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HomeMy WebLinkAboutBLD-19-000250Y e Vse Only Permit expires 180 days from - issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: _ Z oR8 S /"� A t? ASSESSOR'S INFORMATION: Map: Parcel: OWNER CO YK152 t' kj- -b(-AewCf S ���L AIBNTfrC �� cSUD, CONTRACTORIZI SPr�K SIC'�����✓0r1� �g o232Y NAME T- MAILINGADDRESS T TEL. # 5 -VY -807- 0705— O.Keside¢tial ❑ Commercial Est Cost of Construction S i-rorpl Home Improvement Contractor Lie. # L? 8 Construction Supervisor Lie. # 16 S 9!1? l Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I amr71' ��Jthe sole proprietor have Worker's Compensation Insurance Insurance Insurance Company Name: &-e- � & C,,, Worker's Comp. Polity# 6 Si � U 90 6s I S Z N 71a Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: # of Squares Replacement windows: # Replacement doors: # Roofing: # of Squares ( ) Remove eristing* (max. 2 layers) Insulation -Sr-- Old Kings Highway/Historic Dist. ( t/replacing like for like Pool fencing 0" W,4I I , FA:A+, } 4 r4doocr rtdarp s Ine debris will be disposed of at 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 will be just cause for denial or revocation of my license and for prosec under M.G.L. Ch. 268, Section 1. Applicant's Signature: e Date: %h R Owners Signature (or attachment) Date: Approved By: Dam: Building Official (or designee) EMAIL ADDRESS: Zoning District Historical District ❑ Yes ❑ No Flood Plain Zane: ❑ Yes ❑ No Water Resource Protection District: Within 100 R of Wetlands: 0 Yes 0 No 0 Yes 0 No ., The Commonwealth ofMassai lhusetts Department oflndustrialAccidents I Congress Street, Suite 100 Boston, MM 02114-2017 www. mass.gov/dia workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Aonlicant Information Please Print Leoibiv Name (Business/Organization/Individual): Address: City/State/Zip: Phone 9:_ Areyou an employer? Cheek the appropriate box: 1. old' m a employer with employees (full and/or part-time).* ?.Q I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ 1 am a homeowner doing an work myself [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that an contractors either have workers' compensation insurance or are sole proprietors with no employ=. 5. 1 am a general contractor and I have hired the sub -contractors listed on the attached sheet These sub -contractors have employees and have workers' comp. inssance.t 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §l(4), and we have no employees. [No workers' camp. insurance required.] Type of project (required): 7. ❑ New construction 8. ❑ Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions 12.0 Plumbing repairs or additions 13. Roof repairs 14. ❑ Other *Any applicant that ebecla box#1 must also fill out the section below showmg their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside connectors must submit a new affidavit indicating such. tCormactors that check this box must attached an additional sheet showing the name of the aub- crrt actcrs and state whether or not those entities have employees. If the sub -connectors have employees, they must provide their workers' comp. policy number. I am an employer that is providmg workers' compensation insurance for my employees. Below is the policy and job site information. , Insurance Company Policy # or Self -ins. Lic. #: %n 5 (a a V 50 & / Z) (7 j 2 Expiration Date: [f Job Site Address:_ -5 /d.AP City/State/Zip: ` .JfL. 44?f OZ`j(�V, Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration 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. hereby certzf under the pans and penaftie^of perjury that the information provided above is true and correct. Zjo' /— 6 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 7 Contact Person: Phone -' - Information and Instructions Massaghusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuantto this statute, an employee is defined as %.every person in the service of another under any contract of hire, express or implied, ore or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct building in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone numbers) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advisedlhat this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permitfUcense applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a do, -.license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents I Cono ess Street, Suite 100 r Boston, MA 02114-2017 Tel. # 617-727-4900 ext 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia A�auo® CERTIFICATE OF LIABILITY INSURANCE DATE (MM DDYYYY 07/09/2018 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(les) 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 CONTACT David Rust NAME ROGERS & GRAY INSURANCE AGENCY INC PHONE 508 760-4608 FAX No E ADM -A DRESS IL dwst@rogemgray.com INSURERS AFFORDING COVERAGE NAIL# 434 ROUTE 134 INSURERA: ACE AMERICAN INSURANCE CO 22667 SOUTH DENNIS MA 02660 INSURED INSURER B : INSURER C: INTEGRITY CONSTRUCTION & DEVELOPMENT LLC INSURER D: INSURER E: 121 SPRING STREET INSURER F: BRIDGEWATER MA 02324 COVERAGES CERTIFICATE NUMBER: 289394 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 LTR TYPE OF INSURANCE ADDL SUSR POLICYNUMSER POLICY EFF POLICY EXP LIMITS COMMERCIALGENERAL LIABILITY EACH OCCURRENCE E CLAIMS -MADE FIOCCUR CAMAGE TO RENTED PREMISES Ea wmm,nce E MED EXP An aneperson) E PERSONAL &ADV INJURY $ N/A GEN'L AGGREGATE LIMIT APPLIES PER GENERALAGGREGATE $ POLICY ❑ JET LOC PRODUCTS -COMPIOP AGG E $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea codart BODILY INJURY (Per Person) b ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY (Per accident) E PRCPERTYDAMAGE $ Pe cci en NON -OWNED HIREDAUTOS AUTOS E UMBRELLA LIAB OCCUR EACH OCCURRENCE & AGGREGATE $ EXCESS LIAB CLAIMS -MADE N/A DED I I RETENTIONS & A WORKERS COMPENSATION ANDEMPLOYERS'LIABILITYYIN OFFCEORIM MB REXCW ED?ECUTIVE NIA (Mandatory In NH) NIA NIA 6S62UBOG15211718 07/03/2018 07/03/2018 PER IOTH- STATUTE ER e.L. EACH ACCIDENT & 500,000 E.L. DISEASE -EA EMPLOYEE & 500,000 It yes, describe under DESCRIPTION OF OPERATIONS below EL DISEASE -POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached S 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 t0 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.govAwd/workers-compensalionfnvestigations/. CERTIFICATE HOLDER CANCELLATION ©1988.2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Daniel M. CL ro a ey, CPCU, Vice President— Residual Market— WCRIBMA ©1988.2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD (92w (ppowtmo)wvea&1& VbAwadmilets Office of Consumer Affairs and Business Regulation 10 Park Plaza -Suite 5170 Boston, Massachusetts 02116 Home ImprovemeiiYCohtractor Registration INTEGRr1YCONSTRUCTION & 121 SPRING ST. BRIDGEWATER, MA 02324 SCAT ea 20M -05n1 F7% Winvma�uoea� o�Q��oaay.%�ella Office of Consumer Affairs& Business Regulation ! ORO HOME IMPROVEMENT CONTRACTOR I TYPE: LLC Registration Exniratfon I _- -,182569. 07/0512 01 9 INTEGRITY DONSTRUCT)ON-&DEVELOPMENT LLC KENNETH BARNARO-- > -Q— 121 SPRING ST. - C} BRIDGEWATER, MA 02324 Undersecretary Type: LLC Registration: 182568 Expiration: 07105=19 Update Address and return card. Mark reason for change. Registration valid for individual use only before the expiration data If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, MA 02116 Not valid without signature Comm. onweallh of Massachusetts l Division of Professional Licensure z YBoard of Building Regulations and Standards Const ruciitrlra pervisor CS -105871 EXpires: 06126/2020 KENNETH F BARNARD—''C 121 SPRING STREET BRIDGEWATER:NJA 02324 '.•IS:S �t7 Commissioner Construction Supervisor Unrestricted -Buildings of any use group which contain less than 35,000 cubic feet (991 cubic meters) of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Call (617) 7273200 or visit www.mass.govldpl a DocuSIgn Envelope ID: 3C21ADBA-DOAA-48CS-982D-9EOiC639FC27 - NTEGRITY CONSTRUCTION • CONSULTING 121 Sptng Street Brldgewat% MA 02324 50e -e07.0706 (Omce) 608-217-4120 ADJUSTER AUTHORIZATION 7.11.2018 Constantine Digenis 228 S. Sea Ave W Yarmouth. MA 02673 HIC Registration #: 123245 Federal Tax IN: 47-436-5277 Fax: 508-659-2300 I, - Property Owner, of the subject property listed above, hereby authorize the Insurance carrier-lu adjuster(:) and/or their Independent adjuster(s) to communicate directly with our contractor, Integrity Construction & Development, LLC and/or their authorized representatives regarding any and all aspects of this claim and repair estimates to the property listed above. Signature: Date- PERMITAUTHORIZATION Constantine Digenis I. Property Owner of the subject property listed above, hereby authorize and direct Integrity Construction & Development, LLC and/or their authorized representatives to act on my behalf regarding all matters relative to PERMITTING AND REPAIRS and/or to deal directly with all government officials within the Town of Yarmouth regarding any and all aspects of this damage claim and rr01 „t q above reference property. l” "'s 7/12/2018 6:44:35 Aro PDT Signature: ... Date: