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HomeMy WebLinkAboutBLDX-25-875 application f 04 Y T..\\ Otlice Lse Only ,[��� p�\ Pennna O N1111 Amount • EXPRESS BUILDING PERMIT APPLICATION „1.5-4-7S TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (50 398-223 t.Z J CONSTRUCTION ADDRESS: ! /ti [�. \\., OWNER: ' �/40 e N:\\1P PRfiS4 'I I) SS TEL++a CONTRACTOR: L-- _— -'— t NA 1h NI AHEM,\DORI�ti TEL a EMAIL:3u.� , _//)Jfj.,� ... _Residential _Commercial Est.Cost of Construction S��f- Homeowner is Applicant? Yes No �Q 'k Home Improsement Contractor Lic.# �? F)3 Construction Super,isor Lie.# D 6V J�o�V WORK TO BE PERFORMED Tent Duration ' (Fire Retardant Certificate required) Wood Stove Siding: #of Squares Lj Replacement ssindows:# Replacement doors: #_ Roofing: #of Squares Insulation Temporars 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 sears old require historical re,less *The debris will he disposed of at: Location of Facility I declare under penalties of per sty rat the s temen s here onto, d are mu:and correct to the best of my knowledge and belief I understand that any false answers sl will be just cause lirr denia r mf as nse and for •.tion under hi(I L.Ch.268.Section I. /J Applicant's Signature. ....... Date: _'t A C J, �`y''� JCN, Owners Signature(or attachment) Date: �" CV) s Q� 4\ :\ppmsed By: Date: Budding Official for designee) Res 6 24 't The Commonwealth of Massachusetts ci Department of Industrial Accidents _;11 Office of Investigations _ '= 1---7. - Lafayette City Center I pisi ' 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/Or .zation/Individual): i 11, Address:7 19 4 ' City/State/Zi : A1/4. > Phone#: —CV 7757e-:-'6" Are you an employer? heck the appropriate box: Type of project(required): 4. I am a general contractor and I 1I am a employer with Ai 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. kfiLILtemodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employes and have workers' 9. 0 Building addition [No workers' comp. insurance comp. insurance.t required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.El 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.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no 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. #: 06r Expiration Date: — Job Site Address: 1�City/State/Zip: , Attach a copy of the workers' compensation policy declaration page(showing the policy numbe 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 S 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 adv.•. :t a copy of this statement may be forwarded to the Office of Investigations of the DI, insurance coverage cation. I do hereby certify ,nder e p li„ i' .141111P- of perjury that the information provided above is true and correct. Si ature: - r�r 7. Date: vI Phone#: A , w�17 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): 11:1Board of Health 20 Building Department 30Cityrrown Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: es- — C� rnmonw�dt ; f Ia a hu ,tts Division of Or cupational a ice sure Le:)a_rd of &&i:ding Regulations and Standards Cons .1 OiliUN Kati . C -O608 6 ,cc- 4pires: 1 V22/2026 MICHAEL A HE. MN 72 OLD MAINST SOUTH YARIOLOUTH MA 02664 . ;.. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs & Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE: individual Registration Expiration 173878 10/11/2025 MICHAEL HEALY MICHAEL A. HEALY -72 OLD MAIN ST ` Y SOUTH YARRMOUTH, MA 02664 Undersecretary AC0 DATE(MM/DD/YYYY) �-. 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 _LA/CONr o Ext) (508)775-4559 (AIC,No): ADDRESS: marshall@loveletteins.com 396 MAIN ST INSURER(S)AFFORDING COVERAGE NAIC# WEST YARMOUTH MA 02673 INSURER A: HARTFORD UNDERWRITERS INS CO 30104 INSURED INSURER B: HEALY BROTHERS CONSTRUCTION INC INSURERC: 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 ADOLLTR INSD TYPE OF INSURANCE INSO WVD DI POLICY NUMBER (MM/DD//YYYY) (MM/DYYYY) LIMITS LT COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO $ CLAIMS-MADE OCCUR PREMISES(EaENToccu ence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO _ JECT LOC PRODUCTS-COMP/OP AGG $ , OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (E 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 EOTH- R AND EMPLOYERS'LIABILITY A OFFICER/MEMBEREXCLUDED?ECUTIVE N/A 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/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 . South Yarmouth MA 02664 Daniel M.CroWll y, CPCU,Vice President—Residual Market—WCRIBM,4 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD