HomeMy WebLinkAboutBLD-23-001178 . q/z/2/2
Office Use Only
o1..Y1tR
e.� O Permit#
Amount
MnTrn n 5.34 ^4
%*a.z..tto* cf.?' Permit expires 180 days from
issue date
RECEIVED
EXPRESS BUILDING PERMIT APPLICA I1N_._..._--
TOWN OF YARMOUTH SEP 0 2 2022
Yarmouth Building Department
1146 Route 28 BUILDING DEPARTMENT
South Yarmouth, MA 02664 BY —
A (508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: A V0,4 10 / V/Iczykoaot foT , 44 .
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: I IM Ali/►-r. CS A-feyN ( Li 4 44,0 frh e9ar Q-03 60,E e y Z
NAME PRESENT ADDRESS I TEL. #
CONTRACTOR: i LE 0 CON S M M/ {�+ (Il�ti Pr-<�'I }•,7,J7 60 g Y IC
N E MAILING ADDRESS V j(t-t-I an-4 4- TEL.#
Residential 0 Commercial Est.Cost of Construction$ 'I 0
Home Improvement Contractor Lic.# 11- O2S2 Construction Supervisor Lic.# CS `)725 6+
Workman's Compensation Insurance: (check one)
El I am the homeowner 0 I am the sole proprietor 156 have Worker's Compensation Insurance
"�,) C J t(�l'L PPolicy# (,1L.V 0150?
Insurance CompanyName: Worker's Comp. l Q
WORK TO BE PERFORMED
Tent . Duration (Fire Retardant Certificate attached?) Wood Stove U
11
Siding: #of Squares ,0 Replacement windows:# • Replacement doors: #___
Roofing: #of Squares (e
Re ove existing*(max.2 layers) Insulation ri
1XOld Kings Highway/Historic Dist. Replacing like for like Pool fencing I I
do L,K, , (1 at, 2,
*TINII tis will be disposed of at:
Location of Facility
1 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 f my license and f r prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: Date: d S- 2a !4,
Owners Signature(or attachment) Date: 6 , 14 , 7/t
� Date: C �f L 1
i
Approved By: Z.A%
Building Official(o esig a /'` EMAIL ADDRESS: -
Zoning District:
Historical District: LI Yes i No Flood Plain Zone: 1: Yes ❑ No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes Li No L i Yes Cl No
Lk%
' The Conrmnnrt•eal h of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WiTH THE PERNIiTTING At'TIIORiTV.
Applicant Information Please Print I eoibiv
Name (Business/Organization/Individual): /Pcit/ 5-12,A/6
Address:_._ r 0 )¢ax bj___
City/State/Zip: 1�1. t1i-s✓i iol 1N- OLbSI Phone#: -61 - ti b �q
Arc you an employer?Check the appropriate has: Type of project(required):
I❑1 am a employer with employees(full and/or part•timei* 7. New construction
2❑1 am a sole proprietor or partnership and have no employees work try tier me in S. Remodeling
any capacity !No workers'comp insurance required I
3❑1 a a homeowner doing till work myself (No workers'comp ms.uatcc required.(` q ❑Demolition
0
4 ElI am a homeowner and will he hiring contractors to conduct all work on my property twill 1 El Building addition
ensure that all contractors either have workers'compensation insurance or arc sole 11.0 Electrical repairs or additions
proprietors with no employees
12.0 Plumbing repairs or additions
S Bj6 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
G❑We arc a corporation and its officers have exercised their right of exemption per MGLc 14.❑Otller_—,— —152,§1(4),and we have no employees [No workers'comp insurance required I
'Ain 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 arc 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 subcontractors and state whether or not those entities have
employees lithe sub-contraciors have employees,they must provide their workers'comp policy number
I ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: 'InAf nS
Policy d or Self-ins.Lie.ti: 6 UPS ��244--2-t Expiration Date: t 2121 I 1023
Job Site Address: ei 5 AtfOh4 i City/State/Zip:__of 2/hOtn.rd P (T t 'fl OtifriS
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 S 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 S250.00 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 untie r'u •that the information provided above is true and correct.
Signature: fir Date:
Phone t:: 1
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):
I. Board of Health 2.Building Department 3.City/fown Clerk 4.Electrical inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
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ACC I CERTIFICATE OF LIABILITY INSURANCE DATetMM/DD,YYYY,
Iteeame 06/01/22
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 poticy(ies)must have ADOmONAL INSURED provisions or be endorsed.
If SUBROGATION IS WANED,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 N JIM HINDMAN
Schlegel&Schlegel ins Brokers,Inc. r.EA), 508 771-8381 FAX No): 508 77i-0603
34 Main Street tPHON
*Ess: schlegelinsurance@gmailcom
West Yarmouth,MA 02673
INSURER(S)AFFORDING COVERAGE RUC.
INSURER A: MGM
INSURED INSURER B: ATLANTIC CHARTER
MAZZEO CONSTRUCTION LLC INSURER C:
157 PINE BLUFF RD INSURER D
BREWSTER,MA 02631
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN 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.
LTR TYPE OF INSURANCE 1HSD %li I PPOLICY NUMBER POLICY YT POLICY YLOARDOITTY
, LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000
DAMAGE TO KEN IED
CLAIMS-MADE .� OCCUR PREMISES(Ea ocnrnence) S 500,000
MED EXP(Any one person) $ 10,000
A r MPJ9994A 03119122 03/19/23 PERSONAL&ADV INJURY S 1,000,000
GENT.AGGREGATE MIT APPLIE r-iS PER: GENERAL AGGREGATE $ 2,000,000
POLICY f l LOC ,PRODUCTS-COMP/OP AGG $ 2,000,000
OTHER: S
_ _
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
(En acddent)
ANY AUTO BODILY INJURY(Per person) S
— OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE S
AUTOS ONLY AUTOS ONLY IPer accident)
S
UMBRELLA LIAB OCCUR EACH OCCURRENCE S
EXCESS UAB CLAIMS-MADE AGGREGATE $
DED RETENTION S S
WORKERS COMPENSATI I ON STATUTE I I ER
AND EMPLOYERS'UASILIIY Y IN
B ANY OFFICER/MEMBER EXCLUDED?PROPRIETOR/PARTNER/EXECUTIVE N� N I A WCV01509901 03/20/22 03/20123 E L.EACH ACCIDENT $ 1 OOA00
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE 5 100,000
If yes describe under ,
DESCRIPTION OF OPERATIONS below _EL DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHI LES(ACORD let.Additional Rosnarks Schedule.rsay be aItadmdIt mare Metes is required)
CORPORATE OFFICERS HAVE ELECTED TO BE COVERED UNDER THEIR CURRENT WORKERS COMPENSATION POLICY
INSURANCE COVERAGE IS LIMITED TO THE TERMS,CONDITIONS,EXCLUSIONS AND OTHER LIMITATIONS AND ENDORSEMENTS OF THE
POLICY
CERTIFICATE HOLDER _ CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
TOWN OF BREWSTERACCORDANCE WITH THE POLICY PROVISIONS.
BUILDING DEPARTMENT -
BREWSTER MA AUTHORIZED REPRESENTATIVE .,
01988-2 1 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
•••••=......,mmt. •
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IT'w 7-CEIVEti, .-?:,)P1- TOWN OF YARMOUTH 1146 ROUTE 28, SOUTH YARMOUTH,MA 02664-4451
AUG 11 2022
'' f Telephone(508)398-2231 Ext. 1292-Fax(508)398-0836
K'YAP,iv.19,11-P DIG'S HIGHWAY HISTORIC DISTRICT COMMITTEE
OLD KING'S HIGia_j r-,--:-
APPLICATION FOR 16:. )17- CEIVEr
CERTIFICATE OF APPROPRIATENESS
Application is hereby made for issuance of a Certificate of Appropriateness under Section 6 of Chapter 470. Acits 19SCE R ci 1 3 2022
amended,for proposed work as described below&on plans,drawings,photographs, &other supplemental info accdmp nying this
application. PLEASE SUBMIT 4 copies OF SPEC SHEET(S),ELEVATIONS PHOTOS,&SUPPLEMENTAL INFIOBtppRI6---- ------- —....
DEPARTMENT
Check All Categories That Apply: Indicate type of Building: Commercial .
1)Exterior Buildin Construction: New Building .n.Addition Iterations Reroof EiGarage
E[Shed Solar Panels I Other:
.,
. 2)Exterior Painting . Siding Shutters r[VI Doors EXim ,W)ther: aeWe.6303Pci Cia.......OS '
3)Signs/Billboards: NewAI.n Change to Existing Sign
• 4)Miscellaneous Structures: LiFence Wall liFlagpole DPool LlOther: .
Please type or print legibly:
Address of proposed work (i26 AVON ,-RD, Map/Lot# gg 1 45//7
e..1.•
Owner(s): 3am--63 .' feArzt LIN-A ku8A-1- • Phone#: 2,03 -t--))t5:age+
All applications must be submitted by owner,or accompanied by letter from owner approving submittal of application.
• Mailing address, Year built:
, .... _
Email. 14,(4120dan %.)ki a+ i90cc1 Preferred notification method. El , Phone Er-Email
.
Agent/contractor. -LtWs M472,Er? Phone tt: .5o fl -qb0-3g35
Mailing Address,_____ —
Email; tifik-zzeD cons+ ,H,Dt c ice • matt, corm
referred notification method:1:1_Phone a_Email
Description of Proposed Work: ' . -.COig
,
r e et act. 02-urntaCilt 174*
1-e-plack... (1,i- i ifil-c0)rc,t+i it s c:141.41 -1, 1pli A bo inj sc.12iar.vied R ov2cli *1) eattf-?orui-
ovia__.
reptacc ta cotkid7-ows' •.§. sUcimPOooz.i-
replaCe cii2urif Lacie-ci`ova. '-f1
renloditt faccitat„ tn a S'leravri ava--&-frAcilb '
Signed(Owner or agent). ____ Date al2.V2...2...,
1. ericont,actoria,ent is aware that a permit is required from the Budding Department (Chock other departments.also.)
. If application is approved,approval is subject Co a 10-day appeal period required by the Act
:- This certificate is good for one year from approval date or upon date of expiration of Building Permit.whichever date shall be later.
All new construction will be subject to inspection by OKH OKH-approved plans MUST be available on-site for framing 6 final inspections.
For Committee use only: Approved Approved with Modifications Denied
Rcvd Date; 1 46 1112- ._. Reason for Denial
Amount L. *0 I
CashiCK*: 21 4(7
.,.
SEe.m-- vo9
ZOO
Revdby Signed, ( lii i!46 Days:
...
Date Signed. CI I 121
_ _ -
1
APPLICATION#:
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