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HomeMy WebLinkAboutBLD-23-000224 F Of'Y`4R Office Use Only �; _�c tIeh)13)� permit# /-��,) , {0 _ H Amount f"� MATtACM CS[ �`...... 0 End Permit expires 180 days from {issue date EXPRESS BUILDING PERMIT APPLICATIO ' E C E I V E D TOWN OF YARMOUTH LAM, Yarmouth Building Department 1 12022 1146 Route 28 South Yarmouth, MA 02664 Buie'j, r,_ _0, 44 (508) 398-2231 Ext. 1261 8Y CONSTRUCTION ADDRESS: 1:12 o 1049 p o✓1 oC ✓Lc ASSESSOR'S INFORMATION: Map: 6 g I Parcel: 34 OWNER: 1#'i f ern ri'iv,/ PRESENT ADDRESS fO opt a ye f -4'2 6 - 1/ 13 NAME TEL. # CONTRACTOR: Vri✓l S Tto1n? go o tGP tcicIGC ,2c2 141'5h p6 Cur- b i$'-y33 NAME MAILING ADDRESS TEL.# ['Residential 0 Commercial Est.Cost of Construction$ 9, co a 4 c'`1 Home Improvement Contractor Lie.# Itf O 3 Construction Supervisor Lic.#_o9 it y?Z Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor ❑ rhave Worker's Compensation Insurance Insurance Company Name: 19tetal c jvi gm.,.wt,(,ee e'O. Worker's Comp.Policy# WG 4 S'2/ 7 .Z 9 y 16 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares .> S Replacement windows:# S Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing 'The debris will be disposed of at: f).e iv 4 ed.►-oeck CA 4S tc- 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:�'jh,..-- Date: 7/ssS /1-X. Owners Signature(or attachment) Poe-4" ---------; Date: 7 6i 2 2— _ Approved By: I Date: /—/ 2 2 Building Official(or design '�� 7�DRESS: ✓y O coo..? S J� how. Q fc.411 v • C Zoning District: Historical District: ❑ Yes 0 No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No • The Commonwealth of Massachusetts _ Department of Industrial Accidents __ /Ilv 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia \Yorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly /� Name(Business/Organization/Individual): ► 4.ry✓1 $T/'o✓vt Address: 9 a U to"'Fie[ rice City/State/Ziprh45hpe— 074, 0.2_6Y.7 Phone#: 6398 — 61 9'— 936 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).• 7. ❑New construction 2.01(m a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] ' 3. I am a homeowner doingall work myself. t 9. El Demolition ❑ ys [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 an contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑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.t / 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[]�Otbet S l t�"/Wt nQi 152,f 1(4),and we have no employees.[No workers'comp.insurance required] `Any applicant that checks box N l 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. tContracmrs 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'camp.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: pcu,.'y 1-31.5 ,,rvt•ZGa e 0• Policy#or Self-ins.Lic.#:wcrf S21 7 2 rY— 1 4 Expiration Date: 7/C/2 Job Site Address:Y !a.49 tOo.-7[' /La City/State/Zip: e,,,.zo41i {,►yam 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 /`/ Date: 2/6122- Phone#: 'C ' — 6y8 -y35S 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#: •` R1fffCc�'Of�b4l4crt14( t�ikf��rf $ srtnests:44v yt142itioli HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE: Individual before the expiration date. If found return to: Registration ExWI:010n Office of Consumer Affairs and Business Regulation 140358 10/13/2023 1000 Washington Street - Suite 710 AARON STROM Boston, MA 02118 D/B/A DS CONSTRUCTION AARON M. STROM 90 DEERFIELD RD ec;44v7f.41i MASHPEE, MA 02649 Undersecretary Not Valid without Signature Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constructio r414A4 ,,1 & 2 Family CSFA-092482 Expires 09'23,2023 AARON M STROM 90 DEERFIELD RD MASHPEE MA 02649 1\11.16,s• . Comm loner C laytk K. �ern auk. r ACRE® E(MMDDf CERTIFICATE OF LIABILITY INSURANCE DATE 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 pollcy(les)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 Michael Bonacorso NAME: Bonacorso Insurance Agency,Inc. PHONE (781)937-3200 I Faz (781 937-3202 INC.No.Ertl: Wc,No): > 10 Cedar Street E.MAL Inchael bonacorsoms.com ADDRESS: Unit#32 INSURER(S)AFFORDING COVERAGE NAICa Woburn MA 01801 INSURER A: Tri-State Insurance Company of Minnesota 31003 INSURED INSURER B: Acadia Insurance Company 31325 Aaron Sirrom INSURER C: DBA D and S Construction INSURER D: 90 Deerfield Road INSURER E: Mashpee MA 02649 INSURER F: COVERAGES CERTIFICATE NUMBER: 22-23 Master 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 UP TYPE OF INSURANCE INSD W VD POLICY NUMBER (MM/DD/YYYY) (MMIDDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILity EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ®OCCUR DAMAGETO RENTED PREMISESTO(Ea RENTED occurrence) $300,000 MEDEXP(Any one person) $ 10,000 A — ADL5212747-17 06/04/2022 06/04/2023 PERSONAL SADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $2,000,000 a POLICY©JE PRCT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: E AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT $ (Ea sateen) ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED ADL5212747-17 06/04/2022 06/04/2023 BODILY INJURY(PeracadenrI $ AUTOS ONLY AUTOS yet HIRED v NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY !�AUTOS ONLY (Per accident) HIRED/NON-OWNED $ 1,000,000 X UMBRELLAUAB _OCCUR EACH OCCURRENCE $ B EXCESSIJAB CWMR.uanF CUA5306818-15 06/04/2022 06/04/2023 AGGREGATE $ DEO I XI RETENTION$ NONE $ WORKERS COMPENSATION s�II PER OTH- AND EMPLOYERS.LIABIUTY Y/N �I STATUTE I I ER B ANY OFFICERIMEM ER EXCLUDED?ECUTIVE M N/A WCA5217284-17 07/08/2022 07/08/2023 E.L.EACH ACCIDENT $ 1,000,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 It yea describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 INLAND MARINE LEASED OR RENTED A A0L5212747-17 06/04/2022 06/04/2023 EQUIPMENT $50,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remark.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 DEUVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE {���-i7 South Yarmouth MA 02664 j oorteta 14 0 I ©1988-2015 ACORD CORPORATION.All rights reserved. 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