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Home My WebLink AboutBLD-19-000975 t..y. ce Use Only 3z 'R ►' 44_Nimq `_a 'a"—i-,-4-,,,I. c- • •i" rAmount 2/: Permit expires 180 days from .issue date I EXPRESS BUILDING PERMIT APPLICATIO lECEIVED1 TOWN OF YARMOUTH Yarmouth Building Department 1 AUG 20 2018 5iltiv 1146 Route 28 i South Yarmouth, MA 02664 11/0 DEPART (508) 398-2231 Ext. 1261 — -- CONSTRUCTION ADDRESS: en4 St 14014dv01 Kt • ASSESSOR'S INFORMATION: • Map: Parcel: OWNER: I Ilia i ect(ESc-l4U 1)V- Sr Nir {�rit (id Sa - 7,10-82147,10-82148o-gz NAMM PRESENT ADDRESS ' TEL # coNTRACTOR: NA 0131 ('p. &r 413 F4 mos' owl S4c-SG6-$dg7 / MAILING ADDRESS TEL#(�G A Residential 0 Commercial Est Cost of Construction S U O° Home Improvement Contractor Lia r # I Yee Itr Construction Supervisor Lic.# 05-1 D,7 Workman's Compensation Insurance: (check one) 0 I am the homeowner ^❑ I am the sole proprietor I have Worker's Compensation Insurance 7 Insurance Company Name: 1 aw S Worker's Comp.Policy# ( 61/.4¶3 14 14I l 7 WORK TO BE PERFORMED �Nia6K adkni !,t of rAufr N C4 o.sa1 t1 ra,X(a W cin Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation bgd Kings Highway/Historic Dist. ( eplacing like for like Pool fencing "The debris will be disposed of at lA^'w R 1 Location of Facility I declare under penalties of perjury that the statements herein contained are true and comet to the best of my knowledge and belief I understand that any false answer(s) will be just cause for denial or revocatio y lic d for prosecution under MGL Ch.268,Section 1. Applicant's Signature: Date: ieZvi-ND Owners Signature(or attachment) - Date: p- ,f Approved By. . . .....A.-a Date: 0' b�-�-6. Building Official(or designee) EMAIL ADDRESS: • 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 "r The Commonwealth of Massachusetts P �= .L __, =6' Department of Industrial Accidents • -a F. . 1 Congress Street, Suite 100 _4l. • 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):individual): 0401 tMtsdoRy Address: Co k 4c - City/State/Zip: l�ut�llf CiSlft Phone #: Sri S3-a6-6 Are yo n employer?Cheek the appropriate box: Type of project(required): 1. I am a employer with � employees(MI and/or parttime).~ 7. ❑New construction 2.01 am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] 8. ❑Remodeling 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. ❑Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on any property. I will 10 ❑ 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.❑I am a general contractor and I have hired the subcontractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance? 13.E Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checla box k1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit Indicating they are doing all wort 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 employes. If the sub-contractors have employees,they must provide their workers'comp.policy cumber. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: R•a45 Policy#or Self-ins.Lic.#: Lit l(a3I‘C-i11 3, Il7 Expiration Date: 0 � X11 Job Site Address: 9.14- LiJI3V " RI^tci A pu' City/State/Zip: We t4 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 un a pat dpenalties of perjury that the information provided above is true and correct. Simlature. 4 Date: % -to —ti Phone#: S1 _t6- c U 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#: • _a • 11 • • 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 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 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 contract 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-contractors)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 advisedmat 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 A`ORD® CERTIFICATE OF LIABILITY INSURANCE DATE osro no 17 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 CONTNAME: Sharen Rabesa MURRAY&MACDONALD INSURANCE SERVICES INC PWC XO ro Eq,,; (508)289 also FAX E-MAIL sharen nskadvice.com ADDRESS: C� 550 MACARTHUR BLVD INSURER(S)AFFORDING COVERAGE NAIC BOURNE MA 02532 INSURER A: TRAVELERS INDEMNITY CO OF AMERICA 25666 INSURED INSURER B: KADY STEVEN DBA STEVEN KADY&SON MASONRY CONSTRUCTION INSURER C: INSURER D: P O BOX 493 INSURER E: FALMOUTH MA 025410493 INSURERF: COVERAGES CERTIFICATE NUMBER: 190323 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 POUCY EFF POUCY EXP WAITS MI INSD WVD POLICY NUMBER (MWDD!YYYYI (MDOfYYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S N PED CLAIMS-MADE OCCUR PREMISESDAMAGE ES(Ea omur GR ccurrerKe) $ MED EXP(Any one person) $ N/A, PERSONAL ADV INJURY _ $ GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE E POLICY n JPERC0. n LOC PRODUCTS-COMP/OP AGO $ OTHER E AUTOMOBILE LABILITY COMBINED SINGLE LIMIT $ _No accident ANY AUTO BODILY INJURY(Per person) $ ALL AUTOS OWNED SCHEDULED AUN/A BODILY INJURY(Per accident) $ HIRED AUTOS _ AUTOS ((Per PROPERTY - $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE _ S EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ _ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE OTH- ER AND EMPLOYERS DABIUTY A OAF CERiM MBOEEXCLUDED?EClfiNE Yn N/A WA 6HUB931X732117 08/29/2017 08/29/2018 E.L.EACH ACCIDENT $ 500,000 (Mandatory In NH) EL DISEASE-EA EMPLOYEE $ 500,000 lives,decade undo DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,AddMlonal Remarks Schedule,may be attached II mem 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 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 dally by accessing the Proof of Coverage-Coverage Verification Search tool at www.masegov)lwdNrorkerasompensatlon/Investlgatlons/. Sole proprietor has not elected coverage. 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 POUCY PROVISIONS. 1146 Route 26 - - -- -- -- --- AUTHORIZED REPRESENTATIVE CAL South Yarmouth MA 02664 Daniel M.C y,CPCU,Vice President—Residual Market—WCRIBMA I 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD H Steven Katy Phone: 508.583-2515 Ma.Licensed Construction Supervisor#059847 Toll free:800-567-9787 P.0 Box 493 ' Falmouth.Ma 02541 Cell:508.566-5087 Fax:508.563.2516 Email:Steve{TSteveKedyMasonry corn www SteveKadyklasonry corn t{f PROPOSAL August 7,2018 Damian Pxeeeau 974 W.Yamkoudt Rd. Yamwuthpat Ma. 508-280-8296 48 FadFanadcftiomail corn WORK TO BE PERFORMED: • Construct ground staging • Construct roof staging • Remove center chimney down to roof ine • Panflash • Re-construct chimney o Using Rocky Mtn.Blend Brick 0 Wnh detailed crown TOTAL: labor,Material,Disposal:$5,500.00 Building Permit&Fees,ADO $300.00 TOTAL: $5,800.00 Stainless steel chimney cap,if wanted ADD $400.00 50% to Schedule, balance due upon completion 411P 0LAM-14Ae_ .5% 20 - , 7