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HomeMy WebLinkAboutBLD-23-000622 Un V J/� 1 Office Use Only a pg'r RR� or ,iPermit# O't.1. H i Amount MATTAc11 ESEl o..r„ :6dI Permit expires 180 days from l issue date BO -0.3- bbb,2Z- EXPRESS BUILDING PERMIT APPLICATI TOWN OF YARMOUTH ' RE. D C E I�/ E Yarmouth Building Department 1146 Route 28 AUG 05 2022 • South Yarmouth, MA 02664 P .' (508) 398-2231 Ext 261 BU ���`� By.________--- A CONSTRUCTION ADDRESS: 1 S4 Z C 9\rT ASSESSOR'S INFORMATION: 1 Map: Parcel: • V OWNER: `11J .1 (MCA ‘31- iA►lam ELvaan NS,ell=, Z5 3 S i ttS NAME PRESENT ADDRESS TEL. # CONTRACTOR;.jAM .5.- ciC.Z€8A' k vrh I Z6' 5m i-t- S- 4CPEL�o N MA 0100 7 NAME MAILING ADDRESS TEL.# cr.is 537 $'Z9 0 Residential 0 Commercial Est.Cost of Construction$ 7G 0 0 A Home Improvement Contractor Lic.# I/566 i "Construction Supervisor Lic.# 05fl 9 6 6 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor dgi I have Worker's Compensation Insurance Insurance Company Name: ZA,r1 LJ d Worker's Comp.Policy# (,ut/,3 -ZE jg,s-99-8"Z Z I WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows: # Replacement doors: # Roofing: #of Squares i 0 (Pc')Remove existing* (max.2 layers) Insulation Old Kings Highwav/Historic Dist. ( )Replacing like for like Prnol fencing *The debris will be disposed of at: C,✓AS tit /lad vu A.4 IS pi f Ili4 L.fi L 8. .04 gon/vi. /0211 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 fo osecution under M.G.L.Ch.268,Section I. ` Applicant's Signature: G---4.. g ,,✓✓' Date: '�'2.t Z.xj Owners Signature(or a achment) fv�' 71- Date: toI15 ��-Approved By: Date: --S Building Official(or gn EMAIL AD 1 Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No ❑ Yes ❑ No 1 • The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 ttir_ ' 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): � C�n�r'C "�, u�A 3 Address: i 'Z 6 J, ,n,•-.";-1‘*" • • City/State/Zip: /y{F/ (/�T „-, 7 Phone #: L(l3 ,;.2 7 r 3 Z-9 Are you an employer?Check the appropriate box: Type of project (required): 12,1 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 8. U Remodeling any capacity.[No workers'comp.insurance required.] — 9. — Demolition 3._I am a homeowner doing all work myself.[No workers'comp. insurance required.]t 10 Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will — ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp. insurance.$ 14. 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 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. 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: „ t-1.k,I Policy#or Self-ins.Lic. #: !-1 Z�3aF- v Z Expiration Date: yC Job Site Address: 1 5 14 A 'it,o r.- 6 ' City/State/Zip: 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 under the pains and penalties of perjury that the information provided above is true'and correct. Signature: Date: 7_L/ / ''*+ :/ . Phone#: it ,i� 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 Phone#: Contact Person: ��„...1 JSCONTR-01 CPOROWSh AFRO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 2/22/2022 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 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). CONTACT PRODUCER 'NAME — AXiA Insurance Services PHONE 84 Myron Street E MAIL' ) (413)7884;000 T/c,No.h(413)886- 190__ info axis rou .net Suite A I_At)Iamel___-_� 9 p.--- West Springfield,MA 01089 — _. — -- I_NSURER(S)AFFORDING COVERAGE —._I •_� -_.—NAIC#,— I INSURER A_Evanston Insurance Company __._ 135378 -- i INSURED !INSURERB:MSA Main Street America Assurance Company 129939 J S Contractors,Inc. 1 Tammy Szczebak INSURER C:Travelers Casually Ins Co of America____—_ 119046 _, 126 Summit Street �SURERD: —__e----_ .--___—_.____-__ T_ ..___I Belchertown,MA 01007 F INSURER E: ,..—_—_ii ---_----- 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.INSR i !ADDL SUBR' POLICY EFF 1 POLICY EXP ( LIMITS LTR II TYPE OF INSURANCE INSD WVD POLICY NUMBER IMMIDD/YYYY) IMMIDD/YYYYI! A LX COMMERCIAL GENERAL LIABILITY i 'EACH OCCURRENCE I$ — —1,000,000 1 ,CLAIMS-MADE Xi OCCUR 3AA499482 18/23/2021 j 8/23/2022 'DAMAGE TO RENTED 0,000 �PREMISES(Ea .trencaL--LA._ 105r000 I MED EXPiArty_one_kersonZ j$ PERSONAL 8 ADV INJURY _'$ 1,000,000 GEL AGGREGATE LIMIT APPLIES PER: 2,000,000 GENERAL AGGREGATE y$-_— POLICY f 1 jE a I—_1 LOC I PRODUCTS-COMP/OP AGG 1$_ 1,000,000 OTHER: !COMBINED SINGLE LIMIT 1,000,000 B AUTOMOBILE LIABILITY j L IERAccident) $ __. __ 1 ANY AUTO _ All P7360E 12/1/2021 12/1/2022 1 BODILY INJURY(Per personq$ OWNED ( I SCHEDULED AUTOS ONLY i X t AUTOS 'BODILY INJURY(Per accdent)I$ X IHIRED NON-OWNED ! PROPERTY DAMAGE I AUTOS ONLY j X 1 AUTOS ONLY ( I L(Per accident) $ I I$ UMBRELLA LIAR L OCCUR ,_EACH OCCURRENCE '$ 4 EXCESS UAB CLAIMS MADE I !AGGREGATE 41__ DED RETENTION$ I '$ C WORKERS COMPENSATION , j I X I PER ! OTH- i AND EMPLOYERS'LIABILITY — ANY PROPRIETOR/PARTNER/EXECUTIVE IY/Nl( I A 6RUB-2E38599-8-22 2/22/2022 2/22/2023 sTA�t TE ! I 1,000,000 El.EACH ACCIDENT ; OFFICER/MEMBER EXCLUDED? 1 N I 1,000,000 I (Mandatory In NH) I E.L_DISEASE-EA EMPLOYE $ If yes,describe under I E.L.DISEASE-POLICY LIMIT;$ 1,000,000 DESCRIPTION OF OPERATIONS below I ) ! I I . DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Proof of Coverage ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD t;ommonweann or massacnuseua Division of Professional Licensure Board of Building Regulations and Standards r~ars,r: tien9 rvisr CS-058968 Expires:08/28/2022 JAMES E SZCZEBAK : 126 SUMMIT ST BELCHERTOWN MA 41i Commissioner �f fz v,-0 vpaate AaaPass and rsisC4in�dr`u. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE:Corporation Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street -Suite 710 115861 03/27/2024 Boston,MA 02118 JS CONTRACTORS,INC. JAMES E.SZCZEBAK 126 SUMMIT ST. BELCHERTOWN,MA 01007 Undersecretary Not valid without signature CPL-02 Rev 06,13 843064 CORPORATION STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECT N 450 Columbus Boulevard ♦ Hartford Connecticut 06103 Attached is your Home Improvement Contractor registration. This registration is not transferable. The Department of Consumer Protection must be notified of any changes to your registration within thirty(3o) days of such change. Questions regarding this registration can be emailed to the License Services Division a- 1_ -' In an effort to be more efficient and Go Green,the deparintent asks that you keep your email information with our office current to receive correspondence. You can access your account at www.elicense.ct.gov to verify,add or change your email or address. Visit our web site at www.ct.gov/dcp to verify registrations,obtain applications and the booklet for The Connecticut Contractor for Home Improvement and New Home Construction. STATE OF CONNECTICUT DEPI RT1!I \T OF CON-SI VIER PROTE`(TIO\ J S CONTRACTORS INC HOME IMPROVEMENT CONTRACTOR 126 SUMMIT ST J S CONTRACTORS INC 126 SUMMIT ST BELCHERTOWN,MA 01007 ( BELCHERTOWN,MA 01007 Registration# Effective Expiration HIC.05 21 12/01/2021 03/ /2023 SIGNED ._._ uommonweaitn or massacnuseus Professional BoardDivision of Buildingof Regulations andLicensure Standards C,,nstro tia a °,Supervisor CS-058968 Expires: 08/28/2022 ' JAMES E SZCZEBAK 126 SUMMIT ST BELCHERTOWN MA 01007 Commissioner icu �f tlpadle ikatIraVb 4hO1EJ Drtt%A a THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE:Corporation Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street -Suite 710 115661 03/27/2024 Boston,MA 02118 JS CONTRACTORS,INC. JAMES E.SZCZEBAK 126 SUMMIT ST. BELCHERTOWN,MA 01007 Undersecretary Not valid without signature CPL-02 Rev 06'13 843064 CORPORATION STATE OF CONNECTICUT DEPARTMENT F CONSUMER PROTECTION 450 Columbus Boulevard ♦ Hartford Connecticut 06103 Attached is your Home Improvement Contractor registration. This registration is not transferable. The Department of Consumer Protection must be notified of any changes to your registration within thirty(3o) days of such change. Questions regarding this registration can be emailed to the License Services Division tea, e: In an effort to be more efficient and Go Green,the department asks that you keep your email information with our office current to receive correspondence. You can access your account at www.elicense.ct.gov to verify,add or change your email or address. Visit our web site at www.ct.gov/dcp to verify registrations, obtain applications and the booklet for The Connecticut Contractor for Home Improvement and New Home Construction. STATE OF CONNECTICUT DEP4RT11EN OF:COti151 1E1(fROTFGT1O J S CONTRACTORS INC HOME IMPROVEMENT CONTRACTOR 126 SUMMIT ST J S CONTRACTORS INC BELCHERTOWN,MA 01007 126 SUMMIT ST BELCHERTOWN,MA 01007 Registration# Effective Expiration HIC.05 21 12/01/2021 03/ /2023 SIGNED