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HomeMy WebLinkAboutBLD-23-002318 IOti.X�R Office Use Only C � • Permit#_-eas1) C I Amount >5 0. to' MA„A;-...,,,, cscJ� i ® ����? ( 4*•Mo4110.Q, !Permit expires 180 days from j issue date 6 L-0 —0Z 3 -oil 0L 3 i? EXPRESS BUILDING PERMIT APPLICAT TOWN OF YARMOUTH R E C E i Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 ! OCT28 QZ 508 398-2231 Ext. 1261 f E l iL0,1 G ❑-1 .aRTFv1ENT CONSTRUCTION ADDRESS:_ pi 2 S aj/ r g goo "2;0 ASSESSOR'S INFORMATION: Map: Parcel: OWNER: C- Y/1 Fi 14 D NAME 6 a X s w i r 7 fRooie P-ID 5-eig g,7,� y,7,,70 PRESENT ADDRESS TEL. _ CONTRACTOR: I A fh f/L'-I JJ 7 Ld j✓NVit4.4 P4 why ilA WF ineuri( _we 2a)t gS_'"p NAME MAILING ADDRESS TEL.# 34 sidential ❑Commercial Est. cost of Construction$ (y; J a®a ! -- Home Improvement Contractor Lic.# 090'7 fp Construction Supervisor Lie.# l j 7 , '"/ Workman's Compensation Insurance: (check one) �� ❑ I am the homeowner 0 I am the sole proprietor IIhave Worker's Compensation Insurance Insurance Company Name: '2 Li R. I C r< Worker's Comp.Policy# 6 z...2._u.6 K 4'$'7 , -,..)? WORK TO BE PERFORMED Tent _— Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows: # Replac.meta cloths: # Roofing: #of Squares ic ( Remove existing* (max. 2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencincr *The debris will be disposed of at: �a��+J�,]�/�LC1_�( LI r ip ��"--"�` Location of Facility r 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 ansv,e1(s) will be just cause for denial et revocation of my license and for prosecution under M.G.L.Ch.268,Section I. Applicant's Sib ature: 7 ,24A,. �., Date:_ Doc y , Owners SignaturOr attaci ent Date: AEproved By: I F� 2� Building Official(or desi_�r� r • L ADDRESS: All Date: Ir Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No \ • The Commonwealth of Massachusetts - p-.. � __ _� Department of Industrial Accidents :.:I j�j . - 1 Congress Street, Suite 100 ••f Boston, MA 02114-2017 IMP www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A I a licant Information Name (Business/Organization/Individual): Please Print LeQibl Address: _ .j 4/ Al Z....' City/State/Zip:_�/� dpy1 Phone #. •8 ..4 it Are you an employer?Check the appropriate box: l• Prat.;a employer with_employees(full and/or part-time).* Type of project(require.): 7. 2.0 I am a sole proprietor or partnership and have no employees working for me in ❑New construction any,capacity.[No workers'comp.insurance required.] 8. Remodeling , 3.0 I am a homeowner doing all work myself. [No workers'comp.insurance r squired.] 9 ❑ Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 1.0 Building addition ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 11, Electrical repairs o additions 12.0"Plumbing repairs o additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp. insurance.t 13.Q Roof repairs 6.0 We are a corporation arid its officers have exercised their right of exemption per MGL c. 14.0 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 indicati _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 ave 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 policyand information. / b site Insurance Company Name: v1 . I. Policy#or Self-ins. Lie.#: 0?at Expiration Date: .— ,4). Job Site Address: S �I t D Attach a copy of the workers' compensation policy declaration page(showing the Cpity/Sty ate/Zip: J J r 1144 Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a finea up $1 on date). C�� and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a p 500.00 day against the violator.A copy of this statement may be forwarded to the Office of Investigations of theDIA Au to ,250.00 a verage""verification. for in.urance p?,,3 iunature: „Kt -=hereby certify under the pains and penalties of perjury that the information provided above is true and corre. . sLi: ,i/( G fJ " ?� ., one#: Date: 02®,2 Official use only. Do not write in this area, to be completed by city or town official. t: City or Town: ,fssuing Authority (circle one): Permit/License#____ I.''Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical - 6. Other Inspector o. Plumbina Ins b p:ctor Contact Person: Phone#: < .y , Office ' r , a " 'T irc r' ,;, 4 .a.^ ,„ e ‘ . ii , , ,„,,, , 1 . ,. " (0s,ABR) HIC Registration Complaints Registration 167281 Registrant MULLIN ROOFING AND SIDING INC Name MARK MULLIN Address 7 CONNEMARA WAY City, State W. YARMOUTH, MA 02673 Zip Expiration 02/24/2024 Date Complaints Details No complaints found for this registrant. You can also view arbitration and Guaranty Fund history. Back To Search 0 a (1-4., as a, c Z4*T ',. -,• 't' '''' th ..-+ = nt 4a5 th 0 s- s -, v 15-isio,c •y (c .- .iys' ' LI ..,j11 ?4, C. 5 0 '-1• ,1—,,z,,aom.°...t.1. e* -3 4 ,..,f, 8 eel - ''',....:--,..,4 .4.••• 1 , ,,0 al n ...,. 4.1, ..„..4• 0 C ". C .:(4 0!fil,RVI )••d E 0 z 0 =4 a) E 0 2 2 re c 0 la 4 t.)cl.T, 2 2 >-• .(7),,. to w z I— to 0 .rt 0 UJ M E 0.r., (..) C) 0 0 o — u, 0 0 on 4- liZi 0 0 cc 4., .0 ,. vl +0 0 ct3 -c" a) a c a) CD I-a c, — 4". 11E102 0 C ic, 0 co *.''-' 0) > ° 0 MI 10 411 4,0 \ 415 CI = c :;; e8g2 cx4-60 cce0,-ra s _......... _.._,....,,_,_ ... 131 S> a) CO ° — C.> f/111 = cr s— 'mt* (3)47 t 0 0 .0 . . , D 2 in C)17.)1 11.41 ..0"I° ° 0 r:x us o-- 1-•• 04 2 0 ''''',. ...1 4- ILI .. C ',.5.... n t r< >„W 0 0 0 gA 0:tt LD.f\CI (0 Z E Ci.0 * Vs l'• 0 g a • ..,T, z <:c 0 a Z, 0 (...) 0 z 0 ...fr j..... ...... LAJ p (-) _1<n or AC l Co NCE ® CERTIFICATE OF LIABILITY INSURA DATE(MM/DD/YYYY) I08/01/2022 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 MARGARET J GRASSI INSURANCE AGENCY INC PHONEAME (A/C,No,Ext): (508)295-2007 FAX E-MAIL (A/C,No): 1188 MAIN ST ADDRESS: Grassi-ins@comcast.net W WAREHAM INSURER(S)AFFORDING COVERAGE NAIC# MA 02576 INSURER A: AMERICAN ZURICH INSURANCE COMPANY 40142 INSURED MULLIN ROOFING & SIDING INC INSURERS: INSURER C: 7 CONNEMARA WAY INSURER D: W YARMOUTH INSURER E: MA 02673 INSURER F: COVERAGES CERTIFICATE NUMBER: 799923 ER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED ENAM D ABOVEVISION FOR OR 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 POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER COMMERCIAL GENERAL LIABILITY (MM/DD/YYYY) (MM/DD/YYYV) LIMITS EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A GEN'L AGGREGATE LIMIT APPLIES PER: PERSONAL 8 ADV INJURY $ POLICY ECT LOC GENERAL AGGREGATE $ PRO- OTHER: PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY $ • COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) OWNED SCHEDULED BODILY INJURY(Per person) $ AUTOS ONLYAUTOS HIRED NON OWNED N/A BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE (Per accident) $ UMBRELLA LIAB OCCUR $ EXCESS LIAB EACH OCCURRENCE $ CLAIMS-MADE N/A DED I RETENTION$ AGGREGATE $ WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY X PER STATUTE ER" ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N A OFFICER/MEMBEREXCLUDED? N/A N/A N/A 6ZZUB6R48878522 E.L.EACH ACCIDENT $ 1 OO,000 (Mandatory in NH) 07/09/2022 07/09/2023 If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 100,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 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 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 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/. P Y precedes the CERTIFICATE HOLDER CANCELLATION SHOULD ELLED BEFOE THE EXPIRATION HDATE VT THEREOF, NOTICE POLICIESE DESCRIBED WILL CBE AN CDELIVERED RIN Mullin Roofing & Siding Inc ACCORDANCE WITH THE POLICY PROVISIONS. 7 Connemara Way AUTHORIZED REPRESENTATIVE West Yarmouth MA 02673 ; Daniel M.Crow )by,CPCU,Vice President—Residual Market—WCRIBMA ACORD©1988-2015 CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered ma ks of ACORD