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Home My WebLink AboutBLD-23-000689 O� Vll1l:C USC VLLly f y�. k.. • O 124 ?//(1/&Z ;Permit# i}i— (O/� :*11='� H - Amount 9o.a o MATTACf1 CSE 1 e '*.qOo""a°''ca d Permit expires 180 days from ;issue date I514)—a 3 -60(160 j EXPRESS BUILDING PERMIT APPLICATION. E D E I V E D TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 AUG 10 2022 South Yarmouth, MA 02664 _ ___ (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT CONSTRUCTION ADDRESS: a 3 a 3 ( 7 28 S.�14 gonexad ril4 otaecit<4 ASSESSOR'S INFORMATION: Map: Parcel: OWNER:P4ft ^'/L�/,��(4'1` fido L-y -retest . NAME PRESENT ADDRESS ,�J TEL. # },CONTRACTOR /r✓/0} Awl,y 32404 moidd f f�./,�'frt� i m4.02444 d2)8-s�'—?61 NAME MAILING ADDRESS TEL.# ❑Residential yCommercial Est.Cost of Construction$ dad"'OO Home Improvement Contractor Lic.# Construction Supervisor Lic.# d�IA--- Workman's Compensation Insurance: (check one) I am the homeowner XI am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 4 Replacement windows:,# Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: Yiatel ad 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 on f my licen e and for prosecution under M.G.L.Ch.268,Section 1.Applicant's Signature: Date: O p //o 1 Z.--- Owners Signature(or attachment) L— Date:• yi/ 9 if,,__;- ? ......---- Approved By: Date: b"‘0 " t 411. Building 0 icial r d signee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes r2 No Flood Plain Zone: 0 Yes D No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts r L Department of Industrial Accidents t 1 Congress Street, Suite 100 Boston, MA 02114-2017 `�M,,.5•`'' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/Individual): Oje�� Aloe wai Address: 386 a(Q/ I4) S City/State/Zip 0 A4t4 oN , Phone 4: 5—ti - Q^W2Z Are you an employer?Check the appropriate box: Type of project (required): 1.— I am a employer with employees(full and/or part-time).* — 7. _ New construction 22I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers'comp. insurance required.] 8• - Remodeling 3. I am a homeowner doing all work myself. — 9. ` Demolition y [No workers'comp. insurance required.]t 4.— ProPerty. w I am a homeowner and will be hiring contractors to conduct all work on myI ill 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.[1]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.I. l •[Roof repairs 6.[We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E Oth er.r/..k Alfee 152,§1(4),and we have no employees. [No workers'comp. insurance required.] 511 4_ 9/4 37 *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: h//js e/a) Wiz ANS Ca Policy#or Self-ins. Lic. #: / AJP8 24 36 e) Expiration Date: 9 /2/2.Z. Job Site Address:/34?J P7 91' .S;0(f,P,FadlAl City/State/Zip: A o4 c:›246€4, 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 certi 'er the pains and pe aides of perjury that the information provided above is true and correct. Signature: AO �� Date: 2 f 6 122--- Phone#: P-e)R-, s- Q -76. 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 m: _ Commonwealth of Massachusetts t®f� Division of Professional Licensure Board of Building Regulations and Standards Consitr: tti 14A1S isor CS=061815 spires:06/20/20 .' DAVID L HAI URT;.1•1, ` 'y 326 OLD MAINE St a tt SOUTH YARM9U1 V( (jLL‘ • Commissioner eX A'. iefCm • U *. • • i i • 1 00 ARD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDlYYYY) 11/10/2021 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 Christian Barber,CIC NAME: The Oceanside Insurance Group PHONE (508)775-0500 (A/C,No,Ext): (A/C No): (508)790-7955 AIL E-DDM ARESS: 52 West Main Street INSURER(S)AFFORDING COVERAGE NAIC# Hyannis MA 02601 INSURER A: Western World Ins Co INSURED Y Safet Insurance 33618 INSURER B: David Hanbury Construction,Inc. INSURER C: 326 Old Main St INSURER D: INSURER E: South Yarmouth MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: CL21111008692 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 ALIUL3UBK POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD wVD POUCY NUMBER (MM/DD/YYYY) (MM,DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY �/ EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE /� OCCUR DAMAGE TO RENTED 100,000 PREMISES(Ea occurrence) $ MED EXP Any one person) $ 5,000 A NPP8743630 09/03/2021 09/03/2022 1,000,000 PERSONAL&ADV INJURY $ GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 XI POLICY PRO- JECT LOC PRODUCTS-COMP/OPAGG $ 1,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ - ANY AUTO (Ea accident) BODILY INJURY(Per person) $ 100,000 OWNED B AUTOS ONLY X AUTODULED 5904918 08/30/2021 08/30/2022 BODILY INJURY(Per accident) $ 300,000 HIRED NON-OWNED _ AUTOS ONLY _ AUTOS ONLY PROPERTY DAMAGE $ 100,000 (Per accident) Medical payments $ 5,000 UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY PER OTH- Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A E.L EACH ACCIDENT $ (Mandatory in NH) If yes,describe under E.L DISEASE-EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) - Insurance coverage is limited to the terms,conditions,exclusions,and other limitations and endorsement of the policy.Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE S Yarmouth MA 02664 gr'4:°e*----..,___ 5 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD