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HomeMy WebLinkAboutBLD-23-002737 • .Ya 1, Pj1.17-ZZ d/��' ` O Office Use Only .• c // — /u-Z2 z c 0 Perm 'it# 111-4 O 'j �4..0/7/ i9 rtd -AA - ( .Amount 0i0 Le) M,,,," , �� Permit expires 180 days from issue date I-Ad& 6 14v -.23 -pda-73-7 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department RECEIVED 1146 Route 28 South Yarmouth, MA 02664 1 NOV 15 2022 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT CONSTRUCTION ADDRESS: 1 4_Matthews_Lane_- __-__.__ ASSESSOR'S INFORMATION: Map: 118 Parcel:11 i 1 OWNER: Mackenzie Barnard 14 Matthews Lane 508-221-8790 NAME PRESENT ADDRESS TEL.. • CONTRACTOR: P. Barnard, Builder LLC 9 Princes Street, Harwich, MA 508-360-6794 NAME MAILING ADDRESS TEL.# 2'Residential 0 Commercial Est.Cost of Construction$25,000.00 Home Improvement Contractor Lic.#CS-115678 Construction Supervisor Lic.# 201694 Workman's Compensation Insurance: (check one) 0 I am the homeowner IB I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: AIM Worker's Comp.Policy# WCC50050274662022A WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove U Siding: #of Squares 13 Replacement windows: #2 Replacement doors: #2 Roofi : #of Squares 12 (0)Remove existing* (max.2 layers) Insulation n Old Kin s Highway/Historic Dist. �) Replacing like for like Pool fencing 11 paz/� - / -dG� ?Z Harwich Transfer Station *The debris will l be disposed of at: ich 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. 1 understand that any false answer(s) will be just cause for deni o Ivi,ation of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: .._\ _,,,,,, Date 11/15/2022 2— Owners Signature(or attachmen' Date: 11/15/2022 Approved By: ,I/` // '``!1�Date: Building Offi or gnee) EMAI RESS: peter@pabbuilder.com Zoning District: Historical District: L Yes _1 No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No r, Yes No The Commonwealth of Massachusetts I A- Department of Industrial Accidents WAN 1 Congress Street, Suite 100 MA Boston, 02114-2017 \_?t��`SY.=1 www.mass.gov/dia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): P. Barnard, Builder LLC, Peter A. Barnard Address: 9 Princes Street City/State/Zip:Harwich, MA 02645 Phone #: 508-360-6794 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. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall work myself. t 9. ❑Demolition ❑ y [No workers'comp.insurance required.] 4.0I am a homeowner and will be hiring contractors to conduct all work on mYP roPertY• I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.QElectrical repairs or additions proprietors with no employees. 12.['Plumbing repairs or additions 5.0I 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.: 6.1=1We are a corporation and its officers have exercised their right of exemption per MGL c. 14.©Other window, door, siding 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: AIM Policy#or Self-ins.Lic.#: WCC50050274662022A Expiration Date: 07/18/2023 Job Site Address: 14 Matthews Lane City/State/Zip: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 f this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verifi tion. I do hereby c ' under t e ains and penalties ofperjury that the information provided above is true and correct Signature' Date: 11/15/2022 Phone : 08-36 - 794 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/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: BARNARD OP ID: KS AcoRlf> CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) �'' 11/15/2022 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 508-398-6060 CONTACT Bryden&Sullivan Insurance Bryden&Sullivan Ins Agency PHONE 508-398-6060 I FAX 508-394-2267 of Dennis Inc. (NC,No,Ext): (A/C,No): 485 Route 134, PO Box 1497 E"DORILss: So. Dennis, MA 02660 Bryden&Sullivan Insurance INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:James River Insurance Company PNBarnard Builder LLC INSURER B:A.I.M. 9 Princes Way INSURER C: Harwich,MA 02645 INSURER D: 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LTR INSD WVD 4MM/Drl!YYYY) (MM!DD/YYYY1 LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 00118731-1 DAMAGE TO RENTED 06/28/2022 06/28/2023 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 PECOT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULEDS BODILY INJURY(Per accident) $ AUTOSO ONLY AUTOS NON-OWNED AUTOS ONLY L PROPERTY DAMAGE (Per accident) $ $ I UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE WCC50050274662022A 07/18/2022 07/18/2023 500,000 E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? Y 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) Peter Barnard has elected to not cover himself for Workers Compensation benefits. CERTIFICATE HOLDER CANCELLATION DELANEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Delaney Murphy 414 Matthews Lane South Yarmouth, MA 02664 AUTHORIZED \ QG. ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Commonwealth or Massachusetts .�`fr �iyi�fry rivriJl!r rJ ..:.•,. Division of Professional Licensure Board of Building Regulations and Standards Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR onstruCtion Supervisor TYPE:LLC Registration Expiration CS-115678 Expires: 10r06/2024 201694 04/24/2023 PETER A BARNARD P.BARNARD,BUILDER,LLC 9 PRINCES STREET HARWICH MA 02645 PETER A.BARNARD 9 PRINCES STREET •�G�.�%aG ,•Gc' � t IARW ICI I,MA 02645 Undersecretary Commissioner ,,,', Construction Supervisor Unrestricted -Buildings of any use group which contain Registration valid for individual use only less than 35,000 cubic feet (991 cubic meters) of enclosed before the expiration date. If found return to: space. Office of Consumer Affairs and Business Regulation 1000 Washington Street -Suit Boston,MA 021 Not valid without signature Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Call(617)7273200 or visit www.mass.govldpl Fallon, Rosa From: Sherman, Lisa Sent: Wednesday, November 16, 2022 1:09 PM To: Clarke, Kristin; Fallon, Rosa Cc: Sherman, Lisa Subject: 14 Matthews Lane OKH Hi, I spoke with Peter Barnard regarding the building permit for 14 Matthews Lane. Since the changes that are going to be made (roof, siding, door, window) are like for like, OKH is fine with the plans. Please let me know if you have any questions. Thanks, Lisa Lisa Sherman Town of Yarmouth Administrator, Old King's Highway Historic District and Yarmouth Historical Commission 508-398-2231, ext. 1292 Isherman@yarmouth.ma.us