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Home My WebLink AboutBLDX-26-270 application 61 7,4,4 RECEIVED ` Office Use Only ?�\ Permit# r.o-a a ;10,5y` APR 0 2 20261 Amo mt 4C;RPORATEO�� BUI ING D PAZAENT I EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231�,EExxtt..9ttemarfiN, 1261 GATE. �7 CONSTRUCTION ADDRESS: 24 i€ LAASk (es` 0267"3 764G OWNER: �t B8a &LKN 1 1 � c 11 � ie , /"4 o2459^ �T 1 if g NAME PRESENT-ADDRESS TEL. # CONTRACTOR: (T i A0 Pit� l4iS 3PAWle AisS 4-La U& NAME V MAILING ADDRESS TEL.# EMAIL: bAc4c rnSn.,CC)m c lJ Residential 0 Commercial Est.Cost of Construction$ / J`t Homeowner is Applicant? Yes)1 No C - c5C191a Home Improvement Contractor Lic.# Construction Supervisor Lic.# WORK TO BE PERFORMED Il Tent Duration (Fire Retardant Certificate required) Wood Stove [� Siding: #of Squares -/.l) 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: II 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 oofmy'license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: ��`j63A Owners Signature(or attachment) /// Date: Approved By: Date: Building Official(or designee) Rev 6/24 .� I he t;ommonwea/th of Massachusetts Department oflndustrialAccidents 1: Office of Investigations iit- Lafayette City Center ii, 2Avenue de Lafayette,Boston,MA 02111-1750 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name(Business/Organization/ndividual): 6 p.+rim.) I340K,iv8CA.) Address: I i �I.oef-,l 61- City/State/Zip:IUel lerI l mler cs 'S9 Phone#: I(.1"1 1 5'•2L,B9 Are you an employer?Check the appropriate x: Type of project(required): 1.❑I am a employer with 4. I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. El 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 ❑Building addition [No workers'comp.insurance comp.insurance. required.] 5.0 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 12.0 Roof repairs insurance required.]t c.152,§1(4),and we have no ylAi,vx�t employees.[No workers' 1 Other fi i U 43 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. l 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 certi under theand penalties of perjury that the information provided above is true and correct. Signature: /��114 Date: 3/3/ Phone#: o/7" 775'-c?S89 Official use only. Do not write in this area,to be completed hr city or town official. City or Town: Permit/License# Issuing Authority(check one): l❑Board of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector SD/Plumbing Inspector 6.❑Other Contact Person: Phone#: iv> `Val v • :ln)1+• , .v.. fi41, dr . n5:; )#111(1-1140 :tt noiluzinqrno:.)`219:41‘91 . i; Ciffitf:y.070111111101141_,.. ';•.:/,116[.3A ; •)ril 4:1•ati 'fly= :I/. '1 litiw vv011w)i. ri El. ihit) 1r, : ;• •, • • • ./. / :', ' ;;'' :; •. 1.•:!7...; •.i t!, .•' v • .'E ,.1t,? r . . .•.:!•:..1:”.p..:,;;101 Ala ri-19 ••• Ns. •'1111,,,'•i‘l'ilVuu'i*"",'‘A•'"il •rl•11:)si'l • ' s,••.c", ,..11 'OATH 11111[1(1 :11c118 . _. _ :11•/) io Ill: ii. . ‘,4;iiiy.,p1 •• ,..It i; . t/ ",: 2 til. 1 Commonwealth of Massachusetts IF Division of Occupational Licensure � Beard of Building Reggulations and Standards `Fi 0.-on: st rvisor C S-0 8 0 9 1 ' : spires; 02/16/2028 BRIANCBARK. I ' , P '� 11 LORING R ;ya=Ks.�,y, J,, ., z NEWTON C ''E1 ' T i�f41ir' .� E t Commissioner c 4i.,e vA,a.t;is,1___ f ACORD Client#: DATE CERTIFICATE OF LIABILITY INSURANCE 03/27/2026 THIS CERTIFICATE IS)SSUED 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(les)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 oonter rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT Raphael Oliveira PHONE (508)771-4600 DISCOVERY INSURANCE AGENCY LLC (NC,No,En): 888 Main ST,BA HYANNIS,MA 02601 Phone:(fi06)7714800 EMAIL npheaMiscovery®9meil canADDRESS. Raphaeldiscovery@gmail.com INSURERS)AFFORDING COVERAGE NAIC INSURED INSURER A:Nautilus Insurance Company INSURER B: UR HOME IMPROVEMENT INC INSURER C: 102 LOVELLS LN INSURER D:PENNSYLVANIA MANUFACTURERS MARSTONS MILLS,MA 02648 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:000015 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. Wart ADOLF clNA PDLJCY PPP POLICY EIP 1R TYPE OF INSURANCE eWE YPVD POLICY RUINER fleVCCrnnYY1 IEIYOONYYY) LINTS A GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00 X,,MMPRCIALGENERAL LAM., PREMIETOaENTEO DAMAGE RENTED $ 100,000.00 ICLAIMSM..E I C I OCCUR MED EPP(Airy on Prnnl $ 5,000A0 NN1918694 10/21/2025 10/21/2026 PERSONALS MN!Wu. $ 1,000,000.00 GENERAL AGGREGATE $ 2,000,000.00 - E LIMIT APPLIES PRO: PRODUCTS-000010P AGO $ 1,000,000.W-I PO GATE PROJECT I ILOC LIABILITYCO BIINNEOO'SINGLE LIMIT B AUTOMOBILE LIABILITY ANY ALIRD BOOILY INJURY IPr p.m) ALL OWNED SCHEDULED ANT. AUTOS BODILY INJURY Mr AMP.) HONMWNED PROPERTY WAAGE HIRED AUTOS AUTOS IMP P../ Q UMBRELLA LAB UR EACH OCCURRENCE EACESS LAB CLAM HAT, AGGREGATE DEO I RETENTION D WORKERS COMFEMBAOOM iwC NIEIOI00Y I 1I AND EMPLOYERS.LIA&DIY I PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT µor`E""'E"oER EXCLUDED? N/A WCMA000532600 10n1/2025 10/21n026 $ 1000,000.DU (M.M.bry In NMI EL DISEASE EA EMPLOYEE $ 1,000,OOO.l1U DESCRIPTION OF OPERATIONS PAR EL DISEASE POLICY LIMIT $ 1,000,000.00 tyESCAP ION OF OPERATIONS/LOCATIONS/VEHICLES AtIEdr,'CORD 101,Additional Remarks 4d,odde,Y more spece)s omNirerS Job Site Address.'24 Doherty Lane-West Yarmouth,MA 02673 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Brian C.Badrigian THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 11 Loring Street Newton,MA 02459 RAPHAEL OLIVEIRA 1/1 C 198E-2010 ACORD CORPORATION.All rights reserved. • lei... 't. ',w'C'7IT553 • :7411TW-464e‘,C•q,-M :.1?.1 URL' N! 1 G • FT I i. ...�_ ... .. .. _ .. .. .. ...._-.�.__ . i r „e + t �� Brian C. Badrigian General Contractor CSL 080910 Residing work at 24 Doherty Lane, West Yarmouth, MA 02673 will be by: UR Home Improvement, Inc 102 Lovells Lane Marston Mills, MA 02648 UR Home Improvement, Inc does have employees See attached Certificate of Insurance with 24 Doherty Lane West Yarmouth listed as job site