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HomeMy WebLinkAboutBLD-23-000796 RECEIVED gLI)--0)3-tavq Office Use On th 1 5 2022 ,4fiKARN," AUG Permit# ” 4'#,-.. *.• ,y,.1,`0‘, --______ .. ..._ BUILDING DEPARTMENT Amount 50 )$( 2. By: '.Permit expires 180 days from 'issue date cv,3()Nci(f) EXPRESS BIJILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 15 Glenwood Street ASSESSOR'S INFORMATION: Map: 20 Parcel: 13 I OWNER: 15 Glenwood Stu 60 Sutton Place South, Ned 917-603-1849 NAME PRESENT ADDRESS TEL # CONTRACTOR: McPhee Assoc PO Box 799, E. Dennis, M8 508-385-2704 NAME MAILING ADDRESS (52vi I TEL.8 0 Residential CI Commercial Est.Cost of Construction$ 17,000 Home Improvement Contractor Lic.# 104158 Construction Supervisor Lie.N CS-097057 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 1 am the sole proprietor El I have Worker's Compensation Insurance insurance Company Name: Cincinnati Casualty Company Worker's Comp.Policy-i EWC0600890 WORK TO BE PERFORMED Tent 11 Duration (Fire Retardant Certificate attached?) Wood Stove [1:1 Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 15 ( 1E)Remove existing*(max.2 layers) Insulation 11 ri Old Kings Highway/Historic Dist. (7)Replacing like for like Pool fencing_ *The debris will be disposed of at: S&J Exco and on-site dumpster 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 he just cause for denial or rcvocatio i -license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: //a— PI Pdi e-J.A1/ Date: 8/12/22 Owners Signature(or attachment) lease see attached Date: Approved By: Building Date: Official(or designee I3MA II,ADDRESS: Zoning District: I listorical District: ' Yes ; No Flood Plain Zone: ' Yes 1 No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes "..; No August 9, 2022 TO: TOWN OF Yarmouth ATTN: Building Commissioner To Whom It May Concern: This letter is to confirm that we, David Officer and Marcia Wade, trustees of 15 Glenwood Street LLC for the property at 15 Glenwood Street, West Yarmouth, authorize McPhee Associates, Inc. to act on our behalf as the contractor for work to be performed at the above referenced address. aki/ 011//- avid Officer if Marcia Wade The Commonwealth of Massachusetts rig VO r Department of Industrial Accidents f1 Congress Street, Suite 100 colon Boston,MA 02114-2017 �r 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): McPhee Associates, Inc. Address: 1382 Rte 134, PO Box 799 City/State/Zip: East Dennis, MA 02641 Phone #: 508-385-2704 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 25 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. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 9. ['Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑ Building addition 4.❑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 11.0 Electrical repairs or additions proprietors with no employees. 12.Q 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.: 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑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: The Cincinnati Casualty Company Policy#or Self-ins.Lic.#: EWC0600890 Expiration Date: 1/1/2023 Job Site Address: 15 Glenwood Street City/State/Zip: W.Yarmouth,MA 02674 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: u <'i M . l/W Date: 8/12/22 Phone#: 508-385-2704 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#: c` Commonwealth of Massachusetts Division of Occupational Licensurejim Ctsmnaanwealth of Massachusetts Board of Building R ufations and Standards Division of Professional Licensure i Con IOltrfi vjsor Board of Building Repllyations and Standards 1 "'� to Cons rUtt�s't isor CS-018520 v 4'< E3tpires.04/30/2024 P�;;' ROBERT H iipPi7i j i ` CS-070755 JI y � t�Plres:02t0912023 PO BOX 797 r PERRY L ERMI as . EAST X 797 fi+lA` , k $ £ii ' PO BOX a#1 . r-y ,, .') . - Ci - ' tt�+iARSTC3Ns ti7l).L5 A ` ., ,,/�^ rat ' t Commissioner eitV�/2 K. iderst fra.. Commissioner c 11. +.J.. Commonwealth of Massachusetts Commonwealth waafth offl onsl Ucenetts Division of Professional Licensors Divisionfuil occupational and Stoe an 1. F Board of Building R Motions and Standards Board of Building Regulations and Standards f ._ Cons onr�visor Const��bnsLpervisor 4 >. CS-097067 mires 11,�29f2022 C3-044�5 {4 .4 p..epires:04/20/2024 JSSNATHAN PHILd.I� -: ' ROBERT m MCPI I s- r J 40 A" ` RC i - „' _ 28 BAKERS POND RO - r Bi�,7C -- ' $ SouTH DENAII MA 02$ , i ' ,7 i- , . ,f, r k .sy�°�� e Commissioner e„.. . �:E,,, COrterratasit er . G Commonwealth of Massachusetts Commonwealth of Massachusetts rlivisltars of Professional l iceresure Division of Professional Licensure Board of 13uilding.lte ulations and Standards Board of Building Regulations and Standards CoriStirmiliparvisor Coast i&Sti ,rvisor CS-098835 7 Expires 08/16/2023 CS-091094 , ' , [fires,03/15/2023 82 NORTf#SUSJUV S3N. ; CHRISTOPHER M _ , ', 25 THICKET R1IN= HARWICH SANDWICH 025'r' ` �.,Y�.. , commissioner 4 is rr€ ,�!7 �R�� 0Commissioner !+ t m_ Commonwealth of Massachusetts Commonwealth of Mess riuSe+tts ice/,'` Division of Professional Licensure C Di ioti of{octlpadorta1 Lie ore Board of Building Regulations_g and Standards Board olt Su ling RIy Lions and stand ds ``9a :;R ` :a`c>v aS4i " C*Uiari for F 't` C;S-09 - , �if ,t�uti8f2023 CS-072339 .y7' , - ri, icpires:12/27/2021 B WYMAN W ggMKS J ' -, "` PO BOX 811 j t f F't3 Box Tt i4f i k 2 PLYMOUTH MA, 023462 �. i ft rram�// ki- ri. ,, _- Commissioner dad t K. i7C�irtt.i. Camrnisaio r � ,'pa U r . THE CoN1t40111t ALTH OF MASSACHUSETTS -.._.._ Offise Consumer Af1,4,?f;Business Regulation . ifONIE IMPROVEM t C3NTRACT F vei0d for Individual t only before Tx Pt.. � - rat€Of 4sLe. if found - tD a Office of t;o tinter Moire end BusinessRo utaition 1ege W n Street .Suite 719 MCPHEE A; l � +' t MAt' tt} r RTi'L C�i>„E i; .t , 132RRT130 `" i .t t altL �1 - „r dorSere ry fl94O, INot tta d without signature A9RD® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 1/6/2022 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). PRODUCER CONTACT RogersGray, Inc. -Kingston Branch NAME: 63 Smith Lane PHONE (A/c.No.Extl:508-746-3311 FAX No 877-816-2156 Kingston MA 02364 ADDRESS: mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:The Cincinnati Casualty Company 28665 INSURED MCPHASS-01 McPhee Associates Inc INSURER B P.O. Box 797 INSURER C: East Dennis MA 02641-0797 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1710374837 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 ADDL SUBR LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DDY/YYYYY) (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY EPP0600883 1/1/2021 1/1/2024 EACH OCCURRENCE CLAIMS-MADE X OCCUR DAMAGE TO RENTED $1,000,000 PREMISES Ea occurrence $500,000 MED EXP(Any one person) $15,000 PERSONAL 8 ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY I GENERAL AGGREGATE $2,000,000 JECT LJ LOC PRODUCTS-COMP/OPAGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY EBA0600886 1/1/2022 1/1/2023 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $1,000,000 OWNED BODILY INJURY(Per person) $ AUTOS ONLY X AUTOS X HIRED X NON-OWNED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE $ Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ A WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY EWC0600890 1/1/2022 1/1/2023 X PER OTH- Y/N STATUTE ER ANYP RO P R I ETOR/PARTN ER/EXEC UTI VE OFFICER/MEMBEREXCLUDED? N N/A E.L.EACH ACCIDENT $1,000,000 (Mandatory in NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $1,000,000 __DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 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 ACCORDANCE WITH THE POLICY PROVISIONS. For Insurance Purposes Only AU .•t ED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD