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Home My WebLink AboutBLD-23-001803 Urn IO ju l� `dd eta& ea- P _ RECE VED uoyintre./- RECEIVED OCT 0 4 2022 Office Use Only ��y � OPermit# cet h p • ;ry5aey?94,..1 I -I r P'RT M E T Amount ltl • By _ 4.gyiiew E c' Permit expires 180 days from BUIL ING DEPARTMENT _ issue date By — — . �(A) —a.3 . i q . D EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 �• South Yarmouth, MA 02664 3 i2 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 3r�ll o L.1 'VeN at ST s. if a Foix\cV a.66q ASSESSOR'S INFORMATION: Map: Parcel: OWNER: \JOH Y1 )U C,sah NAME PRESENT ADDRESS TEL. # CONTRACTOR: lJ a 13<L W a C.,N 19 Sur, s-r W, �F�V� iTCi+ S �' 3Cc --�o NAME —MAILING ADDRESS RESS TEL.# ❑Residential ,Commercial Est.Cost of Construction Sid. 0 C]C', .G Q. Home Improvement Contractor Lie.# , O_LC) Construction Supervisor Lic.# G`— 11_6 6 Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: R-k Worker's Comp.Policy# W cri �y WORK TO BE PERFORMED Tent I l Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares j_3 Replacement windows:# Replacement doors: # Roofing: #of Squares (n)Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. (Q))Replacing like for like Pool fencing *The debris will be disposed of at: y M a()' / 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 my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature:_ Qrt.. � � - . Date: 1.0 /O_3/ ,D. Owners Signature(or attachment) Approved By: Date: �� ✓' � Building Official si EMAIL AD Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No The Commonwealth of Massachusetts 1 —*? 1, Department of Industrial Accidents — = 1 Congress Street, Suite 100 S,_ t Boston, MA 02114-2017 `,,-'s www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): W d L a r ' r.,a.i-1,l Address:J._ _ Cu.3 „ p .s-t- ?c:)-V' ..3---!.:-.,- City/State/Zip: �_ c t JT Li cis�3 Phone#: ,Sc.)g 36z c l I c Are you an employer?Check the propriate box: Type of project(required): I.E1I am a employer with_ i employees(full and/or part-time).* 7. D New construction 2.0I am a sole proprietor or partnership and have no employees working for me in 8. ®Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 0 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I I.Q Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.01 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.0We 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#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. tContractors 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: ge cki'c. ' _ Policy#or Self-ins.Lic.#: 'r1`3 LOC `111 Q ` `Ja Expiration Date: a q/o 9 boa?, Job Site Address: a 41 0 L 0 p.-1 /J —y City/State/Zip: S.1la K\ry<,jTi -1 AYE,A.00 C `r 6 Attach a copy of the workers' compensation policy declaration page(showing the policy num 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 the pains and penalties of perjury that the information provided above is true and correct Signature: (.,J Date:1Ci/ l,:oc, Phone#: 8 3 cc:_, ( I c 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#: Commonwealth of Massachusetts i . Division of Occupational Licensure Board of Building Regulations and Standards Const ionIT S ' yrvisor CS-116646 6cpires: 12t2912025 WALACI P MftCHADO 193 CAMP SV APT J5 WEST YARMOUTH MA 02673 Of Iva:0' Commissioner c /,. - Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE: Individual Registration Expiration 201015 02/22/2023 WALACI PEREIRA MACHADO WALACI MACHADa 193CAMPSTAPT J-5 WEST YARMOUTH,MA 0267? Undersecretary Registration valid for individual use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 1000 Washington Street -Suite 710 Boston,MA 02118 • Not valid without signature ®Acizo /Y CERTIFICATE OF LIABILITY INSURANCE DATE 10/03/2022 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 NAME: BIBERK PHONE 844-472-0967 FAX 203-654-3613 P.O. Box 113247 (A/C,No E_xt); __ ___ (A/C,W. E-MDRIL customerservice@biBERK.com Stamford, CT 06911 ADESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:National Liability&Fire Insurance Company 20052 INSURED INSURER B: Walaci Machado INSURER C: 193 camp st apt j5 INSURER 0: West Yarmouth, MA 02673 INSURERS: 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYI') LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 0 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) I$ 0 MED EXP(Any one person) $ 0 PERSONAL&ADV INJURY I$ 0 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 0 PRO- 0 POLICY JECT LOC PRODUCTS-COMP/OP AGG -$ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT I$ ANY AUTO La_accident) BODILY INJURY(Per person) $ OWNED _..._— SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE !$ EXCESS LIAB CLAIMS-MADE AGGREGATE 1$ DED RETENTION$ WORKERS COMPENSATION - - $ AND EMPLOYERS LIABILITY Y/N X STATUTE PER I ERH A OFFICER/MEMBEREXCLUDED?ECUTIVE N/A EL.EACH ACCIDENT $100,000 N N9WC772492 09/09/2022 09/09/2023(Mandatory in NH) EL DISEASE-EA EMPLOYEE$100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$500,000 Professional Liability (Errors & Per Occurrence/ Omissions): Claims-Made Aggregate 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 John Duncan THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 324 Old Main St ACCORDANCE WITH THE POLICY PROVISIONS. S Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE n 4 ,LL , t ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORDORD CORPORATION. All rights reserved.