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HomeMy WebLinkAboutBLDX-26-834 applicaiton RECEIVED —� y9� Oc Office Use Only JUL 27 2026 pp P�g�R,T�AAgg Amami a' °a i3OV11NfG"IS air*Ea EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTFI Yarmouth Building Department 114t+Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext.1261 Peet) /1)ct I<ct� ,W C P rt t CONSTRUCTION ADDRESS: "�•Xf C..W 1C's, 1 sE 3� p N,• ,foo - Ce /11A OWNER: hr<an. t `f t_�'r.iSJGtC j �L)H - G9f57.r-r-(a NAME 't l q MUSES!.ADDRESS ADDRESS PI CONTRACTOR: ur�s L�lt,w� ! !1't r�. .�.(�. �•�.,t �t,(�. � Cyr 'G,/(.,7 NAME 1 ]lA l •ADDRESS 1'hl..t) • EMAIL: C c\\\CAIrt-ten-A; CL.relitCu'Lil /1J'ce *Residential ❑Commercial (cm Lost nlConsmnuctinttS Z,f�••77 •cr')CJ. Homeov.ner is Applicant? Yes No Home Improvement Contractor Lie.* Construction Supervisor Lie.# C.-.:5 r-A C7,a(.c 3 WORK TO BE PERFORMED l ens Duration (Fire Retardant Certificate required) Wood Sure Siding: #of Squares Replacement nindosss:# 2 2— Replacement doors: # Roofing: #of Squares Insulation Tcntporarl ttonne Dome • "temporary Construction Trailer Demolition-Interior only Demolition Raze Structure Solar System_ ESS System Chimney_ 1•cnce . •The dkdnis will he disposed of at: yG.f I4 Location of Facility I dechn:under potatoes of perjur'(lul the ual crnaus herein canlainnl me true and toned lu the toil Odin)knnwlnlg.and helot.t mulctswul that:my false answeusl will he lust cause tut denial non tnon of my lice'e a din pmnecuuu ha SIC.L.Ch.21d1,Section I. �.j Applicant',Sipn:nure' // _ ((//''��__ Uale'_ 7 �;,. (tu ners Sitnalure lee attachment/ ``,+�-p.3' Dater /j V m .ypry .ae o)td Hy: Rathbun Official for deigned _. RAN Sf24 DATE(MM/DD/YY ,acoKv� CERTIFICATE OF LIABILITY INSURANCE 06/19/2026 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: HILB GROUP OF NE-CAPE COD HILB GROUP OF NE-CAPE COD PHONE FAX PO BOX 1990 (A/C, No,Ext): 508-775-1620 _ (AJC, No): HYANNIS MA 02601 E-MAIL ADDRESS: clmail@doins.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A : Midvale Indemnity Company 27138 INSURED INSURER B Charles Holman INSURER C 9 MAY RD South Yarmouth MA 02664 INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 00003473898996 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 ADDL SUBR POLICY EFF POLICY EXP LTR INSURANCE INSR VD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS W N CP00152949 07/17/2026 07/17/2027 $1,000.000 EACH OCCURRENCE A COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED CLAIMS- X 0o MADE OCCUR PREMISES(Ea occurrence) $500,000 0 MED EXP(Any one person) $10,000 o PERSONAL&ADV INJURY - $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 coPOLICYnPRO- _OC PRODUCTS-COMP/OP AGG $2,000,000 X JECT OTHER: 0o AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) OWNED AUTOS ONLY SCHEDULED AUTOS BODILY INJURY(Per accident) HIRED AUTOS NON-OWNED PROPERTY DAMAGE ONLY AUTOS ONLY (Per accident) • alc UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE AGGREGATE DED RETENTION S WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNERJEXECU -TIVE OFFICER/MEMBER EXCLUDED? N/A E.L. EACH ACCIDENT (Mandatory in NH) E.L. DISEASE-EA If yes, describe under E.L. DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS below PROFESSIONAL LIABILITY OCCURRENCE AGGREGATE DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule, may be attached if more space is required) Interior Carpentry CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CHARLES HOLMAN ACCORDANCE WITH THE POLICY PROVISIONS. 9 MAY RD AUTHORIZED REPRESENTATIVE SOUTH YARMOUTH MA 02664 4-4rf © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Licensee Details Demographic Information Full Name: CHARLES A HOLMAN Owner Name: License Address Information City: South Yarmouth State: MA Zipcode: 02664 Country: United States License Information License No: CSFA-060653 License Type: Construction Supervisor 1&2 Family Profession: Building Licenses Date of Last Renewal: 3/27/2025 Issue Date: 4/1/2011 Expiration Date: 3/20/2027 License Status: Active Today's Date: 7/27/2026 Secondary License Type: Doing Business As: Status Change Reason: License Renewal Prerequisite Information No Prerequisite Information No Available Documents Home(/s/) Contractor Log In Vs/contractor-login) Contractor Search Tool(/s/hic-contractor-search) Submit Complaint(Is/submit-a-complaint) • An official website of the Commonwealth of Massachusetts Here's how you know Search Contractor Registration and History CHARLES HOLMAN Registration Status:Active Information Related Businesses Guaranty Fund Claims Public Complaints Arbitration Case History Business&Address Information Business Name:CHARLES HOLMAN Phone:5083988937 Mailing Address: 9 MAY LANE S.YARMOUTH,Massachusetts 02664 Physical Address: 9 MAY LANE S.YARMOUTH,Massachusetts 02664 Registration Information HIC Number 132454 Registration Status:Active Effective Date:2025-09-22 Expiration Date:2027-09-22 Responsible Person Details Name:Charles A Holman Email:caholman@comcast.net Office of Consumer Affairs and Business Regulation I Home Improvement Contractor Program x 1 Federal Street,Suite 0720,Boston,MA 02110-2012 Fpjprise Information Technology Accessibility Polfcv_tps://www.mass.ggy[Do -advisorv/enterorise-information-technology accessibility-oolicv#oolicv-statement?) ' s►on of Occupar,odal E3Jard of Buildina f'4 cu:1 :ons and r.dards Constructio.;t4tirarrv '§ 1 & 14 CSFA-06065s :. 5# i-es: 03120/2025 CHARLES A HOLMAN 9 MAY LANE., SOUTH YARMQUTH MI% 02664 Commissioner . , • The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations trf- 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 '1 / , Please Print Legibly C✓Name (Business/Organization/Individual): v��t — �S7 cJ�VI.le� Address: J7'7«7 2� City/State/Zip: S Yc .- 144 L Phone#: c:� 39 - � l 3 7 Are you an employer?Check the appropriate box: Type of project(required): 1.0 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 2. 1 am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have 8. Demolition workingfor me in anycapacity. employees and have workers' P Y $ 9. ❑ Building addition [No workers' comp.insurance comp. insurance. required.] 5. ElWe are a corporation and its 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' right of exemption per MGL Y comp. 12.0 Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.n 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: 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 S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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 of perjuty that the information provided above is true and correct Signature: Date: ( - Phone#: `O �' `j�`15 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 5Llumbing Inspector 6.0Other Contact Person: Phone#: