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HomeMy WebLinkAboutBLDX-26-272 application • RECE1i� ED Office Use Only iirwl"r44/L? a. ! Permit# y a�a3 �` APR 02 2025Q.-. a z ►�,! I Amount c� MAnAcnZcsc BUILDI IRA:� u T EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 3 N a JC QA12-NCjLIM ' 0 ZA:7 OWNER: j e: �,(Avia(-A.)D 3 m x Ake_ a ( A 5DB` 0 ` V be NAME .,O� PRESENT ADDRESS TEL. # 7 p CONTRACTOR: rAMctG (- ( J 3kEe_ s `cab 4 ' 1(07 I NAME MAILING ADDRESS TEL.# EMAIL: b In( t nd @ C1Cx -cG m IYResidential /❑Commercial Est.Cost of Construction$ (� ( V W Homeowner is Applicant? Yes r/ No Home Improvement Contractor Lic.# 11 Construction Supervisor Lic.# 09 j 3 u 7_ WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares Replacement windows: # Replacement doors: # Roofing: #of Squares It,—1f7 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: 1.)f[Vc i t SPorcyt-� 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 vocation of m icense and for prosecution under M.G.L.Ch.268,Section I. Applicant's Signature: Date: 1 ZI Z f0 Owners Signature(or attachment) Date: 7 ZI atop Approved By: Date: Building Official(or designee) Rev 6/24 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations =is > 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): Ott- :vve]"— Address: s N 1(1L P 1J C City/State/Zip: 0 J P fl)771 J M Phone#: '3,C)•(���rl Are you an employer?Check the appropriate box: 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. ❑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' comp.insurance.: 9. ❑Building addition o workers'comp.insurance 1rie uired.] 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.❑Plytrtbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.2✓Roof repairs insurance required.]t c.152,§1(4),and we have no employees.[No workers' 13.❑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 under,the ppins and penalties ofpetjuty that the information provided above is correct. /true and Signature: I Date: LiL�/ .21, Phone#: hb�(P0 s578g' 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): 1❑Board of Health 20 Building Department 3❑City/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: ® DATE(MM/DDIYYYY)A�� CERTIFICATE OF LIABILITY INSURANCE 03/18/2026 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 CONTACT NAME: Y Carol n Milano THE HILB GROUP OF NEW ENGLAND LLC PHONE (508) 957-4239 FAX (A/C. No. Ext): [AIC.No): E-MAIL cmilano hilb rou com ADDRESS: g p 973 lyannough Rd - INSURER(S)AFFORDING COVERAGE NAIC# Hyannis MA 02601 INSURER A: AIM MUTUAL INS CO 33758 INSURED INSURER B: EMMANUEL CONSTRUCTION INC INSURER C: INSURER D: 286 STRAWBERRY HILL RD INSURER E: CENTERVILLE MA 02632 INSURERF: COVERAGES CERTIFICATE NUMBER: 1202637 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 EXPM1 LIMITS LTR INSD WVD POLICY NUMBER (MDPIYYYY) : (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE _$ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ -- GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY J JJERD L LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED N/A BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) — i UMBRELLA LIAB OCCUR EACH OCCURRENCE $ - EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION S WORKERS COMPENSATION X PER OTH- AND EMPLOYERS' LIABILITY STATUTE ER YIN 500,000 IA (Mandatory MBER EXCLUDED?DXECUTIVE AWC40070343862026A 04/05/2026 ! 04/05/2027 EL. EACH ACCIDENT $ OFFICERlMEMBER NIA NIA N1 E.L. DISEASE- EA EMPLOYEE $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE-POLICY LIMIT $ 500,000 I f N/A I I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule, may be attached if more space is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage - Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Scoot Stewart ACCORDANCE WITH THE POLICY PROVISIONS. 3 Nicole Ave AUTHORIZED REPRESENTATIVE Yarmouth Port --- MA 02673 Daniel M. Crowley, CPCU, Vice President— Residual Market— WCRIBMA 401988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD , ., �!. : a t..rA O:i r _ —. r1'., —.:.—.103Ni z — ,..:h O31JZZ e'i 3TA0i iT?yU 211T ^'. •.,r i'-iT 2137111,AC,t_.,',= l:lriiu P. t'J_ ^.�,?6,n - ,4id51111A TO✓2300 37t.3i d 3') i .;. st': - -. ,-,is301X1CAA ft0 3V1TA'.N32s 1iP • n - _sjd•- .C?aV?AW ,asf s be a d a to on ehi,A t o .,, ,to 's 1e oo..k. to i 3p ,n - _ Of^.dp..ko1V16Yi CTQ. t .ty.., .:.:Jiro L'U:aJ3Ul A/M3 1 } ,:• .".!.ItN r'-fl33WAP 28S • 3:3N A tMOO'• W. ` b, h,i.i 4 rn�C ` YY .rP. C iM3ON® 1 W.; kN M rsDnuu' ',DVS 7s•.o±k"., :n;.. .. ..:A? LEt aprci bS t';C')A. AOREP CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYV) 03/18/2026 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 CONTACT Carolyn Milano NAME: The Hilb Group New England,LLC PHONE (800)640-1620 FAX [A/C,No,Extl: (A/C,No): E-MAIL cmilano@hilbgroup.com ADDRESS: 973 lyannough Road INSURER(S)AFFORDING COVERAGE NAIC Hyannis MA 02601 INSURER A: Western World Insurance Co 13196J INSURED INSURER B: Midvale Indemnity Company 27138 Emmanuel Construction,Inc INSURER C: C/O Hector Sanchez INSURER D: 286 Strawberry Hill Road INSURER E: Centerville MA 02632 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 NUMBER POLICY EFF POLICY EXP LIMITS LTRINSD WVD (MMIDDIYYYY) (MMIDD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 DAMAGE TD CLAIMS-MADE X OCCUR PREMISESO(EaENTE occur occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 A NPP6172546 04/05/2026 04/05/2027 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 POLICY 'M JEa LOC PRODUCTS-COMP/OPAGG $ 1,000.000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ B OWNED N/ SCHEDULED CA00030381 09/01/2025 09/01/2026 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) X 19 a UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE DED RETENTION $ S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABIUTY YIN _ _STATUTE_ ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (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 I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached It 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 Scoot Stewart ACCORDANCE WITH THE POLICY PROVISIONS. 3 Nicole Ave AUTHORIZED REPRESENTATIVE Yarmouth MA 02673 ©1988-2015 ACORD CORPORATION. All rights reserved. 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'...-/, •",...,;..14. •....40 -;:',..r.,,.)71-'i YAA' . . . . : •'''''A'.' 7.1:,'•,-10 , i.14,ni tn coM) . . ... . .. ,.... . .. . -:..fikP„:-./t4lt)?(4 ,,,IT41;',"• .," I _ . _...... . . . , • . . • 1 1 - ! 1. , - --• '-I .... _ . : . . • . . - • • -,,,,,...-.. . ,...,...,...„,. ,•...- .,.. ...., „ .1, "... ' '' ,• ;.• ...1;-1..11. •:1111...%;1A 7..; •'7?•.-.tietc4:44-,. le)ietttt;4•41-4;";. ''''; f , . i.. . i ' g '';'... 'C''/-f‘";7:-."":-; •"' ' '-',..._ -.4..J•' ' ''"' i • , , '4, .... 7.,•• ,, '• • ' ,.......... .,.....;:-..,-/, , t;e:', '4,te:/...' -,.." 4 . 1 rill.,4'.;r1:':' . f . .. --. . .. - ..4:- -..4i/..- .,. : ,f14.C...,-•/';t-41 4:41E:-..poi .-:;Jf.;• ....,- (.3c-..,.:-11.-..,:t r .).,) :.1':ej$403A . 54. EMMANUEL ""6 Whew*Oat You Cowed Job#1280 Date: 3-11-2026 Name: Scoot Stewart Phone: 508-360-6463 Address:3 Nicole Ave Yarmouth MA Licenses: Construction Supervisor#Cssl-099382 Home Improvement# 145356 Work Description: Main House 1. Strip entire roof of house. 2.All loose boards will be nailed, and all rooted boards if any will be change. 3. Install 3' of ice and water 1 sc course of roof, and all valleys,2'on all rakes, skylights, pipe boots, chimneys. 4.Install 8"white aluminum drip edge. 5.Rest of roof will be Roof Runner by CertainTeed. 6. Install CertainTeed architectural shingles, 6 nails per shingles, 7. Install Shadow ridge for cap. Total for materials& labor: 10,900 Dumpster Fee: $700 Trim front piece 1/12 with 1/3 will change to PVC. $700. This will allow us to install new step flashing. Also, will cut tree branches touching the house. Thank you for your Business. C 4 Emmanuel Construction. Cape Cod 508-367-1679. Boston 781-559-0007 Emmanuelconstruction.com & all newenglandroofing.com enunnauelconstrcutiondivision@gmail.com