The URL can be used to link to this page

Home My WebLink AboutBLD-23-001621 '0i*.Y44' , 1 U/51 RECEIVED Office Use Only✓� j2,, 0 y` Permit# aft` 3615 :� M�ri � ; SEP 2 6 2022 Amount ') OD `y' '- B U I I N G DEPARTMENT Permit expires 180 days from By issue date cV y303 3 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH 80 -. 2 -bDiUz,( Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 ?� (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: I C( C e Kt o 1-Er c et, Ya...molktk.p c r t ASSESSOR'S INFORMATION: �j' Map: l32. Parcel: 116 OWNER: ../ K TEL 't,K. Wo zLa,r© I%6G NAME 7y ILL Mr, Lit. 1)Ll icr 6r t G lk. ILl hPRESENT ADD S TEL. # )) q _old_ 0 1 CONTRACTOR: ©r e a.v f, litt, 37 �r ladik„J-t, U, Yo r&ou . A ' ,4-/01- 1NEE MAILING DRESS # *Residential 0 Commercial Est.Cost of Construction$ CI Q a1O Home Improvement Contractor Lic.# I CO O I V 4 Construction Supervisor Lie.# © 0'G/30 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor B'have Worker's Compensation Insurance Insurance Company Name: A,Af Q('!✓Qtp L h J ri Gf� rL ,r Worker's Comp.Policy e C ©l WORK TO BE PERFORMED Tent 0 Duration (Fire Retardant Certificate attached?) Wood Stove n Siding: #of Squares Replacement windows: # 2_, Replacement doors: # a, Roofing: #of Squares (❑)Remove existing*(max.2 layers) Insulation n Old Kings Highway/Historic Dist. Of Replacing like for like Pool fencing 6 %-1-4 Ck-i)Ill V n *The debris��be disposed of at: V E X co 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 re cation of my license and for prosecution under M.G.L.Ch.268,Section I. Applicant's Signature: q 21, Date: ;(1 Of Owners Signature(or attachment) J.\tG dtt, c 946 Ill Date: / Approved By: �� —5 BuildingOfficial(or desigDate: EMAIL ADDRESS: Zoning District: Historical District: . Yes No Flood Plain Zone: 1 Yes -1 No Water Resource Protection District: Within 100 ft.of Wetlands: Yes ' No Yes No Entire Agreement This Agreement represents and contains the entire agreement between the parties. Prior discussions or verbal representations by the parties that are not contained in this Agreement are not part of the Agreement. Permit Authorization By signing below, the Owner(s) authorize George Davis, Inc., to act on Owner(s) behalf relative to the work to be performed at this address. Project Address: 76 Center Street; Yarmouthport, MA 02675 Accepted: Signature ` vo-/ J Na o\--\6— Date Signature L__.____ G Judith N zaro ate Signature Ueoroe Davis Jt41C 22, 2022 George Davis, Date President, George Davis, Inc. Initial Page 10 of 10 Commonwealth of Massachusetts Construction Supervisor ir Division of Professional Licensure Unrestricted -Buildings of any use group which contain Board of Building Regulations and Standards less than 35,000 cubic feet(991 cubic meters)of enclosed Constriictrion bupervisor space. CS-056130 ' Eacpires:03/01/2023 GEORGE F IPVIS ., I.. s 33 N MAIN S1 n SOUTH YARMOUTH MA 02664 - '� 0 r ?'fiFSS E_SO� . Failure to possess a current edition of the Massachusetts ,�/ State Building Code is cause for revocation of this license. Commissioner r ti�k /'. D&nro, For information about this license Call(617)727-3200 or visit www.mass.gov/dpl THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYl?E corporation Office of Consumer Affairs and Business Regulation Re.istrat'on '—Expiration 1000 Washington Street -Suite 710 16t 1. ;,_ e,7/01/2024 Boston,MA 02118 GEORGE DAVIS,INC ) i, t; .G F T:.,. 33 ORGENORTH F.DAVIS i r=— g 4� n 33 NORTH MAIN STREEij, �/. rGlrask' SOUTH YARMOUTH,MAC 02 i•=' :" Undersecretary Not valid without signature The Commonwealth of Massachusetts 1" -F 1. Department of Industrial Accidents t_e1eff. ! 1 Congress Street, Suite 100 o,, tef=_ Boston,MA 02114-2017 =i www.mass.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): G co r e. 3cLv 4' /T'14,C. Address: 33 I U 6 r t k, ItcuL Gl- (116 rc.e City/State/Zip:J. Yarlik j (L ) ItA, d 02.(�01i Phone#: 5 D ?-3 9 '1- 00P(..302., Are you an employer?Check the appropriate box: Type of project(required): i I am a employer with 1,' 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.,Eremodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 10 Q Building addition 4.❑I 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.❑ p ROOF 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. 14.Q 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: of Q C(( 2(i. 14(bid t,jr( v :l dt,f ct,rail C e Policy#or Self-ins.Lic.#: 63 CC, '0 O 5 011/A 9 0.Z 01.2 k, Expiration Date: 3 l al/3 Job Site Address: 1)0 C G{t t t r Jt rL et City/State/Zip: Yar n ct tk40 0 kt Attach a copy of the workers' compensation policy declaration page(showing the policy number and expir tion 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: , 1• Date: 9 icity/61,2, Phone#: 3 Of 1 'lh(p - 14 C 0 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#: DATE(MM/DD/YYYY) AD® CERTIFICATE OF LIABILITY INSURANCE 3/4/2022 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 AHT Insurance, A Baldwin Risk Partner PHONE Tom Messier FAX 458 South Ave (A/C.No.Ext): 800-648-4807 (A/C,No):781-447-7230 Whitman MA 02382 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# License#:CA#0658748 INSURERA:Western World Insurance 13196 INSURED GEORDAV-01 INSURER B: NGM Insurance Company 14788 George Davis, Inc. 33 North Main St. INSURERC:Associated Industries Insuranc 23140 South Yarmouth MA 02664-3437 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:600930477 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY NPP1577750 1/12/2022 1/12/2023 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $100,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY PRO- JECT LOC PRODUCTS-COMP/OPAGG $2,000,000 OTHER: $ B AUTOMOBILE LIABILITY M9M28491 10/26/2021 10/26/2022 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$ $ G WORKERS COMPENSATION WCC50050143902022A 3/5/2022 3/5/2023 X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500,000 OFFICER/MEMBEREXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 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 BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Evidence of Insurance AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD C f T • F YA Mi T r " t 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451 = E P 2 b Telephone(508) 398-2231 Ext. 1292-Fax(508)398-0836 i0 trn�"tivi .OLD KING'S HIGHWAY HISTORIC DISTRICT COMMITTEE -QiAPPLICATION FOR CERTIFICATE OF EXEMPTION Application is hereby made for the issuance of a Certificate of Exemption under Sections 6 and 7 of Chapter 470 of Acts of 1973, as amended, for the proposed work as described below and on plans, drawings, or photographs accompanying this application. Type or print legibly: Address of proposed work: I?6 C r nt,c y f k. y i;i. /t/t f r.. ___MapiLot#_J3 Z///` , Owners) i 1\-ti q' `�``�'� Phone# ///- All applications must/be sl3CökiCLULtLLt)f4e[ bmitted bner or accompanied by letter from owner appp, ving submittal of application. Mailing address 1560G Creeit.,Fi..31- edr built:_:q d Email C w Preferred notification method, \one Email AgenVContrac c r t,?SS eo r C Y_i_ LL. er _.d/n_.._. Phone#. 61 )," .. T�. • Mailing Address. �'j�_,N-, L_l , 6 rn T Email, t+� 0 C . Preferred notification method Phone mail t Descrip ion of Proposed Work(Additional pages may be attached if necessary): 1epLacc frot ci0or ,- Lassf et°i.tCr ptctUrc wt✓ .( to - botk) L kc f©r tLkc,. c ),,ac;t rear toLIL,C100 - ft.©t vcsC6Lc Cake for Leke, Signed(Owner or agent) ~" Date G 5 " r Owner/contractor/agent is aware that a permit may be required from the Building Department.(Check other departments.also) > This certificate is good for one year from approval date or upon date of expiration of Building Permit,whichever date shall he liter. For Committee use only: 61/a.1 3.2 V Approved Approved I Date pprvv..d with than �ll' ��,� i Amount r Reason for denial F E 2A 20 1 CasniCK#:4 by Revd by: .�L.St .,QI,Lt Kl S Hl 6(-{' . '�� ` Date Signed , 1 Signed: '�f �' '%�� fh't')Z( ) _ 2 APPLICATION# -I~1 J vs<arr