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HomeMy WebLinkAboutBLDX-25-585 applicaiton C VED ' 0 we'-�` "� RE 0 Office Use Only 0 o� Permit# �: MAY 0 1 , /',� 5 Amount J v �� (,,,,,a y �; � acr::,, TEaNe BBUILD G DEPA ENT - g W)C-075-5 5 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 MAY 0 8 2025 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT CONSTRUCTION ADDRESS: 44 Strawberry Lane By. OWNER: Paul White & David Nault NAME PRESENT ADDRESS TEL. # CONTRACTOR: Jeffrey Morin 55 Mountain Ash Rd. MARSTONS MILLS, Ma. 02648 NAME MAILING ADDRESS TEL.# EMAIL: jmorin4995@gmail.com )0 Residential 0 Commercial LiEst.Cost of Construction$3,350.00 Homeowner is Applicant? Yes No Home Improvement Contractor Lie.# HIC-1 79299 Construction Supervisor Lic.# CS-092132 WORK TO BE PERFORMED r Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares 2'5 Replacement windows:# Replacement doors: # Roofing: #of Squares Insulation Temporary Mobile Home Temporary Construction Trailer n0 Demolition-Interior only Demolition Raze Structure Solar System ESS System Chimney Fence 'Please submit utility disconnect letters tor electric & µ.as s:. ,.,t et es€Ner'75 years old require historical rcvie r *The debris will be disposed of at: Yarmouth Landfill Location of Facility I declare under penalties of perjury that the statements erein 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 re ion lice e or prosecution under M.G.L.Ch.268,Section I. Ar/,5. Applicant's Signature: /deDate: Owners Signature(or attachment) . /L/(__. / Date: G //)... Approved By: Date: Building Official(or designee) Rev 6/24 �f W DATE(MM/DD/YYYY) AC RL CERTIFICATE OF LIABILITY INSURANCE 04/30/2025 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 Samantha Kuter NAME: CoverWallet, Inc. IAH,CC,"N Ext): (646)844 9933 FAX No)__-__ One Liberty Plaza, AIL ADDRESS: customer.service@coverwallet.com Suite 3201 INSURER(S)AFFORDING COVERAGE NAIC# New York, NY 10006 INSURER A:NorGUARD Insurance Company 31470 INSURED INSURER B J. M. Morin Incorporated INSURER C: 55 Mountain Ash Road INSURER D: Marstons Mills, MA, 02648 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 -rADDL SUBRI I POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD.;J POLICY NUMBER LIMITS _,_ - {MMIDD/YYYY) (MMIDD/YYYY)'� COMMERCIAL GENERAL LIABILITY ' EACH OCCURRENCE I $ ' I DAMAGE TO RENTED CLAIMS-MADE ; OCCUR ' PREMISES(Ea occurrence) I $ .- - 1 MED EXP(Any one person) $ li PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: L GENERAL AGGREGATE $ 1 POLICY JER CT LOC PRODUCTS-COMP/OP AGG $ OTHER: I i -------- ---- $ AUTOMOBILE LIABILITY : ! COMBINED SINGLE LIMIT -- ';(Ea accident) $ ANY AUTO I BODILY INJURY(Per person) $ 1 OWNED I I SCHEDULED BODILY INJURY(Per accident) $ j_-__,AUTOS ONLY 1 ;AUTOS --- HIRED I NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY • AUTOS ONLY j (Per accident) $ I UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB 1 CLAIMS-MADE ! !AGGREGATE $ .- --.T_. 1 DE I RETENTION$ ' $ WORKERS COMPENSATION X STATUTEER Rf I OH AND EMPLOYERS'LIABILITY Y/N JMWC545265 07/10/2024 07/10/2025 A ANYPRO RIETOREXCLUDEE?ECUTIVE N/A'; l E.L EACH ACCIDENT $ 100,000OFFICE !(Mandatory in NH) 1 !, E.L.DISEASE-EA EMPLOYEE $ 100,000 !If yes,describe under _ i DESCRIPTION OF OPERATIONS below � I E.L.DISEASE-POLICY LIMIT $ 500,000 I 1 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION Yarmouth Building Department SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1146 Route 28 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN South Yarmouth, MA, 02664 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE / // ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ,z The Commonwealth of Massachusetts Department of Industrial Accidents ,' Office of Investigations is$.�A Lafayette City Center 7 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): Jeffrey Morin Address: 55 Mountain Ash Road City/State/Zip: Marstons Mils, Ma. 02648 Phone#: 508-776-0055 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. Q I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. ❑ Remodeling 2.❑ 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. ❑ 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 11.0 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 siding employees. [No workers' 13.®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'compensation insurance for my employees. Below is the policy and job site information. insurance Company Name: Policy#or Self-ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: 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 u e the pains and ies of perjury that the information provided above is true and correct. Signature: '01/16 Date: 57/ Phone#: 5.&pJ ')ICJ_ ,C5 1 Official use only. Do nor 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 4.0 Electrical Inspector 51:1Plumbing Inspector 6.0Other_ Contact Person: Phone#: Home Improvement Contractor Registration Card Registration valid for use type,only before the expiration date. Type:Individual oY`"""`"`Qa Number: 179299 Expiration:05/07/2027 ,4 ' Issued to: f,2 5 Jeffrey Morin ^od Jeffrey Morin 55 MOUNTAIN ASHRddDpA(1�Rdd ��� � 'offrCa'br Crirts6rtrai'Rrt§irsiB'BiYShT@SS Regulation Layla R.D'Emilia 1 Federal St.,Suite 0720,Boston,MA 02110-2012 Undersecretary Licensee Details ', Demographic Information Full Name: JEFFREY M MORIN Owner Name: License Address Information City: MARSTONS MILLS State: MA Zipcode: 02648 Country United States License information License No: CS-092132 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 8/22/2024 Issue Date: 10/3/2010 Expiration Date: 10/3/2026 License Status: Active Today's Date: 5/1/2025 Secondary License Type: Doing Business As: J. M. Morin Inc. Status Change Reason: License Renewal Prerequisite Information No Prerequisite Information No Available Documents