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HomeMy WebLinkAboutBLDE-23-000470 /f %/ ii Ca- 1� /+ r� J ,Office Use Only °g"Y W/ /a `y Permit# O _ ;1,. H Amount ®, o 0 4 r...am - r E : Permit expires 180 days from issue date 8t_ - 23 - OOOK10 EXPRESS BUILDING PERMIT APPLICATIO TOWN OF YARMOUTH I RECEIVED Yarmouth Building Department 1146 Route 28 JUL 2 9 2022 South Yarmouth, MA 02664 L (508)q 398-2231^ Ext. 1261 BUILDING DEPARTMENT CONSTRUCTION ADDRESS: ii Vie((�/y fI J / t/f5 71 �/7 fffl W 41 NA- 006 ?i ASSESSOR'S INFORMATION: /� Map: Parcel: OWNER: YA71 rN,Cf./4 (0..5 ep h C.5 8)835-0s3 NAME PRESENT ADDRESS TEL. # CONTRACTOR: whit,( f. avatis R-(Se o ti vs . -ka C`ezric/e 14.64.0aczz E-82c (YZ$Y NAME MAILING ADDRESS TEL.# 00 'Residential 0 Commercial Est.Cost of Construction$ #7t 3 OC)• Home Improvement Contractor Lic.# t 3 1 3 L 2 Construction Supervisor Lie.# es'- 0ep 6Le'( 9 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: L 107 as 1 1.,0 u-cto,,-C. Worker's Comp.Policy# eg A b.€c3 cs-9 G e a-6 WORK TO BE PERFORMED Tent El Duration (Fire Retardant Certificate attached?) Wood Stove El Siding: #of Squares Replacement windows: # Replacement doors: # Roofing: #of Squares / ( }Remove existing* (max.2 layers) Insulation El nOld Kings Highway/Historic Dist. 0)Replacing like for like Pool fencing n *The debris will be disposed of at: 7. ..e 144-40 u rt VoLA-7t4 -0 ur— W` /'°` 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�orrevocation of my license and for prosecution under M.G.L.Ch.268,Section 1. '�III Applicant's Signature: N\EC. ?. AL; S Date: '7/2 g /z- Owners Signature(or attachment) (--4i ./df I Date: /^'�7 ! Approved By: Date: /— g`-1 -� Building Official(o si EMAIL ADDRESS Zoning District: / ,/ /f Li)A-� Historical District: ,.-1 Yes CI No Flood Plain Zone: Yes I No J G'��! Water Resource Protection District: Within 100 ft.of Wetlands: 57 ' 1317 Yes i l No Yes r_ No q, Ls4 The Commonwealth of Massachusetts s � L Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 \14, Sv.° www.mass.gov/dia lur Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): " " Address: a Y Se ys 10.444-1-4 City/State/Zip: ,4 .4)L Ik L& 4.. 64 C 3& Phone #: 0 >r 2 a7g1.4 Are you an employer?Check the appropriate box: Type of project(required): I.pi am a employer with employees(full and/or part-time).* 7. ❑New construction 2.0I 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 10I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4.0I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑Building addition 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.in am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs ese sub-contractors have employees and have workers'comp.insurance.1 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152,§I(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: L t o G>!S u 1‘) p r�-d(-�( Policy#or Self-ins.Lic.#: 9+ S e 4e3 85 5 G F a O Expiration Date: a ^ 13 a 3 Job Site Address: II Vtr-f a' $ F t4J 1 7,a ov'if tit City/State/Zip: Atd Q 6 7 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, tion. I do h eby c ;67 n er the pain and penalties of perjury that the information provided above is true and correct. Siena • Date: 7,0.15-, 1 ?/ Phone#: D 3 7 9 ' 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): I.Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYRE: IndividuaL, Re istratis -Expiration 1393 2 11/04/2023 )ANIEL P ALMAS � - - � 144 — )ANIEL P.ALMAS ROADD ;ENTERVILLE, MA 0263Z#, ,,- Undersecretary Commonwealth of Massachusetts 11) Division of Professional Licensure Board of Building Regulations and Standards Co nst rut tiillAiSpgrvisor CS-006419 Excpires: 07/12/2023 DANIEL P ALMAS 24 SEA MARSH RD CENTERVILLEMA 02832 r f 0 Commissioner t. fi. t�3c1�a Construction Supervisor Unrestricted -Buildings of any use group which contain less than 35,000 cubic feet(991 cubic meters) of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Call(617)727-3200 or visit www.mass.gov/dpl Registration valid for individual use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 1000 Washington Street -Suite 710 Boston,MA 02118 Not valid without signature ACCPRO® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) • 02/16/2022 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 NAME: Dowling&O'Neil Insurance Agency PHONE (800)640-1620 FAX 973 lyannough Road (A/C,No,Ext): (A/C,No): E-MAIL coi@doins.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Hyannis MA 02601 INSURERA: Lloyds of London XS0123 INSURED INSURER B: Daniel Almas INSURER C: 24 Sea Marsh Road INSURER D: INSURER E: Centerville MA 02632 INSURER F: COVERAGES CERTIFICATE NUMBER: E&O 2022-202 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 AUUL SUBH LTR TYPE OF INSURANCE POLICY EFF POLICY EXP INSD WVD POLICY NUMBER (M M/DD/YYW) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'LAGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ POLICY PET LOC PRODUCTS-COMP/OP AGG $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANYAUTO (Ea accident) BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ WORKERS COMPENSATION $ PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ (Mandatory in NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ PROFESSIONAL LIABILITY/ EACH&EVERY CLAIM $1,000,000 A ERRORS&OMISSIONS PSK0438896820 02/13/2022 02/13/2023 AGGREGATE $1,000,000 DEDUCTIBLE $2,500 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations,and endorsements.Nothing contained in the Certificate of Insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. 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 ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD