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HomeMy WebLinkAboutBLDX-25-493 application 4 YA Office Use Only ,� ko,,,, PcrmiLl 0 4 1L i 11 !y! Amount 1 V ' c ieri °9PORA 0. etA)X— �5- 3 C t4d �31 ' EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department --- 1146 Route 28 APR 22 2�25 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT CONSTRUCTION ADDRESS: p �/ f�j®,r f��- '-'�c- 4...`..�ea, / ' &266Y OWNER: c-l?X'• l /c, /". ., AA-4- P407 t- ,l�of�.., /'2it- (/ ? O/ ?-r. .f. NAME- PRESENT AI i)RI.tiS TEL. # ' CONTRACTOR: rk 1 C>L \ AIe 7 ptt 4_w S 4 S I "L C�'�S1___i—/__(1 37(7D NAME \ NC;ADDRESS TEL.u EMAIL: 1L3 �'{' V t� .44..du4-1/ • L.-v\ , `$esidential Commercial Est.Cost of Construction S �Q 0,OD Homeowner is Applicant? Yes No `� C_ Dome Improvement Contractor Lie.# /73 /"] !� Construction Supervisor Lic.# O 0 rJ WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares S.1 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 '•)')case submit utilit% disconnect letters for electric & gas -- structures user 75 Sears old require historical re%iess i *The debris will be disposed of at � ).,.frt.„, ( !L 1 G Locatioof Facility I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. l understand that any false answedsl sill be just cause tic denial or revocation of my license and for prosecution under M.G.L.(•h.268.Section I. Applicant's Signature Date: Owners Signature(or attachment) Date: Approved By Date: Building Official for designee) G-4.AS k e CA,1 I /y)I (to The Commonwealth of Massachusetts Department of Industrial Accidents —;;; Office of Investigations == . = ' 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 {� v Please Print Legibly Name (Business/Organizatio ividual): I' y ! 1 ;12.vitk Jitv Address: � L> City/State/Zip: l i� 6 6 Phone #: -6-(2 Are you an employer? Check the appropriate box: Type of project(required): 1. am a employer with 4. ❑ I am a general contractor and I 6. El New construction employees (full and/or p -time).* have hired the sub-contractors listed on the attached sheet. 7. ►� Remodeling 2.CI 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' 9. El Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other 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'comp sation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ` Kk- , U it)`` Wal4( (0c C0 . Policy#or Self-ins. Lic. #: spi cpu !c Zri‘ f-Pf expiration Date: Job Site Address: Lass.A.e City/State/Zip: . f 1j4-il th 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 veri at?on. I do hereby certify finder the pains and enalties erjury that the information provided above is true and orrect. Si ature: Date: / Phone#: )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): 1❑Board of Health 20 Building Department 31:City/Town Clerk 4.12 Electrical Inspector 50Plumbing Inspector 6.❑0ther Contact Person: Phone#: l ® DATE(MM/DD/YYYY) A 4CC)R o CERTIFICATE OF LIABILITY INSURANCE 02/19/2025 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 Marshall Lovelette NAME: MARSHALL K LOVELETTE INSURANCE AGENCY INC (A/C No.Extl: (508)775-4559 FAX No): ADDRESS: marshall@loveletteins.com 396 MAIN ST INSURER(S)AFFORDING COVERAGE NAIC# WEST YARMOUTH MA 02673 INSURERA: HARTFORD UNDERWRITERS INS CO 30104 INSURED INSURER B: HEALY BROTHERS CONSTRUCTION INC INSURER C: INSURER D: 72 OLD MAIN ST INSURER E: SOUTH YARMOUTH MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: 1091293 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 OCCURRENCEDAMAGE RENTE $ CLAIMS-MADE OCCUR PREMISESO(Ea occur ence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ POLICY PRO LOC PRODUCTS-COMP/OP AGG $JECT 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 EORH AND EMPLOYERS'LIABILITY A OFFICER/MEMBER EXCLUDED?ECUTIVE NIA N/A N/A 6S60UB0W65672424 08/19/2024 08/19/2025 E.L.EACH ACCIDENT $ 100,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ N/A DESCRIPTION OF OPERATIONS I 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 Vernda LLC ACCORDANCE WITH THE POLICY PROVISIONS. 1261 Route 28 AUTHORIZED REPRESENTATIVE C South Yarmouth MA 02664 Daniel M.Cro I y,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 THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE: ao- Registration EVabor> ?AICHAAEL A_ Nov 72 CtO MAIN ST SOUTH YARRMOUTI-r, 621364 a �.;OPATI0,c P$9Z0 YN H1f1O)j}JVA H1foS is sIYW❑l0 ZL AlY30:V 13VH01W 9ZOZ/ZZij. !0S .a 414 rVI� SLjE P sp.mpuejg pue utiopeinEes Buipiln8;o paeeg e.rnsueio;feuariedn 0;o uoisi:uQ ss}esnyoesse }^.;�ee�uo:u:uo0