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BLD-19-000919
a _ O Use Only aj R P /fes 7 ' an d. . i'�Ig- S Amount 1 wn :44:•••y aa P expires 180 days from 1 ' 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: 36. S�eteEs fie /it, S�/ `)%4asY 4/1 ASSESSOR'S INFORMATION: flB P�vtA/oA' Map: Z(' Parcel: 3 e4.'OOcyo ,y/t�� p v 71O GO�t d 4' OWNER fiSEAW 1-5s,o, , 9>7/0 � 3/!/� jwGOff/ft ,,.t yi..r) &E $t 227 1" NAME PRESENT ADDRESS 1EL # Email Address: CONTRACTOR c/OE lNeel orifi tera 647.014714v /114 010.7 4'/7-90f-/ll7 NAME MAILING ADDRESS TEL# OD Email Address: 0 Commercial Est Cost of Construction$ n 6740 - Home Improvement Contractor Ile.* //3 74/ {,�,/ Construction Supervisor Lie.# C 5 61e6.0 / 2- Workman's Compensation Insurance: (check one) I am the homeowner ,�,, I am the sole proprietor COI Mane Worker's Compensation Insurance d /� f.� (,/� Insurance Company Name:/ ?4A'4 J 6� 4 • Worker's Comp.Policy# wli i D1O`� e &) WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares ' <eplacement windows:# Replacement doors: # .2.. Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation n: .e044e47 rico twsik st1,OleS Old Kings Highway/Historic Dist. ( )Replacing like for like anrg 7ZCPO ,gxwt R.O. O1.10.f..15 /9.4.go - p aLoa Of? ye evew e ass J, rotas . *The debris will be disposed of at /A4'iniZeJ �4c th-3 770 Location of Facility I declare under penalties of perjury that the •. - 1.. ..-in contained axe true and correct to the best of my knowledge and belief. I understand that any false answer(s) wall be just cause for denial v 1„ d for prosecution under M.G.L Ch.268,Section 1. //� Applicant's Signature: JDate:Owners Signature(or at chmen4,,, / 1/ Date: 5 t' Approved By: ,...7C., i' .4 i Date: VS —i 6-11 Building Official(or designee) - Zoning District Historical District Yes No Flood Plain Zone: Yes No Water Resource Protection District Within 100 ft.of Wetlands: Yes No Yes No • Boston, MA 02114-2017 Jwwry mass.gov/dia \Zrorkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Ap[rlicant Information Please Print Legibly fame iBusiness/Organitation/Individual): 2N4 54917 .ddress: ? o. & oox mG,E ay/State/Zip-JP l/KiA t/ ' 6',17, Phone #: e/7- fat -/2.2L7 t you an employer? Check the appropriate box: - Type of project(required): I am a employer with 10 employees(full and/or part-time).* Is 7. ❑New construction I am a sole proprietor or partnership and have no employees working for me in ((rr,xr any capacity.No workers'comp. insurance required.] 8. Remodeling 3 I am a homeowner doing all work myself(No workers'comp.insurance required.]t 9. Demolition I am a homeowner and will be hiring contractors to conduct all work an 10 ❑ Building addition ensure that all contractors either have workers'compensation insurance oorare sale I will 11.❑ Electrical repairs or additions proprietors with no employees. I am a general contractor and I have hired the sub-contractors listed on the attached sheet .12.El Plumbing repairs or additions These sub-contractor have employees and have workers'comp,insurance? 13.0 Roof repairs We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,31(4),and we have no employees.[No workers'comp. insurance required.] •applicant that checks box/l must also fill out the section below showing their workers'compensation policy irtfonnation. neowners who submit this affidavit indicating they are doing all work and then hire outside contractor must submit a new affidavit indicating such. Tactors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have yees. If the sub-contractors have employee;they must provide their workers'comp,policy number. t an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site rmation. �/,r�� "� /� rance Company Name: ,f' 4kZ'4 Truer- et, ' y# or Self-ins.Laiie.#: WC4 ©/D? 2-ef-Z y Expiration Date: /4_7./7 Site Address: 1p e�lfl744 /0GI, 2k U( , City/State/Zip: 41• Aer000n,< 4/e-- ch a copy of the workers' compensation policy declaration page(showing the policy numb and expiration date), Ire to secure coverage as required under MGL e. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 nr one-year imprisonment, as w l as civil penalties in the form of a STOP WORK ORDER and aline of up to$250.00 a against the viola e . , .opy . „s statement may be forwarded to the Office of Investigations of the DIA for insurance rage verific.a on. hereby -rtify und Agar . , dpenalties of perjury that the information provided above is e d correct Arr ature: a Date: Cr C le#: ,, ✓ — ea --- Zv fflcial use only. Do not write in this area, to be completed by city or town officiaL ity or Town: Permit/License# suing Authority(circle one): Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Other ontact Person: Phone#: Massachusetts General Laws chapter 152 requires au euiNwy.,e w r•-••-- Pursuant to this statute, an Rmployee 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,orHowevthe • , rreceiver or trustee of an individual,partnership,association or other legal entity,employingemployees. owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of o do aintenance, dwelling ho or on the grounds or building appurtenant theretoer who employs persons tshall not because of such construction mployment be deemed tocbe an h mployeuse 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 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 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 wodcerS' 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 othr licenseww or if you art required o ' btain a not the Department of • Industrial Accidents. Should you have any questionsregarding compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self insurance license number on the ap.ro iriate line. City or Town Offiri,Is ' Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit foryou 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 s a neef referencernly submiter.one In a davrtn,an apng current applican that must submit multiple permit/license applications in any givenyear, 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 Boston, MA 02114-2017 • Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFB Fax#617-727-7749 • Revised 02-23-15 www.mass.gov/dia /^1 PANDO-2 OP ID: LH A ORO- CERTIFICATE OF LIABILITY INSURANCE DATE IMMIDD/YYWI 04/02/2018 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 Phone: 978-433-2728 CONTACT Brown 8 Brown(Pepperell) PHONE FAX 2 Tarbell Street Fax:866-848.6097.Iac N ,fi IaaNO�: Pepperell,MA 01463 E-MAIL BB of Hartford(DM) ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC e INSURER A:Union Insurance Company 25844 INSURED Pandolfo Company,Inc. INSURER B:Acadia Insurance Company 31325 PO Box 1068 Burlington,MA 01803-1019 INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. NOTTMTHSTANDING 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. /NSRTYPE OF INSURANCE 7IZO [SUBR POLICY EFF POLICY EXP LTR INSRIWUD POLICY NUMBER IMMIDD/YYYYI IMMIDDIYY'/Y) LIMITS GENERALLIABIUTY EACH OCCURRENCE S 1,000,000 A X COMMERCIAL GENERAL LIABILITY CPA0100280-24 01/0112018 01141/2019 PR-0REMSES(EaOaEoccurrence) S 300,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 5,000 PERSONAL SADV INJURY $ 1,000,000 _ • GENERAL AGGREGATE $ 2,000,000 GENL AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 2,000,000 X�POLICY ri°�T ri LOC Emp Ben. $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) B ANY AUTO MAA0100231.24 01/01/2018 01/01/2019 BODILY INJURY(Per person) $ ALL OWNED -1-7 SCHEDULED BODILY INJURY(Per accident) $ _ AUTOS AUTOS NON-0WNED PROPERTY DAMAGE S X HIRED AUTOS X AUTOS (Per accdent) It $ X UMBRELLALIAB X OCCUR EACH OCCURRENCE _ $ 6,000,000 B EXCESS UAB CLAIMS-MADE CUA01002e3-24 01/01/2018 01/01/2019 AGGREGATE S 6,000,000 DED X RETENTIONS 0 S WORKERS COMPENSATION WC STATU- OTH- ANDEMPLOYERS'LIABILITY TORY LIMITS ER B ANY PROPRIETOR/PARTNER/EXECUTIVE YIN WCA010028d-2A 01/01/2018 01/01/2019 EL EACH ACCIDENT S 500,000 OFRCER/MEMBER EXCLUDED/ n NIA (Mandatory In NH) EL.DISEASE-EA EMPLOYEE S 500,000 If yes,desmbe under DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATORS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Renv,as Schedule,If more space Is numbed) v. • CERTIFICATE HOLDER CANCELLATION 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 19M ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts l®J Division of Professional Licensure J Board of Building Regulations and Standards Cons`,kictt6rt%i p,rvisor CS-006892 E Fires:• 03/08/2020.. JOSEPH P P4DOLtO ' „` O r Ca • 3 MEADOWCR FT.J2Q y BURLINGTON M4 0182_03'/I ),6" • .i Commissioner v'"6 • Y. (71171e (6,nemon lora' rikircr.a.kir Are).ill; Office of Consumer Affairs&Business Regulation ryi= ;;y HOME IMPROVEMENT CONTRACTOR • "artTYPE:Corporation Registration Expiration r:Y„ 113748 07/14/2019 PANDOLFO CO INC • JOSEPH P. PANDOLFO (tCCP. '- 3 MEADOWCROFT RD BURLINGTON,MA 01803 Unddrsecretary • • • IV- 6econd Floor Flan kna &'Z1 W1171 0-' AA77 � btort R .0 - 55izk NEW RESIDENCE FOR: Roy 36 Shore Side Drive S.Yormouth, MA FLOOR 1: 1248 SQ.FT. FLOOR 2: 1751 SQ.FT. TOTAL: 2999 SQ.FT. GARAGE: 576 SQ.FT. r:7 11111! 11 IN q1I SHEET TITLE:' Floor Plan SCALE: 1/411 SHEET NUMBER: �of11 DATE: July 9. 1999 WORKING DRAWINGS oil 114.111 1, 1 rz ALL CONCEPTS, DESIGNS, LAYOUTS AND PLANS REPRESENTED BY THIS DRAWING ARE PROPERTY OF ELZEAR & PAT ROY AND WERE DEVELOPED FOR THIS PROJECT. NO CONTENT IS TO BE USED FOR ANY OTHER PURPOSE WITHOUT THE WRITTEN CONSENT OF THE OWNER. C 1999 REVISIONS: �� 2 NO. DATE: DESCRIPTION: CORTLAND MORGAN, ARCHITECT, AIA 6910 .Woodland Dr. Dallas, Texas 75225 (214) 368-3687 TO A- �/'AI Leh# fm kna &'Z1 W1171 0-' AA77 � btort R .0 - 55izk NEW RESIDENCE FOR: Roy 36 Shore Side Drive S.Yormouth, MA FLOOR 1: 1248 SQ.FT. FLOOR 2: 1751 SQ.FT. TOTAL: 2999 SQ.FT. GARAGE: 576 SQ.FT. r:7 11111! 11 IN q1I SHEET TITLE:' Floor Plan SCALE: 1/411 SHEET NUMBER: �of11 DATE: July 9. 1999 WORKING DRAWINGS