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HomeMy WebLinkAboutBLDX-26-103 application ,. ,r_ g Office Use Only .. 7\ Q` ° Permit#Q3l-(>>(-ain-tp3: kQu - � '� -: - Amount 01— r� E: / MAT TACM[[8E q7�] /` / asii E CN EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH FEB 13 2026 p Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 3 b�0VIAton LV► OWNER: TO h i A/c 3o TOAnSo Lrl. W Yvon (J og) qq-7 5--z NAME 1J PRESENT ADDRESS TEL. # CONTRACTOR: J OS AIA:t ,BUSS Y'l- P,U. IUx iag 1✓ liyann,'S/Jo/t (Ca$)?G0 NAME MAILING ADDRESS TEL.# EMAIL: j I4S,SetA; l-©try 'Residential ❑Commercial Est.Cost of Construction$ / 01 00 (), Homeowner is Applicant? Yes No_ Home Improvement Contractor Lic.# /3(p 3 95' Construction Supervisor Lic.# f S— // WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove tr Siding: #of Squares / 4 . 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: YC f n/U �l 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 y licens and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: 2ll/Z Owners Signature(or attachme t) Date: Approved By: Date: Building Official(or designee) Rev 6/24 The Commonwealth of Massachusetts ' =k= Department of Industrial Accidents Office of Investigations Lafayette City Center 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/Organization/Individual): Address: City/State/Zip:® Phone#: Are you an employer? Check the appropriate box: Type of project(required): 1. I am a employer with 0 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 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 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. 0 Building addition [No workers' comp. insurance comp.insurance.t 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' right of exemption per MGL 3's . comp. 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no 13.�r Other 7r employees. [No workers' 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: Po v'll y (,n ell Policy#or Self-ins. Lic. #: 1/'LC '(DO 5'oo 7$5'.8- Expiration Date: //V/2 7 Job Site Address: 30 J cX h5Ort Lvt City/State/Zip: 104, ydr,r,uig 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties ofperjury that the information provided correct. /above is true and Signature: G7 ' Date: G/�7/2-C° Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(check one): 10Board of Health 20 Building Department 31:City/Town Clerk 413 Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: :- JOShassettflC. Proposal ua Home Improvement Wood & Asphalt Specialists 0 h n A/4C /� 508-360-0162 /''/ /, Jbassetthi@yahoo.com 3 o - o h ei S o r1 tit) PO Box 128 � /1 � / West Hyannisport, 4'V , 1 f mU(41 02672 MA CSL#113552 HIC#136395 t 1 P e do C.deuia II Cock wu (1) Tit rvi a Nood Acose is Door A u-ke r i IS L c( or ' Clew) OF � p Cosi-- A0000, Nc,j`1 - Labor r Auf ef145 PUS 1 8"lk ono FCC rov. 0 i 'rap 0.(- co s} A 4 d omP av ire r�; Payed &u `'. t We propose hereby to furnish material and labor-complete in accordance with the above specifications for the sun of$ tot cot , With payment made as follows P(05 res S O n Ft,&/uy3 0✓ („ fit n Tim,I4e I, Any alteration or deviation from the above specification involving extra costs will be executed only upon written order and will become an extra charge over an above the estimate.All agreement contingent upon strikes,accidents,or delays beyond our control. Respectfully submitted (note:this proposal may be withdrawn only by us if not accepted within days) ACCEPTANCE OF PROPOSAL The above prices,specifications and conditions are satisfactory and are hereby accepted.You are authorized to do the work as specified. Payments will be made as outlined above. Signature Date of acceptance it /1 Signature �l-�� Commonwealth of Massachusetts Construction sot,. Division of Occupational Licensors 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. ConstonH' rvisor CS-113552 res:05/2512027 JOSHUA B13SETf'11 . PO BOX 1211 . W HYANNI8P25T MA 22 2 7 Q 40I,LVd0:33 Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Commissioner Contact OPSI:(617)727-200 or visit www.mass.gov/dpuopsl COMMONWEALTH OF MASSACHUSETTS :Moe of Consumer affairs&Business Regulation SOME IMPROVEMENT CONTRACTOR —"PE:individual Reaistrat an figigrAge 136395 07/21/2026 JOSHUA B.BASSETT JOSHUA B.BASSETT L 7 24 NEWTON ST HYANNIS,MA 02601 Undersecretary DATE(MWDD/YYYY) A�D® CERTIFICATE OF LIABILITY INSURANCE I �, I .,./05,202G 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 POUCIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED RI PRESEN"fAtlVE OR PRODUCER,AND 1HE GER111ICAIE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the polloy(les)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 — CT Glen Davis The Hilb Group New England,LLC PHONE (800)640-1620 1 FAX IA/C.No.Exfl: I LAIC,No): E-MAIL davi hil rou .Wm ADDRESS: 9 � b9 P 973 iyannough Road INSURER(s)AFFORDING COVERAGE NAIC N Hyannis MA 02601 INSURERA: Midvale Indemnity Company 27138 INSURED INSURER B: Associated Employers Insurance Co 11104 Joshua Bessatt Inc. - INSURER C: P.O.Box 128 INSURER D: INSURER E: West Hyannisport MA 02672 INSURER F: COVERAGES CERTIFICATE NUMBER: CL261533209 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POUCIES 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 POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INSD WVD POLICY NUMW D/ER (MMIDYYYYY) (MMIDO/YYYY) UI TS X COMrERCIAL GENERAL Lamm EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE 1 OCCUR PRREM oq ISES Ea T Suxrencel 500,000 f� GE TO MED EXP(Am one person) S 10,000 A CP00116075 03/11/2025 03/11/2026 PERSONAL 8ADVINJURY S 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL $ 2.000,000 POLICY PRo n 2,000,000 JECT I 1 LOC PRODUCTS-COMP/OP AGG $ OTHER: $ COMBINED SINGLE LIMIT AUTOMOBILE LUIBHUTY (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) a UMBRELLA UAB OCCUR EACH OCCURRENCE S — EXCESS LWB CLAMS-MADE AGGREGATE S sDCD I I RETENTION S • WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER B ANY PROPRIETOR/PARTNER/EXECUTIVE N N/A WCC50050078592026A 01/04/2026 01104I2027 E.L EACH ACCIDENT S 500,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) EL DISEASE-EA EMPLOYEE $ 500,000 If Yes,describe under -------- ----DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500'000 I DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations,and endorsements.Nothing contained in the Certificate of Insurance . shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions 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. AUTHORIZED REPRESENTATIVE l~ __----"` ------ I OD 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD