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Home My WebLink AboutBLDX-25-543- f X6 Office Use Only ��'o\ RECEIVED Permit✓; 10 ----- --.3) Amount SOD ,00 t-/ MAY 01 2025 BUILDING DEPARTMENT Z, EXPRESS BUILDING ATION TOWN OF YARMOUTH Yarmouth Building Department I2 , \ -25 _ 3 1146 Route 28 r�/�J South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 II CONSTRUCTION ADDRESS: 9 A-1T 1CA /GI n� ne,i fit? 3af r totA44 por 1 OWNER: AOOL 'eO hO✓ N7 C r JoA✓r.4.0 \ e- 7f/ NAME PRESENT ADDRESS TFL. CONTRACTOR:Lvfievii1�/OhQV �//t- 7c) Anoe /h 4/, /Wod6j5 "'ice be 9JO NA L oo� MAILING ADDRESS TEL.V a EMAIL: / ge-0Ht�- vC�h /✓ Q )v— SS. CO l/ (Residential _I Commercial Est.Cost of Construction S oC 5 5- Homeowner is Applicant? Yes No Home Improvement Contractor Lic.# O 0Z Construction Supervisor Lic.# r1/ 00 6 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares £ Replacement windows: # Replacement doors: #__ Roofing: #of Squares Insulation Temporary Mobile Home_ Temporary Construction Trailer Demolition- Interior only Demolition Raze Structure Solar System ESS System Chimney Fence *Please submit utilit} disconnect letters for electric & gas - structures os er 75 s ears old require historical re%icss 'The debris will be disposed of at: TOWN jar✓evr ,yoS Q/ Q.✓P-Q Location of Facility I declare under penalties of perjury that the statements here) ontained are true and correct to the best of my knowledge and belief I understand that any false answers) will be just cause lix denial or revocation of . a for pr ssecution under M.G.L.('h.268.Section I. �� /d Applicant's Signature — � Date: t�5/v Owners Signature(or attachment) a AX e-A tf Date: Approved By. Date: Building Official(or designee) Res 6 24 ia`.1 b ro nD tier) rrJeS , co 07 t , The Commonwealth of Massachusetts _ = Department of Industrial Accidents _ ,w►.= Office of Investigations m— Lafayette City Center __ 2 Avenue de Lafayette, Boston,MA 02111-1750 • www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 6 vz,v av &-/-/9 ✓'i,$-e s , '') c Address: 1 , , 71 r ,Ah.Ov- ivt City/State/Zip: C7 ` 'J � /�. Are you an employer? Check the appropriate box: Type of project (required): 1. I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction listed on the attached sheet. 7. ❑ Remodeling 2.0 I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' comp. insurance.: 9. El Building addition [No workers' comp. insurance required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.El officers have exercised their I am a homeowner doing all work 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.E Other S : Aj `4 ^3 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: 1`�pvtYe /�v'S Policy#or Self-ins. Lic. #: t'7-t/Lif 60&I /4,2_ 09301- y Expiration Date: -2 i 113 /o Job Site Address: Cr Oc-f I c- / d•" City/State/Zip:.ya-v'r-oc-t ✓d AO 27676—Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that 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 pe • s of perjury that the information provided above is true and correct. Signature: Date: 02 Phone#: 1,50. E.-,a'5--cj/c 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(check one): 10Board of Health 20 Building Department 3❑City/Town Clerk 4.❑Electrical Inspector 50F'lumbing Inspector 6.0Other Contact Person: Phone#: re Commonwealth of Massachusetts Construction Supervisor Division of Occupational Licertsure Unrestricted-Buildings of any use group which contain less than Board of Building Regulations and Standards 35,000 cube feet(991 cubic molars)of enclosed space. �aA r c,�•. CS-114006 ilfplres:10/25/2026 EVGENIY BINOV 72 ANCHOR E COTUIT MA 635 2 (1111:\ �1 �c `ti01.7,iddA) Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Commissioner _J,, ,,eivf,, :�s_ Contact OPSI:(617)727-3200 or visit www.mass.govldpi!opsl THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home improvement Contractor Registration Type: Corporation 79 BRONOV ENTERPRISES INC Registration: 1624 Expiration: 06/25/2025 72 ANCHOR LANE COTUIT, MA 02635 Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for Individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE:Corporation Office of Consumer Affairs and Business Regulation Registration gxpiratLon 1000 Washington Street -Suite 710 182479 06/25/2025 Boston,MA 02118 BRONOV ENTERPRISES INC EVGENIY BRONOV ,- 72 ANCHOR LANE /nr�rl %.:' ,Cfis�{c• COTUIT,MA 02635 Undersecretary Noalid without signature Harwich Ecumenical Council for the Homeless, Inc. (HECH) Housing Emergency Loan Program General Contractor and Owner Agreement Attachment A NOTICE TO PROCEED To: Jay Bronov, Bronov Enterprises, Inc.: You are hereby given authorization to proceed with the renovations at 9 Dutchland Drive, YarmouthPort, MA 02675 in accordance with the General Contractor and Owner Agreement dated May 1, 2025. The work is scheduled to begin on May 1, 2025, and to be completed on or before July 31, 2024 &tit), Owner: Brook4c) O'Connor Date j_ j -J ,)—' s to s by: Ki ourgea,Executive Director Date ® ACCORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM YY IDDIYY) 07/09/2024 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 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 Benson Young&Downs Ins B CT Elaine Donoghue 56 Howland Street l,IyM1F,,). (508)487-0500 FAc,N,).(508)487-4135 PO Box 559 EMAIL edonoghue@BYandD.com Provincetown MA 02657-0559 INSURERISI AFFORDING COVERAGE NATO ll INSURER A,Atlantic Casualty Insurance Co 42846 INSURED INSURER B:Arbella Protection Ins Co 41360 Bronov Enterprises Inc INSURER o:Travelers Indemnity of America 25666 72 Anchor Lane INSURER 0 Cotuit MA 02635- 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 ADDL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE wan win, POLICY NUMBER IMMIOD/YYYY1 INOAIDD/YYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY Y M2050018110-01 07/02/2024 07/02/2025 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR PRFUIRFS(DAMAGE TO REer,. I $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X IPOLICY JEC i I LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER 8 8 AUTOMOBILE LIABILITY 1020102822 12/29/2023 12/29/2024 °M& )S INGLE LIMIT $ _ANY AUTO BODILY INJURY(Per person) S 500,000 ALL OPINED X SCHEDULED BODILY INJURY(Per accident) S 1,000,000 AUTOS X HR DSAUTOS X ANlOH gWNED PRROrPE�RTYyDAMAGE S 250,000 UMBRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DFD RETFNTION S $ C WORKERS COMPENSATION 6HUBOG14209324 07/03/2024 07/03/2025 X 4rATl1TF OTH FR AND EMPLOYERS'LIABILITY �(,�, ANY PROPRIETOR/PARTNER/EXECUTIVE I 1 E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEES 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORO 101,AddINonal Remarks Schedule,may be attached S more space Is required) Carpentry&Remodeling Operations and Cleaning Service. Officer Olga Bronov is exempt from Workers Compensation Insurance Policy. Certificate Holder is additional insured by written contract. CERTIFICATE HOLDER CANCELLATION Al 008861 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF YARMOUTH THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN BUILDING DEPT ACCORDANCE WITH THE POLICY PROVISIONS. 1146 ROUTE 28 SOUTH YARMOUTH MA 02664- AUTHORED REPRESENTATIVE 7..... --7 _ (/.��/Z%G' E/�---�- I Fax:(508)398-0836 ®1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD