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HomeMy WebLinkAboutBLD-23-000322 CC/fLt e t li '1„Z(Z i� v Office Use Only: • s f Permit# t 1 . •���. O 51 0 �1� (Jt� H' +Amount . �ri „ • ..•,� Permit expires 180 days from issue date t 6[/)-0t3 -6003ZZ EXPRESS BUILDING PERMIT APPLICATI ;• E C V. D TOWN OF YARMOUTH — _� __ _ _ Yarmouth Building Department 1146 Route 28 JUL 1 9 2022 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT By CONSTRUCTION ADDRESS: 50 Keel Cape Drive ASSESSOR'S INFORMATION: Map: 101 Parcel: 65 owNER: Elaine Singer 50 Keel Cape Drive 508-385-9228 NAME PRESENT ADDRESS TEL. # CONTRACTOR: McPhee Associi POB 799 E. Dennis, MA Oil 508-385-2704 NAME MAILING ADDRESS TEL.# Residential 0 Commercial Est.Cost of Construction$ 13'000.00 Home Improvement Contractor Lie.# 104158 Construction Supervisor Lic.# CS-097057 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: Cincinnati Casualty Company Worker's Comp.Policy# EWC0600890 WORK TO BE PERFORMED II II Tent I l Duration (Fire Retardant Certificate attached?) Wood Stove Li Siding: #of Squares Replacement windows:# 9 Replacement doors: # Roofing: #of Squares (❑)Remove existing* (max.2 layers) Insulation I I Old Kings Highway/Historic Dist. (J)Replacing like for like Pool fencing 1 1 *The debris will be disposed of at: S&J Exco, 200 great Western Rd., S. Dennis & On-site dumpster 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 myijsense and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: (, 1°c: - ;v, r�'° '?M1=, Date: 7/14/22 Owners Signature(or attachment) please see attached Date: r. 2-2/1 - Approved By: / Date: Building Official(or gn EMAIL ADDRES Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes C No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes Ii No ❑ Yes 0 No The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 = www.mass.gov/dta Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): McPhee Associates, Inc. Address: 1382 Rte 134, PO Box 799 City/State/Zip: East Dennis, MA 02641 Phone #: 508-385-2704 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 25 employees(full and/or part-time).* 7. ❑New construction 2.0 I 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.] 10 ❑Building addition 4.01 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.❑Plumbing repairs or additions 5.0 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.: 14.®Other windows 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 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. I.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: The Cincinnati Casualty Company — Policy#or Self-ins. Lic.#: EWC0600890 Expiration Date: 1/1/2023 Job Site Address: 50 Keel Cape Drive City/State/Zip:S.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$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 ynifer the pains and penalties of perjury that the information provided above is true and correct. Date: 7/14/22 Signature: 1 /�� 1�7 Phone#: 508-385-2704 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#: 1 8 DATE(MM/DD/YYYY) A�o CERTIFICATE OF LIABILITY INSURANCE 1/6/2022 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 CONTACT NAME: RogersGray, Inc.-Kingston Branch PHONEFAX 63 Smith Lane tA/C.No.Ext):508-746-3311 (A/c,No):877-816-2156 Kingston MA 02364 ADDRESS: mail©rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:The Cincinnati Casualty Company 28665 INSURED MCPHASS-01 INSURER B: McPhee Associates Inc P.O. Box 797 INSURER C: East Dennis MA 02641-0797 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1710374837 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 WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY EPP0600883 1/1/2021 1/1/2024 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED X PREMISES(Ea occurrence)CLAIMS-MADE OCCUR $500,000 MED EXP(Any one person) $15,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY JECOT- LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: A AUTOMOBILE LIABILITY EBA0600886 1/1/2022 1/1/2023 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION EWC0600890 1/1/2022 1/1/2023 X STATUTE ERH AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE N N/A E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBEREXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I 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 ACCORDANCE WITH THE POLICY PROVISIONS, For Insurance Purposes Only AU .•: ED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts Division of Occupational Licensure Cbmmonweaitn of Massachusetts • Board of Building Re ulations and Standards t Division of Professional Licensure Tr' Board of Building Regulations and Standards Cons lOrl� iSOr constrottl tl ilpdrvisor r CS-018520 E A,Aires;04/30/2024 sres:02/0gf2023 ROBERT H Ac PNE t CS.070755 iA PERRY L ERM2 k = PO BOX 797 t EAST DE NNIu;M a PCIAAARSTOIll eii¢ r ' ` � ; tl `�'' ii�as a OIS 4:1(�� %.:b`" '4,. �J 'if I Commissioner d K. (7 eta..- � Commissioner Clio K. amc , v Commonwealth of Massachusetts � Commonwealth of Massachusetts Division Occupational Licensors �i Division of Professional Licensure Board of Bulldln utations and Standards Board of Building Regulations and Standards Coos n F visor" 1 Constar dCtlbitil5iiipprvisor "' '' CS 4310 irpires:04120/"2024 CS-097059 „= Eat iras.11/290202.2 ROBERT AA AIJCP JONATHAN PHIL " 48 ATYti WOOD RG 28 BAKERS A tTt314 4 a StiEt'l'li DEN AAA 02 .:' A.*4 +"j • '� 'A t "'i 0 Commissioner l'euda {. rid-la Commissioner X. Commonwealth of Massachusetts Commonwealth of Massachusetts Division of Professional Licensure Division of Professional tic-ensure Board of Building Regulations and Standards Board of Building Regulations and Standards Cons rvisor Consr #iQlit p tvisor CS-098835 €pires 05t1612023 CS-091094 .7 .` , Aires-03/15/2023 sttsAN E Copt? t CHRISTOPHER NI 9 • 1 102 NORTH $ ci ° i =" _ 25 THICKET RIJN R a •^ ' HARWICH Mit9,2�� s' SANDWICH 025 .1 ,° �wtn€, }- Commissioner °� Commissioner K. t em s. r _ Occupational Com ftlt of Massachusetts of MassachusettsII Division of u hnnai Lic ure Division of ProfessionalonalLicensure 94txartd of`Buildirtg..Nytations and Standards Board of Building Regulations and Standards C c�'r€s1� }"zsxar' g*£orrrs oei Ivor ' 1 it •07?t3/202.3 CS-072339 fires:12/27/2021 C�� 7 _- e WYMAN W BROOKS J ,' PO sox 112 _at — 1 '` PO BOX 811 t r. f ,.. , PLYMOtJTH 023�B2 ' . ,F 'r, 7, �$TDALr!ik ,.it, Commissioner d, Rr g- aOram Crtrrtissiriilltr o f . l ar, /14E COMMONWEALTH OF MASSACHUSETTS Office of Cstnilter A iris Rttirt . ' CONTRACTOR . , e ',I sa t o t ol ceraS d w= tt f o ft trdtvreitttrutl toems#g only tha �of Coalo rnarMalts and ultras*Reiltositior► r q ' ,t �7 Ito 719 Boston,MA 41 r•rao�a.. �447/�O tt }111t "Su ROSF,..RT ff.MCPME i -4— o,''. .'..,.:7 1 i without sIgnaturat June 22, 2022 TO: TOWN OF Yarmouth ATTN: Building Commissioner To Whom It May Concern: This letter is to confirm that I, Elaine Singer, trustee of the Myer R Singer Living Trust of the property at 50 Keel Cape Drive, South Yarmouth, authorize McPhee Associates, Inc. to act on my behalf as the contractor for work to be performed at the above referenced address. • Elaine Singer