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HomeMy WebLinkAboutBLD-23-005964 (Lim q/ ,0 L/7\ il mos vasvryis Permit expires 1t0 days bum,:- issue date 13 GD - '73 -005g(D`I EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH _. R'E-C E l V E Yarmouth Building Department 1 146 Route 28 APR 26 2023 South Yarmouth, MA 02664 (508)398-2231 Ext. 1261 ;ill.PING DEPARTMENT CONSTRUCTION ADDRESS ffo i4-/t E-A/ tio',4 y So. Yrnz-mc Sri i¢ a :...- ' • ASSESSOR'S INFORMATION: IMap: Parcel: OWNER: A A AAJ AQ A/ZAME .// - 5ar,a.SY- 375'(f / PRESENT ADDRESS TEL M cONrRAcrO C e Reayja EL/� �4Pi1�/A1 llJo YES Qd d`a ARMdeni NAME MAIL110 ADDRESS TEL/ aideatial O Commercial5d4- a-37 -9.S�9 9- 53 7 q)-- Eat.Cost of Construction S ?,k'O * etc, jj Home Improvement Contractor Lie.k /ttg-4f D7 1.. J Construction Supervisor Lk.k ( o "i / a t Watiansn's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor ❑ I have Worker's Compensation Insurance i } / Q''0 Insurance Company Name: r�-"'(Ifs\C-T Worker's Comp.Policy* -1J C LI(S 1 5 1 0 i WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares t I S4 Replacement windows:# . Replacement doors: # Roofing: #1 of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like ' r Pool fencing *The debris will be of at 4 V (--:, - 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 undastend that my false auswer(s) win be just cause for denial or revocation of my license and for prosecution under M.O.L.Ch.268,Section I. Applicant's Signature: -4)f�L r" t 1 ( (.-f=i t>. Date: Owners Signature(or attachment) /4 Date: a/c? ,2-3 Approved Br r."(" 3 Date: <7 Z 7-1.-- Building Official(a tgnee ADD / Zoning District Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District Within 100 ft of Wetlands: 0 Yet 0 No 0 yes 0 No . The Commonwealth of Massachusetts f�1 � Department of Industrial Accidents y)j. 1 Congress Street, Suite 100 Boston, MA 02114-2017 ,o5• 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): J., ' f (fryyri( -e...te,—. Address: ? - ;-- 1 pt,- p City/State/Zip: S - Phone #: 0 P c)--3 /9S-Z__2____ Are you an employer?Check the ap ropriate box: Type of project(required): I.[ t am a employer with employees(full and/or part-time).* 7. _^New construction 2.E I 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 doing all work myself. 9. ❑ Demolition y [No workers'comp. insurance required.]' — 4. I am a homeowner and will be hiring contractors to conduct all work on m property.y I will 10 _ Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.❑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. Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 54 vLA , 11 wt 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: A—CCL CI - Policy# or Self-ins. Lic. #: WC V 01 5 1 V 8 d l Expiration Date: V 4/ ,3- ,RA, 9 Job Site Address: 6 7. u"--i City/State/Zip: t (VV1 C,J� Attach a copy of the workers' compensation policy page(showing the policy numb r 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 under,he pains and penalties of perjury that the information provided above is true and correct. Signature: I �- - -�_._ Date: 0 4 (32'ti lJ'�' 5 Phone#: 5 or,9 9- 3 195 9.2_-- Official use o ,. 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#: ACO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) �� 04/26/2023 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 NAME: Corby Schilling Leonard Insurance Agency,Inc PHONE (508)428-6921 FAX 683 Main Street A/C No,Ext): (A/C,No): (508)420-5406 -MAIL corby@leonardagency.com Suite B ADDRESS: YG gency.com INSURER(S)AFFORDING COVERAGE NAIC# Osterville MA 02655 INSURER A: Evanston Insurance Company 35378 INSURED The Commerce Ins.Co. 34754 INSURER B: C&F Remodeling Inc. INSURER C: Associated Ind.Of MA-ARWC 26158 248 Camp Street,F2 INSURER D: INSURER E: West Yarmouth MA 02673 INSURER F COVERAGES CERTIFICATE NUMBER: 23-24 Master 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 AUUL SU1fK LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY YTEF PMIDDIY EXP (MM/DD/YYYY) (MM/DDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE n OCCUR DAMAGE TO RENTED 100,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 A 3AA659329 04/15/2023 04/15/2024 1,000,000 PERSONAL B ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY n PROCT ri- 1 JE l I LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO $ BODILY INJURY(Per person) $ 250,000 B OWNED SCHEDULED RVM277 AUTOS ONLY x AUTOS 01/18/2023 01/18/2024 BODILY INJURY(Per accident) $ 500,000 X HIRED �/ NON-OWNED PROPERTY DAMAGE AUTOS ONLY /- AUTOS ONLY (Per accident) $ 250,000 Medical payments $ 10,000 UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY PER OTH- YIN STATUTE ER C ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT 1,000.000 OFFICER/MEMBER EXCLUDED? n N/A WCC-500-5018589-2023A 04/30/2023 04/30/2024 $ (Mandatory in NH) .L 1000,000 If yes,describe under E .DISEASE-EA EMPLOYEE $ , DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Contractor in MA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN PA Construction Inc ACCORDANCE WITH THE POLICY PROVISIONS. 334 Bumps River Road AUTHORIZED REPRESENTATIVE Osterville MA 02655 I I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD (; i y Ofciz i 1 rnoi ,. a 1 �'' , s; ii HIC Registration Complaints Registration # 153792 Registrant C & F REMODELING INC Name CARLOS FIGUEIROA Address 20 CAPTAIN NOYES RD, City, State Zip S, YARMOUTH, MA 02664 Expiration Date 01/07/2025 Complaints Details No complaints found for this registrant, You can also view arbitration and Guaranty Fund history Back To Search 0- A �_ Ni V Ni N co a oo co " n o(n r cn -0 r t. n N_w c r p—n C . ›UUH r, o � .� c co v D Z Ofol cn r*m m .cD � ZZ 0W C0 . co o ", X �+ o CD 0 0 VDl =NN D o; C r-r at o '< . - 0 g CD C3) CD m m a �'(nc w o FIT a o m N c° ; s Tr a w w r v D co 0 Ni N cCD . U) Q N N N=•O N CD Q_cp 41. - Co ( O = � � ' n *Z CD co D CO C. Cl, 0 Q D m T xr !° ca C�py. o — mDo v-•mn o `=, Zvi= o m Q CD n i v C o (D 0 w CD Cl) f N N N No so C WW-t= o ( t C a. o {