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Home My WebLink AboutBLDX-23-15638-application-;r", ;e CtJl/8/3 n-ount.l0.h.) Permit expires lE0 days from issue dale 6LDI - ?3 -t5u3r EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1 146 Route 28 South Yarmouth , MA 02664 (508) 398-2231 Ext. 1261 dz R ECEIVTD N;rr*l ,*a ouoootrJ,BIJILDBv -- CONSTRUCTION ADDRESS: ASSESSOR,S I.\TORIVL{TION:I /)Jo(O\INER: N CONTR.ACTOR: )iA.\lE f Residential Insuance Compafly Name Ten t Du ration Siding: # of Squares / 820 PRESENT ADDRESSlarl14P.,/o iUAILNG ADDRESS Home lmprovement Contractor Lic. # Workman's Compensation Insurance: (check one) Est. Cost ofConstruction S 6"roo Construction Supervisor Lic. #/oL /( / I I have Worker's Compensation lnsurance Worker's Comp. Policl*I P,J abb p)Ets)/7a \\'ORK TO BE PERFOR\TED i Commercial/K 803 I I am the sole oroorietor fhe^-/e i g (Fire Retardant Certificate attached?) Replacement wirtdows: #_ lVood Stove_ Replacement doors: #_ Itrsulation Pool fencing Rooling; # ofSquares_ ( ) Remove eristing" (mar.2layers) \_ Old Kings Highrva)',/Historic Dist. ( ) Replacing like for like rThe d.bris will be disposed ofa!: Map I declare under p€nahi wilLbejusr cause for d Applicanr's SignaEre. Ows€rs Signature (or attachmeIl Approved By Locrtion ofFacilit_v es ofpedury that the statements herein contained are true and conect to the best of my howledgc and beliei I undersrald thar any falsc answer(s) Ienial or revocation for pr.sccution under IU.G L. Ch. 268. Secion Date t_ E\,L{.lL ADDRESS Zonirg District Historical Distdctr rr yes _ No Water Resource Protection District:I Yes iNo D|ile: Date Flood Plain Zone: _ yes Wifiin 100 ft. of Werlardsi Yes I No oN Building Oflic 'l ttn : I am the homeowner Parcel: 2a& Mass.oov Office of Camsumer Affairs and tsulsiness Regulation {ocA*Ri HIC Registration Gomplaints Registration # 198803 Registrant llya Lavrenov Name llya Lavrenov Address 13 Birch street City, State Zip Hyannis, MA 02601 Expiration Dale Ad17 12024 Complaints Details No complaints found for this registrant. You can also view arbitration and Guarantv Fund history, Back To Search Site Policies Contact Us O 2018 Commonwealth of Massachusetts. Mass.Gov@ is a registered service mark of the commonwealth of Massachusetts. U _Commonwealth ot Massachuselts _ utvtston ot occupauonal Licensuret oard of Butlding Regulattons and Standa C o n s.t4ltibfi btgegvi s o r cs-1 07181 ILYA I3 BIRCH HYANNIS Commissioner a rds ires: OSt27 IZO2S2 , !-' ,)\'\lrJvd,l P"{/L,* ,r lbti I AcoRif!, 11114123 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. TXIS 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), AUTHORZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLOER. CERTIFICATE OF LIABILITY INSURANCE IMPORTANT: lf the cate an ) must have ADDITIONAL IISURED provisions or be endorsed. lf SUBROGATION lS WAIVED, subiect to the terms and conditions of the policy, certain policies may require an endoGement. A statement on lhis cenificate does not confer to the certificale holder in liqu of such endorsement(s), JIMMY HINDMAN 508-771-0663 sch tnsuran il.com 14788 COVERAGES CERTIFICATE NUlilBER:REVISION NUMBER: 508-771{381 AFFOROING COVERAGE Schlegel & Schlegel lns Broker 34 Main Street West Yarmouth, MA 02673 PROOUCER rnsuaenr: NGM INSURANCE I SURER B: TRA!y'ELERS INSURER C INSt'RER O INSURER E A GRADE EXTERIOR SOLUTIONS LLC 393 BUCKSKIN PATH CENTERVILLE. MA 02632 INSURED INSURER F INSR LTR TYPE OF IiISIJRAr|CE POLICY NUMAER EACH OCCURRENCE OAMAGE TO RENTEO PREMISES lEa 6..!mn.6l MED EXP (Anv one De6or) PERSONAL & AOV INJURY GENERAI AGGREGATE PROOIJCTS. COMP/OP AGG CO MERCIAL GEIERAL L|^AIL|TY GEN'[ AGGREGATE TIMITAPPLIES PER OTHER CLAIMS,MAOE OCCUR POLICY LOCJECT AOOTLY INJURY (Pe. peB6) BODILY INJURY (Per E6idenl) PROPERTY DAMAGE AUTOUOBILE LIAAILITY olviJEo AUTOS ONLY HIREDAUTOS ONLY SCHEOT]LEO AUTOS NON.OWNEO AUTOS ONLY MtT7484M o2llol23 02110124 EACH OCCURRENCEUXBRELLA LIAB EXCESS LIAB OCCUR CLAIMS.MAOE AGGREGATE DEO RETENTION $ STATI-ITE OTH.ER E.L EACH ACCIOENI E.L OISEASE. EA EMPLOYEE WoRKERS COXPEISATTOT{ AI{D EIPLOYERS'LIAEUry ANY PROPRIETOR/PARTNEFVEXECUTIVE OFFICEFVMEMBER EXCLUOEO?(M.nd.tory ln t{H) DESCRIPTTON OF OPERAIIONS b6l6w 7PJUB6ROEO57122 09123t23 09t23124 E.L. OISEASE. POLICY LIMIT THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOO INDICATED, NOTWITHSTANDING ANY REOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED AY THE POLICIES OESCRIAEO HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS ANO CONOITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, $ $ $ 5 $ $ 100,000 300,000 100,000 100,000 500,000 oEscRtPTlol oF oPERATIONS / LocATloNS / VEHICLES (ACORD I01, Additlonar Rlhrrt! Sch.dul., may be attach.d ll mo.e rp.ce ti requtEd) CORPORATE OFFICERS HAVE ELECTED NOT TO BE COVERED UNDER THEIR CURRENT WORKERS COMP POLICY INSURANCE CoVERAGE ls LIMITED To THE TERirS, CONDITIoNS, EXCLUSIoNS AND oTHER LttritTATtONS AND ENDORSEMENTS OF THEPOLICY CERTIFICATE HOLOER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED AEFORETHE EXPIRATION DATE THEREOF, I{OTICE WLL SE DELIVERED INACCORDANCE WTH THE POLICY PROVISIONS, @ l9E8-2015 ACORD CORPORA TOWN OF YARMOUTH BUILOING DEPARTTIIENT WEST YAR'I'OUTH MA 026?3 ACORD 25 (2016/03)Th6 ACORD name and logo are registered marks ot ACORD TION. All rights res;rvJd B is-\ Name (Busiress/Organizatior/lndividual www.mass.gov/dia \\:otliers' Compensation Insurance Affidavit: Builders/Contractors/Electricians./Plumbers. TO BE FILED WITH THE PET{JVIITTING .{TITHORITY. t Info on PIea e t blkp E+fte ,lAddress: CitylStatelZip:006p/ 'Any applicant that check box # I must also fill ou! thc section bc Homeowre.s who submit thls affidavit indicaring thcy are doingtContractors that check this box must attachcd ah additional sheei tos sda 2 7. 8. 9. l0 ll 17 Type of project (required) New construction Remodeling Demolition Building addition Electrical repairs or additioos Plumbing repairs or additions 13. f] Roof repairs 14 fl Other low showing thcir workers' coEpcnsadon policy information- all work and thcn hirc ouEidc confactors must submit a neq affidavit indlca:ing such. showing thc name of ttre sub-contractoc ald stale whethcr or not thosc cntitics have empioyees. if the sutsconE_actors have employees,lhey nrust paovidc their workcrs'comp_ poLiry nuober Ar. you aD €mploy.r? Chcck the approprirtc bor: I 1. I am a cmploycr with / employees (fuli and./or parr-rimc).* I am a solc proprictor or parulership and have no employe.s working for m. in ary capacity. [No workcrs'comp. insunnce required.] I ara a homcowncr doing all work myself [No workers' comp. insurance rcquircd.] i +. fl I am a horncowncr a.nd will bc hiring contracto.s to conducr all work on my p.opcrty. I wili. ensuac that all conEiclors eithcr hava workers' compcnsatioo irsuranca or arc soie proprictors with no Btrployecs. 5.! I am a getrcraj contractor and I hav. hircd the sub-conE-acton lisrcd on he atbchcd sheer. Thcsc sub-conEactp6 havc cmployccs and have workc6' comp insurancc.t 6.! Wc arc a corporation ald ils offc.rs havr cxerciscd thctr right ofcxcmption pcr MGL c. I 52, $ I (4), and wc have no ernployces. [No workers' comp. irsuraDcE requircd] 3 I am an emploler thsi is proyiding worken' compensotion insurancefor my employees. Below is the policy andjob siteinfornation Insurance Company Name: Policy # or Self-ins. Lic. #:Expiration Date Job Site Address: Ciry/Stare/Zip:_ Attach E copy ofthe workers' compensatiou policy declaration page (showing the poli"y nurnber and expiratiou 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 oiup to $250.00 a day against the violator. A copy of this statement may be forwarded to the ofEce of Investigations ofthe DIA for insurance coverage verification. 0 I do hereby cerfify under the pains and penalties of perjury that the informaion provided above is trud and correcL ate: Phone al use only. Do not write in this area, to be completed by city or town ofJicial Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk6. Other 4. Electrical Inspector 5. plumbing Inspector Phone #: OfJici City or Town: Contact Persorl: -PermiVLicense# The Co mmo nw ea lth of Mas s ac lt us etts Departmenl of f ndustrial Accid.ents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Phone #: