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HomeMy WebLinkAboutBLDX-25-734 application �', ,�O�.Y`�R�OTrwifritiO/ ' X T � ./�_��Vt/' ' Office Use Onlyr.�! CAPermit# n • �l`'� $ 1 ��1� l Amount / lJ ' MATTA r, CS[ �/L/ "�'`°°'°"•"°"Pcad /�i/ '3C1 (9? ;,Permit expires 180 days from` `/ ')'- I issue date B itIx—a s—73 u EXPRESS BUILDING PERMIT APPLICA'-'ION TOWN OF YARMOUTH RECEIVE Yarmouth Building Department ,c,� ,�1 1146 Route 28 J A 2025 ' 1'I(,� South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT By: CONSTRUCTION ADDRESS: ' ASSESSOR'S INFORMATION: / / ""H " ce,„....,41:'"-. • 3 Map: Parcel: OWNER: to A) . t--)1°en /Vl' Sect /I-tic (An;/- 3 2VS - 5-Z 5 .3-7 38 NAMEi/ ,, � rr�� PRESENT ADDRESS TEL. # CONTRACTOR: 04 V)P l�o(\ 43 m u it Nq V4g Mw ti 772./ 3? } 19 g 2- NAME MAILING ADDRESS TEL.# Kesidential ❑Commercial Est.Cost of Construction$ I .- Home Improvement Contractor Lic.# 13 2 3 b I Construction Supervisor Lic.# (:. 0 5 IU (13 Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor have Worker's Compensation Insurance I '/ Insurance Company Name:112/4 (/S 6.E f 2› Worker's Comp.Policy 6 t� i1 1j I k C/b 4 3 K j 2tI WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 0 7- Replacement windows:# Replacement doors: # Roofing: #of Squares 12 ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: D l2-o I h cS 1) i 191) J4 Location of Facility I declare under penalties of perjury that the statements 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 revocation of my license and for prosecution under M.G.L.Ch.268,Section 1. / Applicant's Signature: � I/ 1 D WO 0 OS Date: 0 b / Oc 1 20 2 C / Owners Signature(or attachment) /�iUu °i'Wt �v` •L. Date: (o //2.02-r Approved By: Date: Building Official(or designee) L ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No -� '� '` R1 DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 10/ 4n4 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 CNTNAME ACT JIM HINDMAN WORLD INSURANCE ASSOCIATES LLC PHONE No,Ext): 508 771.8381 FAX (A/C,No): 508-771-0663 34 Main Street E-MAIL West Yarmouth,MA 02673 ADDRESS: schlegelinsurance@gmail.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: NGM INSURANCE COMPANY 14788 INSURED INSURER B: TRAVELERS MARCOS SILVA INSURER C: DBA EMERSON CONSTRUCTION INSURER D 67 SEA ST APT 11 HYANNIS,MA 02601 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 TYPE OF INSURANCE ADDLSUBR POLICY EFF POLICY EXP LTR INSR WVD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 500,000 MED EXP(Any one person) S 10,000 A MPT9375T 11/09/24 11/09/25 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 O- POLICY JE T LOC PRODUCTS-COMP/OP AGG $ 2,000,000 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 STATUTE ER Y J N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 B OFFICER/MEMBER EXCLUDED? N N/A 6HUB1 K96638A24 04/17/24 04/17/25 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below - E L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 1 D1,Additional Remarks Schedule,may be attached if more space is required) MARCOS SILVA HAS ELECTED TO BE COVERED UNDER HIS CURRENT WORKERS COMPENSATION POLICY INSURANCE COVERAGE IS LIMITED TO THE TERMS,CONDITIONS,EXCLUSIONS,OTHER LIMITATIONS AND ENDORSEMENTS OF THE POLICY 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. DAVID WOODS 43 MATTHEW WAY MARSTONS MILLS MA 02648 AUTHORIZED REPRESENTATIVE DAIA BENFICA ©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 �= /. Department of Industrial Accidents __Al_� 1 Congress Street, Suite 100 a 11 Boston, MA 02114-2017 IMMEMIMIP,,`5..`' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/Individual): D4 lit (3 WOO D5 Address: L13 (V14 Tl461/i 0(416 iu# I,g City/State/Zip: I'ii A O )_6 t{ 'S Phone #: l' 31 3 Z.9- 7OZ Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 111 Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑ Demolition 3.E I am a homeowner doing all work myself.[No workers'comp.insurance required.]1. 10 [ Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 6. I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.ROof repairs These sub-contractors have employees and have workers'comp.insurance.= 14. 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. Other 152,§1(4),and we have no 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' compensarion insurance for my employees. Below is the policy and job site information. _ Insurance Company Name. "�'� 1i 9 I/ L6 S //_ Policy#or Self-ins.Lic.#:6.14 ( $ I '< 9 b 6 3 D�-21q Expiration Date: 024 17 20GV Job Site Address: I 'j 4 S S E 4 A l/F UI/71-' 0 3 City/State/Zip: 414 4 e►l1OVl7 ' Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. 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 penalties of perjury that the information provided above is true and correct Signature: 0/ /I 0 I vOVDS 0 6/ /22.cDate:7- 9t' r Phone#: . 44 3 2 '- q') $Z Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Phone#:Contact Person: Commonwealth of Massachusetts 1) Division of Occupational Licensure Board of Building R.e ulations and Standards Con`toniSisor CS-035693 ti L�},�cpires:01/18/2024 DAVID A.WQJpDS A 43 MATTHEW WAY MARSTONS PILLS MA 02648 ,4''')/.1.VX,133 digit; I�II.IJJIV�161 1/ l2 H/`� .II... :/l "� I t. •�trw.. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE: Individual Registration Expiration 132361 11/18/2024 AVID WOODS AVID A.WOODS 3 MATTHEW WAY em , �{� - ii IARSTONS MILLS,MA 02648 { THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration 132361 03/03/2027 DAVID WOODS DAVID A.WOODS �p / 43 MATTHEW WAY iltwprc+ • MARSTONS MILLS,MA 02648 U Undersecretary