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HomeMy WebLinkAboutBLDX-25-906 94a, Office Use Only �\, TO; Permit#T. ZDk- C I, �! /v C �_ ,1��:y i Amount -4P" *. - . 'I '0\ 00 R A..,000, C �'" 1 ti5 EXPRESS BUILDING PERMIT APPLICATION ',, o- , TOWN OF YARMOUTH * --'?,e- Yarmouth Building Department 1146 Route 28 e��� South Yarmouth, MA 02664 o (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: ✓ /U w h flail' pie / c• i-c Imo / - 1 6 OWNER:i!M He/6t (/1 /4 j own Ha,W /,✓e, S. ritri.tocog �14 o266 t '6O- J 43- 65db NAME U PRESENT ADDRESS TEL. # CONTRACTORAZ 7 6.1? -I c t. ( o Pt a 2 ko r f d c i W.1'L C ofOy'4 Se.)Q r 5 13 f S. NAME / MAILING ADDRESS " MA 0;.6:4 3 TEL.# EMAIL: ate i.cold -U CL_G-�`at( I C< t- V Residential 0 Commercial qr Est.Cost of Construction$ 91 '° • 1-9-e7 Homeowner is Applicant? Yes No V Home Improvement Contractor Lic.# I'J 1I a oal— Construction Supervisor Lic.#C SSL- -10 16 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares Replacement windows:# 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: 647 6 re r 4 r<1 V • !A'C s'0 c'''(`i 1 /1 4 0) Location of Facility I declare under penalties of perjury that the s ents 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 license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: 4/`D/ ` �5 Owners Signature(or attachment) `� Date: V/Eet�Z S Approved By: Date: Building Official(or designee) Rev 6/24 ' ;I . ,• . ' • s I .41+011 4 .1 41' • )T it :7101)1, ,r• *14 nR 51i1 ,r.f...“.,"..‘"4 9 . s‘' _ ,10 , tr. ••• ••-•, tkr* irl AC-0 DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 12/13/2024 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 AshleyPaiva NAME: — —ARTHUR J GALLAGHER RISK MANAGEMENT SERVICES INC PHONE N ExtL (800) 333-7234 FAX No): E-MAIL ADDRESS: Ashley— @19 Paiva a .com 470 Atlantic Avenue INSURER(S)AFFORDING COVERAGE NAIC# Boston MA 02210 INSURER A: ATLANTIC CHARTER INS CO 44326 INSURED INSURER B: ALT CONSTRUCTION LLC INSURER C: INSURER D: 22 HORSE POND ROAD INSURER E: WEST YARMOUTH MA 02673 INSURER F: COVERAGES CERTIFICATE NUMBER: 1073424 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 ADDL SUBRI 7, POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD(WVD POLICY NUMBER j (MM/DD/YYYY) (MM/DDIYYYY} COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE J OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY j PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: AUTOMOBILE LIABILITY ~ COMBINED SINGLE LIMIT $ (Ea 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 i CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER SH TATUTE ER AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBEREXCLUDED? N/A N/A N/A WCV01420406 12/04/2024 12/04/2025 (Mandatory in NH) E.L. DISEASE-EA EMPLOYEE $ 1,000,000 If yes, describe under E.L. DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below i 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 ACCORDANCE WITH THE POLICY PROVISIONS. Display Purposes Only 22 Horse Pond Road AUTHORIZED REPRESENTATIVE W Yarmouth MA 02673 ` " 1, Daniel M. Crowley, CPCU, Vice President — Residual Market —WCRIBMA © 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 ., .. _;,. Office of Investigations .a Lafayette City Center WV 'h 2Avenue de Lafayette,Boston,MA 02111-1750 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builder's/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): 4Z 7 r COOL.4rg .0 eiliOvt t L L C Address: 2 a- KOr'S c Pao rd City/State/Zip:►+/.Ycwt0 44/MA/0d.645 _ Phone#: S-02-360_ (3ez� Are you an employer?Check the appropriate box: Type of project(required): 1.ll I am a employer with S 4•0 I am a general contractor and I 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. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9. 0 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.D Roof repairs insurance required.]t c.152,§1(4),and we have no ,n employees.[No workers' 13. Other QP`- % �a-J 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: ,/r-/In..lei C G ..c C .,tti S, Policy#or Self-ins.Lic.#: IN (//GI C21'(�-0�06 Expiration Date: Vox I"'/O!// //� Job Site Address: 5' iD win iL c9t i/ d•✓P- City/State/Zip:S.7o rW1 oti<l fl t1/V.2.66 y 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 and a pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 0-1/l0/2-001-5 ar pPhone#: 8— �'�t —/3 d s 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): 1❑Board of Health 21:1 Building Department 3.City/Town Clerk 4.0 Electrical Inspector 5EIPlumbing Inspector 6.0Other Contact Person: Phone#: Commonwealth of Massachusetts J �Nfr% Division of Occupational Licensure Board of Building Regulations and Standards Construct upper' ofr Specialty CSSL-106169 E3,pires: 04/14/2025 ALIAKSANDG TURAU 20 HORSE POND ROAD WEST YARMOUTH MA 02673 r Commissioner eiu�a K. SF ,c ta.. 2:46 PM Office of Consumer Agars&amino a Regulation'Mass.Gov Mass.gov Difice of Consumer Affairs and Business Regulation (OCABR) HIC Registration Complaints Registration# 194702 Registrant ALT CONSTRUCTION LLC Name ALIAKSANDR TURAU Address 22 HORSE POND RD City,State Zip W.YARMOUTH,MA 02673 Expiration Date 04/13/2026 :;ompia rots Details No complaints found for this registrant. You can also Arai arbitration and Guaranty Fund history. Rack To Search SitB�,y_Poli_C.ies Contact Us 2018 Commonwealth of Massachusetts. Mass.Gov®is a registered service mark of the Commonwealth of Massachusetts. Licensee Details Demographic Information Full Name: ALIAKSANDR G TURAU Owner Name: License Address Information City: WEST YARMOUTH State: MA ipcode: 02673 ountry: United States License Information ;License No: CSSL-106169 License Type: Construction Supervisor Specialty Profession: Building Licenses Date of Last Renewal: 5/9/2025 Issue Date: 6/28/2019 Expiration Date: 4/14/2027 License Status: Active Today's Date: 5/13/2025 Secondary License Type: Doing Business As: $tatus Change Reason: License Renewal Prerequisite Information ,Licensee: TURAU,ALIAKSANDR G Relationship: Attribute Of License No: CSSL-106169 No Available Documents