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HomeMy WebLinkAboutBLDX-25-1591 ©,Eta 0 2625 Office Use Only 44.11ki Permit#PAW-35 P1 kg ►�. amount 50— \\/�C�RPORRTEO,s EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 r CONSTRUCTION ADDRESS: '-00 l'_7u C Ic 1 S tn. o' 22 / OWNER: NAME y PRESENT ADDRESS TEL. # CONTRACTOR: I-t/k&4 S Z. frtC / G L e 77L123 0 2_6 Z 3 NAME MAILING ADDRESS TEL.# EMAIL: / /° Pt✓1e COv -YU2 C (S • Gott.. `-(7 Residential 0 Commercial Est.Cost of Construction$ u Ov Homeowner is Applicant? Yes No q� -77 Home Improvement Contractor Lic.# 0QO /73 Construction Supervisor Lic.# 1 d 0 Cie 7 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: ()( f �le5 r l/"CST yfx,I'fr, " 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 I. Applicant's Signature:_ Date: Owners Signature(or attachment) Date: Approved By: Date: Building Official(or designee) Rev 6/24 T 1 r i ,...—� PINECON-01 BZURAWSKI C-.C.),"?r;/I CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 11/18/2025 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, 1:he 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 Barbara Zurawski O'Connor & Co. Insurance Agency Inc. VPHONE 508 943-3333 FAX No):(508) 943-3257 (A/C, No, Ext): (508)135 Thompson Road P.O. Box 1090 E-MAIL ADDRESS: barbaraz@oconnorinsur.com — Webster, MA 01570 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : MAPFRE Commerce 34754 INSURED INSURER B : Pine Contractors Inc. INSURER C : 22 Tanner Road INSURER D Webster, MA 01570 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/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE r 1 OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ MED EXP (Any one person) $ --- PERSONAL PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ —_ POLICY PRO- JECT LOC PRODUCTS - COMP/OP AGG $ --- OTHER: A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1 ,000,000 (Ea accident) ANY AUTO L08864 3/27/2025 3/27/2026 BODILY INJURY (Per person) $ OWNED X SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ X HIRED X NON-OWNED PROPERTY eOPERT ntDAMAGE AUTOS ONLY AUTOS ONLY ) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE S DED RETENTION $ , $ WORKERS COMPENSATION PER OTH- STATUTE ER AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N / A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below — E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATIONSHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Horse Pond Corporation ACCORDANCE WITH THE POLICY PROVISIONS. 300 Buck Island Road West Yarmouth, MA 02673 - -- AUTHORIZED REPRESENTATIVE (21 .. ACORD 25 2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD /" A The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations OBI 'i Lafayette City Center -1. - 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 r \ Name(Business/Organization/Individual): ✓�e �kp.lj 1`�`� O rJ — Address: a 19(A)Vli (;l- )2lo IA f(0S`r P r {M GAF /S7 a City/State/Zip: Phone#: Are you an employer?Check the appropriate x: Type of project(required): 4. I am a general contractor and I 1.❑ I am a employer with 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. ❑Remodeling 2.ID I a sole proprietorpartner- These sub-contractors have ship p and have nnoo employees mploo yees 8. ❑Demolition working for me in any capacity. employees and have workers' 9 0 Building addition workers' insurance comp.insurance.t [Nocomp. 5.❑We are a corporation and its 10.0 Electrical repairs or additions required.] 3.0 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 12.0 Roof repairs c.152,§1(4),and we have no insurance required.]t 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. tContractors 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 DIA for insurance coverage verification. I do hereby certify der the pains and penalties of perjury that the information provided above is true and correct Date: 12—Li—Z S— Signature; 2 Phone#:` 774 n2 3 0�6 2 3 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 4.0 Electrical Inspector 50Plumbing Inspector 6.0Other Phone#: Contact Person: i i i I THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1 Federal She- uite 720 Boston,:Massachusetts 02110 Home ImproNtement-eStmTractor Re Istration - ,. f IP 1414 ''' "4 , fr, 7. riType: Supplement Card PINE CONTRACTORS, INC feg►stration: 207738 22 TANNER ROAD Expiration: 02/23/2027 WEBSTER, MA 01570 Y . t :. ' ,1 ,,,, °" Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE:Supplement Card Office of Consumer Affairs and Business Regulation Re st .aa a + Expiration 1 Federal Street-Suite 720 2077 .' ., ,02/23/2027 Boston,MA 02110 PINE CONTRACTOR . LUCIANE ZAMPILIS w,i ,s4� t 22 TANNER ROAD WEBSTER,MA 01570 1. i a; Undersecretary Not valid without signature THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1 Federal Street - Suite 720 Boston, Massachusetts 02110 Home Improvement Contractor Registration Type: Corporation Registration: 207738 PINE CONTRACTORS, INC Expiration: 02/23/2027 22 TANNER ROAD WEBSTER, MA 01570 Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. if found return to. TYPE:Corporation Office of Consumer Affairs and Business Regulation Registration Expiration 1 Federal Street-Suite 720 207738 02/23/2027 Boston,MA 02110 PINE CONTRACTORS, INC LUKASZ MRZYGLOD S 22 TANNER ROAD 9 $;• �' WEBSTER, MA 01570 Undersecretary Not valid without signature 4 vm 4 ftt o c C �' r o - dt U C w • p £ � k r !S GC 2 gL° CRC Cgpf SG t• �4 GLCIr � a r .9 G 14. to 0 s t" '*"• r 0 tr 44 ✓ zw- e i o V