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HomeMy WebLinkAboutBLD-23-001862 0'YR C C 14tL Office Use Only �e /V ' Permit# ' #4 6 010i Amount q 0 0+ 1 , V 7 9 ATT L CSC coif,a Permit expires 180 days from issue date 3t4 -023 dd is EXPRESS IL N IT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 OCT 06 2022 (508) 398-2231 Ext. 1261 _ BUILDING DEPARTMENT CONSTRUCTION ADDRESS: gct R /17 .e,z ASSESSOR'S INFORMATION: Map: c� -PPaar^cel: OWNER: ©� d C}S ` L� 'L Zrda + - f-- 117/ &/fiett 14 0 Z 5-7 ��tt PRESENT ADDRESS TEL. # CONTRACTOR: i��� A�Q G�ft t ( K • O ©vA '7 4/4 4/1/e l� ((4 D 2 '7/ NAME MAILING ADDRESS TEL.# s-O y 9(4 s\ o ❑Residential Est.Cost of Construction$ Home Improvement Contractor Lic.# /_j k 5 f) Construction Supervisor Lie.# C..S—Q 9`-k 5 Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: /,� 7 ►^fJ �.. / g)(U) Worker's Comp.Policy# 6 U {; C t< 76(..t s"`_S-1 2 J WORK TO BE PERFORMED Tent EJ Duration (Fire Retardant Certificate attached?) Wood Stove El Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 2 ) (0)Remove existing* (max.2 layers) Insulation I I I I Old Kings Highway/Historic Dist. (Q))Replacing like for like Pool fencing *The debris will be disposed of at: (Ae jVO S Location of Facility I declare under penalties of perjury that a statem erein 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 revO license and for prosecution under M,G.L.Ch.268,Section 1. Applicant's Signature: Date: /7/ 22 Owners Signat or attachm `- DaterApproved By: J Buil ' g Offici designee) L ADDRESS: Date: Zoning District: Historical District: L Yes C No Flood Plain Zone: C Yes C No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes C No ❑ Yes No f --7, --, .,e_... '; -,,,,_ ..1-, > J-. 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C,It iiO4,15' '`��C,,,�RD® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/OD/YYYV) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO HOLDER.TE THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER RIGHTS COVERAGE AFFORDED ABY 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 polio (ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsdment. A statement on this certificate does not confer rights to the certificate holder In Ileu of such endorsement(s). PRODUCER CONTACT NAME_ David Dlugasch COLLABORATIVE INSURANCE SOLUTIONSLLC PHONE (A/c,_No.Ex;); (781)929 1459 1 FAX E-MAILRE -.-..-- -- -----1(A/C No) -_..._..— ADDSS;"., david@collaborative-insurance.com 91 Providence Highway — _ Westwood INSURER(S)AFFORDING COVERAGE NAIL p MA 0 2090 _.._._ —_ INSURER A: HARTFORD UNDERWRITERS INS CO 30104 INSUREDI NBE MANAGEMENT CORP INSURERCNSURER : --" INSURER D: 20 TOWER TERRACE INSURER E! WAREHAM MA 02571 — — -- — — INSURER F COVERAGES CERTIFICATE NUMBER: 722893 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"--- ------- LTR TYPE OF INSURANCE POLICY EFF" POLICY EXP'_ INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DO/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: -- —"--..-_- _—_. POLICY PRO- L I GENERA!.AGGREGATE $ JECT I LOC PRODUCTS-COMP/OPAGG $ OTHER: AUTOMOBILE LIABILITY $ COMBINED SINGLE LIMIT $ _ ANY AUTO LEa accident) _.__,,,.._._ BODILY INJURY(Per person) $ ALL OWNED —I NON-OWNED SCHEDULED N/A AUTOS I BODILY INJURY(Per accident) $ _ HIRED AUTOS AUTOS PROPERTY DAMAGE Per H_Lcciden $ UMBRELLA LIAR $ OCCUR EACH OCCURRENCE EXCESS LIAB $ CLAIMS-MADE N/A IAGGREGATE DED I RETENTION$ I $ WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY X PER I OTH- ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N _1 STATUTE ER A OFFICER/MEMBEREXCLUDED? N/AJ N/A N/A 6S60UB1 K76455921 E.L.EACH ACCIDENT $ 1,000,000 (Mandatory in NH) 12/22/2021 12/22/2022 — — If yes,describe under EL.DISEASE-EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below — — E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,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 8,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 date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensation/investigations/. 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. AU—T-H�ORIZED REPRESENTATIVE Daniel M.Cro,vey, CPCU,Vice President—Residual Market—WCRIBMA $ ACORD 25(2014/01) The ACORD name and logo are registered ma ACORD CORPORATION. All rights reserved. sof ACORD . The Commonwealth of Massachusetts h 11, Department of Industrial Accidents 1 Congress Street, Suite 100 \' r Boston, MA 02114-2017 tiri.•"'''' 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): 11/5 r 04 4 kJ cp,co2A„,..A..k.,,‘Lft Address: Q v r City/State/Zip: \k} ck k,„4. (v '12,j Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1.0I am a employer with employees(full and/or part-time).* 7. 0 New construction 2.0I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers'comp.insurance required.] 8. ®Remodeling 3.01 am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. ❑Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on myproperty. 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. a genefaf5teontraetor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.t 13.0 Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14_Other,� ) /L2,'.1 024 152,§1(4),and we have no employees. [No workers'comp.insurance required.] *Any applicant that checks box#I 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: 11 kf Q N .v<S Policy#or Self-ins. Lic. #: 6. S Go ( (1` k 7 b 4 2— Expiration Date: /g /21722_ Job Site Address: P.1 2. City/State/Zip: ii. rf g'O \ KA 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 of this statement may be forwarded to.the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u , ins and penalties of perjury that the information provided above is true and correct. Signature: ` Date: \�\ �k 2..- Z__._ Phone (,--f _ ® `Q 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): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: