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HomeMy WebLinkAboutBLD-23-003541 LOBBY - Y 1 Office Use Only `G ' ARC ( IZ13112 yam* ,�. j Permit# /G/.�V • 0 OU. - H ,Amount a t MATTAGM ESE x0„,.,,or'end iPermit expires 180 days from issue date t31, 17 . 3--eo 5 5q i EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department RECEIVED 1146 Route 28 South Yarmouth, MA 02664 DEC 29 2022 (508) 398-2231 Ext. 1261 — _ \ `�I^, fir/(^' BUILDING DEPARTMENT Z ` �+�7 1` Ott �S By '. CONSTRUCTION ADDRESS: ASSESSOR'S INFORMATION: I—+0 50iC� ' l�Dbbg Map: Parcel: p r ,\ OWNER: ,.. � ` 1 ^ 'osoesnenA- �(� �J6i LI 0 W•`3Osmcih NAME PRESENT ADDRESS TEL. # CONTRACTOR: \O - Z•WC CO- . .nC, 24G-IC'8)-3,t- WC�t-erl1 Tiff haxw:'ci oefog a �5c30 NAME MAILING ADDRESS TEL.# ❑Residential C3.f,ommercial Est. Cost of Construction$ /POD°.O? Home Improvement Contractor Lic.# Construction Supervisor Lic.# C-Z— ©C Z ,Crz1 Workman's Compensation Insurance: (check one) 0 I am the homeowner ❑ I am the sole proprietor i/have Worker's Compensation Insurance Insurance Company Name: wub Ir)%e O 1 A)e.uD Worker's Comp.Policy# L)3 pA Q-2)1 C07C0-1-2,3 '.n 1ond WORK TO 1 PERFORMED -TJV 12 4 0 it-- 2 0.1 0 Tent Duration (Fire Retardant Certificate attached?) Wood Stove • Siding: #of Squares Replacement windows: # Replacement doors: # 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: t 1 1 O Y 1 Gil + ,/i��1��C�1`/� S+z& ii V Location of Facility I declare under penalties s pe, �j the st. e ents 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 de r:.ion of y icense and for prosecution under M.G.L.Ch.268,Section 1. e (Z\ZtI1 Applicant's Signature: ► Date: Owners Signature(or attachment) Date: 1—&1 ZZ''ZZ Approved By: Date: /L 2 9 2—� Building Offici. -or de1, ee) EMAIL ADD S : Zoning District: Historical District: ❑ Yes I No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft. of Wetlands: ❑ Yes 0 No 10 Yes ❑ No Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards ConsiructIbtitAt p visor CS-092761 expires:06/03/2023 ABIGAIL O ROSE ` g�r� 24 GREAT WESTERN ROAD � HARWICH NIA'02645 Commissioner � r CJitut% tl�rmtL,c�, Construction'supervisor Unrestricted.-Buildings of any use group which contain less than 35,000 cubic feet(991 cubic meters)of enclosed space. • Failure to possess a current edition Masshu State Building Code is cause for revocationofthe of thisac licenssettse. For information about this license Call(617)727-m200 or visit www.mass.govidpl • ��,...,.,41 ROBEBOU-01 MVERTENTES aCORCr CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) �--- 11/3012022 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 CONTACT Catherine Lawrence NAME: HUB International New En land PHONE A/C,No): FAX 222 Milliken Boulevard g (A/C,No,Ext):(508)235-2207 Fall River,MA 02721 E-MAILSS:catherine.lawrence@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. INSURER C:Navigators Insurance Company 42307 24 Great Western Road 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 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 LIMITS LTR TYPE OF INSURANCE INSD MD POLICY NUMBER IMM/DDIYYYY) IMMIDD/YYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR X CPA1301428-32 12/1/2022 12/1/2023 DAMAGEair:C it 1,000,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 20,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: 2,000,000 POLICY f X PRO-CT X LOC PRODUCTS-COMP/OP AGG $ JE OTHER: $ COMBINED SINGLE LIMIT 1,000,000 A AUTOMOBILE LIABILITY (Ea accident) $ X ANY AUTO MAA1301425-31 12/1/2022 12/1/2023 BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ HUTOS ONLY NON-OWNEDAUTOS PROPERTY DAMAGE HIRED UOS (Per accident) $ AUTOS ONLY — AUTOS ONLY $ B 1 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 7,000,000 EXCESS LIAB CLAIMS-MADE CUA 5460543-12 12/1/2022 12/1/2023 AGGREGATE $ 7,000,000 DED RETENTION$ _ $ A WORKERS COMPENSATION EMPLOYERS'LIABILITY X STATUTE EORH AND YIN WPA0316767-23 1/1/2023 1/1/2024 EL EACH ACCIDENT $ 1,000,000 'ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N . . 1 000000 N/A(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1 000 000 1 If yes,describe under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below C ICommercial Umbrella GA22EXC8887101V 12/1/2022 12/1/2023 each occ/aggregate 9,000,000 B Equipment Floater CIM5182149-18 12/1/2022 12/1/2023 Each occ/aggregate 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Re:Trenching Permit Certificate holder is named as additional insured. 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 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE 9,,,,,? 7-.4---79-- 1 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID:ROBEBOU-01 MVERTENTES r+■� LOC#: 0 ACClRQ ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY License#1780862 NAMED INSURED HUB International New England Robert B Our Inc. 24 Great Western Road POLICY NUMBER P.O.Box 1539 Harwich,MA 02645 SEE PAGE 1 CARRIER NAIC CODE SEE PAGE 1 SEE P 1 EFFECTIVE DATE:SEE PAGE 1 ADDITIONAL REMARKS 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#CIM518214918 term: 12/01/2022-12/01/2023 Limit$500,000 Per Conveyance Installation Floater Acadia Insurance Co Policy#CIM518214918 term: 12/01/2022-12/01/2023 Limit$300,000 Per Jobsite Deductible$5,000 Professional Liability Ironshore Specialty Insurance Co Policy#DCP7BABOPFQ003 term : 12/01/2022 12/01/2023 $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 ' The Commonwealth of Massachusetts . 1 ;}, _ /, Department of Industrial Accidents wi"'' 1 Congress Street, Suite 100 Boston, MA 02114-2017 o,M 5�,,, www.mass.gov/dia MP Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): 1))M .Nc\---13 - dLY- C c ` -Y ) C• Address: -1 eP�� W \-e.)-'n Tit City/State/Zip: k'�('`�.\ A" \�'1l 11-)(j�,S c - S Phone #: ��� - 432' c 3C Are you an employer?Check the appropriate box: Type of project(required): 1.11714 am a employer with 1 employees(full and/or part-time).* 7. New construction 2.D I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. 1.Demolition ` 3. I 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 work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions proprietors with no employees. - 12.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.El Roof repairs These sub-contractors have employees and have workers'comp. insurance.1 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El Other 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: Ob =`(- -� 'nO,.\-ty-p j k)ei .ps`a1 cj Policy#or Self-ins. Lic. #: PAO3(Q7C67-'2,3 Expiration Date: 1 I i I Job Site Address: 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 co'y of -*. statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Aoioir I do hereby certi A :+f •pains and penalties of perjury that the information provided above is true and correct. i Signature: /� Date: Phone#: 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#: