The URL can be used to link to this page

Home My WebLink AboutBLD-22-007512 e_meLf )cam. - RECEIVE Office Use Only JUN 2 9 2022 Permit,/ It Z t ' Amoun I BUILDING DEPARTMENT �°'�" NT Permit expires 180 days from By -- - - — issue dale 6co -22-0O 1SiZ EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 577(C� gieK ii/ab1ci Rood ASSESSOR'S INFORMATION Map: 95 7S;/ Parcel:3I AO03 Aoo yormanfA jj� J '31: *tier"af„)nc M et'tie OWNER:W ,c/- (1�Q � IIIG�C Nur& alM MI) a1070 Gy/vJ 7v4'V7-1c2 NA ESENT r\D RESS TEL, # CONTRACTOR: 13004k ce ,Te• tot/ 6t./t't'\,MA 0 teal cui,) 7 `i- I 9 NAME MAILING ADDRESS TEL.# ❑Residential ®Commercial Est.Cost of Constructions Jg 7Sp 0.0 0 Home Improvement Contractor Lie.# Construction Supervisor Lic.# t�s 0-I?701X Workman's Compensation Insurance: (check one) -/ 0 I am the homeowner 0 I am the sole proprietor O I have Worker's Compensation Insurance Insurance Company Name: S.cl ' 'Nt leT(M341C Worker's Comp. Policy! W to C).g 3 g y l WORK TO BE PERFORMED Tent El Duration (Fire Retardant Certificate attached?) Wood Stove Ei Siding: #of Squares t'ors Replacement windows:# Replacement doors: # Roofing: #of Squares (❑)Remove existing*(max.2 layers) Insulations Old Kings Highway/Historic Dist. CI)Replacing like for like Pool fencing 1 *The debris will be disposed of at: CI(, / I oviS f(,r stho n 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 for prosecution under M.G.L.Ch.268,Section 1. { Applicant's Signature C�++ ! p` 0�_t�, +] i /12E1 -. � l"'tJt�u�t'�_ '� L " y�c('�_.._..n# I�Data: ��Efi.ti� �'*�V eta, Owners Signature(or attachment) Date: 6/29/2�22 Approved Byy_. Date.: h - )L��Building Official(or designee l t DRESS: Zoning District:, _ Historical District: :1 Yes :' No Flood Plain Zone: Yes i, No Water Resource Protection District: Within 100 ft.of Wetlands: Yes 11 No i_I Yes I No "....41 BAYSSTI OP ID:SG ACORU` DATE(MM/D01YYYY) 4.,.- CERTIFICATE OF LIABILITY INSURANCE 06/28/2022 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 net confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER 781-431-2500 c vcr NorthSter Ins.Services,Inc. PNONE 781-431-2500 FAX 78 t 431 134 300 First Ave,Suite 100 We,NIT Esll: (A/C.NW: Needham.MA 02494 - INSURERS)AFFORn1NG:COVERAGE HAIC I INSURER A:Selective Insurance Company 19259 INSURED INSURER B Bawl*,Services,Inc. 48U Wiluwood Ave,. ,INSURER C Woburn,MA 01801 - INSURER U t ,,.....�...__. _w,..., .._ INSURER 6: 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. 1 TR TYPE OF INSURANCE ADDL SUBIL POLICY EFF POLICY'EXP INSO WWI POLICY NUMBER IMMIOO/YYYY1 IMMMIWYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY —CACHQGCUJL99NGE„, j 1,000 000 I CLAIMS-MADE ! X OCCUR S 2440223 12/31/2021 12/31/2022 DAtelA(it TO PENTAD 500,000 ARFettsr -n,.ougnoi $ — MED EXP any one person) ;. 15,000 PERSONAL 4 ADV INJURY $ 1,000,000 +iel•<.NI.AGGRf EpCT LIMIT APPLIES PER: ENERdI AGGRFGAT JE Fg +�. 2,000,000 POLICY -1 LOC ' PRODUCTS-OOMP[OP AGO.$ 2,000,000 OTHER Emp Ben. s 1m/2m A AUT*MOBILE LIABILITY O' DNdnIDSINGSLEOMIT $ 1,000,000. X ANY AUTO A 9108481 12/31/2021 12/31/2022 so y uM4uR aeP i ; $_ OWNED . SCHEDULED AUTOS ONLY AUTOS� 5OOILV INJURY IPA,SeelelAbIL .._ AUTOS ONLY —AIJT 12T I se YNQAMAGE $ -- u S A X UMBRELLA Lute �X OCCUR EACH 4CC RRENCE s 10,000,000 EXCESS LAB � CLAIMS-MADE S 2440223 12131/2021 12/31/2022 AGGREGATE 10,000,000 DEO i RETENTIONS A WORKERS COMPENSATION S AND EMPLOYERS'LABLITY X PER I,ER� .,. ANY PROPRIETORIPARTNERIEXECUTNE t l WC 9083841 12/31/2021 12/31/2022 FI FACHACCMDENT $ 1,000,000 ¢QFFFICERIM£MBER EXCLUDED? t i N(A ((klartdslory In NH) If es,dasalbsundar _,1,.. EASE-EAEMPLQYEE,3 I,000,000. ,DESCRIPTION OF OPERATIONS below ,E<L,DISEASE-POLICY LIMIT .$. 1,000,000 A Leased/Rented Equl S 2440223 12/31/2021 12/31/2022 150,000 A Crime S 2440223 12/31/2021 12/31/2022 25,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached H more space Is required) CERTIFICATE HOLDER CANCELLATION YARMOUT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1146 Route 28 ACCORDANCE WITH THE POLICY PROVISIONS. S.Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) OD 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD i r c 4. 1:4*":1 •e,:,:' ,..„„„,...-„,,44 (4 g- - 04*-, = . T.:3 it; . _. . , , . „, . . , 14,0 „ , ..1, - fl,- .-415k„ •„ ,,,,,,,, „ % ---t ft > . , - ,,A, '..* .,,, _ ft **""' -- ;' .:. ° • ,f f' . », y ,k ro 41.4 3 .... . .„ „ % 141 ; ,,p “.... *.r, . . „, 2,,,,,,,,,..„ .. . • . #,,,,, -..,--ce .i.i „'.',,,,,m MAPLEWOOD senior living CHECK REQUEST Instructions: V Both Check Request&W-9 form should be submitted to:apinquiries@maplewoodsl.corn ✓ W-9 Form can be obtained by the Business Office or https://www.irs.gov/pub/irs-pdf/fw9.pdf Please allow at least two weeks'time to process your request for payment Invoice #: CKRQ 06292022 Date: 06292022 Payable to: Town of Yarmouth - Building Department Address: 1146 Route 28, South Yarmouth, MA 02664 COMMUNITY CODE AMOUNT GL ACCOUNT MAM000 $280.00 1800-2920-000 Please indicate: ( ) Return Check to Community ( ® ) Mail check to above address ( ❑ ) Other: Purpose of Expenditure: Permit fee related to the Siding Replacement project at Mayflower Place. Permit application and fee schedule are attached. Requested by: Nick Gullusci Authorized Signature of A Nick Gullusci Digitally signed by Nick Gullusci p p rova l: Date:2022.06.29 12:45:26-04'00' This form should be used to cover miscellaneous expenditures that require prepayment. Original receipts should be reconciled and submitted to Accounts Payable for record keeping.