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HomeMy WebLinkAboutBLDX-25-218- „Office Use Only .„,..-i-----le-4--iii,--__ g VED ;Permit# � ° .._= t_.__ i i 0 - , i ;Amount ( ` MAT1A M CSf ry -I ' °"°°""`°40�' FEB 2 ! 2025 !Permit expires 180 days from I issue date P: '[DING DEPARTMENT EXPRESS BUILDING PE ATION1 Y ~ TOWN OF YARMOUTH 1 Yarmouth Building Department ' FEB 2 7 2025 1146 Route 28 South Yarmouth, MA 02664 e u I — f- E—NT (508) 398-2231 Ext. 1261 I� ' CONSTRUCTION ADDRESS: 3 r©C -rdi-- i' Ale- 1/(10- S VecC�o4 d a ”u 4 /7� O r7%V 61( ASSESSOR'S INFORMATION: / /' Map: Parcel: / /� n OWNER: 8)i/I G /(t5f 33 too not;hit- i 1a .-�. ,Vetr nOCI-J4 nil O 6'C (2,03) 4/40- l2 9 g NAME // / PRES T ADDRESS l t TEL./ # CONTRACTOR,4 I CA!'!°c4rcw 'I o 0 £2 YOP5t. Con d C-d, W. Y1,0440 (coEj _' co ` /3 ?S / NAME MAILING ADDRESS �A d IS TEL.# �l Residential 0 Commercial Est.Cost of Construction$ S 000- 0 a Home Improvement Contractor Lic.# 7 g/ 14Do2- Construction Supervisor Lic.# IOC- 62 Workman's Compensation Insurance: (check one) / ❑ I am the homeowner ❑ I am the sole proprietor 1- I have Worker's Compensation Insurance er Insurance Company Name:4'L le-h-i/C. C40-47 1—r s. Co Worker's Comp.Policy# VV V G 0/Lt 10 u L' WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 357 Replacement windows: # 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: 6'©6 rori',s4 CJf �• j -(L4Ocz- PI Ala.t-5 ;'('�- Location of Facility I declare under penalties of perjury that e 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 rev 1 license and for prosecution under M.G.L.Ch.268,Section 1. /� Applicant's Signature: Date: 0 2 /a- 4/ at O.'Jc Owners Signature(or attachment) / f/�Z. �� Date: C' /'.c //-' -04 -..j —_ Approved By: Date: Building Official(or designee) EMAIL ADDRESS: a. COhs 4 rr,c4i0 h 5-S5 g34.4 41. 176O�1 Zoning District: a Historical District: ❑ Yes El No Flood Plain Zone: ❑ Yes ❑ No - Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No ❑ Yes ❑ No I 1 1 ` The Commonwealth of Massachusetts =.411 _ IDepartment of Industrial Accidents �e 1 Congress Street, Suite 100 • = if Boston, MA 02114-2017 °�r! i� 5,,�''` 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): A /z f Cons 'iC D4 1-4-c✓ Address: 2, L go(Se- r)w ei c J City/State/Zip:il. YQ.r Ps d at /t'/i4 I016' -Y3 Phone #: 503- 3Ce) ` q z3 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. _New construction 2.01 am 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 doing all work myself. [No workers'comp. insurance required.]t 9. ❑ Demolition 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.❑ Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.❑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.: , r-• . e 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other /L e- % i c7 1 0. 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. r Insurance Company Name: Al'L `d-N. ��i �i vt-0 4`''I _Los Policy#or Self-ins. Lic. #: V'JC;,V O 1 q)-Z GI 0 6 Expiration Date: 1.z/pi(1 2..402 -* Job Site Address: > > �n ! 0-e- kip, o{ City/State/Zip:.StLCt OK t(N/I/0 2C6 1 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 u r the pains and penalties of perjury that the information provided above is true and correct. Signature: ------Th Date: 0.2/ ri / ; --J Phone#: 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#: �.2:46 PM Office of Consumer Affairs&Business Regulation-Mass.Gov eYa"�J gov Dffice of Consumer \ffairs and Business Regulation OCABR{ ) HIC Registration Complaints Registration # 194702 Registrant ALT CONSTRUCTION LLC Name ALIAKSANDR TURAU Address 22 HORSE POND RD City, State Zip W. YARMOUTH, MA 02673 Expiration Date 04/13/2026 complaints Details No complaints found for this registrant. j You can also view arbitration and Guaranty Fund history. Back To Search Sit g Policies Contact Us 0 2018 Commonwealth of Massachusetts. Mass.Gov®is a registered service mark of the Commonwealth of Massachusetts. • Commonwealth of Massachusetts ®� Division of Occupational Llcensure Board of Building Re ulations and Standards Constructi0446044qr Specialty CSSL•106169 $ I pires:04/14/2025 ALIAKSANDF�G TURAU I a 20 HORSE POND ROAD 7 WEST YARMOJJTH MA 02673 r Apt Commissioner c,w,12t / • `�"' ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 12/13/2024 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 AshleyPaiva NAME: ARTHUR J GALLAGHER RISK MANAGEMENT SERVICES INC (A/C No.Ext): (800)333-7234 FAX (A/C,No): E-MAIL shle Paiva a ADDRESS: A y_ G Ig•com 470 Atlantic Avenue INSURER(S)AFFORDINGCOVERAGE NAICiI Boston MA 02210 INSURER A: ATLANTIC CHARTER INS CO 44326 INSURED INSURER 8: ALT CONSTRUCTION LLC INSURER C: INSURER D: 22 HORSE POND ROAD INSURER E: WEST YARMOUTH MA 02673 INSURER F: COVERAGES CERTIFICATE NUMBER: 1073424 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) , ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY • (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE OTH- ER AND EMPLOYERS LIABILITY A OFFICER/MEMBER Ecl1TIVE WA WA N/A WCV01420406 12/04/2024 12/04/2025 EL EACH ACCIDENT $ 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage- Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Display Purposes Only ACCORDANCE WITH THE POLICY PROVISIONS. 22 Horse Pond Road AUTHORIZED REPRESENTATIVE W Yarmouth MA 02673 Daniel M.Crowley,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD