HomeMy WebLinkAboutBLDX-25-343 application l
t
IREC � , 1a
4 Office Use Only
° Yq [ o251 l...as --.� Amount/170,00
k.. ,r BUILDREf' RTMENT
I CC�{
9 BY
1,,a ORAr b3
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 5 Jacqueline Circle
OWNER: Delvecchio Francis D
NAME PRESENT ADDRESS TEL. #
CONTRACTOR: J.A.D.G Home Improvement Corp. 5 Captain Blount Rd South Yarmouth 508 815 9889
NAME MAILING ADDRESS TEL.#
EMAIL: I t]l
ha rb p r i rs. .ho-1 6,--i;Z t I .CU (11
A Residential 0 Commercial Est.Cost of Construction$38'900'00
Homeowner is Applicant? Yes No X /,
Home Improvement Contractor Lic.#215126 Construction Supervisor Lic.# (1'� /19 Q 79-
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate required) Wood Stove
Siding: #of Squares 16 Replacement windows:#5 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 utility disconnect letters for electric&gas—structures over 75 years old require historical review
*The debris will be disposed of at:
Location of Facility
I declare under penalties of perjury that the t.,ements 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 revocatio' i i t Jjccn for prosecution under�M..G.�L.Ch.268,Section 1.
Applicant's Signature: // / /(Q� �> co2 LJ it .O Date: 03/14/2025
.1 03/14/2025
Owners Signature(or attachmen.� Date:
Approved By: Date:
Building Official(or designee)
Rev 6/24
The Commonwealth of Massachusetts
t Department of Industrial Accidents
Office of Investigations
Lafayette City Center
TO / 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): , 'aif-TO r �( ('�`14ers Horns e r vt ce
Address: Hco0t-4 P rS_ )r.
City/ fate/Zlp:L ( ' - P Phone#: 5C 22-1( Scre. •
Ar• ,. n employer? heck the appropriate box: Type of project(required):
1. PI am a employer with 4. ❑ I am a general contractor and I
mployees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction
2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
workingfor me in anycapacity. employees and have workers'
P ty. 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.I
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 13.❑ Other
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. _
Insurance Company Name: (� I V Ca.r L l- C �/- n c_
Policy#or Self-ins. Lic. #: ) fl< % (3 Cl Expiration Date: ) Q'j G
Job Site Address: 5 oP Yi& Cj CI (' City/State/Zip:
'•-(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 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
NJ N.
of up to$250.00 . , against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations J s A for insurance coverage verification.
I do hereby ✓• .er the pains and penalties of petjury that the information provided above is true and correct
Signature: Date: ,3/46/Z:3
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(check one):
lDBoard of Health 20 Building Department 3DCity/Town Clerk 4.0 Electrical Inspector 5D'lumbing
Inspector 6.❑Other
Contact Person: Phone#:
Clarke, Kristin
From: Harbor Painters_Home Services, Inc. <harborpainters@hotmail.com>
Sent: Wednesday, March 26, 2025 3:16 PM
To: Clarke, Kristin
Subject: Re: express permit
Attention!:This email originates outside of the organization. Do not open attachments or click links unless you are sure this email is
from a known sender and you know the content is safe. Call the sender to verify if unsure. Otherwise delete this email.
Hi Kristin
This was my fault.
I selected the first option, but we have no employees; I work alone.
It should have been the second option.
Sorry, it's my first time.
Do you need me to stop by to correct it?
Evaldo
Sent via the Samsung Galaxy S25 Ultra, an AT&T 5G smartphone
Get Outlook for Android
From: Clarke, Kristin <KClarke@yarmouth.ma.us>
Sent: Wednesday, March 26, 2025 2:29:45 PM
To: harborpainters@hotmail.com <harborpainters@hotmail.com>
Subject: express permit
Hi,
On the workers compensation affidavit, it states you have workers comp. The certificate of liability has the liability insurance information only. Can you
either change the workers comp to sole proprietor or provide the workers comp policy information.
1
Thank you,
Office Assistant
Building Department
508-398-2231x1261
2
AC[Rd CERTiFiCATE OF LABILITY INSURANCE °"'E rr -�'Y'
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 TFE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUNG INSURE3t(51_AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
._. ._._.__
IMPORTANT: II the canniest*Bottler is asADO(TIONAL VISORED,the pollcy(iesi must have ADDITIONAL INSURED provisions or he endorsed.
II SUBROGATION IS WANED.NOON In*elms&Ind anNMie&s d Nis soh*nerleie poneles may require se enciersoniont A sleIsmeen on
this cartdloale toe¬ conies tights ID tle eerllto&b Mike in INN of mob awsaewer(s}
RPaCOOCEll MUM" Jades Msdeiios
Uni.assa<tilrli►aaos AVM*iec.+ IR
ISD N752•43333 !aim, ININT524303
374 DATIOrt Suess NW ihnisA
samisink
INSU I IPPOImMe DOMaABB lIM[f
:., MA O1604 min=A_ EWWBTON INSURANCE CO 3an2a
KELARD allIeeote
HARBOR PAHTERS A HOME SERVICES !nnimt c:
45 HEADWATERS DR awn=e_
fie=
WEST YARMOU'TH_ MA C1 Tti igAnER r 1
COVERAGES CERTIFICATE NUMBER: -• REVISION NUMBER.
THIS EEL TO CERTIFY THAT THE F CiES OF NISURANCE L.LSTED BELOW HAKE BEEN t iJED T I-E t*.B RED INAALIEO d1.SCAi'E Ft 'HE Pack Y E Cu
NOICATED- NOninTHSTANDoiC.ANY REOtAREUENT TEftil OR OOid3TK w OF AIW CONTRACT OR GTI-ER DOCUMENT WITH RESPECT TO RICH THS
CERTIFICATE WAY BE MI3E0 OR iiim PERTAIN.THE I* uRANCE AFFORDED EY THE FORCES OESCRR&D HE TEN s St1EJECT TO A[LTME TERMS,
z ExCLoSaCNS AND CONDR'XiNS OF RI k,I PCLICES LyetTE SP AIII WY HAVE SEEN REDUCED Sr PAZ CLAMS
IMIKAARMT, wuxr Err MILKY Ei®
ale UPC 0111111BURAMEE uaa Ma POLICE MY WNWa1ed ttu
ODNYrr, Ica NINV) Mule .
4 X e-c o eeelALLLNMET ghat es 1OXIDIO
oW �I TIENTeo
000
CAISWESE C- #CiAlSOUSIIB T
MO WgosPnoi $ 10
A �•• 3FICIND 1011142O24 111016r202S PtaeTi3eet&AINpaw vii 1p90,OM
i
_ ++'Bs€L Liar APF'L!R'FGIt. � _.._'-_i1i.5,C17QJ�0 I
rain, Li L3L PRODUCTS-CEIMIOP ALG S 2.000.006
XS
STT;I! S
AVTONOMLL UMILITY C9 StI LE.Leer S
ANY AUTO ICCMLY MMRY Sit wow -f
AUTOS CND ......IL'Tr..: ��`Mil�r: •«acno.F s
WED tikaACAMZ 1 PREPENTYDAAILa
AiMM o OS MY �, AUTOS C1.Y 7 N"+ r
WIRED
L
tlaeRELLA LAB ..i£7CAR CA OCi7{M�IL6L .$
—
ElCES5 LISA CLAYS k:.'q Ai"it>tliilai S
I ID NS S
ERE'ECIUSIIMEEME I SWIM I I
AWE ET,iPLO+t5i LJMILeY it II
AN)VrtC►`IIT,Ca CARY RC XtEL IaE ❑ M,A r -' _.
O'T3[111.,EULER E.t:::,rr C'
flLrRhswri in me E t Lam,W.CA CLiLv°•
7LS}2P'01%-=R DFEPATsV;,Wiz« E L 06Lkw•POLICYi.lar
.ri 3SRItION Or OPERAINNIS t LOGOIO O p KACLE%IACONO ill.AdidNenal Rswwrb ecimdsl emir IA aladmiNemiamalluNplme
i
CERTIFICATE HOLDER
_ , CANCELLATION
SnouLD ANY Of THE ABOVE DESCRIBED POLICES BE CANCELLED
THE EXPIRATION DATE THEREOF,pbTICE WILL BE 6E5HERED&1
Donal Del VSCciu, AEcOED ICE WITH DIE POLICY P*Ovr9tlNS.
5.iallwa*Cr ee .-
xu*uoessn ssREscir*Anat
WOO Yirnio stt MA 07673 — _
f
�� The ACORD Hams and1919E.2O15 ACORD CORPORATION AN rights reserved
Inge__ staved marks o1 ACORD
f:
•
Commonwealth of Massachusetts
Division of Occupational Licensure
It/
Board of Building Re ,ulatsons and Standards
Constkt- L
u tikOn btmervisor
*\. t
CS - 119072 ..„ E".. x...„pires : 08/28/2027
TULLIO MASOSO DE NOVAES .0.0.
PEREIRA I
/ .4r
.......,
31 BLACK VALLEY RD
.00.
CENTERVILLE1VIA 02632 .vik *lit
,...., ,
A.
.....-
..
Commissioner ...... .a-„'
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs and Business Regulation
1 Federal Street-$ule 720
Boston,Massachusens 02110
Home trt icitemeni C€nuacior Regtslraucet
tom}
213133
JAZZ Za NOW OAPROtvEAAENT ODRP tea,: usi2,2021
3 CAPTAIN OUNTRD +**,
SOUTH YARAMOUTH MA er2N1A °`
°
wrr■aairees aw.w.Cara
TM.COfeaOlaarLAL TM Or rASSACtwa!TTS
Mao o+Caeaneer Alain a eusaraa.Regulation Ydaiiaaiaso Wag Wowit
HOW WPRO.Lly6rl dale Ntlalaaaralc
?YRC Cerpo'nten flan al CaleolantArYe aai/ Yam1611111fillielt
1 Pearai -Oi TATI
2't5%X - 0.3o1 i2.'S7 Deena-A
:.4 O G HOME tgaltelttlielel.v0RO
3 CAP!ANMOUNT t4.1'
50.f?P7 Y11/YG4/Tri.itl!11444
- - lltatfi;faeafiry Not t 3aor1iCJr1i