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HomeMy WebLinkAboutBLD-23-000483 • 0f•y`AR C, C I Iiq 1 . Office Use �Onnly� / 's rk.. �! p 1Permit# l 1`aw/iZ(, = o . t> C 7 S�Ol) O �� . H -Amount l r {� l ` MATTACM ESE 4. e ":.Lace*E 3Permit expires 180 days from r tissue date 8LI -&3 - 0664g3 EXPRESS BUILDING PERMIT APPLICATI TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146Route28 JUL 292022 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT By: CONSTRUCTION ADDRESS: 18 GpES I Ci a 1 E (J C$ T 1prz ,?')O v 1 L 0 ASSESSOR'S INFORMATION: Map: Parcel: OWNER: I} AME( C0nG Pi Il10 C 5oS ? 3S 7991 N PRESENT ADDRESS TEL. # CONTRACTOR: 39Ho DCMOt)0 as Sm lTh( 5T xyAInnis 506 36 'I88 56 NAME MAILING ADDRESS TEL.# residential 0 Commercial Est.Cost of Construction$ 800l0 Home Improvement Contractor Lie.# i q T g 3 1 Construction Supervisor Lie.# C S — 1 O 9 g 1 Workman's Compensation Insurance: (check one) 0 I am the homeowner ❑ I am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: Li bE L I-y mVTUA I Worker's Comp.Policy# ,pi C p7 2 J I S 6 C2 go e2' o . WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 9 Replacement windows:# Replacement doors: # Roofing: #of Squares 8 ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: 'rol.11f) O C '/A Q*1 OU-Pi D I S 120-j,A 1 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-o; of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: 0 3 iR 9 lac; Owners Signa„re(or a ..I ment) / 19—t Date: -�7 Approved By: __ Date: /19/Z Z Building Offic i 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 Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Re ulations and Standards Cons�f �,S visor CS-109981 I JOAO DEMO' ' , Pires: 12/22/2023 22 SMITH SIRE-1 t 1 HYANNIS M4J12 :d Commissioner cifaida K. Fi Ma 4.SSW SIOSSASSIVIEM MIOIIt ,,''"i" CREATEb*Di ri- -• r� t/ ems ' , JOAO 69E fYIC A�1rA •:-:� ' = ',, HYA AMISS,IA OM01 ;(.4\- Via.' (w�a,I!'CL. '.416rv�i ..a i. 9,k s • • Undscascretary • • • i -' The Commonwealth of Massachusetts r ....411B /, Department of Industrial Accidents gel= 1 Congress Street, Suite 100 Boston, MA 02114-2017 ,,,gmwww.mass.gov/dia yy Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/Individual): c RE(\1?. f u1 JD (1. (+1JOCC r IOC Address: aol 3n' i j/-i S T City/State/Zip: kiwi n C)i S 14),_ pad,01 Phone #: .?°8 3611 8 8 S 6 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. E New construction 2.❑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. C]Demolition 3.-I am a homeowner doing all work myself.[No workers'comp.insurance required.] — - 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.❑Eleel.i ical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.*I 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. 6.0 We area 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 41 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 wit cm employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. ��pp Insurance Company Name: L in Su V1 n C E Policy#or Self-ins.Lic.#: kij C — 13 0 I ! 5 2 Expiration Date: 0 8 - 01 -,„) a Job Site Address: is (, C-.ST- C I IZL.1 C City/State/Zip: WE 61 kpae,(warm frill UaG 9� 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 r t e pains and penalties of perjury that the information provided above is true and correct. Signature: '' Date: 0-? /441s / e7)- Phone#: 50el 36 k 8 8 5 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 Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone 4: ,AC. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 07/28/22 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 NAM'AC I : CONE: JIM HINDMAN F PHONE 508-771-8381 (AC,No): 508-771-0663 Schlegel&Schlegel Ins Brokers,Inc. (HIC,No,E:t): 34 Main Street E-MAIL ADDRESS: schlegelinsurance@gmail.com West Yarmouth,MA 02673 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: NGM INSURANCE COMPANY 14788 INSURED INSURER B: LM INSURANCE COAST CARPENTRY HOME IMPROVEMENT INC INSURER C: 250 SUDBURY LANE INSURER D: HYANNIS,MA 02601 INSURER E 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 ADDLSUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 500,000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 A MPJ5180E 08/30/21 08/30/22 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: 2,000,000 PRO- PRODUCTS PRODUCTS-COMP/OP AGG $ POLICY JECT $ OTHER: COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY (Ea accident) BODILY INJURY(Per person) $ ANY AUTO OWNED SCHEDULED BODILY INJURY(Per accident) $ _ AUTOS ONLY AUTOS HIRED NON-OWNEDPROPERTY PRO(PerERTYP DAMAGE $accident) AUTOS ONLY AUTOS ONLY $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ $ DED I I RETENTION$ PER OTH- WORKERS COMPENSATION I STATUTE I I ER AND EMPLOYERS'LIABILITY YIN E.L.EACH ACCIDENT $ 1 OO,000 ANY OFFICER/MEMBER PROPRIETOR/PARTNER/EXECUTIVEEXCLUDED? EXECUTIVE N/A WC-1301152 08/31/21 08/31/22 100,000 B (MadE ory in N ) EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ (Mandatory in NH) 500,000 If yes,describe under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) COPORATE OFFICERS HAVE ELEXTED TO BE COVERED UN THEIR CURRET WORKERS COMPENSATION POLICY INSURANCE COVERAGE IS LIMITED TO THE TERMS,CONDITIONS,EXCLUSIONS,OTHER LIMITATIONS AND ENDORSEMENTS OF THE POLICY CANCELLATION CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. TOWN OF YARMOUTH r BUILDING DEPARTMENT AUTHORIZED REPRESENTATIVE WEST YARMOUTH MA 02673 y III ©19 lipi 5 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of • ORD ACORD 25(2016103) MG ma i l Create Build &Remodel <createinccapecod@gmail.com> Permission Email for work to be done at 18 Crest Circle West Yarmouth Pilling, Katherine <katherine.pilling@cpii.com> Thu, Jul 28, 11:14 AM To: createinccapecod@gmail.com <createinccapecod@gmail.com> Cc: kpilling@gmail.com <kpilling@gmail.com> To Whom It May Concern: I am the homeowner of the property at 18 Crest Circle West Yarmouth, MA 02673. I hereby give permission to Joao DeMoura, owner of Create Build &Remodel Inc. 22 Smith Street Hyannis, MA 02601, to do roofing and siding work at my property. Any questions I can per reached at either of the phone numbers below. Sincerely, Katherine Pilling Katherine Pilling Buyer Communications & Power Industries LLC Radant Technologies Division Inc. 255 Hudson Road Stow, MA 01775 USA +1 (978) 637-2575 (office) +1 (508) 735-7499 (mobile) katherine.pilling©cpii.com www.cpii.com/radant