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HomeMy WebLinkAboutBLDX-26-822 applicaiton Ofyq��, R E C E I. V.E D l Office Use Only �', } t Permit# oZ[o-�. c, JUL2 fE 2025 Amount `5-,--- •le AT TACO,[ES .. I '+co � B IA D`FrPAR M T ,141 R `' L;POR�TEO � G2G - EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 !, (508) 398-2231 Ext. 1261 7 CONSTRUCTION ADDRESS: / c7 i2, L.,,,,It 5 f . 614,tr,y,0-4---- OWNER: NAME PRESENT ADDRESS TEL. # CONTRACTOR: '2//G ee-4. ' 8 MAILING ADDRESS ' 4C'e- why TEL.# /" b e s 3‘.06 7ir.9� `NAME EMAIL: iC4likA�Qi We-of/At— C AiAtr(. Cd/r1 1e(sidential ❑Commercial Est.Cost of Construction$ 34 )C Homeowner is Applicant'' Yes No Home Improvement Contractor Lic.# /6. Construction Supervisor Lic.# C 4(0/a f WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) NAood Stove Siding: #of Squares 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: 76L.n Location of Facility I declare under penalties of perju 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 r ation my is se and for prosecution under M.G.L.Ch.268,Section I. Applicant's Signature: Date: Owners Signature(or attachment) Date: Approved By: Date: Building Official(or designee) — --- Rev 6/24 The Commonwealth of Massachusetts Department of Industrial Accidents At.__; �r Office of Investigations "�l.=-. Lafayette City Center r :1-.7 2Avenue de Lafayette,Boston,MA 02111-1750 L`' www massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print Legibly Name(Business/Organization/Individual): " )//. Address: ///).Ais i - , a--'7-- City/State/Zip: il„„,," ,„,,( ,,2J Phone#: 1 6 3 Coo 6 2 -‘)- Are you an employer?Check the appropriate box: 1.Cr I am a employer with 4. 0 I am a general contractor and I Type of project(required): 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. 0 Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.insurance.: 9. ID Building addition required.] 5.0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a homeowner doingall work officers have exercised their 11.0 Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12 Roof repairs insurance required.]t c.152,§1(4),and we have no employees.[No workers' 13.0 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. :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: 71 fM !-i/a,, ( C Policy#or Self-ins.Lic.#: if, _yoo 7 oo/// 3.. o:1 a Expiration Date: ; %�/,9 7 Job Site Address: /y 7 /7Y.,_,,;e 5/` City/State/Zip: S o_-GC 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 above is true and correct Signature: /IX ru /7"/l6' •e-vLz-, Date: 7 70)`//)C Phone#: /e. .7 6:r, r-)'3- 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 30City/Town Clerk 4.0 Electrical Inspector 51DPlumbing Inspector 6.0Other Contact Person: Phone#: A CCU?LLJ! DATEDDlYYYY)CERTIFICATE OF LIABILITY INSURANCE (MMI 026 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 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 2209-3 NAMEACT 2209 2209/3 Smith Brothers Insurance LLC (AI+°,NE No, Ext): FAX No): 300 Main St E-MAIL cleng©smithbrothersusa.com Oxford, MA 01540.r, INSURER(S)AFFORDING COVERAGE NAIC# INSURER A : A.I.M. Mutual Insurance Company (400) 33758 INSURED INSURER B : Libero Molinari INSURER C : Molinari Home Improvement 11 Sheep Pasture Way INSURER D East Sandwich, MA 02537-0000 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY' HAT 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER $ AUTOMOBILE LIABILITY a O tlBrINED SINGLE LIMIT(Ea ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) _ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION X WC STAT OTH- AND EMPLOYERS' LIABILITY Y/N UTOR Y LIMIT ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 100,000.00 OFFICER/MEMBER EXCLUDED? N AWC-400-7008113-2026A 5/21/2026 5/21/2027 A (Mandatory in NH) ' N/A If yes,describe under E.L. DISEASE - EA EMPLOYEE $ 100,000.00 DESCRIPTION OF OPERATIONS below E.L. DISEASE- POLICY LIMIT $ 500,000.00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION Town of Yarmouth SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 11456 Route 28 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD �r Commonwealth of Massachusetts d Division of Occupational Licensure Board of Building Re ulations and Standards Constt fi t44p, rvisor CS-040124 * , expires:03/29/2027 LIBERO J MQ}I m 11 SHEEP PAST B. EAST SANDigIC ?b,Ul,LV.1C1��0 Commissioner �. l?�✓ :, THE COiviiviutivvh,ALTH4OF MASSArlitIQETTS Office of Consumer Aff, &Business Regulation HOME IMPROVEONTRACTOR TY Re.Ist P- Q dllal rotation _IBERO J. MOLINAR�_��f • _IBERO J.MOLINARI 4 4# ,p I1 SHEEP PASTURE C11 g B1(07 .li, =AST SANDWICH,MA 0 Undersecretary • T