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HomeMy WebLinkAboutBLD-23-005870 O in 6 / y l 74? Og•Y RECEIVE ® Office Use Only 44 17 - QQGT� Permit �.�i/`^�r,' 3d N 'l .' APR 212023 Amount -�?I611 �*MIusP"�E�d _..44, eV BUILDING DEPARTMf�tl� " Permit expires 180 days from issue date BY EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 2 L U Poe Sk-, )cUTYDut Port M P l- / ,�/Ud„ 7 ASSESSOR'S INFORMATION: lJ Map: Parcel: OWNER: (..„�MACS,ACS, aN" \ 02 LLD (Vt AC • AIC-W kit 4k 0210 CS" O 8103 NAME[� Czecw(- PRESENT ADDRESS TEL. # CONTRACTOR: ,OSSC [� 4 Nam S • � �1 tl.l.Q oar c) c Sat- 4,2-11 77 NAME MAILING ADDRESS TEL.ff- gl Residential ❑Commercial U� I �) 1 Est.Cost of Construction$ /n�p� �(0 . Home Improvement Contractor Lic.# �'^"� � Construction Supervisor Lic.# l 15 Workman's Compensation Insurance: (check one) 0 I am the homeowner ❑ I am the sole proprietor III have Worker's Compensation Insurance Insurance Company Name: LI ab\i l t ti1/4'` J ()Soma Worker's Comp.Policy# V is 3 Is S Flo(M7 2 WORK TO BE PERFORMED Tent 1:1Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 25 ' ( Remove existing*(max.2 layers) Insulation L I Fq Old Kings Highway/Historic Dist. Replacing like for like Pool fencing I I ;The debris will be disposed of at: laXIMOittf.\ ill`Sc1 SZ,h 1 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 y license and prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature:/5k� ,It.: Date: Li—it 2-6* Owners Signature(or attachment) al-wi 4 Date: Li-1 zr Approved By: G 1 v Date: / -1 Building Official(or de • ee EMAIL ADD S. Zoning District: Historical District: -- Yes No Flood Plain Zone: L Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes _ No Yes No PAUL J. cittejaaeCLUCt. ' & SONS Owner Affidavit Property Owner Must Complete & Sign This Form If Using a Roofer/ Builder (print) C_.- ,,V a y hi ,,-, Lr, a /IlY„ e y ,.e 4 y , as Owner! Agent of the subject property, hereby authorize Paul J. Cazeault & Sons Roofing Inc, to act on my behalf in all matters relative to work authorized by this building permit application for: Address of Job 2 yo P; f rr-L-•f Y4rind ✓ 2 rJ Signature of Owner Cau. 1i Mailing Address of Owner .2 yo P,' rM u✓ P r , . ? 4- C) z t '7S Telephone # I' .s-'7 5" S;'6 c r _co), .2C ( '73.'y(ce.'eg-) Date y//Z / -3 Please return this form to Paul J. Cazeault Roofing along with your signed contract. It is needed for us to obtain the building permit required by your town to complete your roofing project Fax: 508-420-4555 Email: office@cazeault.com r• .. The Commonwealth of Massachusetts Department of Industrial Accidents ""_• '— " 1 Congress Street,Suite 100 ... rant.( , =" a Boston,MA 02114-2017 x,,v. www.mas&gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Letribiv Name(Business/Organization/Individual): ? j l . "C/c--a F 3oNs Address: /O I ,Va tN 31-P--za i - City/State/Zip: t tt AO OO g? Phone#: vie ira 8 ( 1 `I- Are you an employer?Cheek the appropriate box: Type of project(required): ' I. I am a employer with f5 employees(full and/or part-time).* �� 7. 0 New construction 2.0 I am c sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] 8. ®Remodeling 3. I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9- ❑Demolition 4.0I 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. 11.0 Electrical repairs or additions 5.0tam 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.: l3.®Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14•❑Other 152,§1(4),and we have no employees,[No workers'comp.insurance required.] *Any applicant that checks box#3 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. l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: t96 (l.t. `i A& ( -A-(„ /I _Co4 iN ce �p PC0 Cal tit® Policy#or Self-ins.Lic.#: kile531 S 3 8 ek 00' 2 Expiration Date: 3/I Q 41,06g8 Job Site Address: City/State/Zip: Attack 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 foam of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and ena ' ofperjury P (perjury that the information provided above is true and correct e---7_,2atte& '' - Sienature: Date: Phone#: 50d 4.02 / Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 0 H.W C <Dm p r n 1 m(221 m m �0 pow OCn o WD D -I-C Dmc r PO m X)S.c_ o-�I- -I ND - o I ,� i .N.. -a c Z FZ0 -a may* ti, r� F� r ! ^E;vp . m m .F, pit 1 „ 1" -I m g ,,� oP < Da ��7D , ,k s �� � ,gyms Dmc ,7,,cl.,.,, �,jj , ..., , .. M T- 2 i �� �e$ r�Z p o-I-I IV go 01 CD C 0NS Z 0 - X°c m m t -I X c , " = CD m- m p 0 m 0 0 CD 00 00 m tO0D 3oocn ` o low. cn c O 3 ET . m , w CD TO oceM< � c a �.a �r' '�� � < , 17 a as 4- m i I of c - cn - cD _..„ a a) N oco CA m D. o o m v 0 O w cia N o - Mw a o0 0 - COrt- 0 Cl) IV O C S C. nO O N 71 . A C -s 7 , 0 __ - .._ .___ __ __ .__ _ Cl) Ti I 1 i i • • I gy Commonwealth of Massachusetts• • Division of Professional Licensure ,. Board of Building Regulations and Standards i Constr uct it iSr rvisor i j CS-108157 { . - gires:11/23/2022 i RUSSELL C RIOR :;t 'a �EA„ 163 BAXTER5NEC MARSTONS M�i..LS _ tom- 0• • Commissioner 13JEky»t • • F0/22/22/01/Wleadi 0/fgac,le.)-aelar.4-ea,i Office of Consumer Affairs and Business Regulation 1000 Washington Street-Suite 710 Boston, Massachusetts 02118 Home improveme>:i :Contractor Registration Type: Corporation • Registration: 103714 PAUL J.CAZEAULT&SONS,INC. _ i. ,:_- Expiration: 07/08/2022 1031 MAIN STREET =- _ OSTERVILLE,MA 02655 - • • = _ Update Address and Return Card. SCA 1 Co 20M-05//(117p7 .JZ gny,x6vac'a G,-/ // �_�� �f Office of ConsumerAffairs I u ffs' e9 tion g HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation fQ314 07/08/2022 1000 Washington Street -Suite 710 • Boston,MA 02118 PAUL J,• CA2 >x&=StrTiS„INC. RUSSELL C ZE 1.4L � • 1031 MAIN STREW:.- -' st Not valid without signature OSTERVILLE,Meg f,55• Undersecretary AC /R /Y CERTIFICATE OF LIABILITY INSURANCE DATE v 04/29/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND 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 Tina Reeves NAME: Dowling&O'Neil Insurance Agency PHONE (800)640-1620 FAX (A/C,No,Ext): (A/C,No): 973 lyannough Road ADDRESS: treeves@doins.com INSURER(S)AFFORDING COVERAGE NAIC# Hyannis MA 02601 INSURER A: James River Insurance Company INSURED INSURER B: Safety Indemnity Insurance Company 33618 Paul J.Cazeault&Sons,Inc. INSURER C: QBE Insurance Corporation 1031 Main Street INSURER D: INSURER E: Osterville MA 02655 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2242909764 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.LINITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SLU ' LTR TYPE OF INSURANCE INSD_WVD POLICY NUMBER POLICY EFF POLICY EXP (MM/DD YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ 50,000 - MED EXP(Any one person) $ 1,000 A Y Y 000715306 04/30/2022 04/30/2023 PERSONAL&ADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: - GENERAL AGGREGATE $ 2,000,000 POLICY X 2,g, LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY J COMBINED SINGLE LIMIT $ (Ea accident) ANYAUTO BODILY INJURY(Per person) $ B OWNED SCHEDULED BODILY INJURY_ AUTOS ONLY AUTOS (Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ C EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY- Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT OFFICER/MEMBER EXCLUDED? $ N/A (Mandatory in NH) - E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below 1 F..L.DISEASF_-POLICY LIMIT $ 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. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ® AR� CERTIFICATE OF LIABILITY INSURANCE DATE(MM@DfYYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPONOS/05/2022 OLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDEDABY 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 THE HILB GROUP OF NEW ENGLAND LLC NAME; Linda Sullivan PHONE FAX Arc,No.Exq; (508)957.4239 I.(Arc.Not: ADDRIESS: Isulllvan@dolns.com 120 Turnpike Rd INSURER(S)AFFORDING COVERAGE NAiC tt Southborough MA 01772 INSURER A: LM INS CORP INSURED 33600 PAUL J CAZEAULT&SONS INC INSURER C1 INSURER C INSURER 0: 1031 MAIN ST , INSURER E OSTERVILLE MA 02655 INSURER F COVERAGES CERTINIGA-1•^NUMBER: 801276 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, ILSR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP VD wVD POLICY NUMBER (MM/DDJYYVYI IMMIDO/YYYY1 LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE I CLAIMS-MADE I I OCCUR DAMAGGE TO RENTED $ PREMISES(Ea occurrence) $ MED EXP(Any one parson) $ N/A PERSONAL$ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PROJEC- I LOC GENERAL AGGREGATE $ PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Eaaccldani} $ OWNED SCHEDULED BODILY INJURY(Per person) $ AUTOS ONLY AUTOS N/A BODILY INJURY(Per Bed dent) $ HIRED NON-OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE $ (Per accident) $ T UMBRELLA LIAR OCCUR EXCESS LIAR EACH OCCURRENCE $ CLAIMS-MADE N/A AGGREGATE $ DED I I RETENTION$ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y!N i $ X 1 STATUTE I 1 ERH ANYPROPRIETORJPARTNERIEXECUTIVE E.L.EACH ACCIDENT A OFFICER/MEMBER EXCLUDED? NIA N/A N/A WC531S386670022 08/10/2022 08/10/2023 $ 1'000'000 (Mandatory NH) E.L.DISEASE-EA EMPLOYEE $ 1,001},000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,006,000 I N/A DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES(ACORD lot,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization Is given to pay claims for benefits to employees in states other than Massachusetts If the Insured hires,or has hired those employees outside of Massachusetts, This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the Issue data of this certificate of Insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search toot at www.mass.gov/iwd/workers-compensationfinvesttgationsl. 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, AUTHORIZED REPRESENTATIVE I Daniel M.CroJby,CPCU,Vice President—Residual Market—WCRiBMA ACORD 25(2016/03) The ACORD name and logo are registered a marks of ACORD ACORD CORPORATION All rights reserved. , ' Ic`A►ii a P TOWN CJ. `;,, "• 44 TOWN • F YARMOUTH 4 1146 ROUTE 28, SOUTH YARMOUTH. MA 02664-4451 Telephone(508)398-2231 Ext. 1292-Fax(508)398-0836 OLD KING'S HIGHWAY HISTORIC DISTRICT COMMITTEE i APPLICATION FOR OLD r- Uktv' _`° 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. Tape or print legibly: Address of proposed work: 290 T"Irt€ A- \t1 '1Guit,1 \)00- (VIP! (Y2(j2 7 p W 11 _ a lLot# Owner(s): C Ak{Ct Het(V 1 0Phone#: 5O 3 5 -OR((I 3 All applications must be submitted by owner or accompanied by letter from owner approving submittal of application. Mailing address: Z1-1 O ?Me St-. yarM(,`, kf t t `_ 07,075 Year built: i ei 8 3 Email: 1 H '14f../ 2-SI—I6 C�('(7Sj,,Preferred notification method: Phone Email Aaent/Contractor R�1 i sj i �t L{7&U 1 j`i?Wt 1,,azgjt)l i & Seim y9 i Phone f#; S —L 2 '—I 177 Mailing Address: 11 j 1 r�Al ,({� S ,J , (\f11 M O2. c (' (2 Lt Email: � w`s, T" i t V Preferred notification method: Phone Email pescriotion of P oPesed WorkjAddltional pages may be attached If necessary): ernove eyc Sal r _s,/1.1viote yocf Insl-c }�,�. �L ,ii..19 S\IA!vv) willi ct-dA(Aectuct( _ch:( les 47 Ct wealltet-r w I 3242llL2 Signed(Owner or agent). `�}�(` � , Date: iy/21/2,3 ➢ Comer/contractor/agent is aware that a permit may be required from the Building Department.(Check other departments,also.) A This certificate is good for one year from approval date or upon date of expiration of Building Permit,whichever date shall be later. For Committee use only: Date; ✓ �)2 23 Y Approved _Approved with changes I, 44 e„, ' Amount ?0,10 Reason for denial: cashiCl( a:I 3103 , r Revd by: Li5r _ 1 . L.J 2 ` Date Signed: -r! 5a3 Signed: Kp�f I ar"Vi ';?' APPLICATION#: R. '�r ° ` v7,2017