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HomeMy WebLinkAboutBLDX-25-1456 yqR e. Office U eOny. ,�. O t - `. rcrtnitu(sj'N11WLS-J 45'(e l �t 3• y . OCT 2 8 2025 ,mount t0O— r EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: Loci tmendwa W OWNER: 605,,,ken 190•.lO'PA(F'D J60.4415WAkMa 6t8JVD -Z,VL2_ N,1h1E PRESENT V:\DDRI SS ,.. TEL. CONTRACTOR: —• C�RT/vf�i ]� � p: •�1,/ NAME Al AILING ADDRESS TI I - EMAIL Cnana CZ U3 Ockvx 1406 Cs,ma.0.ccan Residenlia C,nmercial Est.Cost of Construction S bbo D O_ Homeowner is Applicant? ties V No Home Improvement Contractor Lic.# I '? ?I Construction Supervisor Lic.# F�—O!q( WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Sid_ipg�oS uar Replacement windows:# Replacement doors: # 171 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 titer 75 rears old require historical rev iess 'The debris N i II be disposed of at: y l .1�7A1 UL _. Location o faclRtt I declare under penalties o1 pe slat yy4 Is here rue at correct to the best of my knowledge and belief: I understand that any false answensl N ill be just cease for denial t r 410110W n tin Mil I..Ch.26X.Section I.Applicant',Signature. Date: Q >IVzs Owners Signature for attachment) Date: Approved Hy: Dale: _ Budding Official for designee) Res(.24 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center iIIIt� ' 2 Avenue de Lafayette, MA 02111-1750 Boston, WWW.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 514/e7 g55661t t'J Address: © , Ey )( & $5 City/State/Zip: l� Q� Cps t}2I' hone#: 5t)f= Are you an employer? Check the appropriate box: Type of project (required): 1.❑ I am a employer with 4. [}Q I am a general contractor and I employees (full and/or part-time).* Tf have hired the sub-contractors 6. 0 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 have workers' [No workers' comp. insurance comp. insurance.[ 9. ❑ Building addition r uired. 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions eq l 3.❑ 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 a airs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.q Other comp. insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy info on. 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. #: Expiration Date: Job Site Address: City/State/Zip: 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 P fo urance coverage veri n. I do hereby • , urn t d al ' o % that the information provided above is true and correct. X D/Z� Signature: /,Z c Date: Phone#: 0o?).. 9qt. 7'1Z 7 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): 10Board of Health 20 Building Department 31:City/Town Clerk 4.❑Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: ACORD Client#: DATE TM CERTIFICATE OF LIABILITY INSURANCE 09/18/2025 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHT 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 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 Raphael Oliveira MAMF PHONE (508) 771 4600 DISCOVERY INSURANCE AGENCY LLC EMAIL raphaeldiscovery©gmail.com 668 MAIN ST ADDRESS: HYANNIS, MA 02601 INSURER(S)AFFORDING COVERAGE NAIC INSURED INSURER A: ATLANTIC CASUALTY INSURER B: CAPESIDE CONSTRUCTION INC INSURER C: 59 WAGON LN INSURER D: AIM MUTUAL INS CO 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 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 TALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRL ADDLI SUBR POLICY EFF POLICY EXP TR TYPE OF INSURANCE NSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS A GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES(Ea ocurrence) $ 100,000.00 CLAIMS-MADE I I OCCUR MED EXP(Any one person) $ 5,000.00 L261006565-2 10/29/2024 • 10/29/2025 FERSONAL&ADV INJURY $ 1,000,000.00 GENERAL AGGREGATE $ 2,000,000.00 PRODUCTS-COMP/OP AGG $ Z,000,OOO.00 ri GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PROJECT [1LOC • COMBINED SINGLE LIMIT B AUTOMOBILE LIABILITY (Ea accident) BODILY INJURY(Per person) ANY AUTO ALL OWNED AUTOS SCHEDULED BODILY INJURY(Per accident) AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) C UMBRELLA JAB OCCUR EACH OCCURRENCE EXCESS LIAR CLAIMS-MADE AGGREGATE DED RETENTION S D WORKERS COMPENSATION Y/N WC STATUTORY OTH AND EMPLOYERS'LIABILITY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED E.L.EACH ACCIDENT VWC10060232962024A 10/26/2024 10/26/2025 $ 500,000.00 (Mandatory in NH) EL DISEASE-EA EMPLOYEE $ 500,000.00 If yes,describe under E L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS below $ 500,000.00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION Bosworth Associates SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE IT IS THE CUSTOMER'S RESPONSABILITY TO INFORME ANY ,. lr1C ier I OSWOrtk CHANGES OR CANCELATIONS. ^^¢¢ // P.O Box 685 1645WF--,1,i1 th Rd s,,,, i: Ci, I C .f?�j 1��01 RAPHAEL OLIVEIRA nit Centerville, Ma 02632 1 / 1 © 1988-2010 ACORD CORPORATION. All rg; Commonwealth of Massachusetts W Division of Occupational Licensure Board of Building Regulations and Standards es- 14,04,CY CS-019611 '� spires: 09/22/2027 WARREN C gtosvvoRTK PO BOX 6867, CENTERV1LLS MA 02832 * `` �4Ot7, art'S'0 Commissioner :.� Construction Supervisor Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991 cubic meters)of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Contact OPSI:(617)727-3200 or visit www.mass.gov/dpl/opsi THE COMMONWEALTH OF MASSACHUSETTS ;Jtflce of Cone.=mer Affairs;&Business Regulation HOME IMPROVEMENT CONTRACTOR YPE:1n ividual Rsgisatlon Expiration 114889 11R)4/2C25 yIARREN BOSWORTH JR. /B/A BOSWORTH ASSOCIATES WARREN C.BOSWORTH, 645 FALMOUTH RD -ENTERVILLE,MA 02632 Qa Undersecretary siaL,,tration valid for individual use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 1000 Washington Street -Suite 710 Boston,MA 021 r. jilZOLVI1 Not valid Without signature 6f Ag-ii i3RD H �S ACORD Client#: DATE TM CERTIFICATE OF LIABILITY INSU�ANCE 10/31/2025 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHT PON 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 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 Raphael Oliveira AlAru1c. PHONE (508)771 4600 DISCOVERY INSURANCE AGENCY LLC EMAIL raphaeldiscovery@gmail corn 668 MAIN ST ADDRESS: HYANNIS,MA 02601 INSURER(S)AFFORDING COVERAGE NAIC INSURED INSURER A:ATLANTIC CASUALTY INSURER B: CAPESIDE CONSTRUCTION INC INSURER C: 59 WAGON LN INSURER D:AIM MUTUAL INS CO 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 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 TALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRL ADDLI SUER POLICY EFF POLICY EXP TR TYPE OF INSURANCE NSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS A GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES(Ea ocurrence) $ 100,000.00 CLAIMS-MADE I I OCCUR MED EXP(Any one person) $ 5,000.00 L261006565-3 10/29/2025 10/29/2026 PERSONAL&ADV INJURY $ 1,000,000.00 GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 2,000,000.00 EN POLICY I I PROJECT I ILOC COMBINED SINGLE LIMIT B l AUTOMOBILE UABIUTY (Ea accident) BODILY INJURY(Per person) ANY AUTO ALL OWNED AUTOS SCHEDULED BODILY INJURY(Per accident) AUTOS -NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) C UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE AGGREGATE DED RETENTIONS D WORKERS COMPENSATION YM WC STATUTORY OTH AND EMPLOYERS'LIABILITY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E L EACH ACCIDENT VWC10060232962025A 10/26/2025 10/26/2026 $ 500,000.00 (Mandatory in NH) EL DISEASE-EA EMPLOYEE $ 500,000.00 If yes describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ 500,000.00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101.Additional Remarks Schedule,If more space is required) CERTIFICATE HOLDER CANCELLATION Bosworth Associates SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE IT IS THE CUSTOMER'S RESPONSABILITY TO INFORME ANY Chandler Bosworth CHANGES OR CANCELATIONS. P.O_Box_685 1645 FaC 2nd RAPHAEL OLIVEIRA Unit C 2nd floor orr Centerville,Ma 02632 1/1 ©1988-2010 ACORD CORPORATION.All rights reserved.