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HomeMy WebLinkAboutBLDX-26-405 application .I ' RECEIVED , . . • SAY 0 4 2026, 1 i Ferran ex 13f1 plres days from BUILDING DEPARTMENT ilissue date __ _ _al By EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508)398-2231 Ext. 1261 7,-- c it o‘slycltos, ‘DDRESS. 2g ../crisit ,c4'47c)(4.__ W),A-r- At--?iry.vot,( h 1 AssEssoRs INT oRmATioN. i I Map_ I Parcel: 1 ..--,-- OWNFR Ada,g _ 110i NAME PRESENT (I/gV19.40/r) 25dCPJ7 Xineie hell J/91 C q kJ 4:07? 11 0`"12 ) PRESENT ADDRESS Co\TR ACTOR..aiU/ 0 WoobS/Lii mertkil iguj&2/Crkvi) Nat 15'-'`q'--.1-721 3 NAME MAILING ADDRESS TEL # I /As:del:nal 0 Commercial Est.Cost of Construction S 2 q 0 0 Home impro%einent Contractor Lic.# /3 2 3 6 / Construction Supervisor Lie.0 a 0 3' q.3 WO11.17..ari.s(.:‘,Inp3,11.vil LiS,ir..uc:: I 1,-, hf.-F.';- ,•,r,:r sle proprietor I have Worker's Comprir,Fat:on Insurance 1; :'' '1 p,1:::‘`,,.7:-:All,firric '.\C rkr s Cc.•:rip Folic:.• (A(CC—5 0 0 .__21-1z'3 q6—2025 4 WORK TO BE PERFORMED I lent Duration (Fire Retardant Certificate attached?) Wood Sto e 1 Siding: i'-of Squares Replacement windows:# Replacement doors: # 1 Roofing: r-of Squares / a ( )Remove existing*(max.2 la)ers) Old k inn 1-1illwas Ilistnri..11;,• r )p..f...,:.,;4!!.,,f .:!:;,.. rul crucinl2 insulation C"' 1 : ,cii,:ilr:Olf-2-CilitIT i - r.under NI C L Ch 1 0 I//0 A ;4_VV391)C -- :., 5 1 20 2 6 _.: .1:. :: ,DDKLss ;1.-' , „.. l- • ; .: '"•:• '-,o Flood Plat::Zoi:e Yes r N.,,, A;tlrn I i)11 l'• ,, \s i __. ) --- CO . ,,,),1 N 60AA-0,0 , i '� The Commonwealth of Massachusetts IL G / Department of Industrial Accidents 1 Congress Street,Suite 100 e Boston,MA 02114-2017 %L www.mctss.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/organization/Individual): OAti1 0A whoop Address: 44'3 ii474-rri-1 e i J tam t City/State/Zip:/44ciry- /yL LC_ Phone#: 9--;t 3 2'?-, 90 5 2 Are you an employer?Check the appropriate box: Type of project(required): .0 I am a employer with employees(full and/or part-time).• 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in I. 0 Remodeling any capacity.[No workers'comp.insurance required.] `3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. ❑Demolition 10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property.I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions prietors with no employees. 12.❑Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed en the attached sheet. 13. Roof re pairs These sub-Contractors have employees and have workers'comp.insurances p 6.❑We area corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,1 1(4),and we have no 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. tConbacmrs that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have 1 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. ��[[ �l Insurance Company Name:/^ft/4 fVfT i 1. C/45 Vfi n L Policy#or Self-ins.Lice.#:(��kc-,S`o -$,�2.46 ?76 10 Z 5 A Expiration Date:l' /o1 2 N Job Site Address:?S�0 t�YI ,�,vCA LA 5't 'V1I iYW I h CiTy/State/Zio: _ _ Attach a copy of the workers'compensation policy declaration page(showing the policy number and e' '.don date). Failure to secure coverage as required under MGL c.152,§25A is a criminal violation punishable by 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.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 of perjury that the information provided above is true and correct. Signature: lin(fu 4 ' Woo bS Date: S'/3 /20 2 6 Phone#: fl2132 -' 90 g2 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Regulations and Standards Cons tonesrvisor CS-035693 ctti *- tpires: 01/18/2028 DAVID A WOpoS 43 MATTHEIIKWAY MARSTONS MILLS MA 02648 y 0!LVdt030 Commissioner THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration 132361 03/03/2027 DAVID WOODS DAVID A.WOODS a`• 43 MATTHEW WAY -- MARSTONS MILLS,MA 02648 Undersecretary Saco CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 10/8/2025 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. ' - • ` • ` : t e certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION 1S 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 NAME Kimberly 1 Thomas Montello Insurance Agency Inc PHONE No,Ext): 508-658-3444 FAX No): 508-658-3535 E-MAIL _. 760 Main St Ste 7R ADDRESS: Kim@montelloins.com INSURER(S)AFFORDING COVERAGE NAIC# Hyannis MA 02601 INSURER A: Atlantic Casualty 42846 INSURED INSURER B: AEIC Emerson Valle Construction Inc INSURER C: 67 Sea St apt i 1 INSURER D: INSURER E: Barnstable MA 02601-4467 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 MA.Y HAVE BEEN REDUCED BY PAID CLAIMS- INSR ADDLISUBR; — POLICY EFF POUCY EXP LTR TYPE OF INSURANCE INSD 11NVD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) UMITS X COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE $ 1000000 DAMAGE 1 U KEM EL) CLAIMS-MADE Xl OCCUR PREMISES(Ea occurrence) $ 100000 MED EXP(Any one person) $ 5000 A L261010158-0 8/7/2025 8/7/2026 PERSONAL&ADV INJURY $ 1000000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2000000 X POLICY ROT P LOC PRODUCTS-COMP/OP AGG $ 2000000 JEC OTHER: $ AUTOMOBILE UABILITf UUME3INEU SINGLE LIMI i $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS- PROPERTY DAMAGE NON-OWNED OWNED (Per accident) HIRED AUTOS AUTOS UMBRELLA LlAB' OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER AND EMPLOYERS'LIABILITY X STATUTE H- ER _ Y!N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 500000 B OFFICER/MEMBER EXCLUDED? N N!A WCC-500-8244796-2025A 8/7/2025 8/7/2026 -- (Mandatory in NH) E.L. DISEASE-EA EMPLOYEE $ 500000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE-POLICY LIMIT $ 500000 DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) for operations usual and normal to the insured's business as described on the insured's policy David Woods CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE David Woods THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Woods Remodeling 43 Matthew Way AUTHORIZED REPRESENTATIVE Marstons M Its MA 02648-1005 l?2l © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD w ml n:�„• -. . . ._ It r 1l1--i A7ki 10 s