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HomeMy WebLinkAboutBLD-23-000613 O�• .Y9R`'� J�U Ql���� Office Use Only f..! Permit# C1//6 O . .. iit . H i �A.,T t c cstyd� JAmount 90 d2) Permit expires 180 days from issue date 610—a3—odd(0, EXPRESS BUILDING PERMIT APPLICAT i.:TOWN OF YARMOUTH _ E I V E D Yarmouth Building Department 1146 Route 28 AUG 05 2022 South Yarmouth, MA 02664 _ _ (508) 398-2231 Ext. 1261 Bull Dl G DEPgRTN►ENT BY: Abh CONSTRUCTION ADDRESS: 7 Sec\ t�_.(2 t fi 7 i ASSESSOR'S INFORMATION: Map: Parcel: OWNER: ca'\- O s-2,-Q 4\ 4r- S_h NAMF P ENT/��� SS TEL. _7 7 7 6 Li et CONTRACTOR: --�� 1 :Tv /;„15 tI( 34 '^� NAME MAILING ADDRE� TEL.# ��� ��� ❑Residential Commercial Est. Cost of Construction$ l 0. Z V /Home Improvement Contractor Lic.# 73 'Y 7? Construction Supervisor Lic.# ©a) U . �. Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor yXI have Worker's Compensation Insurance Insurance Company Name: lie '� Worker's Comp.Policy# CS C)OZ"7 P1 7257422 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares ' 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: /►1� D(� L kw Pt�/, ✓ 1 / Location of Facility I declare under penalties of perjury that th- :tements herein contained are -and`correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or revoca.s of..y lic- se and f rosecution ender M.G.L.Ch.268,Section 1. Applicant's Signature: Date: '- 2 "� Owners Signature(or attachment) t,i:� G� , �� / Air Date: 2. 2-2/Approved By: Building Official(or designe-/� / • L ADDRESS:/ ,..of Date: �2 Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No ) ❑ Yes 0 No • _* The Commonwealth of Massachusetts _> � Department of Industrial Accidents =1 . `A_= 1 Congress Street, Suite 100 _ ` Boston, MA 02114-2017 'y`�,:. •'' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information lease Print Legibly Name (Business/Or nization/In i 'dual): l'A k L ,.: -C. I ,_.......1 ` �. ; 2 ../ Address: . , -„ L d t,i t- ss,4 s 6 4 f a, i City/State/Zip: Phone #: b 77( T " [- Are you an employer?Check the appropriate box: Type of project(required): I I am a employer with 7 employees(full and/or part-time).* — 7. _ New construction 2. I 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. [No workers'comp.insurance required.]t 9 ❑ Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on m YProe property. I will 10 n Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.El Electrical repairs or additions proprietors with no employees. - 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance.$ 13•Ell Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other i_i_k—. 7 , 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. $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 f r my employees. Below is the policy and job site information. Insurance Company Name: 1 \` -C. \.....\,r� -� �� 1 Policy#or Self-ins. Lic. #: 6s 6 V 0 '/ A,‘ 3 2 S 742 i on Date: C,S - L) .- .2 '.3 Job Site Address: 3 'T- —c -Q�•_ )- °�'`rP Attach a copy of the workers' compensation � '� � � � .� 1t�5t�/ p' � � C� l� policy declaration page(showing the o number and e- 'P icy ration 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 ains an penal s of per' ry that the information provided above i true and correct. ' l Sia _._ Date: Z i !Cs ,' nature: Phone#: -) --i 7 t' -K (6 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 CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: AC Ro D® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) �/ 05/25/2022 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 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). CONT PRODUCER NAMEACT Marshall Lovelette MARSHALL K LOVELETTE INSURANCE AGENCY INC PHONE.Ext): (508)775-4559 i FAX No) E-MAIL ADDRESS: marshall@loveletteins.com 396 MAIN ST INSURER(S)AFFORDING COVERAGE NAICA WEST YARMOUTH MA 02673 INSURER A: HARTFORD UNDERWRITERS INS CO 30104 INSURED INSURER B: HEALY BROTHERS CONSTRUCTION CORP INSURERC: INSURER D: 72 OLD MAIN ST INSURER E: SOUTH YARMOUTH MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: 778513 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 IADDL'SUBR POLICY EFF I POLICY EXP LTR TYPE OF INSURANCE I INSD i WVD POLICY NUMBER (MM/DD/YYYY)1(MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY i EACH OCCURRENCE i$ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ ` N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: i PRO- GENERAL AGGREGATE 1$ POLICY JECT LOC PRODUCTS-COMP/OP AGG I $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) 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 LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER ERH- AND EMPLOYERS'LIABILITY X STATUTE ER Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBEREXCLUDED? N/A N/A N/A 6S60UB4N38257422 05/29/2022 05/29/2023 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 I N/A I DESCRIPTION OF OPERATIONS/LOCATIONS/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 Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE -Th South Yarmouth MA 02664 i ) �' ° Daniel M.Cr y,CPCU,Vice President—Residual Market—WCRIBMA ACORD 25 2014/01 ©1988-2014 ACORD CORPORATION. All rights reserved. ( ) The ACORD name and logo are registered marks of ACORD *. Commonwealth of Massachusetts Division of Profee,sional Licensure Board of Building:Re ulations and Standards Const\ n ,rvisor /i CS-060855 f 4 Aires: 11/22/2022 MICHAEL A MEALY f a 72 OLD MAIN,°¢T SOUTH YARM)UTH ..44 • >: Commissioner di /.• �Fint tag, • HQIME FMPROVEI CONTRACTOR lon NT CONTRACTOR ' TYPE:Individual Re ----aistr'tign E it i n 1778 04/22/2023 MICHAEL HEAD :.. MICHAEL A.HtAL'r72 OLD • SOUTH MAIN ST MiJy 4;� MA 02664 � Undersecretary • r