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HomeMy WebLinkAboutBLDX-23-15678- Office Use Only ?. opteoPji it i %"")0 44moon.to*` ' ,Permit expires 180 days from E- issue date , • EXPRESS BUILDING PERMIT APPLICATAWE C [TRV E D TOWN OF YARMOUTH Yarmouth Building Department 1 1 NOV 13 2023 1146 Route 28 Av South Yarmouth, MA 02664 10 y,E Pf FRENT (508) 398-2231 Ext. 1261 y CONSTRUCTION ADDRESS: 4; N,CitI -5 -bgN-e d 4 /4r iMoi)i-4 Poit 114, 0;11,75. ' A- ) ASSESSOR'S INFORMATION: _Map: Parcel: OWNER: 13Pi 444 PC,e0 i'Ar•0 ( lai#14 a$ 6thrk) 77'1 gig 0953 NAME PRESENT ADDRESS TEL. # CONTRACTOR: Vphitt ettrvedito 8100 .511:Klaf 0, 6I'0,4).AZ ittil qv qqo &telly NAME MAILING ADDRESS TEL # Residential 0 Commercial Est.Cost of Construction$ /5; 5.00 Home Improvement Contractor Lic.# dta gig Construction Supervisor Lic.# CS — /0/'TIM Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor kil have Worker's Compensation Insurance Insurance Company Name: A Air 14 Ilielfb We* Worker's Comp.Policy-4i 6,.5(4);Lib -Lig iiii 1 3-A -03 WORK TO BE PERFORMED Tent 0 Duration (Fire Retardant Certificate attached?) Wood Stove 1:1 Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares L2 (0)Remove existing* (max.2 layers) Insulation 7 FOI Old Kings Highway/Historic Dist. gal Replacing like for like Pool fencing ri *The debris will be disposed of at: ..,5 t2(C6 ge# eff Iti..)W40,94.4e.,ed- Location of Facility I declare under penalties of pen j 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 ori ;on of my hyense and for prosecution under M G L.Ch.268,Section I Applicant's Signature: il 1 ( 0 IV 4 I Y - -------- Date: Alm/ f 1 919;3 Owners Signature(or atirhment) Date: Approved By: . 1 4/ Date: Building Off ' I(or ignee) EMAili:ZD . , I._ i-- : .I ., d I n. .4orm Gitmict 1 nAi C.4.151-PVC"tOw j iff C f L'O lift Zoning District: ___ __ Historical District: :1 Yes : No Flood Plain Zone: :1 Yes _, No Water Resource Protection District: Within 100 it of Wetlands: i:', Yes I No . Yes ' No „. 4-4 i'-,:i— 7:1-, ,,,, -,I.., .., -,.. ...... — ./...., , .„... ' 4 7.,,,, .470, i,f/./ - k - , --?-;.67(,..' . ,,. i i f iii.1_, , i?-0,„.:4” / i 1 Proposal (-PROPOSAL NO. DATE 14 ./"; 4-51 BID NO. ARCHITECT ' TO , PHONE NO. DATE OF PLANS br 1 et4: Fail.' et4367 ADDRESS WORK TO BE PERFORMED AT: / , ki ,if / et P\ , i, i,r' A el e L':'"!,*''".*'," *M424,914W""'5'..,'7, ,,,k,;04.4713.0,0aWgpat -74T-,VERSINAMI.,,..' ,,, :"......agANNOMICPZIMPSO.Aftvz.,WIG,10441MIX=RE"Mr:,,,nwt:01 fir,5402312'''':: We hereby propose to furnish the materials and perform the labor necessary for the completion of i - ..,!.. ,'2,J5Pti,5.,.. .,:,,•,=',,,:.':.I'',F.'VYARVTL'rZCMWWSWNX7*rgV.Z.*ifiCMFZNWPNMXGZrre'nT'"nZVV;r-M“,"'',1"-'",'"e.'7.14,:',:rrtS: Area below for additional description and/or drawings: — ,--; f-, /) r .6? of ,,e,„./c,j,;77„H4( 511't'.;1'*114,1,';', L i',2 fidt,` ,401,41i14,1,T' j,:ile;,, , ,,,,, _. , , / .,„ , „. ..., / — Pi CAtei ae 4- liki ti -- , -1,014if't Peee Atigil ;$' d:IL. :4;,) ' 1 iAir31/1/41 f444--t r '' ta-211Y111 gt- ** 1 ns pi! 4, t i„-. ....„4-' —oylotet oty 7,21;,0-e pe 0. 1--' ,- 4 ...... I v itrie 41-140/Matilk a41 45 ,,k6-ioti .,;:.l14,% (7 LII:rt,,o;,c,„; pfcl 4, ,(1_a , /., ,Iziatdr ri,,,,,,e v„,,i,th-i--.' ,y....s-Seeo 4,,,iYA 3 on i'.-":: ,..."21,fr ....., / 4-4e e el. i -*" 1 iV.`o 4, e - 161 If' :,.... rffia C1444 1.44/ > , , 1 ti'et,eal i . '''''. r, ft i-1-et i tfe 0 if 1 i 1 4 ‘;14 kti ir z2 - 54,1 if wf ri bitittips.ilcr. n -..*1 rtave tt,005,i-e ' ,., All material is guaranteed to be as specified,and the above work to be performed in accordance with the drawings and specifications submitted for above work and completed in a substantial workmanlike manner for the sum of Dollars ($ ' ' , :,: )with payments to be made as follows. / 1.092,..,f N., / -; :fr2, -'''''',..-"f,r.",,',.• ' . ' ,-.... ,., - ACCEPTANCE OF PROPOSAL The above prices,specifications,and conditions are satisfactory and are hereby accepted. You are authorized to do the work as I specified. Payments will be made as outlined above. ".., P. -...- Signature i„,.,u.,,A0.1. 1\)/0 V 10 )baik Date Signature j a adams•NC3818-50 11-17. . The Commonwealth of Massachusetts r Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 � sY,� www.rnass.gov/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): AK Cap AN) CijlCM"74; ZLIe at Address: gig) &e/vc .1,1 14-0,1 City/State/Zip: brew te. /utl¢ 15Do31 Phone#: ?77 Wei Zeal? Are you an employer?Check the appropriate box: Type of project (required): 1.01 am a employer with employees(full and/or part-time).* 7. ❑New construction 2.01 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. ❑Demolition 3.0I am a homeowner doing all work myself. [No workers'comp.insurance required.]t 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 11.0Electrical repairs or additions proprietors with no employees. 12,❑p umbing repairs or additions 5. i am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13oof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.❑we are a corporation and its officers have exercised their right of exemption per MGL c. I4.❑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. 1.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: ka Meiro 0 Policy#or Self-ins.Lic.#: Vipc20t --LIN ill/i D3 "4_ Expiration Date: 80/0.0,3 Job Site Address: 13 i C�►o1ei City/State/Zip: yktriDJt i Pot i " 7$ Attach a copy of the workers' compensation policy declaration page(showing the policy ntImber 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify/lit ear the pains and penalties of perjury that the information provided above is true and correct. Si nature: / Date: AV 1; ; �' 3 Phone#: 17g '10 It(o( Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: • w i Y� fib - � .. ::. ate. C$ RPM • d / � / g • e7. EE THE NWEAL Of�AC�� Registration weld f individual use a� t i ��� ', Its¢ M I fit; g e of t �ec�sr+e+r A end ue 54. . t a F 41444. LCTCONS-01 CPOROWSKI AlWI2 Cr CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 8/3/2023 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: AXiA MetroWest PHONE pvc,No,Ext): (413)788-9000 FAX No):(413)886-0190 E-MAIL ADDRESS:info@axiagroup.net INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Kinsale Insurance Company INSURED INSURER B:CHUBB 41386 LCT Construction&Service Inc. INSURER C: 4 Evergreen Lane INSURER D: Hopedale,MA 01747 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 LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER 1 IMM/DDIYYYYI (MM/DD/YYYY)I LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR iO100068934-6 11/21/2022 i 11/21/2023 DAMAGE TO RENTED 100 000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X PE X L. PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ AUTOS ONLY _ NON-OWNEDUUT N PROPERTY DAMAGE i (Per accident) $ $ UMBRELLA LIAB OCCUR 1 EACH OCCURRENCE . $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION PER I OTH- AND EMPLOYERS'LIABILITY Y/N 6S62UB-4N44123-A-23 8/17/2023 8/17/2024 X STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE 600,000 E.L.EACH ACCIDENT (Mandatory in ER EXCLUDED? N/A $ SOO OOO (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 t i 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 Carvalho Construction Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 16 Newfield Lane Yarmouth Port,MA 02676 AUTHORIZED REPRESENTATIVE ACORD 26(2016/03) ©1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD