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HomeMy WebLinkAboutBLD-23-001679 OFFICE/POOL •0 •YqR_, !Office Use Only / $ • 0 i I Permit# OP /c r) vb U - - y' •''' MATTACM ESE ' /IJ /j//� /� 13L�� �/ !Amount � 'aACotll to`gyp �f /` `� I \ I "` A �� I,�/Y^/ -- wl /Vi jPermit expires 180 days from i*"' ;issue date F r, cf2 1 f d/r- fi- ?E) O I (aw& j�.,Fi cl1 J C EXPRESS BUILDIN ERMIT APPLICAT .,_. _.___.._El V E D TOWN OF YARMOUTH I Yarmouth Building Department SEP 2 8 2022 1146 Route 28 South Yaiuuouth, MA 02664 1 By UT_ ARTMENT (508) 398-2231 Ext. 1261 • i ilP 1 ditl ,`,Z, CONSTRUCTION ADDRESS: 553 i` o v 1e 2 2 L�:/qr moo III , M A - O-2 673 . ASSESSOR'S INFORMATION: (j er''ARTt/ `-' 4TEO Map: Parcel: OWNER: "'1RIS1-I /ATE. /6di;r70i/er (e�tLar, Ai/Q,orol ~il- 02703 �I7-glg-$a37 , NAME PREVT ADDRESS TEL. # CONTRACTOR ; C/1 gel. r'l4npap/.0 1g '-I4lbe/te RI. 00rcz8fe," �,q-64o2 55 - `WI- /4-1-4 NAME MAILING ADDRESS ' TEL.# ❑Residential V&mmercial Est. Cost of Construction$ 57000 (4.c6or O4/, Home Improvement Contractor Lic.# Construction Supervisor Lic.# CS U 4 37 2-3 • Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor C I have Worker's Compensation Insurance Insurance Company Name'?/ease See Ate A tf1 cLuzot . Worker's Comp.Policy# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 8 Replacement windows: # 2. Replacement doors: # /0 0 9 cp 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)b Ca VoS59 asposJ t/ Locatlon of Facility I declare under penalties of perjury that the statements herein contained are true and con-ect to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or tion of my license and f prosecution under M.G.L.Ch.268,Section I. / Applicant's Signature: Date: q l /2g/2 2 • Owners Signature(or attachment) '4-.' . . Date: 9�-f EA.?2 . Approved By: Date: C•I `AA e ,'./1✓�t , . Buildin_ fficial(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes E No Flood Plain Zone: E Yes E No Water Resource Protection District: Within 100 ft. of Wetlands: Yes ❑ No C Yes C No ors.=.• ine Commonwealth of Massacnusetrs Department of Industrial Accidents =•u� � �,1_ 1 Congress Street, Suite 100 •=•a ` ' Boston, MA 02114-2017 -,�` www.mass aov/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): v4;) — ictc4es , Address: /d t148e f le S21-. . City/State/Zip: (t)orcoR{-fir 0 /602 Phone #: g - 76'2 - /4 L1, . Are you an employer?Check the appropriate box: Type of project(required): I.E I am a employer with employees(full and/or part-time).* 7. Li New construction 2.E I am a sole proprietor or partnership and have no employees working for me in 8. E Remodeling any capacity.[No workers'comp.insurance required.] 9. C Demolition 3, I am a homeowner doing all work myself. [No workers'comp.insurance required.]t 10 E Building addition 4.E I am a homeowner and will 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.E Electrical repairs or additions proprietors with no employees. • 12._Plumbing repairs or additions 5.X1 I 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.t 6.E We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E Other 152,§1(4),and we have no employees. [No workers'comp. insurance required.] *Any applicant that checks box Al 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. +n Insurance Company Name: 4 l Y Y inn`A-ki 0-32 _ Policy#or Self-ins. Lic. #: flL .`-t(7t7 3 Expiration Date: -7//q/oZ Job Site Address: P110 2_ 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 $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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true'and correct. Signature: Date: ,/.2-2 Phone#: 5-oR - et ..2 - /4-2.4 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 3. Plumbing Inspector 6. Other Contact Person: Phone#: ? jtfactu2P1 Cer . Commonwealth of Massachusetts Division of Professional Licensur€ Board of Building Regulations and Standards e /2$f2023 MICHAEL A MANEGGIO : At I 18 MABELLE"STREET" WORCESTERly1A 01602 Commissionor i 1e,o fi. iCy„+fa THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE Individual Registration Expiration • 108688` 08/20/2024 MICHAEL MANEGGIO D/B/A JAN-MICHAELS CONSTRUCTION MICHAEL A.MANEGGIO 50 MOLASSES HILL ROAD y i� G',i„ "f;a", 4 BROOKFIELD,MA 01506 Undersecretary 1 ,AC ®aRo CERTIFICATE LIABILITY INSURANCE DATE(M7NOWYYYY) 08/08/2022 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()es)must have ADDITIONAL INSURED provisions or be endorsed. if SUBROpATION 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 • CONTACT NAME: Mosarene Scalzer UNIVERSAL INSURANCE AGENCY PHONE _(E-MAILo, t); (508)752-9333 _ 11A No): _ 374 BELMONT ST ADDRESS: mscalzer@univorsaiinsagency.com_—_ WORCESTER --._ .._._. INSURER(s) .FFOROINGCOVERAGE NAIC# INSURED TER — ---------- wsuRERA AIM MUTUAL INS CO _-- ------— —_- 33758 INSURER 8: ORTEGA HOME IMPROVEMENT INC _- `-- INRERC:__ — -- - SU 22 CHURCH HILL ST APT 2 _INSURER D` -- — — MILFORD INSURER E_ MA 01757 INSURERF: -� COVERAGES CERTIFICATE NUMBER: 801912 REVISIN THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE OR-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—" rgGDL SUDR !TR TYPE OF INSURANCE I INSD WVp POLICY NUMBER POLICY EFF POLICY EXP '--` '---- -----._..__._ COMMERCIAL GENERAL LIABILITY (MM!DDfYYYY) (Mh1f00lYYYY) LIMITS EACH OCCURRENCE $ —�CLAIMS-MADE I-�1 OCCUR -t7AMA0E TO RENTED --- PREMISE§LEa occurrence)-. $ - — "-"�'-- - _ MED EXP(Any one person) $ —� N/A GEN'LAGGREGATE LIMIT APPLIES PER: PERSONAL B ADV INJURY $ -- -POLICY n E r]LOC GENERAL AGGREGATE $ OTHER: PRODUCTS-COMP/OP gGG $ AUTOMOBILE LIABILITY $ COMBINED SINGLE LIMIT $ ANY AUTO ,,(Ea a cki_enl) — OWNED —SCHEDULED BODILY INJURY(Per person) $� . AUTOS ONLY AUTOS N/A BODILY INJURY(Per accident) $ HIRED NON-OWNED __..._,AUTOS ONLY __"_ AUTOS ONLY PROPERTY DAMAGE —"—$ —'� (Per en!) __ UMBRELLA LIAB $ OCCUR EXCESS LIAB EACH OCCURRENCE $ CLAIMS-MADE N/A AGGREGATE $ DED RETENTIONS WORKERS COMPENSATION - $ AND EMPLOYERS'LIABIUTY PER OTH- ANYPROPRIETORIPARTNERIEXECUTIVE Y!N X_SLTl3TAC _LEA_ A OFFICERJMEMBEREXCLUDED7 IN,AI N/A N/A AWC40070370612022A 07/19/2022 07/19/2023 'E_-egal,iAcciDENT $ 1,000,000(Mandatary Is In NH) _. If yes,describe under EL.DISEASE-FA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 —�— N/A DESCRIPTION qF OPERATIONS!LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If mare 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 Michael Maneggio dba Jan-Michaels Construction ACCORDANCE WITH THE POLICY PROVISIONS. 18 Mabelle Street AUTHORIZED REPRESENTATIVE �— Worcester MA 01602 "' " `r•\ — Daniel M.Crawley,CPCU,Vice President—Residual Market—WCRIBMA I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD