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Home My WebLink AboutBLD-23-001592 Ia � 1)01— [1)' II,ItILI9 IC..) 'Office Use Only • / . e'. . 1-C `fTO C t/1/�1.� RECEIVED iPermit# ,'I1 1� ', ci 'Z-,j'zL ___.._� _ i Amount ,72, MATTACM CSC -�,°`°"°°°°""Q mod'° SEP 2 3 2022 )Permit expires 180 days from _;.*?:.::..' I issue date BUILDING DEPARTMENT _OLD— e3-4O /5 Q_ EXPRESS BUILDING P e TIOl' E C E E V E D TOWN OF YARMOUTH Yarmouth Building Department r SEP 15 2022 1146 Route 28 South Yarmouth, MA 02664 BUILDING DEPARTMENT y By: �;(508) 398-2231 Ext.E 1261 ----- CONSTRUCTION ADDRESS: l 7q1lI� / 7 �' ' JC1/'i/4,ia c ito- 26y ASSESSOR'S INFORMATION: . Map: Parcel: OWNER: (iLG lec d 'vti0J yf `/' Pt S H 6''2465 NAME PRESENT AIDD !!,RESS TEL. # CONTRACTOR: '1 NAME MAILING ADD S TEL.# esidential ❑Commercial Est.Cost of Construction$ p2 i U. 06 Home Improvement Contractor Lic.# c r1. c )j Construction Supervisor Lic.# (,j- i_CC L i6 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor I have Worker's Compensation Insurance p Insurance Company Name: S e F\K Worker's Comp.Policy#N 1'W T'c�;Q yvc,/ WORK TO BE PERFORMED 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:/q j'\\t'NO J c t- , D j...S P Q C trk,1,,,, Location of Facility I declare under penalties of perjury that the state nts 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 revoc on of m 1 d for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: 11 att,u,..--. Date: i /9.:' 2G7�% Owners Signature(or attachment) ' 0 -c Date: 0 IC /a� Approved By: 0 Date: w esignee)Building ici EMAI DRESS: • / Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft. of Wetlands: 0 Yes 0 No 0 Yes 0 No Office Use Only OY Y� Pernrit# C'.0 Amount - y � Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 �q 1 (508) 398-2231 Ext. 1261 ) CONSTRUCTION ADDRESS: 2t 1 J�(,o�1.e.l Ra1Th ASSESSOR'S INFORMATION: Map: Parcel: OWNER:��t �� N .. Z1 �-r c �D( at f'.t0 ' 6_1 gg NAME PRES T RESS TEL. # CONTRACTOR: N � i1 � ,� .� �i.i 1 1A �Ck��^° NA ` ' �(J MAILING ADDRE- S�� — TEL.# NAME Residential D Commercial Est.Cost of Construction$ 0 SO Home Improvement Contractor Lic. Construction Supervisor Lie.# 1 66 41 E 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: CSS. Vim' 'k Worker's Comp.Policy# W(..l''tv2 4 C)01. WORK TO BE PERFORMED (� Tent LI Duration (Fire Retardant Certificate attached?) Wood Stove I I Siding: #of Squares Replacement windows:# 1• Replacement doors: # Roofing: #of Squares (n)Remove existing*(max.2 layers) Insulation I I nOld Kings Highway/Historic Dist. (0))Replacing like for like Pool fencing *The debris will be disposed of at: >i F i t\. J \-\ 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 underM.G.L.Ch.268,Section 1. �., Applicant's Signature: W` t 4J�9�.-�. J�+� s� Date: 0c1/o c Owners Signature(or attachment) Date: Approved By: Date: Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes r No A`�17� CERTIFICATE OF LIABILITY INSURANCE 09/08/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. Tt CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICI BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZ 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 endors, If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: BIBERK PHONE 844-472-0967 FAX 203-654-361 P.O. Box 113247 IA/C,No,Ext): I(A/C,No): Stamford, CT 06911 E-MAIL DD RIESS: customerservice@biBERK.com INSURER(S)AFFORDING COVERAGE NAIC INSURER A•National Liability&Fire Insurance Company 2005, 1_NSURED INSURER alaci Machado INSURER C: 193 camp st apt j5 INSURER D: West Yarmouth, MA 02673 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 PERII INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH TI- CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERN EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR IADDL SUER POLICY EFF POLICY EXP {MM/DDiYYYY) (MMIDD/YYYY))I DAMAGE TO RENTED S LTR TYPEOF INSURANCE INSD WVD POLICY NUMBE EACH OCCURRENCE 'R PREMISES Ea occurrenceLlMl7 c COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR (". l i$ MED EXP(Any one person) !$ PERSONAL&ADV INJURY $ GEN L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE i$ f JPRO- POLICY LOC PRODUCTS-COMP/OP AGG j$ OTHER: 4 !$ AUTOMOBILE LIABILITY I COMBINED SINGLE UMIT j$ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ • UMBRELLA LIAB OCCUR I + I EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE j$ DED RETENTIONS t$ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS LIABILITY STATUTE ER Y r N APROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $100,000 A NY OFFICER/MEMBEREXCLUDED? N N/A N9WC772492 09/09/2022 09/09/2023 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE]$100,000 If yes,DESCdescrRIPTION under 500,000 DESCRIPTION OF OPERATIONS below � I E.L.DISEASE-POLICY LIMIT j$ Professional Liability (Errors& ; I Per Occurrence/ Omissions): Claims Made I i Aggregate J i l 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 BE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE / - Jt ©1988-2015 ACORD CORPORATION. All rights resew ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts I _ L Department of Industrial Accidents iB_ 1 Congress Street,Suite 100 Boston, MA 02114-2017 `V www.mass.oov/dia SY' Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): a c(-4. Address: . v 4"1" 5 City/State/Zip:(,Jc -r- y a /v\r,")t Phone#:, t oe.R6c. j Are you an employer?Check the appropriate box: Type of project(required): l.EI am a employer with _S employees(full and/or part-time).* 7. D New construction 2.0I 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 4.0I 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 11.0 Electrical 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. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.0We are a corporation and its officers have exercised their right of exemption per MGL c. 14.©Other(st 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. tContractors 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: ,12� > Policy#or Self-ins.Lic.#: )".13 uJC.l i 7 Q 44.E Expiration Date:©c4/C)c) f oar. Job Site Address: Li() _STv,'�L�j' .� City/State/Zip: —S. ‘:k\nncsl ri Attach a copy of the workers' compensation policy declaration page(showing the policy numbef 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 correct. under the pains and penalties of perjury that the information provided above is true and Signature: (,Jc,'J(�«v.. Date: GC\ 1 C.'1 ((act Phone#: 5 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#: Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Remulations and Standards Cons IoiVS rvisor CS-116646 t , spires: 12/29/2025 WALACI P MACHADO 193 CAMP ST; APT J5 WEST YARM6TJTH MA 02673 4r).1 Commissioner °I-r �vnc is "Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:ind"+vidual Registration Expiration 201015 02/22/2023 WALACI PEREIRA MACHADO WALACI MACHADO- � � 193 CAMP ST APT J-5 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 °" O?t'YRR n D p ri mt r&i Office Use Only .4,,, Q . 6�. th.w'— emu , .,O . I,,� y u 1 L MATTACM CSF�� I'9/��'/ ) �'" - 1AmOLInt i S "I'rav AZYI 9 SFr„ ,�y///i("�y—/+�',- —"O�—r es .. Permit expires 180 days from 614)p); ' fig issue date EXPRESS BUILDING PERMIT APPLICATI 114R E C E I V E D TOWN OF YARMOUTH Yarmouth Building Department SEP 15 2022 1146 Route 28 South Yarmouth, MA 02664 BUILDING DEPARTMENT (508) 398-2231 Ext. 1261 ---—_ CONSTRUCTION ADDRESS: Vf </I T !lr// ( /17 t22 69' ASSESSOR'S INFORMATION: Map: Parcel: OWNER: 1 l.®2 V1t7',)// rf ./X* "� 5 117.�`4 N LJ.% 4Y NAME PRESENT ADDRESS TEL. # CONTRACTOR: 52 })_ pq_ J_-/ _� NAME MAILING ADDRESS TEL.# 0 �1 (� LyKesidential ❑Commercial Est.Cost of Construction$ p2 5-D,06 Home Improvement Contractor Lie.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED 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: Location of Facility I declare under penalties of perjury that the state nts 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 revoc .on of d for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: / 0 9 90y Date: Owners Signature(or attachment) Date: Approved By: Date: Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No b� • The Commonwealth of Massachusetts — 1! 1Department of Industrial Accidents 1 Congress Street, Suite 100 \4 ,- 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): . r ' �;;I'Win J Go Address: Vf �i / City/State/Zip: 'WA' / ` Phone #: iA5'‘ $'g-7 6/ Are you an employer?Check the appropriate box: Type of project(required): i. I am a employer with employees(full and/or part-time).* — 2.a I am a sole proprietor or partnership and have no employees working for me in 7. — New construction any capacity. [No workers'comp. insurance required.] 8. Remodeling 3. I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. El Demolition 4. property.a homeowner and will be hiring contractors to conduct all work on myI will 10 n Building addition ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 11.El Electrical repairs or additions 5.]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance.$ 13•❑Roof repairs 6.1:We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑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: Policy#or Self-ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the pol cy 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 cer under t ',is and penalties o P f perjury that the information provided above is true'and correct. Siana tore: G6 —ki- Date: /S` AD.'7, Phone#: d 8 t 5-v- .6/", -- 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#: