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HomeMy WebLinkAboutBLDX-26-387 application '01 Y R CC C E I V E ® 1 Office Use Only ;,� � 0 r _._ _ ._ Permit# X_a(7— APR 2 8 2026 ��-- � Amount' _ { BUILDING DEF ARTMENT By EXPRESS BUILDIN ' PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS; 1 ' /91aC t9/I/ Zie OWNER: Ta y .101lf1 I r 2/ 16 14Z/L©/LGz- ✓t/t7 -e3537 cv NAME PRESENT ADDRESS TEL. # CONTRACTOR: /liv1 vy 09,•7 t€04 510 Cif it L°i'osiy _car-3'/V 44057 NAME �/ MAILING ADDRESS TEL.# EMAIL: le Yee 2�,4Dl . eQof 4TResidential 0 Commercial Est.Cost of Construction S Homeowner is Applicant? Yes 17 No Home Improvement Contractor Lic.# Construction Supervisor Lie.# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove IJSiding: #of Squares 5 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: 11S rn aU*t'Al to (7U f/5/«.. 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 vocation of my license a for rosecution under M.G.L.Ch.268,Section I. Applicant's Signature: C ��_�. Date: //2 /2e2 4, Owners Signature(or attachment) Date: Approved By: Date: Building Official(or designee) Rev 6/24 The Commonwealth of Massachusetts Department of Industrial Accidents 9 Office of Investigations yy=, 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): �; (ylt€p A V ILL A- _ Address: 1 Isla c txe A.)-7 to (II City/State/Zip: 'jC)L,t Phone g.3 5- 3 4/Ci'2 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 1 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. ❑Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in anycapacity. employees and have workers' insurance.I 9. ❑ Building addition [No workers' comp. insurance comp. }required.] 5. El We are a corporation and its 10.0 Electrical repairs or additions 3.Blam a homeowner doing all work officers have exercised their 11,❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] c. 152,§1(4),and we have no employees. [No workers' 13. t[/]rOther 1 l>' )toCr- comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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 pi-twirling woiAers'compensation insurance for my employees. Below is the police 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. 1 do hereby certi under the pains and penalties of perjury that the information provided above is true and correct. / Signature: A V�,4"" Date: 5/Z 2�ZfD 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): 1DBoard of Health 20 Building Department 31City/Town Clerk 4.❑Electrical Inspector 5.DPlumbing Inspector 6.0Other Contact Person: Phone#: ----.1 ANTHONYPO2 AREGULA A`OKL) CERTIFICATE OF LIABILITY INSURANCE DA9/2s 2025 DGVVV 1 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 poticy(tes)must have ADDITIONAL INSURED provisions or be endorsed. H 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). rROoucEN CONTACT World Insurance Associates.LLC .PHONE FAx 34 Main St. LAC No E.q(SO!)771-8381 IAIc No{(508)771-0663 — EMAIL West Yarmouth,MA 02673 I ADDRADOR ESS. Y INSUNERISI AFFORONOSQYEBAQE NAIL 0 e.suRER A AmGUARD InsuranuCompany 42390 INSURED ',INSURERS NorGUARDInsuranceCompany ,31470 _ ANTHONY P CONSTRUCTION INC I INSURER . - ' 56 CAPN CROSBY RD ,.INSURER Q;.. CENTERVILLE.MA 02632 INSURER E: _ INSURER F OVERAGES 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 TADOL SIM POLICY EFF POLICY ESP 7 _LTa TYPE OF INSURANCE MID MVO POLICY NUwaER LIMITS A COMMERCIALLIARI GENERAL UT' • _ 1,000,OOOI :.EACH OGG.VRRENCE CLAIMS MAN X I OCLUR ANBP543212 '1112112024 11121/202/ MUTE TORENTED 500.000 {PBENISES IF.a aIAlnamal ` MED EAT(Any air pore./ I 10.000 _ - - PENSCNAI A AI,/INJURE 1 1.000.000 GATE J Ip JECTLLRlMpI1 APPLIES PER ■POLICY __ 2,000.000 LI_N. PRODuC TS COMP,OPAL.., i µTOMMINE LIAaRRY �c IEII DSINGLE LIMItI I • 1 AOON��YTT��AEUpLTO ( �E�p(AE .LEI YY RY;Pe.pare.• ■AIeUpTEOSONLY L AUpTN0p8yEe�EO ATVs ONLY niggle R JJMIIRIJJA I IAR L_OCCUR EACH OCCURRENCE E.I-I c,i IAN i CIARBMAOE .aaGBEQATE .1 ...ram OE I B WNDAPOOMSr'NLSATY xI STATUTE IE{IH I' PRINR,ELI,R.PANINEREAECUTNE ANINC872941 911812025 W151I024 E.L EACH ACCIDENT .1 1.000.000 L JE YUT,/meI:R EXCLUDED, N NIA - b.II E L DISEASE EA EMPLOY}t I 1.000.000 L• SCRPTION OF Wow Mw E L DISEASE'POLICY LIMIT t 5,000,000 i DE SC RIPTION OF OPERATIONS/LOCATIONS I VEHICLES LACORO 101.AdeIaW MANNA*SHIN Y.may Im attached R Ilea spec..N NRNYadI _ _