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Home My WebLink AboutBLD-19-000914 I 1'Office Use Only i Cj .Z 4....4; !`rr0 S Permitj 'fir , C• 90_, a O _' k _ ' Ammmt F �^•."a'°,�. Permit expires 180 days from issue date g L IJ-I q-000q/ ql EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1 1146 Route 28 AUG 15 2018 j South Yarmouth, MA 02664 /� (508) 398-2231 Ext. 1261 uu,�py arC1(='� CONSTRUCTION ADDRESS: Ib l ?butt.. (P 14 1. r4l 0U f 04 • ASSESSOR'S INFORMATION: • Map: I aa. Parcel:/ )1-11-111-1 OWNER D0 AA "Barak ItoI /vioTt. (PA �arn4.0 tp04 ((�N(��AMEEI Q I- PRESENTADDRES / ff TEL. # CONTRACTOR:1111C110A &1(�5k(1 mg�Zi . 53 ConefecciavzIfr *rY4 0..(075 Sys-a7q-Qq(c4, NAME MAILINGADDRESS ,J TEEJL# n T ❑Residential ,Commercial Est.Cost of Construction$ 9i o O l ,, DO Home Improvement Contractor Lic.# 1 0�'I5� I Construction Supervisor Lia#f J 16-.)..1S..5 Workman's Compensation Insurance: ;check one) 0 I am the homeowner.' I am the sole proprietor 0 I have Worker's Compensation Insurance I Insurance Company Name: -17 A Q145 Worker's Comp.Policy 23\ "O\X4tvf)"1�1 'IS WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 9 Replacement windows:# Replacement doors: # Roofmo: #of Squares ( )Remove existing* (max.2 layers) Insulation LOld Kings Highway/Historic Dist. (Replacing like for like Pool fencing "The debris will be disposed of at Rv\0P.(t\- 00t'CA5 c,Cd7.1(I(V4.r Sec v\(Q . Location of acdity I declare under penalties of perjury that the statements herein contained are true and correct to the best of my Imowledge and belief. I understand that any false answer(s) will be just cause for denial or reyneilttion of my license and for prosecution under M.G.L.Ch.268,Section 1. 1 _ - 7;45//48. Applicant's Simtamre: " i �---�� r Date: i Owners Signature(or attachment) /11 / /�/ C�'R.) Date: Approved By: �! Date: /5/g Bu' .'g o A (or designee) E KESS: Zoning District. Historical District: 0 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 rte= The Commonwealth ofMassadhusetts its� Department oflndustrialAccidents =ei= 1 Congress Street, Suite 100 _ �=_ �� Boston, MA 02114-2017 • 11.t,„ ,.s+'" www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le?ibly Name (Business/Organization/Individual): me \`c ` " ( on Apr Address: ph JrP pna\ �( City/State/Zip:Ya( )(4. ki\A (a( 1 t5 Phone #: )8 Are you an employer?Cheek the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in $. Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall work [Not 9. ❑Demolition ❑ myself workers'comp.insurance required.]red.] 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 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5. 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 repair 6.0 We are a corporation and its officers have exercised their right of exemption per MGL e. 14.1aOther 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-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: 1 oki Q it(JC`5p Policy#or Self-ins.Lic.frie-�-ua-nIIyN'V))-LI-IS Expiration Date: a - p ' q Job Site Address: I(01 R-S8 (.0( City/State/Zip:Ya['()() —rn0 G(61.5Attach a copy of the workers' compensation policy declaration page(showing the policy number and spiration 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 Si 'nature: 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#: • 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 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." 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 buildings 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 contact for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contacting authority." Applicants Please fill out the workers' compensation affidavit completely,by checldng 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 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- hat 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 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 w Q e Wd ,t ea / ,o 1a� 3 Office of Consumer Affairs and Business Regulation a`' 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home ImprovementContractor Registration • - rr r r -=a Type: Corporation tj-±°i; t:e _ '24'6- Registration: 180881 M.B. HOME IMPROVEMENT, INC' :r:;'', "a>t:_=_b.1 Expiration: 01/22/2019 53 Congressional Dr Im1 = Yarmouthport, MA 02675 t` t = =a , .'.±\ '^-.2. ;..-..t.,_ L :+ui,„----s--F.----S; scs- Update Address and return card. Marts reason for change. SCA I O 20M-05111 p� 0 Address Cl Renewal 0 Emntevment 0 Lost Card — C926 Cant o`'�1lostarkaria •1 Office of Consumer Malts 8 Business Regulation fay 1r HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only • !;ppl +a TYPE:Corporation before the expiration date. If found return to: t.tI," r.lieaistration Excite Office of Consumer Affairs and Business Regulation r, _.180881,/ 0122/2019 10 Park Plaza-Suite5170 Boston,MA 02118 . M.B.HOME IMPROVEMENT;INC. - Michael 8emsten== ., ^ _ .';) 53 Congressional'Dr Yarmouthport,WCC2075,.;' ��'4 — __ = wry Not valid without signature } • • ® Massachusetts Department of Public Safety Board of Building Regulations and Standards Ucense:CS-102185 w4^ Construction Supervisor " • ` 1 `-` HARLTSPAIN 3 5A ' 1* 40 MAIN STRUT � �;^°k' SANDWICH MA 0265 i1 ifer,e4 G(' 91/x -- Expiration: Commissioner 12/20/2010 • '9k ¢ommonneal(A riCtieunrAtne//J Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:IndMdual before the expiration date. K found return to: igggl 11 Office of Consumer Affairs and Business Regulation • •177767- 02/0212020 One Ashburton Place-Suite 1301 KARL SPAIN - _ - Boston,MA 021 D/B/A KT.SPAIN CONSTRUCTION KARL SPAIN46 SANNDDIIyICCHH,MA 02563 of valid with signature Undersecretary N 4. EDEat NOTICE I -*= G NOTICE TO ( we1_ . TO EMPLOYEES 1- - ` EMPLOYEES UP The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114 — 2017 617-727-4900 — http://www.statema.us/dia As required by Massachusetts General Law,Chapter 152,Sections 21,22&30,this will give you notice that I(we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: THE TRAVELERS INSURANCE COMPANIES NAME OF INSURANCE COMPANY P.O. BOX 1450 MIDDLEBORO. MA 02344-1450 ADDRESS OF INSURANCE COMPANY (7PJUB-0114N13-4-18) 02-08-18 TO 02-08-19 POLICY NUMBER EFFECTIVE DATES BRYDEN & SULLIVAN INS PO BOX 1497 SOUTH DENNIS MA 02660 C NAME OF INSURANCE AGENT ADDRESS PHONE# M.B. HOME IMtPROVEMENTS, INC. 53 CONGRESSIONAL DR YARMOUTHPORT MA 02675 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of S employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer. if the treatment is na«,.....i..ea roannsbly IM-1 connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS 002154 W20P1016 TO BE POSTED BY EMPLOYER