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HomeMy WebLinkAboutBLD-23-001612 RECEIVED o Y R SEP 2 6 2022 Office Use only 0 y H BUILDING DEPARTMENT Amount b V 'tiwnno« Permit expires 180 days from issue date 131, Z3 --00910IZ EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH G ) 2 Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: _IA JA [��( F"G IJ t� R� S.cr RV c 1 H ASSESSOR'S INFORMATION: g Map: Parcel: OWNER: S(,Je 16iki Po coel NAME PRES T ADDRESS TEL. # CONTRACTOR: Csj (11-- d c? GE,N 1t S G a vw v - u J^la J-ri-k ,5c23(r-3-L-,© NAME MAILING ADDRESS TE ❑Residential ❑Commercial f Est.Cost of Construction$ 6-f C7C), CyG Home Improvement Contractor Lic.# c C)_L )-L Construction Supervisor Lic.# G5—_( 1 ,4g, 146 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 'N I have Worker's Compensation Insurance t� / Insurance Company Name: al. f e K' \ Worker's Comp.Policy# WORK TO BE PERFORMED n Tent L Duration (Fire Retardant Certificate attached?) Wood Stove I I Siding: #of Squares ' Replacement windows:# Replacement doors: # Roofing: #of Squares (n)Remove existing*(max.2 layers) Insulation I I Old Kings Highway/Historic Dist. (0)Replacing like for like Pool fencing 17 *The debris will be disposed of at: 1a kW'.Q i)T rl P V S) 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: 09 Jc2-1.- Ic2U c2t .t...vGy Date: &9/a V/LC_ 2v2 Owners Signature(or attachment) � � Approved By: Date: 9 Building Official(or desi EMAIL ADDRESS: Zoning District: Historical District: E Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No ,4 DATE(MMIDDIYYYY) o CERTIFICATE OF LIABILITY INSURANCE 09/14/2022 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). PRODUCER CONTACTNAME: BIBERK PHONE 844-472-0967 I FAX 203-654-3613 P.O. Box 113247 (A/C.No.EM): 1(A/C,No): E-MAIL customerservice@biBERK.com Stamford, CT 06911 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# ��yygg INSURER A: Wd National Liability&Fire Insurance Company 2UU52 lacl Machado INSURER B: INSURER C: 193 camp st apt j5 INSURERD: I West Yarmouth, MA 02673 INSURERS: I INSURER F: 1 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. INSR I IADDL SUBRI I POLICY EFF 1 POLICY EXP ' LIMITS LTR TYPE OF INSURANCE LINSD WVD I POLICY NUMBER 1(MMIDDIYYYY)'(MMIDDIYYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1$ 0 1 DAMAGE TO RENTED 0 CLAIMS-MADE L ';OCCUR j PREMISES(Ea occurrence) $ 1 MED EXP(Any one person) $ 0 PERSONAL&ADV INJURY i$ 0 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 0 I POLICY JE� LOC ( PRODUCTS-COMP/OPAGG $ 0 I $ I OTHER: COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED 'SCHEDULED 1 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS I HIRED I NON-OWNED I PRO(PerPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY $ dent) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1 EXCESS LIAB i I CLAIMS-MADE I AGGREGATE $ I 1 I 1 DED I I RETENTION$ I $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS LIABILITY Y/N STATUTE I ER A IANYPROPRIETOR/PARTNER/EXECUTIVE N NIAI N9WC772492 09/09/202209/09/2023 E.L.EACH ACCIDENT $100,000 �OFFlCa ory in ER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $100,000 (Mandatory in NH) If yes,describe under 500 000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ r Professional Liability (Errors& Per Occurrence/ Omissions): Claims-Made 1 Aggregate I 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 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Walaci Machado ACCORDANCE WITH THE POLICY PROVISIONS. 193 camp st apt j5 West Yarmouth, MA 02673 AUTHORIZED REPRESENTATIVE r '', , ° ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD glc The Commonwealth of Massachusetts .. .....�, Department of Industrial Accidents j Office of Investigations • ;:,Ni' 600 Washington Street " S'11:71.— " Boston,hA4 02111 ���.. www.mass.gov/din • Workers' Compensation Insurance Affdavit: Bullders/Contractors/EIectricianc/Plumbers Applicant Information Please Print Leuib v Name(Business/Organization/Individm1): Address:-i..9 G a vv.‘r S T 1%Er `J21 City/State/Zip:� c Phone#: ILL Are you an employer? eck the appropriate bon • _ Type of project(required): . - 4. 0 I am a general contractor and I 1. I am a PmPloyea with_ ___...__ _ 6. Q New contraction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. Q Remodeling ship and have no employees These sub-contractors have g. 0 Demolition d have workers' an working for me in any capacity. employees9. Q Building addition [No workers'comp.insurance comp.insurance.: 5. We are a corporation and its 10.Q Electrical repairs or additions required]3.Li I am a homeowner doing all work . officers have exercised their 11.0 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required..]t c. 152, §1(4),and we have no 13 ❑ —- —employees.-P.To-workers'- --- -- comp.insurance required.] ®_•,, *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. •l t Homeowners who submit This affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sob-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: t, ?. e'Rtc p Policy#or Self-ins.Lic.#: NI `I�GI i ail 3c Expiration Date: o /os I a(3a Job Site Address:- :1_ LT tom+ 1�R. Cty/ zP: S.`l a vi*a U i % Attach a copy of the workers'coin ensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties inure form of a STOP WORK ORDER and a fine of up to$250,00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. _ TM_ I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Si—attire: p iv-4......„- --, .. :, Date: 09' I di IcL Phone#: v c1 • C ra c-.---G _ Official use only. Do not write in this area,to be complinPd by city or town offuial 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#: Commonwealth of Massachusetts ? Division of Occupational Licensure Board of Building Re ulations and Standards Const tOI1TS rvisor CS-116646 E`i;pires: 12/29/2025 WALACI P M*CHADO 193 CAMP STY , APT J5 WEST YARMO'JTH MA 02673 Commissioner <. . Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration 201015 02/22/2023 WALACI PEREIRA MACHADO WALACI MACHADO 193 CAMP ST APT J-5 ;/e; j`4 WEST YARMOUTH,MA 02673' Undersecretary Registration valid for individual use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 1000 Washington Street -Suite 710 Boston,MA 02118 Not valid without signature