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Home My WebLink AboutBLD-19-000694 -04„ a - i Office Use Only ,I . 'Z'. ! `dkoi>rO .Permh# y . ,yam t O— � l ,2ti Ammmt 5 ' r .. . 'Permit expires-l80 days from . 1isSbe date i EXPRESS BUILDING PERMIT APPLICATIONtlyi n 3 2018 TOWN OF YARMOUTH 1. Yarmouth Building Department Fyt C 0,aer 1146 Route 28 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 S�. CONSTRUCTION ADDRESS: t7e1von .4,.,, 97 sfa/JICY) diue- ASSESSOR'S INFORMATION: Map: Parcel: OWNER: Down✓f 2s../s...f. ,- a.n1e 7>y £12 • 'Vitro NAME PRESENT ADDRESS TEL. # CONTRACTOR: .00./e. ./Ljs.ci.sane /7oA.eta.- esl.v /lo 1:44.s,'.l Air se, •292 ^ 1'7o p NAME MAILING ADDRESS TEL.# IB'ltesidential 0 Commercial Est Cost of Construction$ 34,0"o` Home Improvement Contractor Lic # /1Z 5,,,t/ Construction Supervisor Lie.# oJv 9.r9 Workman's Compensation Insurance: (check one) 0 I am the homeowner Pit the sole proprietor 0 I have Worker's Compensation Insurance �t �� 9 31 2,2 j+ Insurance Company Name: /a.lefesr 4t.% t.s ea Worker's Comp.Policy# , I WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares h ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at ioai. et fn.*e../[ 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 revocation of my license and for prosecution under M.G.L Ch 268,Section I. Applicant's Signa. / Date: f,I9oic Owners Si if1ZT ,�' y ! Date: iiiii ``rte cJ-!ll Approved By: �L(A/r�� Date: ding !an.; ..,C gnee s EMAIL ADDRESS: LJo-se1.A/...�Ao/, t.... Zoning District: Historical District 0 Yes 0 No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No �� The Commonwealth ofMassadhusetts fr ' P. ='I= Department of lndustria1Accidents si - 1 Congress Street,Suite 100 =F� 1 • Boston, MA 02114-2017 " .;. www.mass.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): � � sit J^.. Address: lye Ju. /1.,.4.„ p„ City/State/Zip: Jzr, . /yl.7 die_ 3A Phone#: Set,, .21.7 _ 4/2. Are yea an employer?Check the appropriate box: Type of project(required): 1.01 am a employer with employees(full and/or part-time).* 7. 0 New construction 2.Eartrn a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required] 3.01 am a homeowner doing all workmyself 9. 0 Demolition [No workers'comp.insurance required.]: 4.01 am a homeowner and will be hiring contractors to conduct all work on my pr petty.o I vnL 10 0 Building addition ensure that all contactors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contactors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance: li.Elaeof-mpeifs_ 6.0 We are a corporation and its officers have exercised their right of exemption per MGL e. 14.0 Other 152,§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. :Contractors that check this box must attached an additional sheet showing the name of the sub-contactors and state whether or not those entities have employees. If the sub-contactors 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: /,,j:,r Z." Policy#or Self-ins.Lic.#:ti,,roe 7 Expiration Date: ey�j/ter Job Site Address: S7 p rn<�n, /r,�- 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 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:.d�.l� Date: ____ _ Phone#: ,co ,¢ — 2 F'1 et.-r•." Official use only. Do not write in this area,to be completed by city or town offzciaL 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#: ed ._ • - • • _Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contact of hire, express or implied,oral 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 ajoint 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, §250(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 cbnstruct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §250(7)states "Neither the commonwealth nor any of it political subdivisions shall enter into any contact for the performance of public work until acceptable evidence of compliance with the insurance ' requirement of this chapter have been presented to the contacting 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 number(s) along with their cerdficate(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 advised that 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 Accident. 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 permit/license 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 dog license or permit to burn 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 1 Congress 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 a CERTIFICATE OF LIABILITY INSURANCE DATE (""3iD 5)1, THS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER TIC COVERAGE AFFORDED BY THE POLICES 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°es)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). PRooucm snot Todd E Sullivan EF SULLIVAN INSURANCE AGENCYPxsNE FAX 507 High Street aNs EMI. (781) 326-5836 IAA Na: (781) 320-0908 Ao41se, todd@efsullivaninsurance.com Dedham, MA 02026 INSURER(S)AFFORDINB COVERAGE NAICC I?JRERA:WeSte2T1 World Insurance Co INJURED INSURER B Michael Woesner INSURER c: 170 New Boston Rd INSURER D: Dennis, MA 02638 • INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSLRED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY TIE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.OATS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. MSR AWL SUER POLICY EFF OUCY EU) LTR TYPE OFINSURANCE INSR WVD POUCY NURSER IMIMDD/YYYY1 1 iDEYYYW) UMTS A GENERALIJAeILrrc NPP8243722 9/19/17 9/19/18 EACH OCCURRENCE $ 500,000 X COMMERCIAL GENERAL LWB ILITY DAMMGETOREMED PRPMISES TOR RENTED $ 50.000 ICIAFRSMADE ❑OCCUR MED EIP Cry ors pram) $ 5.000 _ PERSONAL&ADV INJURY $ 500,000 _ GENERAL AGGREGATE $ 1.000.000 GENLAGGREGATE LIMIT APPLES PER PRODUCTS-COMP/OP AGO $ 500.000 7 POLICY El ERT I r 1 LOC F AUTOMOBILE UNBIIITY CsvnEoSINGLE LMR $ ORVAUTD 1BBODILY INJURY(Pw person) $ ALL OWPED SCHEDULED BODILY INJURY(Per cadent) S AUTOS AUTOS NON.O NED PROPERTY DAMAGE e HIRED AUTOS —AUTOS Pereecider/ F UMBRELLA LIAa OCCUR EACH OCCURRENCE _ I EXCESS LIAR CLAIMS-MAT AGGREGATE S DED RETENTIONS $ WORKERS COMPENSATION WC STATU- ATH- ANDEMPLOYCRSLIABILRY YIN TORY SLITS FR ANYPROPRIETOR/PARTNER/ExECUTNE NIA E.L.EACH ACODENT $ OFFICER/MEMBER EXCL DED? SJaS.t.y In NH) E L.DISEASE•EA EMPLOYEE S F deeaIPTIb under DE SCRON OFOPERATIONS below ELDISEASE-POLICY LIMIT S • DESCRIPTOR OP OPERATORS I LOCATIONS/VEHICLES(Mach ACORD 101.AMMAN Rends Schedule,a more SPIN Mngd,.d) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED N - - ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATWE ROBIN A. BASSETT ®1988,2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The AC ORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: • • • pCommonwealth of Massachusetts u rheamnwmrzw/C.4 iblittuaciterdett3ii C Division of Professional Licensure 3 Oma at Comma;Atffl&Bualnata Ragulaeon t ; / Board of Building Regulations and Standards s „ HOME IMPROVEMENT CONTRACTOR # , Constr t tten i5 rvisor am p"., TYPE:IndMduel f t ,Repletretton Fvoire90n X t [ test91 a52s/2ot9 b , : CS-080957 5 Dlres•03/042020 - i w.<. MICHAELWOES8NER ' + 5 i w+ +i, n a > .F> k ; �.;6 ivt.' i i ; MICHAEL W�ESSIJER'tj? ,ti C �r "` . ��++'F.- T `� : TIO NEW BOSTON ROAD/ ,s : G MICHAEL IC WOESSNE`tt v.t ! DENNIS MA O1638 s, .4. ." JTZ .I L " 3ROWE3T a> to/4Slg�i� :- ; t, STONEHAM,MA 02180'' ' Undersecretary ' e n I Commissioner . _ _� .. „e ..._........1.••._..s firopoSat Page if / of pages Michael Woessner 170 New Boston Road Michael Woessner Dennis,MA 02638 General Contractor 508-292-4703 Email:woesmkw@aol.com r Proposal Submitted To: Unrestricted Builder Uc.#CS-080957 Home Improvement ALMA . f L.-. ..,�.•e Contractor Reg.#16919 Address Job Location .11u� Date Proposal# Y4i ,s ../A /t./.h 7G/2o/y Phone If - 77ei- 7./.Z Fax It Architect We hereby submit specifications and estimates for. 8..r.. ( S... A r.•/. e, / L/o4 r— Exc :.J .e'/e/.r'co/tF.tcw f fl.A,.., ( Rae •4 s '- ' .,, / /a C. Z4 . e rJ : . er/w { f?v(,/...e /eels ( mad /3a. /• n. / _4,, r - sv.'ii a-it,. art.n✓And./ .4 a/c.. .� 2 R...•.... . Caf,, n t n.• / . . t .p..a !/ ,7a.ca/1 obi " dib R /../ t4. :f � 7" -2 /e // / . /e.'/. .•�it .. �i s /na /PA • r i+., -.*Al it" 7 tsar • o ( I?ce( . �( /12..,/a<.. C /ale /f/1)fro " rc • . s .x 1 S' R.-tom..2X Ito. .i�• .1 ! .0 ., .._if ,. /. e7A 0. /Ica( .f(,.- I, L. n,..V,. J /. r(. sl,�� //o. I,'L�.•�l� � Cc- /. � n.�.� _� �_t n Lore • ) Celan.! 1 (/- r/ t L ' . .• e /1 _T.A Aa-/./.-JO a./_6.r .• >Aft Cs We propose hereby to furnish material and labor—complete In accordance with the above specifications for the sum of: $ 3 60 ,0 ' c) d lac till/ / Feld Od Dollars with payments to be made as follows: (viOo o c. /3•A.... a c ere /! -..�. Any Union or deviation Iron above wed •. volt' a coca rA be Respectfully . / o>eotx.a only Wan rmnn oder,end*1�become an e>aA extra cr.r.rW submitted Itsiw/�na1,F�.�.�_ above the eWmets.Al agnomens contingent upon aWka,extents,or drys beyond ars control. Note—this proposal may be withdrawn by us It not accepted within days. Scceptance of Stropo aI The above prices.specifications and conditions are sadslactory and are Signature //V/ a. a.'r V • hereby accepted.You are authorized to do the work as specified. Payments will be made as outlined above. Date of Acceptance Signature