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HomeMy WebLinkAboutBLD-23-000808 RR 1 Office Use Only jc (Permi. y Amount has•`' aPermit expires 180 days from l issue date 30)S-.G1 EXPRESS BUILDING PERMIT APPLICATION C I631 TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 ' AUG 1 2022 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT CONSTRUCTION ADDRESS: L AJITU M N Dk., yftit. (NOU t 0.2 6G 7/, BY ---- ASSESSOR'S INFORMATION: ` Q, Map: Parcel: OWNER: �� CNAki SiME 73,N1 cocarHV l/ti ,NL la 6,..eut.ST Dk,4;0kesr,o4C. ,anA- Oa 508 8 0 orb' (j' PRESENT ADDRESS TEL. # CONTRACTOR: VP, 't/Sjpci CeigicenrRy 1 NC.NAME MAILING ADDRESS TEL.# AResidential 0 Commercial Est.Cost of Construction$ .Q5,000 Home Improvement Contractor Lic.# IQ ki e5 Construction Supervisor Lic.# G S— (I0QI Workman's Compensation Insurance: (check one) 0 I am the homeowner ❑ I am the sole proprietor tg,I have Worker's Compensation Insurance Insurance Company Name: Off CA MU 7- I y# 1 5 6/ 2 � Worker's Comp.Polic f o0. o WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 1 Replacement windows: # S �� �� Replacement doors: # a Roofing: #of Squares I 0 ( )/)Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: Ctt IiciS - De JN t S 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 de al revocatio f my lice a and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: ,lee Date: 6f"/IF/Z 4' Z �Owners Signature(or attachment) Date: e I16( 2 Approved By: g/�22 Building Official(or designee) Date: g ) EMAIL ADDRESS: 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 a • The Commonwealth of Massachusetts+= = I Department of Industrial Accidents =yr, l� 1 Congress Street, Suite 100 f'_'Fi_ �,,i. Boston, MA 02114-2017 :,_ _ 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): l/,g C.v/S ran r-INJ j .y' (ivL Address: 12 f(NGcrlcT bk., I City/State/Zip: /--o/ieS7DA Ie 1 NJA ,C 4 Phone #: 5of 36o t S6 I Are you an employer?Check the appropriate box: Type of project(required): 1 a 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 any capacity. [No workers'comp. insurance required.] 8• ❑ Remodeling 3.0 I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. E Demolition — 4.1: ProPem•I am a homeowner and will be hiring contractors to conduct all work on myI will 10 _ Building addition ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 11.❑ Electrical repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.0 Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance.t 13.❑Roof repairs 6.E We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other i SIDDiNGr WIn S 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: ( 7iCA- 1 I1170r0,l Policy# or Self-ins. Lic. #: 415(o J 020,k) Expiration Date:7).23123 Job Site Address: le A JTtJMN D2 Cit /State/Zip: )/� 1d, MA 0a664 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 ertify under th gins and enalties of perjury that the information provided above is true'and correct. Signature: l Date: g /b zZ Phone#: 5O ' p o25S Official use only. Do not write in this area, to be completed by city or town official. City or Town: Issuing Authority (circle one): Permit/License# 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Ins ector 6. Other p Contact Person: Phone#: 4. ®t Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Consl;ivy>u°t AbOrvisor /i CS-111401 ,,pires:02/24/2023 DIEGO BAVEJ.ONI J40 43 WINSOME/12D •iaril4,444,; SOUTH YARMQU 111 �O Commissioner da.8at /. .Y 0 ilta, Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Corporation Registration Expiration 113648& 11/19/2022 V.B.CUSTOM CARPENTRY INC' DIEGO BAVELONt 12 PINECREST DR f (a)14,0 i FORESTDALE,MA 02644: Undersecretary Ot A CCA � DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE I 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 CUNiACI NAME: Wendy Gaul Circle Business Ins.Agcy,Inc PHONE 978-777-5619 247 Newbury Street IA/C. FAX No,Exn: I(A/c,No): 978-777-4898 E-MAIL Danvers,MA 01923 ADDRESS: wgaui@circleinsurance-net INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: Main Street America Group INSURER B: Utica Mutual V.B.Custom Carpentry Inc- 43 Winsome Road INSURER C South Yarmouth,MA 02664 INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDR ABOVE rFOR 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 ADDL6UHR LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF POLICY EXP X COMMERCIAL GENERAL LIABILITY (MM/DD/YYYY) (MM/DD/YYYY) LIMITS EACH OCCURRENCE $ 1,000,000 I CLAIMS-MADE I XI OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ 500,000 A MED EXP(Any one person) $ 10,000 Y MPJ6611J 07/23/22 07/23/23 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY I I JECTPRO- I I LOC OTHER: PRODUCTS-COMP/OP AGG $ 2,000,000 AUTOMOBILE LIABILITY $ COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) OWNED SCHEDULED BODILY INJURY(Per person) $ AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED _ AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB _ EXCESS LIABOCCUR $ EACH OCCURRENCE $ CLAIMS-MADE DED I I RETENTION$ AGGREGATE $ WORKERS COMPENSATION - $ AND EMPLOYERS'LIABILITY PER OTH- ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N XI STATUTE I I ER B OFFICER/MEMBER EXCLUDED? I N I N/A Y 4561220 E.L.EACH ACCIDENT $ 500,000 (Mandatory in NH) 07/23/22 07/23/23 If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/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 Town of Yarmouth City Hall ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 Yarmouth,MA 02664-4492 AUTHOR ED R RESENTATIVE / ter, „,' ,‘,._.,' ©1988-2015 ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ACORD CORPORATION. All rights reserved.