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HomeMy WebLinkAboutBLD-23-002620 0 1 :7 /1 ,�` tin /.��-,l n Office Use Only wC‘ (' l�/, 1 /I I I U IG/L Pennit# //--�� (0 y Amount 5V J " NATrA N LS "`°" `°"A��d Permit expires 180 days from issue date BCD—023-15o ECEIVED EXPRESS BUILDING PERMIT APPLICATI it TOWN OF YARMOUTH ; . i ' ";"ya Yarmouth Building Department 1146 Route 28 i ' •it -' T South Yarmouth, MA 02664 '��s (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 6&8 Gilbert Street, South Yarmouth, MA 02664 ASSESSOR'S INFORMATION: Map:25 Parcel: 325 ()INNER: Stephen Zaimes 3 Wendy Way, West Dennis 781.367.0663 Cl 7t- M-033 NAME PRESENT ADDRESS TEL. # CONTRACTOR: Ilya Laverenov 13 Birch Street, Hyannis, MI 508.360.2754 t// NAME MAILING ADDRESS TEL.# 0 Residential 0 Commercial Est.Cost of Construction$2,800 Home Improvement Contractor Lic.#198803 Construction Supervisor Lic.#CS-107181 Workman's Compensation Insurance: (check one) El I am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: NGM Insurance - Travelers Worker's Comp.Policy#7PJUB6R08057122 WORK TO BE PERFORMED (� Tent LI Duration (Fire Retardant Certificate attached?) Wood Stove I. I Siding: #of Squares Replacement windows: #4 Replacement doors: #4 Roofing: #of Squares (❑)Remove existing*(max.2 layers) Insulation 11 nOld Kings Highway/Historic Dist. (0)Replacing like for like Pool fencing *The debris will be disposed of at: Coastal Waste Management 129t Sheliback Way, Mashpee, MA 02649 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: D . Owners Signature(or attach ent) C Date: 11/9/202 /%14=--2-2 Approved By: Date: ui g O icial(or designee) r MAIL ADDRESS: Zoning District: Historical District: L; Yes No Flood Plain Zone: Yes C No Water Resource Protection District: Within 100 ft.of Wetlands: Yes .7 No L Yes L' No • The Commonwealth of Massachusetts Department of Industrial Accidents /s moo; 1 Congress Street,Suite 100 Boston, MA 02114-2017 www.tnaS,4.g o v/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le2ibly Name (Business/Organization/Individual): A-Grade Exterior Address: 13 Birch Street City/State/Zip:Hyannis, MA 02601 Phone#: 508.360.2754 Are you an employer?Cheek the appropriate box: Type of project(required): t.❑1 am a employer with employees(full and/or part-titre),' 7. New construction 2.111 am a sole proprietor or partnership and have no employees working for me in S. ®Remodeling any capacity.[No workers'comp insurance required.] 9. 2 Demolition 3.01 am a homeowner doing al:work myself.[No workers'comp.insurance required.]t 10 Li Building addition 4.Ei am a homeowner and will be hiring contractors to conduct all work on my property. I will I ensure that all cons actors either have workers'compensation insurance or are sole 11.®Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.01 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? I4.[Other 6. We are a corporation and its officers have exercised their right of exemption per MGL c. 152,31(4),and we have no employees.[No workers'comp_insurance required.] *Any applicant that checks box r I must a:so 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. '-Contactors that check this box must attached an additional sheet showing the Tame 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 Narne: NGM Insurance -Travelers Policy#or Self ins.Lic.4:.7PJUB6R08057122 Expiration Date: 09/23/23 Job Site Address:6&8 Gilbert Street City/State/Zip: South Yarmouth,MA 02664 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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 1250.00 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. (do hereby certify under the in;aid pe► es of perjury that the information provided above is true and correct. Signature: Date: 11/9/2022 Phone#: 781.367.066 Official use only. Do not write in this area,to be completed by thy or town official City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone 4: AcDATE(MMDDIYYYY) A,.. CERTIFICATE OF LIABILITY INSURANCE 11/07/22 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 N OMA cr JIMMY HINDMAN PHONE 508-771-8381 FAX (A/C,No): 508-771-0663 Schlegel&Schlegel Ins Broker 34 Main Street (AICE-MAIL.No,EMI: ADDRESS: schlegelinsurance@gmail.com West Yarmouth,MA 02673 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: NGM INSURANCE 14788 INSURED INSURER B: TRAVELERS ILYA LAVRENOV INSURER C: DBA A GRADE EXTERIOR SOLUTIONS INSURER D: 393 BUCKSKIN PATH INSURER E CENTERVILLE,MA 02632 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. IPOLICY EFF POLICY EXP NSR TYPE OF INSURANCE INSD WVD ADDLSUBR POLICY NUMBER (MM DDIIYYYY) (MM DDIYYYY) 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) $ 10,000 A MPT7484M 02/18/22 02/18/23 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO LOC PRODUCTS-COMPlOPAGG $ 2,000,000 POLICY JECT $ OTHER: COMBINED SINGLE LlM1T AUTOMOBILE LIABILITY (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ (Per accident) AUTOS ONLY AUTOS ONLY $ UMBRELLA LIAB — OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ $ DED RETENTION$ PER OTH- WORKERS COMPENSATION STATUTE ER AND EMPLOYERS'LIABILITY Y/N 1 OO,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ B OFFICER/MEMBER EXCLUDED? Y N!A 7PJUB6R08057122 09/23/22 09/23/23 E.L.DISEASE-EA EMPLOYEE $ 100,000 (Mandatory In NH) If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) ILYA LAVRENOV HAS ELECTED NOT TO BE COVERED UNDER HIS CURRENT WORKERS COMPENSATION POLICY INSURANCE COVERAGE IS LIMITED TO THE TERMS,CONDITIONS,EXCLUSIONS,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 ACCORDANCE WITH THE POLICY PROVISIONS. TOWN OF YARMOUTH BUILDING DEPARTMENT AUTHORI D RE ESNTATIVE"" YARMOUTH MA I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts :VicDivision of Professional Licensure Board of Building Regulations and Standards Co nstruttioeSnpervisor Expires:0512712023 CS 107181 u I . ILYA LAVRENOV 0 I ` 13 BIRCH STREET .-t HYANNIS MA-.92601 i Commissioner t'. i 'C R U E m c a . m O =C7N co m °� d g ocosi m .n cc 3 I-- -o a c c W O ao �� h ti D � 0 Too 3i�m I fn ti rn I- P. �� �� _ U N Nr N p _ c Q � p y= Eck > To m N m $- d m c wo o. LL 0 a IL) cri C ,.cUm0 a >' Z min V O 020 `;, `� _ uii � 6�Or61 w Pifl 3 1 - c > 0 cOm aQ OUr" U E c� a W O = w +r U a)O¢= 0 0 . . ., -3- talicl1._ 0 tpNZ_rn az m .m V-a xm LLdil-">W0 o O 01 . >tuo -I= uia.. c Zrn2w a a >a atu . U�go cc w m ZEa n QmQ 0 0 z 0wet JCr�= W a) w WN2 =.0 > jSci 5 cc-1Z .-_