Loading...
HomeMy WebLinkAboutBLDX-25-1287 -,1 YA ,,\ t(�-O Cl'v-e :0.-,„Use Only r �Z 1 4a I Pcmrna9s-0X-"4.T714/ Eo y Amount 0-10- l EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 ('�// (508)398-2231 Ext. 1261 >< CONSTRUCTION ADDRESS: //J�.__._..2C,srvi ci .r 7\ OWNER: , ,V4//�e/_Lc-,9 Cy)W.2 PRESE\r:\I)//nR//lti _ /./ / 27 7 ^r7Cg3 /7 CONTRACTOR: _(Afir/i%/Afir�' 9'0 /7iciSt fY _ 7f//.O—a AWE / MAMA( \DD SS �TE.L u EMAIL: _tajko, 1.",v,rT &r0�1r- j"1/I-r Residential `,J_ �:/,Commercial/ Est.Cost of-Construction S�[\ a t o U Homeowner is Applicant? Yes /yr No V �+ �r�/ .�Home Improvement Contractor Lic.# /j'+// Construction Supenisor Lic.#�(�J^(/(.Q�(��C 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 ii Solar System ESS System Chimney _Fence // "Please submit utility disconnect letters for electric&gas-structures over 75 years old require historical res less T 'The debris w ill be disposed of at. /Y WAM.. ti`'' -P� Location Facility I declare under penalties of perjury •u the stateme • crein contained are tore aid correct to the hest of my knowledge and belief.I understand that any false answer's) will he just cause lio denial or o-io f my .e.e and for prosecution under M.(i I.('h.2261i.Section I. /' k\ppl wanes Signature' Date:__ (] C( (3(� `/ Owners Signature(or attachment) Date: -\ (�� Appro.ed lie ��-���"" late: Building Official for designee) CE1VED Raw h 24 •_ SEP 26 025 BUILDING D ME sy The Commonwealth of Massachusetts Department of Industrial Accidents _: ►_ Office of Investigations _ :411= ' Lafayette City Center 71*i- 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/OrganizationMdividuai): v�J�,j/ 4% ,1-Pr' N( Address: ?6, S/ City/State/Zi : i' 4 C J v- Phone #: (tl / Q -Cc) Are you an employer? eck the a propriate box: ,�,/ am a general contractor and I Type of project(required): 4. I 1.[ I am a employer with L ❑ employees (full and/or part-time).* have hired the sub-contractors 6. New❑ construction 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 hive 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 YsP 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 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: rr/7 Policy#or Self-ins. Lic. #: 7/ J (/ f � , >✓ Expiration Date: ///J' p2 C Job Site Address: /-C7 )S->,4 1/7 P4f /4 t✓, e City/State/Zip: Yf/l&,14// � 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 ce ' u der the p ' d penalties of pedury that the information provided above is true and correct. Signature: Date: S(/9 Phone#: t/ `9 0 -CP 6(a 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): I❑Board of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector 50lumbing Inspector 6.0Other Contact Person: Phone#: ACLIABILITY INSURANCE 09/26/2025DATE(M / 2YY) CERTIFICATE OF 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 Robert W. Parker NAME: Charles G. Jordan Insurance Agency PHONE 781-337-0427 FAX 781-335-6897 17 Front Street (A/C,No, Ext): (A/C, No): E-MAIL k arer c ordaninsurance.com Weymouth, MA 02188 ADDRESS: r p @ 9J INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Travelers Porperty Casualty Company of America TRA INSURED Robert Wagner INSURER B : 90 High Street INSURER C : Weymouth, MA 02189 INSURER D : 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DDIYYYY) (MMIDD/YYYY) LIMITS ICOMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S DAMAGE TO RENTED CLAIMS-MADE ? OCCUR PREMISES (Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY S • GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: _ S 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) S UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS S A WORKERS COMPENSATION 7PJUB-9968L41-7-24 11/18/2024 11/18/2025 ✓ PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 100,000 OFFICERIMEMBEREXCLUDED? Y N/A (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 1 LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) The Workers Cmpensation policy does not provide coverage for Robert Wagner. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. Building Dpt 151 Seaview Ave AUTHORIZED REPRESENTATIVE Yarmouth, MA 02664 © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD •ol•••CP+L I n yr MRb ACHUSETTS Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration 117192 09/06/2026 ROBERT WAGNER ROBERT N.WAGNER 90 HIGH ST WEYMOUTH,MA 02187 Undersecretary Commonwealth of Massachusetts Division of Occupational Licensure �., Board of Building Regulations and Standards Const{+; on tServis,o- CS-062764 �ires: 0803/2025 ROBERT N WAGNER , ;f 90 HIGH STREET WEYMOUTH MA 02189 Commissioner