Nickerson Home PO Box 2476 Orleans Ma Dole 3508-240-3081 aC m NAME MAILING ADDRESS TEL.# Residential 0 Commercial Est.Cost of Construction$4575.00 Home Improvement Contractor Lic.#133851 Construction Supervisor Lic.#101-185 Workman's Compensation Insurance: (check one) 0 I am the homeowner El I am the sole proprietor e I have Worker's Compensation Insurance Insurance Company Name: Aim Mutural Worker's Comp.Policy#VWC10060211892022A WORK TO BE PERFORMED Tent n Duration (Fire Retardant Certificate attached?) Wood Stove El Siding: #of Squares Replacement windows:#1 Replacement doors: # Roofing: #of Squares (❑)Remo a existing* (max.2 layers) Insulation I I R1 Old Kings Highway/Historic Dist. Replacing like Avs, ke PoolI fencing I . ,, W U� ► i\ ' I 1 tt. AIL /.)7 f a *The debris will be disposed of at: Daniels Recycling 7 Finlay Rd. Orleans, Ma 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: 9/29/2022 Owners Signature(or attachment) 1 ocikt?'a( vrfratt Date:see contract Approved By: Date: Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes :I No Flood Plain Zone: u Yes G No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No 0 Yes L No PROPOSAL MCAS: LLC . NIC.KERSON HOME IMPROVEMENT •ROOFING •SCREEN PORCHES•SECOND 508-240-3081 P.O.BOX 2476 • STORIES 508-255-5107 FAX ORLEANS,MA 02653 •DECKS •RENOVATIONS•ADDITIONS •INTERIOR/EXTERIOR PAINTING www,nickersonhomeimprovement.com •SKYLIGHTS •WINDOWS/D00RS E-Mail mark1202653@yahoo.com •GARAGES •KITCHEN Sc BATH REMODELING 12 Commerce 8e0 2 D rive ve0 pArE 6/3/22 f TO: John McBride Arrto G 15 Conservatin Drive JOB N me rO comcast.i; et Yarmouthport, MA 02675 S A M E JOB NUMBER j JOB PHONE We hereby submit specifications and estimates for: Remove and dispose of bay window on rear of building Supply and install 1 Anderson 400 series bay window with White exterior and interior,Low-E4 glazing,grills between the glass in all sashes,standard screens and hardware on double hung windows Install new AZEK exterior trim including soffit above window Supply new primed pine interior trim Supply all labor,material and debris removal estimated at Notes Projection estimated as 12.75 inches from siding out At final measure we will determine if a wider projection can be used We Propose hereby to furnish material and labor—complete in accordance with the above specifications,for t e d suns et ) Payment to be made as follows: `Deposit requested with signed proposal, progress payments on request balance on completion ck,__. as ed.All work to be completed in a professlonrcl C , � i^ 'Z mannerl material is guaranteed standard 1 � al�norde+dafonfromabovespecications Authorized axt rdc wit p written orders,and will become an extra Signature trtvatvthg extra costs will be executed only upon contingentreements strikes,accidents or charge delays over our contro Owner to carry d above the estknate.All fire,tornado,and therunececessary Insurance.Our Note:Tht roposai may be delays beyond tion Insurance. withdrawn by us if not accepted within 30 days. workers are fWly covered by Worker's Compensation Acceptance of Proposal—The above prices,specifications a',d conditions are satisfactory and are hereby accepted.You are authorized to do the work Signature as specified.Payment wilt be made as outlined above. `� A Signature -v")V1 , Date of Acceptance: lam" /(e 1 - — The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 14. Boston, MA 02114-2017 vt`''" www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (BusinessfOrganization/Individual): Nickerson Home Improvement Address: PO Box 2476 City/State/Zip:Orleans, Ma 02653 phone#: 508-240-3081 Are you an employer?Check the appropriate box: Type of project(required): 1.01 am a employer with employees(full and/or part-time).* 7. ❑New construction 2.01 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.❑I am a homeowner and will be hiring contractors to conduct all won:on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.QElectrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.0I 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.$ 14.❑Other 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 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: Aim M utu ra I Policy#or Self-ins.Lic.#: VWC 10060211892022A Expiration Date: 3/1/2023 15 Conservation Dr City/State/Zip: Yarmouthport Ma 02675 Job Site Address: tY p: 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 Signature: ` Date: 9/29/2022 Phone#: 508-240-3081 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#: • Commonweailtl of Massachusetts • itDivision of Professional Licensure Board of Building Regulations and Standards ConstructiWegtigine3r Speeielty - CSSL-101185 pires:1012812023 MARK D NICKERSON :-! 7 PO BOX 2476'. , . ORLEANS MA:02653 : f a Commissioner dt# fi. 'Cov_ f• p517 1C2 c00-221/MO-I iwV'ea/t 0-1, � Cleid fJCi t/J'JUa 632' Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston, Massachusetts 02116 Home Improvement:,Gontractor Registration .--7 �" 1 _ ,, Type: LLO ^'''- `. -; is Registration: 133851 = '- b , N Expiration: 43020 MCAS LLC = D/B/A NICKERSON HOME IMPROVEMENT _ '--F PO BOX 2476 ;,'!• '',, �'" ORLEANS,MA 02653 ._ ,? =;, ;.,.ram:- Update Address and return card. Mark reason for change. .". ri C.w-'-.'-.a ' r i i net*.PaNi SCA 1 Co 20M-05111 - ACCP O CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) `...�� 03/11/2022 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 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 CONTNAME:ACT Rogers and Gray Processing BALDWIN KRYSTYN SHERMAN PARTNERS LLC INC, Ext): (508)398-7980 FAX (A/C,No): ADDRESS: mail@rogersgray.com 4211 West Boy Scout Blvd Suite 800 INSURER(S)AFFORDING COVERAGE NAIC# Tampa FL 33607 INSURER A: AIM MUTUAL INS CO 33758 INSURED INSURER B MCAS LLC INSURERC: NICKERSON HOME IMPROVEMENT INSURERD: P O BOX 2476 INSURER E ORLEANS MA 02653 INSURER F: COVERAGES CERTIFICATE NUMBER: 752602 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 ADDL SUBR POLICY EFF POLICY EXP TYPE OF INSURANCE INSDW VD POLICY NUMBER LIMITS (MM/DDIYYYY) (MM/DD/YYYY), COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO RENTED $ CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ __ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED I SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER OTH STATUTE AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBER EXCLUDED? N/A N/A N/A VWC10060211892022A 03/01/2022 03/01/2023 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensation/investigations/. 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 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 Daniel M.Crowley,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD