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Home My WebLink AboutBLD-23-000627 icuSign 7nvelope ID:159D2643-B8CA-4922-925A-4839B3945101 c W,(L v` g I c I zz, Office Use Only ggX'�R `G Permit# 0t; Amount SO 66 `•F" „n,;' n s " Permit expires 180 days from `,'�4 '�'` issue date 60- 023 4&eYed'7 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department LA_UG 1146 Route 28 0 3 2622 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT CONSTRUCTION ADDRESS: 65 Avon Rd, Yarmouth Port, Ma 02675 ASSESSOR'S INFORMATION: I IMap: I Parcel: OWNER: Jim Kubat 65 Avon Rd, Yarmouth Port 203-606-2972 NAME PRESENT ADDRESS TEL. # CONTRACTOR: MAZZEO Constr 157 Pine Bluff Rd, Brewster 508-360-3835 NAME MAILING ADDRESS TEL.# 0 Residential 0 Commercial Est.Cost of Construction$ 1 1 ,000.00 Home Improvement Contractor Lic.# 170232 Construction Supervisor Lic.#CS102587 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 8 I have Worker's Compensation Insurance Insurance Company Name: Atlantic Charter Worker's Comp.Policy#WCV01 509901 WORK TO BE PERFORMED Tent n Duration (Fire Retardant Certificate attached?) Wood Stove ❑ Replacement windows:# Replacement doors: # Siding: #of Squares p#of Squares n Roofing: 20.5 (❑)Remove existing*(max.2 layers) Insulation I I I Old Kings,Highway/Historic Dist. CI)Replacing like for like Pool fencing Cape Cod Disposal dumpster on the site "The debris w�tlbe dispnsedof at: p 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. pocusipne J'- Date: Applicant's Signature: 8/3/2022 rjiwt 61164 / /)� Date: Owners Signature(or attachment) B1E30301286546B. /�, . ' ' Date: e , Approved By: - E ADDRESS: Building Official(or designee) 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 Department of Industrial Accidents —,s, =Mi►[. 1 Congress Street,Suite 100 ` j'� Boston,MA 02114-2017 • — �` ,,N. www.ntass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH TIIE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Bryan Byrne Address: P.O Box City/State/Zip:_ N_Esthar 02651 Phone#: ram /617-967-1499 Are you an employer?Cheek the appropriate box: Type of project(required): I®I am a employer with employees(full and/or part-time)• 7. ®New construction 2 0 I am a sole proprietor or partnership and have no employees working for me in $. ❑Remodeling any capacity [No workers'comp insurance required I 3 0I ant a homeowner doing all work myself[No workers'comp insurance required.)t 9 ❑Demolition 4 I am a homeowner and will be hiring contractors to conduct all work on my property 1 will 10 Building addition ensure that all contractors either have workers'compensation insurance or arc sole 11.0 Electrical repairs or additions proprietors with no employees 12.0 Plumbing repairs or additions 5 DI am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp insurance: 6 a We are a corporation and its officers have exercised their right of exemption per MGL c 14. Other 152,§I(4),and we have no employees [No workers'comp insurance required I *Any applicant that checks box N 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 lithe 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: TRAVELER Policy#or Self-ins.Lic.#: 6HUB-2E14821-8-21 Expiration Date: 02-21-2023 Job Site Address: 65 Avon City/State/Zip: Yarmouth Port, Ma Attach a copy of the workers'compensation 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. I do hereby certify unde r rd err 'u that the Information provided above Is true and correct Signature: Date: 08.03.2022 Phone#: 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ACC U? CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) osrouz2 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: JIM HINDMAN Schlegel&Schlegel Ins Brokers,Inc. PHONE,Ext) 508-771-8381 FAX No): 508-771-0663 34 Main Street E-MAm:mess: schlegeiinsurance@gmail.com West Yarmouth,MA 02673 INSURER(S)AFFORDING COVERAGE NAIC 0 INSURER A: NGM INSURED INSURER B: ATLANTIC CHARTER MAZZEO CONSTRUCTION LLC INSURER C 157 PINE BLUFF RD INSURER D BREWSTER,MA 02631 INSURER E: 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. ILTR TYPE OF INSURANCE AtisM POLICY EFF POLICY EXP Ina WVO POLICY NUMBER ,jMM/DD/YYTTUMM/DD/YYYY}__ LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ' - OCCUR DAMAGE S l a N TED PREMISES(Ea occurrence) $ 500,000 MED EXP(Any one person) $ 10,000 A MPJ9994A 03/19/22 03/19/23 PERSONAL 8ADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 POLICY E 0 LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER $ COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY (Ea accident) ANY AUTO BODILY INJURY(Per person) $ — — OWNED SCHEDULED BODILY INJURY(Per accident) $ _ AUTOS ONLY _ AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED _RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y I N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE— E L.EACH ACCIDENT S 100,000 B OFFICER/MEMBER EXCLUDED? N N/A WCV01509901 03/20/22 03/20/23 (Mandatory In NH) E.L DISEASE-EA EMPLOYEE $ 100,000 II yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,me)/be attached 11 more space is required) CORPORATE OFFICERS HAVE ELECTED TO BE COVERED UNDER THEIR CURRENT WORKERS COMPENSATION POLICY INSURANCE COVERAGE IS LIMITED TO THE TERMS,CONDITIONS,EXCLUSIONS AND OTHER LIMITATIONS AND ENDORSEMENTS OF THE POLICY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN TOWN OF BREWSTER ACCORDANCE WITH THE POLICY PROVISIONS. BUILDING DEPARTMENT BREWSTER MA AUTHORIZED REPRESENTATIVE f I / ®1988-2 11ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACO D .... I cn Alt, 0 3 3 VD 0 XI h3 CO .. '- 21 w -4 Ca 0 VI as, Ul x-1 ,d0 ^st awe voi 0 ION ama ''''''''' Offire to eafaumet Maas a assaass KmAdion I Cl 0 ROME WPROVEISETPT CORTRAWOR CD T t m.11 ° .(-- 0 TYPE:iassatsus 0 co-.' iir 3 asaiiigefirse Esse/Atm s4vs- .544. 2 ITS= 06•17,2025 ; ,,-, EitS0s4ORA,ks..,P7PO i, gC W .... = Mr 06 0, ,ikt ,,,,I EKSANDRA 8 ALs:, 1 413M a : a REWSTER,WA 0263 _ .2 a..11 L • S.'i'-. . .XII at V Deeika " .' 45 4 r undemecmt, . ilk "Az.„.4. -1,..c in 0 - -- . %•744.- K.— :44f2, 4 gaL rn) - . ArOiS4 —m• = 0 =r 0 = Ifj 1111..'""'- — fl. ,`'.1 ...I CA es fp Registration vend fct ihdivichrei use only. . .j.-before the expestflori de if foam;rattan tot as Office of Consumer Affeec and Busioses , , ','• . • t.,.. ..... . a - ..... 1000 Washington Stint -Suilis 710 — DC,: BostonDI, A 0211is F CI 7-1 ----;`, ' 0 ...A...0,--0- ...., , 0. i,.• . fo.) It ____IL IT•, 103 • lei ___ . , flrit vattct vil It 11111111, ... - - . w-. 0crm 1 § 3a8 0 *2 z, ._____ . . ? a t: '4"5a. .. ,A.,......, =.. 4s) 0 .\ \ — : 3c ;Z I 0 fa tp id < . .1 ., :41 ZI 3 a —MU \ r' - 1 1 4 .... r ..1 AO ..••• = 0 r fai 76 LI. C it MOW ..4 ... 0 . IC 3 IZ 0 0 g . ,.....• I 0 a .. . 1 c ... iv e , !, . 1 , 1 i A _ - .,, _ Sherman, Lisa From: RICHARD GEGENWARTH <rgegenwarth@comcast.net> Sent: Monday,July 25, 2022 5:52 PM To: Sherman, Lisa Subject: Re:22-E8086 65 Avon Road Attention!:This email originates outside of the organization. Do not open attachments or click links unless you are sure this email is from a known sender and you know the content is safe. Call the sender to verify if unsure. Otherwise delete this email. I hope they come back to change the siding and paint the trim. To do like for like on windows and roof is a good start. I approve. Richard On 07/25/2022 3:31 PM Sherman, Lisa<Isherman@yarmouth.ma.us>wrote: RECEIVED Hi Richard, JUL 2 6 2022 BUILDING DEPARTMENT By: Resident would like to replace windows and the roof at 65 Avon Road. Like for like. Please let me know if you need any additional information. p p 10, Thanks Richard, E 9 5 /027I Lisa IfARMOu H OLD HI0HWA2Li Lisa Sherman Office Administrator Old Kings Highway Committee/Yarmouth Historical Commission Ei5o2rt,