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HomeMy WebLinkAboutBLD-23-000338 C L( I ZZ12( �"YR� �� I r7 Office Use fOnly .s.f, ! `�O C' Permit# 111 ! {O I H Amount MATTA nst Permit expires 180 days from issue date -03 -0o033 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146Route28 RECEIVED South Yarmouth, MA 02664 `r------- (508) 398-2231 Ext. 1261 JUL 2 0 2022 CONSTRUCTION ADDRESS: 22 Park Ave, West Yarmouth, MA 02673 I3UIt_UING DENAkTb1ENT )1" Y ASSESSOR'S INFORMATION: Map: Parcel Po_S 9 -7- 99 OWNER: Cris Luttazi 22 Park Ave, W Yarmouth 781-563-0054 9`L4 NAME PRESENT ADDRESS TEL. # CONTRACTOR: Ryan Gillis Bayside Tent 508.760.4025 NAME MAILING ADDRESS TEL.# ['Residential ['Commercial Est.Cost of Construction$ / -Q 6),Od Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# •aJ jL e-M 42 9/22 — "7/3WORK TO BE PERFORMED Tent Duration 3 Days (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 I I Old Kings Highway/Historic Dist. Replacing like for like Pool fencing I I *The debris will be disposed of at: 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: Owners Signature(or attachmen Date: 7/Q0/QO Approved By: Date: Building Off ( sig e) EMAIL RESS: Zoning District: Historical District: Yes No Flood Plain Zone: C Yes 1 No Water Resource Protection District: Within 100 ft.of Wetlands: ;i Yes No Yes 7 No 7/20/22, 12:05 PM image001.png I I ,�_..,_.. 0 u o. Lt v�' z 0 , 0 _r,.5i \." _... I I vo vt. vEil P TT:Pi ,' 1{ ii1 td.140,tat.„411 4.4,-,,a,„4 t,„:44.4. AMANDA 1111 CID BAR 11 https://mail.google.com/mail/u/0/#inbox/FMfcgzGpGwsNvddFdWWJFkNgKgMdTICM?projector-1 1/1 f yy\'yyyvvvvvvYYYYYYYYl yw 'yYYY vvyvvYYYYYYYVYYVYY` \' r w . o a w_ n "" w O w n R " f- fa, ..,o tij > [1?) w in 17:6 ro,,.. p� _ wcn co a n y• �r 01 Jt.,....6, G G O' ro n r r et) . ___ .:,v., ryi t cL ra, = r._ • ►,. = O cr P. cC- cr o 1-4 �. �, co 101 ►rDC ^*= .f G) a C r r-,, r. et c-....;.4, LAo trJ 5' Hi ,...., .� CA 43 ' CL' M. a] r) Z ri) " rri CL el) rli,,,, O Pm n m rroo c.n LA y " C 4 n c• Z £ a) a '° Z` p H • o oo o n Al tn Cw O d a "ro a " Q t. 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CERTIFICATE OF LIABILITY INSURANCE • GATE(MNlDWYWY) 0512312022 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 end 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 endorsernent(s). PRODUCER CRABIC ONTACT Joseph Dupuis McShea Insurance Agency,Inc „as , (508)420-9011 FAX.ltel (508) 20-9olt► 1645 Falmouth Road,Rt 28 BLDG D SAIAIL owl! )oeemcsheainsurance.com Centerville,MA 02632 INSUR s}AFFORDING COVERAGE NAIL X _ IN>N,RER A: PENN AMERICA INSURED INSURERS: Progressive Casualty 11770 Bayside Tent&Table,Inc. sauna c: AIM Mutual 40c Whites Path INSURER D: South Yarmouth,MA 02664 INSURER r: INSURER F: . COVERAGES CERTIFICATE NUMBER: 00002179-0 REVISION NUMBER: 1 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 TEL POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY EFF POLICY VW ' LTR TYPE OF INSURANCE MID BNB ADOLILIBR POLICY KINSER tMINDISTYYYI IN5OQI NITS A X COI/IAERCIAL GENERAL LABILITY PAV0380964 05117/2022 0511712023 EACH OCCURRENCE s 1,000,000 APAAGEnenTED C4 MS MADE X OccuR PRE ESQ(Ea occurrence} $ 50,000 — MED EXP(Any won) s $,000 PERSONAL&ADV INJURY 8 1.000,000 GEWL AGGREGATE LUST APPLES PER GENERAL AGGREGATE $ 2,000,000 X POLICY 1 i Loc PRODUCTS-coMP1oeAGO s INC OTHER S B AUTOMOIIILE LIABILITY 02711576.6 10w2612021 10126/2022 FerscidsnaINED sseiGt."Iwr s ANY AUTO BODILY INJURY(Per person) S 100.0Q0 OWNED ___ SCHEDULED BODILY INJURY(Per axidenD s 300,000 , _ Auras ONLY -X - Na OS ► mar 1 WOW_s _ AUTOS ONLY — AUTOS ONLY S WAeRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS-MADE AGGREGATE $ _, DED RETENTIONS $ C' �PI COMPENSATIONDYER4 LUURLnY YlN OTH- WCC-600-50 1 3 32 1-2022A 05122/2022 0512212023 X I STAME I EERR ANY PROPRIETORIPARR.ERJE%EW'rNE � EL EACH ACCIDENT $ 500,000 OffICELNNIEl EXCLUDED? I T 1 N t A(mandatoey In NM EL DISEASE-EA EMPLOYEE S 500,000 gEk dIenifON OF OPERATIONS OP ERATkst0iw EL DISEASE•POLICY LSRT i 500,000 . r DESC*IPT1ON DE OPERATIONS t LOCATIONS I YOWLER(ACORD lot.Additional Remarks Scbdda,may be attached if mars spates Is regWred) Workers Comp:Corporation owner Ryan Gillis Is not Included for coverage under the Workers Compensation policy CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE YVRH THE POLICY PROVISiONS. 1146 Route 28 South Yarmouth,MA 02684 AUTHORIZED REPRESENTATIVE I (JFD) ` b 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and loco are marls of ACORD Printed by JFD on 06/23/2022 al 01:62PM The Commonwealth of Massachusetts I — vinrDepartment of Industrial Accidents S 1 Congress Street, Suite 100 Boston, MA 02114-2017 � www.mass aov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Da /7 lLl Address: `T City/State/Zip: (�%� I'i q 3 -3q 1L7 ---,----�� PIP Phone #: /� - ��_ L Are you an employer?Check the appropriate box: I am a employer with Type of project(required): 3. ❑ employees(full and/or part-time).* 2.01 am a sole proprietor or partnership and have no employees working for me in 7. ❑R eW construction any capacity.[No workers'comp.insurance required.] 8. ElRemodeling 3.0I am a homeowner doing all work myself.[No workers'comp. insurance required.]t 9. El Demolition 4.pI am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 1 I.QElectrical 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.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§I(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. 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: Attach a copy of the workers' compensation policy declaration page(showing the pot 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 certify under the pains and penalties of perjury that the information provided above is true and correct. 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#: