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HomeMy WebLinkAboutBLD-19-745 �+ • the Only .o�' Y` � Zp */�d� 630 • .3,.;---nett , e t. O - i e*' '� `3 � .Amount L'`. r Permit expires 180 days from issue daze EXPRESS BUILDING PERMIT APPLICAT ONE C E E V E 0 TOWN OF YARMOUTH Yarmouth Building Department AUGI01 2018 1146 Route 28 South Yarmouth, MA 02664 B -I of P ,J • (508) 398-2231 Ext. 1261Weird CONSTRUCTION ADDRESS: V 9 it-r- al Soc-n/- \C/v'itt-nit ASSESSOR'S INFORMATION: • �p __ - ©. Map: Parcel:Q OWNEK t-to-H�- t' c Lt V o C NAME ; l 1� PRESENT ADDRESSDtTEL. # q 4:."-C(19 CONTRACTOR: Ptlti�Anfav`T ia)() 'CIW,I LikMI r) / /\1/4I -U5 `'7 NAME MAILING ADDRESS Lew - t)99 ^pni - 27 , ❑Residential YCommercial Est Cost of Construction K )S! I� OfnV I7� Home Improvement Contractor Lie.# Construction Supervisor Lie.# GeZ‘f a7 I Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor dE\have Worker's Compensation Insurance Insurance Company Name: 4/Bei Worker's Comp.Policy# We S )S 4 4 505 of l' J WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# � Replacement doors: # / )(,Roofing: #of Squares all (, 4temove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist ( )Replacing like for like /[�� / Pool fencing ` - 'The debris will be disposed of at"( Cele-UG\t�- ci1 c )c'J-J 1 15 ' -ec Location of Facility I declare under penalties of p ury that the statements herein contained are true and correct to the best of my knowledge and belief I derstand that any false answer(s) will be just cause for denial gfJrevo•a;on of my license and for pro -,uti.. under MG.L.Ch.268,Section 1. y��s,� X Applicant's Sinature: '�!tI. � 1 Date: (J Owners Signature(or attachment) 1 �'' Date: Approved By: /� .9" , " •� Date: e•-- 7 —// Bu;;4`. (o designee) i' • 1 ADDRESS: Zoning District Historical District: ❑ Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District Within 100 ft.of Wetlands: ' 0 Yes 0 No 0 Yes 0 No r The Commonwealth of Massachusetts * A�rP ' Department oflndustrialAccidents • 1 Congress Street, Suite 100 P!�I Boston, MA 02114-2017 ' �c.�.� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH TUE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).• 7. 0 New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.(No workers'comp.insurance required.] 3. I am a homeowner doing all work9. ❑Demolition ❑ 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 10 ❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I 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. insurance.* 13.0 Roof repairs 6.0 We are a corporatlon and its officers have exercised their right of exemption per MGL e. 14.❑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 am 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 ant 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.Lie.#: 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 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 Sistlature: Date: Phone*: 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#: r • Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. • F[rsuantto this statute,an employee is defined as"...every person in the service of another under any contract 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." MOL 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 construct 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 its 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 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 advised-that this affidavit may be submitted to the Department of Industrial Accident 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 Offidals 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, MA02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.rnass.gov/dia • COMM onwealtholMassachuSetts r`si��t1 t pNlsIon of Professth is Land Standards +'� Boar• dolBulldtngReg• rvisor Constrgalp• �$ Pg�r • r , moires:0412512020 • CS-084071 �H A lb MICHAEL LAlIART,E 3 , • :y `,, 541 THOMASIANDERSOAD �.•, .� EASTFALMOtfTH,.,MA042'I1�5 � ` • ' __, • 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)727-3200 or visit www•mass.gov/dpl • • • • •f • • • • • • • — des O'onemonwcc,/N n/(2tlatkrcAtnelt) — ........... ... ... . .._ Office of Consumer Affairs&Business Regulation :Li HOME IMPROVEMENT CONTRACTOR �� License or registration valid for Individual use only Type: Corporation before the expiration date. If found return to: Registration ):xnlrattofl Office of Consumer Affairs and Business Regulation • 185x38 08/18/2018 10 Park Plaza-Suite 5170 Boston,MA 02118 LEON PINSONNEALT BUILDERS INC' � jLJ_ ic2 LIONEL PINSONNEAULT / it"✓ i 541 THOMAS B LANDERS RD. EAST FALMOUTH,MA 02576 Undersecretary Not valid without signature A CERTIFICATE OF LIABILITY INSURANCE DATEIMMno 18 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 NAME: Susan LaFleur THOMAS J WOODS INSURANCE AGENCY INC INC.No Eat/; (508)755-5944 Fac,Na); ADDRESS: slafieur@woodsinsurance.com 20 PARK AVENUE INSURER(S)AFFORDING COVERAGE NAICi WORCESTER MA 01613 INSURER A: LM INS CORP 33600 INSURED INSURER B LEON PINSONNEAULT BUILDERS INC INSURER C: INSURER D: 14 OPEN HEARTH DR INSURER E: WEST WAREHAM MA 02576 INSURER F: COVERAGES CERTIFICATE NUMBER: 298968 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 INSURANCE ADDL SUER POLICY EFF POLICY EXP LTR INSD woo POLICY NUMBER (MWDOIYYYY) IMMIDOWYYYY) LIMITS COMMERCIAL GENERAL UABILITY EACH OCCURRENCE E CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Es Occurrence) $ MED EXP(Any one person) S— - _ N/A PERSONAL INJURY__ S _ GENL AGGREGATE LIMIT APPUES PER. GENERAL AGGREGATE S POLICY PRO- — JECT 0 LOC PRODUCTS-COMPNP AGO E OTHER' S AUTOMOBILE LABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) S — ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) S _ HIRED AUTOS _ AUTOS (Per PROPERTY DAMAGE S E UMBRELLA UAB OCCUR EACH OCCURRENCE _ S EXCESS UAB CLAIMS-MADE N/A AGGREGATE _ S _ DED RETENTIONS 5 WORKERS COMPENSATION ‘, PER OTH- AND EMPLOYERS'LABILITY YIN - STATUTE ER A OFFICE /ME BANYPROPRIETOEREXCLUD DXECUTIVE wA N/A N/A WC531S618501018 02/25/2018 02/25/2019 EL EACH ACCIDENT S 1,000,000 (Mandatory In NH) E L.DISEASE•EA EMPLOYEE S 1,000,000 N yea,deunbe under DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT E 1,000,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,nay be attached a mon space I.sequined) 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 to 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-compensatioMnvestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 I Daniel ML M.Cro y,CPCU,Vice President—Residual Market—WCRIBMA ID 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD I*','LtV; .4 fr;L S. ",!1;* 4.4^ 4n1 nt .1 • :;e74“1* v*"v1.' teTs,. *' v .-e' ff:44, as4''.f -'-i i.e yr . 4sTcv1 r 0e ,,•. Its .yi t•-t,' La.t ' a tr. ,,4 AI: . :- #''. .I .. ' e-4A .trik tt 4 r, 4A, Mass ;icliusetts Department of Public 73 - frt cs <4; i -6, , Board of Building Regulations anti Standa in License: CS-13742/17 Construction Supervisor 4 . bovii ,n. ,... , a % $ e es e"'e • PAUL M DC)WNING 180 ICES WICK ROAD BROCKTON MA 02302' *e, - i ) 1 i ' . , ae 1 7,11-7/1 7 ',/111... 0 0 -44....... Expiration: i Commissio er 04/04/2019 ti : ,A.of - - • op Town of Yarmouth Receipt No.: 38649 1E` 1146 Route 28 South Yarmouth,MA 02664 Receipt Date: 08/07/2018 508.398.2231 RECEIPT RECORD&PAYER INFORMATION Record ID: BLD-19-000745 Record Type: Commercial Express Permit Property Address: 44 ROUTE 28,WEST YARMOUTH,MA 02673 Description of Work: Alteration-2 squares siding,strip and reroof 24 squares,2 replacement window,one replacement door(774-836-7876) Payer. MICHAEL LAHART Applicant: MICHAEL LAHART MICHAEL LAHART East Falmouth,MA 02536 PAYMENT DETAIL Date Payment Method Reference Cashier Comments Amount 08/07/2018 Cash LCIPRO Chad Doe owner $265.00 FEE DETAIL Fee Description Invoice# Quantity Fee Amount Current Paid Commercial Combo Roofing and Siding 41351 1.00 $165.00 $165.00 Commercial Windows and Doors 41351 1.00 $100.00 $100.00 $265.00 $265.00 AAReceipt Template.rpt Print Date:08/07/2018 Page 1