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HomeMy WebLinkAboutBLDX-25-1257 '1t YA44 RECEIVED ) 0111cc lac Only / +ISO Pcmuta+ L(Jy(—a-,-1 (/ [ q •oI q SEP 2 2 2025 Amount 60-- ''�`OQ,04A•„'.'. . BUILDING DEPARTMENT EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1 146 Route 28 South Yarmouth, MA 02664 gleiel.covi(508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 22 awe_ OWNFR: ge,Lni ! , ' . E/o Zg aelfzv bed 1 kod MA- SO2) -vYf-1W S.\\Il I RI SE\T ADM I SS TEL. CONTRACTOR: N1 I0IM4 7l IL_. _ ze cr fj 41 Pone iii4 We) Sz -i s&' ((�,\,�A\11 \I\Il..l\G \I)I)RlSS TEI. ENTAIL: y Q"t1C 1%.,. eovi S4rte4 VT/o koc.. ot/I Aesidenttal .:Commercial East.Cost of Construction S // -V Homeowner is Applicant? l es No ,e Home Improvement Contractor Lic.# Z Jk 303 Construction Supervisor Lic.# 06 5 29) WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares ..i.1 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 user 75 sears old require historicatresless , *The debris will he disposed of at: VO5eli Fea 44i149ti! Location of Facility I declare under penalties of perjury . tie st ement herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will he just cause tiff denial or r ocation a,•., liven e and for prosecution under M.(i l_ Ch.268.Section I. Applicant's Signature /� 'ill , Date �2 2 Zl.�' Owners Signature(or attachment) ''' Date: �� �2 /,D q.., :Approsed Hy: Date Building()tlicraal Ior designee) Re% h 24 The Commonwealth of Massachusetts Department of Industrial Accidents vu►=5 Office of Investigations r ="��= Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 • www massgov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 1 PI se Print Legibly Name usiness/Or anization/Individual : epiAN1114/1 644 AAA ct i L 11I Address: 2 g �-o c t� 1 P-©o)L- City/State/Zip_ Do%)e , Iv)4 022-0$O Phone#: -fig +caf —3 3 Fr Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. 0 I am a general contractor and I 6. 0 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. 0 Remodeling ship and have no employees These sub-contractors have g. 0 Demolition working for me in any capacity. employees and have 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 12.❑ Roof repairs insurance required.] t c. 152,§1(4),and we have no + employees. [No workers' 13. _Other c dA h►P I2 I comp.insurance required.] Q *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. #: 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 cerdfy u r th enalties of pedury that the information provided abo e is true nd correct. Signature: Date: D� Z2- 2.D 2� Phone#: ( (5'1,)-Sv -' 9 Official use only. Do not write in this areg,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(check one): 10Board of Health 20 Building Department 31JCity/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 61:Other Contact Person: Phone#: Act o® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDnYYY) 09/11/2025 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 NAAME: Jessica Pulley The Wicks Insurance Group PHONE FAX (A/C,No.Est): 9 7 8-2 0 8-6111 (A/C,No): 13 Branch Street E-MAIL rou info@thewicksinsurance com ADDRESS: info@thewicksinsurancegroup.com Unit 207 INSURER(S)AFFORDING COVERAGE _ NAIC# Methuen, MA 01844 INSURERA:GREEN MOUNTAIN INS CO INC 20680 INSURED INSURER B: RETRIX CONSTRUCTION INSURER C: 28 Troutbrook Rd INSURER D: _ Dover MA 02030 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXPM/ LIMITS LTRINSD WVD POLICY NUMBER (MDD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ 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) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETO R/PARTNER/EXECUTI VE OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ (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 IS AN ADDITIONAL INSURED CERTIFICATE HOLDER CANCELLATION BUILDING DEPARTMENTS 1146 ROUTE 28 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN SOUTH YARMOUTH MA 02030 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE JESSICA PULLEY ©1988-2015 ACORD CORPORATION. All r ight s reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 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: Individual Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street - Suite 710 21 12l171202 Boston, MA 02118 2ZIMITRY KETRYK ►!B/A KD CONSTRUCTION AND DEVELOPMENT 7 ZIMITRY A. KETRYK 8 TROUTBROOK RD 'OVER MA 02030 I I.'.,4- n.i.nr. �•�r.• 111,11w♦ aiw/i44 •a•:i4noft a.i oft i Am.wok w#..rw Commonwealth of Massachusetts Construction Supervisor Division of Occupational Licensure Unrestricted-Buildings of any use group which contain less than Board of Building Regulations and Standards 35,000 cubic feet(991 cubic meters)of enclosed space. Cons lon trvisor CS-085291 ,W etpires: 05/07/2027 DZIMITRY Kw R m 28 TROUTBI O DOVER MA 203 h"LLVd�'►� Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Commissioner 21./ sK Contact OPSI:(617)727-3200 or visit www.mass.gov/dpl/opsi