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HomeMy WebLinkAboutBLD-22-007150 _ 01.,YelAt 1 icc use lintyy $=•• / �! O PU /�J /I�/`�C. Permit# �3 �.4.;:,,,. ..' i1,� .xAmount 6-6 at) MATTA 11EJ� �`.....«°" c Permit expires 180 days from issue date $(A)--3Z —067150 EXPRESS BUILDING PERMIT APPLICATI TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 LA_INO 8 2022 South Yarmouth, MA 02664 _ _ (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT CONSTRUCTION ADDRESS: ig Ave_ /11 , So L[.-6 YO)-1/ 0 a ASSESSOR'S INFORMATION: �^ p Map: Parcel: / OWNER: Coda 5o /i ' KZ-r'4 19 4b 44. f WR.(�lt�OliC'i £v� - ,311 . - /142 e�AME PRESET 'ADDRISS TEL. # CONTRACTOR:JYL I cons 71���Vcic.-6IaDI4 _22 Hoc `u4 J. VI/. YY.cW�ou-I 5 0 2. 0- I 6 5 NAME MAILING ADDRESS TEL.# `id Residential ❑Commercial Est.Cost of Construction$ 2. t. g2--C:/'��- 00 ` #Home Improvement Contractor Lic.# J if 1 I9 t. `Construction Supervisor Lic.# (('... Workman's Compensation Insurance: (check one) / ❑ I am the homeowner ❑ I am the sole proprietor t I have Worker's Compensation Insurance Insurance Company Name:c�S-1 u 0 Ins-t ,rot n c,c, COG Isl/ 2 e Worker's Comp.Policy# VIC V 0-f 0 y03 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows: # Replacement doors: # Roofing: #of Squares 2 3 ( V)Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool/ fencing /'O fit,, Gt of roic- a/,� „tt *The debris will be disposed of at: (06. FP (e s 4- rJ, V lift/Ka LC. p, s o p S" 0( .+y c-e 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 revocatio my license and for prosecution under M.G.L.Ch.268,Section 1.Applicant's Signature: Date: 061 4)(3/ 2-°°Z.: Owners Signature(or attachmen Date: O6/7/ 2 2- 2- Approved By: Date: y Building Official esigly EMAIL ADDRE " 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 Yes 0 No 0 Yes 0 No '� The Commonwealth of Massachusetts f iri Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 l'.',w 5.•`'' 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): AL '7 '14 5'lri C 44'a I„ ` L C- Address: 22 110 es e- e0 n of k'Cep City/State/Zip: kV, rr4 u'-I f #/i 0,2C-VPhone #: S-17e -°st '© -- L,3 ?S Are you an employer?Check the appropriate box: Type of project(required): 1.1211 am a employer with ,3 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 $. ❑ 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.C I am a homeowner and will be hiring contractors to conduct all work on myroe I will I0 ❑ Building addition P property. ensure that all contractors either have workers'compensation insurance or are sole i i.❑ Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 6.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.VRoof repairs These sub-contractors have employees and have workers'comp. insurance. 6.❑We 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. r 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 ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: LI-s -6:e.4. �Pt, S G(.-,-/& it 6.r 0(92 2 G C Policy#or Self-ins. Lic. :(VC l/O I'fzo'f03 Expiration Date: 1.2. /a�/,2 OcZ , Job Site Address: /9 A14-f : /14 , City/State/Zip:C/tic'1YttnC-1Cn. HA 0266 if Attach a copy of the workers' compen ttion 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 I do hereby certify under the ins and penalties of perjury that the information provided above is true and correct. Signature: Date: 0r./0 V' 2- Phone#: soe - 3 (0 - `3es Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: IQ D -G=D 0 XXN 0 0 0x a o°o x� 0c 30 >00 n 0 O.-. m 0 �C 33�A OZ v w ro C �.0 y 3 m o-n-� W II . 0ro i0,m 20C 33 jmxl v0 2 ocfAT N f 3 O n w . zwai w 0 .. 9 H A n'mN n n c0. 0 R. N = m »N 3 1 00 3 0 0cn K .. v v, c p ', , o0 Z m E FTI y W W o o O O U)W \\S\\\ ID ,7_ al j:NC U) 2maa x( CD O D^^ ` • a'ry G -0.Vim. co 1 N \J cae dm-i 5 �1 cn 2 c gaom v S'Sv N p� C yW$c m >?m ,w CD [DTI oa m O CO A 7 . m a m r 57) CA=..c W W W m C m 1.3 o0 O N m 13. o. p a O N ry 7 C 3 n 9 0. 0 ita / K $ 3 £BP \ ƒ §§ta) [ �xi® G 0 / 7mz . J & / / o07� / F\] agod n2; o _zE , 02 �2q � � � j \ o; m ƒ 7 g- -- ? moo d ° /{ ( . � 2 E « . ),„1, [/ } 0 njJ • § E = ) / \ $ « E t 2 U : ^ § : . . .\. . E BELOW THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED r3E RL.ZNTATIVE 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). 'RODUCER CONTACT Eastern Insurance Group LLC FAX AX ?33 West Central St (A/C.No.pop 800-333-7234 JAIL,No):781-586-8244 Vatick MA 01760 ADDRESS: CSR24CL@easterninsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Arbella Protection Insurance Co 41360 ISURED ALTCONS-01 INSURER B:Merchants Mutual Insurance Company 23329 ;LT Construction LLC 2 Horse Pond Road INSURER C: N Yarmouth MA 02673 INSURER D: INSURER E: INSURER F: :OVERAGES CERTIFICATE NUMBER:662655047 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. SR ADDL SUER POLICY EFF POLICY EXP TR TYPE OF INSURANCE INSD WVD POUCY NUMBER (MMIDDIYYYY) (MM/DDIYYYY) UMITS A X COMMERCIAL GENERALUABIUTY 9520049457 12/1/2021 12/1/2022 EACH OCCURRENCE $1,000,000 TO RENTED CLAIMS-MADE X OCCUR PREMIGE SES(Ea occurrence) $100,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY JET 1 I LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ B AUTOMOBILE UABIUTY MCA1002609 6/2/2021 6/2/2022 COMBINED SINGLE LIMIT $ (Ea arrant) _ ANY AUTO BODILY INJURY(Per person) $20,000 , OWNED X SCHEDULED BODILY INJURY(Per accident) $40,000 AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION I I FOR AND EMPLOYERS'UABIUTY PER STATUTE YIN ANYPROPRIETORIPARTNERIEXECUTIVE ( EL EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? N/A (Mandatory in NH) I E.L.DISEASE-EA EMPLOYEE $ ff yes,describe under DESCRIPTION OF OPERATIONS below I EL DISEASE-POLICY LIMIT $ IESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) :ERTIFICATE 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. Display Purposes Only AUTHORIZED REPRESENTATIVE 1PeONIBILQ I r. ©1988-2015 ACORD CORPORATION. All rights reserved. CORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ( IOU//ZUZ1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CEkTIFICATE 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 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 Kelly Smith EASTERN INSURANCE GROUP LLC P NN.Exo: (508)620-3447 FA,No): E-MAIL ADDRESS: kesmith@easteminsurance.com 233 WEST CENTRAL ST INSURER(S)AFFORDING COVERAGE NAIC/I NATICK MA 01760 INSURER A: ATLANTIC CHARTER INS CO INSURED 44326 INSURER B: ALT CONSTRUCTION LLC INSURER C: INSURER D: 22 HORSE POND ROAD INSURER E: WEST YARMOUTH MA 02673 INSURER F: COVERAGES CERTIFICATE NUMBER: 723258 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 ,INSD WVD POLICY NUMBER POLICY EFF POLICY EXP(MMIDD/YYYY)1MM/DD/Y1'YY)I LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: I $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea ar irk.nt) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED . PROPERTY DAMAGE AUTOS (Per accident) $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION WORKERS COMPENSATION I OTH_ AND EMPLOYERS'LIABILITY YIN( X(STATUTE ER ANYPROPRIETORIPARTNER/EXECUTIVE E.L EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBEREXCLUDED? N/A N/A N/A, WCV01420403 12/04/2021 12/04/2022 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS I 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 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 ALT Construction LLC ACCORDANCE WITH THE POLICY PROVISIONS. 22 Horse Pond Road AUTHORIZED REPRESENTATIVE ( W Yarmouth ` ~ { MA 02673 Daniel M.Crocyiey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD