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HomeMy WebLinkAboutBLDX-25-570 application yA Office Use Only F PermitN / /TiJ��i iit cC . ) Amount 3'Qa) �0a•wrtco — ' EXPRESS BUILDING PERMIT APPLICATION��x`°?6,57e RECEIVE TOWN OF YARMOUTH "--- Yarmouth Building Department MAY 0 1146 Route 28 5 2025 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION / 2 fc I,if By:UILDING DEPARTMENT ill Ar h 0I HOB►rn --`M ?IN tc U1k yfir 56Z 3to65 2q —_ N PRESENT ADDRESS TEL.a coNTRAcroR�mu.0( Ai UAAS RSI Srri m4rat RD(iiset c.tltt 104 Sok 3]4 f 79y NAME MAILING ADDRESS TEL N EMAIL: MP V brill D I''Arh<ou 9Iroi l f et-Y►'1 TAUS ()COin CC(s1.I e I— h4esidential Cl Commercial ❑Est.Cost of Construction S Homeowner is.Applicant? Yes No_/� Home Improvement Contractor Lk.IL/333 g k Construction Supervisor Lie.N doe)GY/9 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: N of Squares Replacement windows:N Replacement doors: N Roofing: N of Squares I Y Insulation Temporary Mobile Home Temporary Construction Trailer Demolition—Interior only. "Demolition Raze Structure Solar System__ ESS System Chimney_ Fence *Please submit utility disconnect letters for electric&gas—structures over 75 years old require historical review 'The debris will be deposed of at:7Ajy1 U1 JAI j, ,4)t-<a _�C4±�y Vn Location of Fealty ------- -- _ _- - — I declare under penalties of perjury dun the atetemanu herein contained see true and corset to the but of my knowledge and belief.I understand that my false answer(a) will be just cause for denial or revocation of my licence and for prosecution under M.G.L.Ch.2611.Section I. App:teant's Signature_ __ _ I �]� _. _ _DUO:__ _�fr _ Owners Signature(or attacbmen ,t�/!�/.mil IJ � Octet 4t f Z-17.A5 r I Approved By: _ _ —. _ _ __ _. Building Oticial(or designee) Rev 6/24 / 1 A`OOREP CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 05/05/2025 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 polioy(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 Glen Davis NAME: The Hilb Group New England,LLC PHONE (800)640-1620 FAX A/C A o.Ext): (A/C,No): dba Dowling&O'Neil ADMDRL ESS: gdavis@hilbgroup.com 973 lyannough Road INSURER(S)AFFORDING COVERAGE NAIC II Hyannis MA 02601 INSURER A: Lloyd's of London INSURED INSURER B Daniel Almas INSURER C: 24 Sea Marsh Road INSURER D: INSURER E: Centerville MA 02632 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2521101668 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 NUMBER POLICY EFF POLICY EXP LIMITS LTRINSD WVD (MM/DDIYYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE I OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GE_N'LAGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ POLICY PRO JECT LOC PRODUCTS-COMP/OPAGG $ _ OTHER. AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED 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 AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE n NIA EL EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT $ PER CLAIM $1,000,000 ERRORS&OMISSIONS A P5N0740243949 02/13/2025 02/13/2026 AGGREGATE $1,000,000 DEDUCTIBLE $2,500 DESCRIPTION OF OPERATIONS/LOCATIONS I 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 ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 1` ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents _ _9 Office of Investigations k.-."z...,- = 1— ` Lafayette City Center t2 Avenue de Lafayette,Boston,MA 02111-1750 aw • www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers ADDilcant Information Please Print 1.eEib(v Name(Business/Organization/Individual):( b A.t.t-ial l`(tA A aS Address:a y Seal WIA/S 4. 1704 d City/State/Zip:/6i6zc t'/('P 1414 O133A. Phone#: 56' 32 a-877 ' 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. 0 New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.insurance.: 9• ❑Building addition required.] 5.0 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 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' 13.0 Other — comp.insurance required.] *Any applicant that checks box MI must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they arc 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. tam an employer that is providing workers'compensation insurance for my employees. Below is the policy and Job site information. I Insurance Company Name:4/D y[.�'s r�[' 4 ou cF p..c Policy#or Self-ins.Lic.#:�Q S/)')O 6 3 c1�JR`(C�l6 Expiration Date: 02 - (3-"2•G Job Site Address:�J/t 3l UO/97�Lr 6fi) City/State/Zip: 1/(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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investigatio the DiA for insurance coverage verification. I do hereby ce ify' nder th j and penalties of perjury that the information provided above is true and correct. i n• Date: 5-3.3.----e7 6-,g5 Phone#: 6_1-6 g - 3 G - e rst- 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 2❑Building Department 30City/Town Clerk CO Electrical Inspector 5EI'lumbing Inspector 6.❑Other Contact Person: Phone#: _ n a o -_ m a D &' _UT2 OROI m N A• r n 0 n<3 O Q ✓pD 003.5 kn a =' 3 sm \.,l„l4 m t�? Tcj. 0 w rN ;qa •li • 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: TYPEfTnaividual Office of Consumer Affairs and Business Regulation Registration ExgUeti2n 1000 Washington Street -Suite 710 139392 -` 11/04/2025 Boston,MA 02118 )ANIEL P ALMAS !,1 RIELSEA P.ALMAS !4 SEA MARSH ROAD ;ENTERVILLE,MA n2632 Undersecretary N Id without signature