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HomeMy WebLinkAboutBLD-19-000945 UM Use Linty ..) 24r; ! �r0, '-Permit# 7 ' '�O � ' � : ; . HAmount -`C .:A . �"^'s'iO i' 1 Permitsue dazexpiree 180 days from - :::<cs-.:.. is bLb—lG-bbbNs . EXPRESS BUILDING PERMIT APPLICATION • TOWN OF YARMOUTH Yarmouth Building Department R E C E I tI E 1. S 1146 Route 28 South Yarmouth,MA 02664 AUG (508) 398-2231 Ext. 1261 i (/. .: 8—s_17 2018 \ l CONSTRUCTION ADDRESS: WWI RTE oil /A%i b' S. ARmd✓l7/,h/ 1y�11 , • ASSESSOR'S INFORMATION: . Map: Parcel: OWNER: JOHN Ht9✓17 s 0N, an 84ael4y D,e,STAMFen,er 0603 2o 3 -S6/-4 90 a NAME PRESENT ADDRESS TEL. # CONTRACTOR: ACK Mvcc.iK 7 c D,4.1 ,tM R4 G/AY con? 1759/ NAME MAILING ADDRESS TEL.if ❑Residential 8//Commercial . Est Cost of Construction S /Sob Home Improvement Contractor Lie.# /01/076 Construction Supervisor Lie.# /G 7 ?3/ Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietorave Worker's Compensation Insurance Insurance Company Name: 2 Vg—%C K.. Worker's Comp.Policy# 67.2(1 la/ Kt;9c`i X /8" WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # •Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation X Old Kings Highway/Historic Dist, ( )Replacing like for like Pool fencing 'The debris will be disposed of at 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 ofmylicense and for prosecution under M.G.L.Ch.268,Section L Applicant's Signature: l4tr,/ V� /�� Date: ' Owners Signature(or attachment ,, / �Ar __ Date: Approved By: �� ' i' Air Date: $�/n ' Building Official(or designee) _ —7: I ADDRESS: ��'VVV 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 The Commonwealth of Massachusetts de i ?= t ,J g—,,._ _ Department of Industrial Accidents =:fr1_ a 1 Congress Street,Suite 100 fit. • 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): Address: City/State/Zip: Phone#: Are yoo an employer?Check the appropriate box: Type of project(required): l.Q[am a employer with employees(full and/or parttime).* 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself 9. Q Demolition [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 I0 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.E Plumbing repairs or additions 5.01 am a general contactor and I have hired the sub-contactors listed on the attached sheet These sub-contactors have employees and have workers'comp.insurance.: 13. Roof repair 6.0 We are a corporation and its officers have exercised their right of e-xemption per MGL c. 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 ails-davit indicating they are doing all work and then hire outside contactors must submit a new affidavit indicating suck tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entitles 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.Lic.#: 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 Sienature: 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): I. 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 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,§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 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 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 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 fixture 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. # 617-7274900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 wwv.mass.gov/dia ACCPREP CERTIFICATE OF LIABILITY INSURANCE DATE(MOol/Te 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 CONTACT NAME Debra Martin MARGARET J GRASSI INS AGENCY PHONE o FSIT (508)295-2007 FAX E-MAIL (A/C,No): ADDRESS: debmjgins©comcast.net 1188 MAIN ST INSURER(S)AFFORDING COVERAGE NAIC• W WAREHAM MA 02576 INSURER A: AMERICAN ZURICH INSURANCE COMPANY 40142 INSURED INSURER B: MULLIN ROOFING&SIDING INC INSURER C: INSURER D: 7 CONNEMARA WAY INSURER E: W YARMOUTH MA 02673 INSURER F: COVERAGES CERTIFICATE NUMBER: 254984 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 OFINSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR11150 WVD POLICY NUMBER IMMIDDIYYYYI IMM/DD/1'YYYI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMA $ CLAIMS-MADE E OCCUR PREMISES ETORENTEO PREMISE$ RNtED occurrence) $ MED EXP(Any one person) $ N/A PERSONAL SiADV INJURY _ $ GEN%AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY 0 Tel: 0 LOC PRODUCTS-COMP/OP AGG _$ _ I OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED -- SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per ecdtlent) $ _ ROPERTY HIRED AUTOS _ NON-OWNEDUOS (Per accidenOAMAGE S - $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ _ DED RETENTIONS $ WORKERS COMPENSATION X STFTUTE ETH- AND EMPLOYERS'LIABILITY A OFFICER/MEMBERXCLUD DI ECUTNE Y® N/A WA 6ZZUB1K24552618 03/07/2018 03/07/2019 E.L.EACH ACCIDENT $ 500,000 (Mandatory In NH) EL.DISEASE-EA EMPLOYEE $ 500,000 B Yee,dearnbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached It more spew 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 daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.govRwd/workers-compensatlon/Investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Chris Herman ACCORDANCE WITH THE POLICY PROVISIONS. 7 Yacht Ave AUTHORIZED REPRESENTATIVE _ L West Yarmouth MA 02673 Daniel M.I;ro y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD • • • JaU°1ss1WW°3 • ' i cSION 1S`3M `)I ' E(, vLw ,Aa`st19ZO \Aw el P:1;",' leoI, 'fit �- 9L040L-Stl 0160 SaJIdA� ,. 6LOZILy'ysu°tl n pieo9 . jo51Nat1S?$1.}� 14 buippei >®' • scow . Ppe s euoessslo d to uols o3 sP eJnsuaon l 0 tale amuowwo0 sllasn4je5seW l iGya+aaq+aP .4. . _ • ,, F4sro . Registration valid for individual use only before the 7ni/ •irj, • • expiration data If found return to: r� 4 44 Office of Consumer Affairs and Business Regulation : 4''4.'4}�� 1+ NI �NIyOtl ! 10 Park Plaza Suite 5170 �0 �' _- 0$dH .x, Boston,MA 02116 - T' rnrMaa8sra03tiklAlj1 494: .'U°nNjjy tlaNl)717tY ! • �%z/ „tilDVlam sopW(3 if t i r� 1 X`f8 a/�°j4400 _ Not valid wit s�¢nature ��