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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH RECEIVED )
Yarmouth Building Department
1146 Route 28 AUG 21 2018
South Yarmouth, MA 02664
rr (, p f(508) 398-2231 Ext. 1261 BUS rLl rl� ,iytl�L73
CONSTRUCTION ADDRESS: 4 1 B / 1 q✓ Ctrs • Y Uj�� L --
ASSESSOR'S INFORMATION: •
•Map: Parcel:
OWNER: c O 5(n►111 C 6 DU mail 4'1 6(1a✓ C, ✓ SOf-6 19 - 32 45
NAME PRESENT ADDRESS TEL. #
CONTRACTOR: (.5'h&UI vie Oe.W i (61 C0M1110h 6 wuy gyE a T-%C57 ,
NAME MAILING ADDRESS TELL./#
/Residential ❑CommercialciFir Est Cost of Construction S /, So `d' 1
Home Improvement Contractor Lie.# 1 66 I t e Construction Supervisor Lic.# /Q 3694?—
Workman's Compensation Insurance: (check one) _�
0 I am the homeowner 0 I am the sole proprietor 1 W 1 have Worker's Compensation Insurance / L }�
Insurance Company Name: A f Lo it'k c. C ki&PT C Worker's Comp.Policy# WC VO ` 3 1 Moo
o
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 id
Old ICings Highway/Historic Dist. ( )Replacing like for like Pool fencing
"The debris will be disposed of at MOL 1156 P:i
5 Pe)sU I
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 rev. ation of my license and for prosecution under MG.L.Ch.268,Section 1.
Applicant's Signature: , . e d / Date: r•—• a I -IF
Owners Signatur. Date:
Approved By: �r.I��f �, Date: g
Buil.'._'ifci. ordesi:.ee) EMAIL ADD' Asa
•
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
•
`m'� The Commonwealth ofMassadtusetts
0.1; - 1 =Cr/ Department of Industrial Accidents
Veil* T 1 Congress Street,Suite 100
=t; E= •
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): A// ('4 P.Q.. g tp01
Address: /C4 and er`Jo.5✓ R a
City/State/Zip:bre,0 etf MA 624 3( Phone #: 3'O- 13553
Are you an employer?Cheek the appropriate box:
Type of project(required):
i.{am a employer with employees(full and/or part-time).* 7. 0 New construction
2.0 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.]
3.0 I am a homeowner doing all workmyself t 9. ❑Demolition
[No workers'comp.insurance required]
4.❑I am a homeowner and will be hiring contractors to conduct all work on myproperty. I will 10 ❑ Building addition
ensure that all contactors either have workers'compensation insurance oare 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. of repairs / ] p
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. l4. Other Aj U /Q/`/�e
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 contactors must submit a new affidavit indicating such.
tContacmrs that check this box must attached an additional sheet showing the name of the sub-contractors and state whether ar not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providug workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Ad-lout �it Ch Gley€( �1
Policy#or Self-ins.Lic.#: (Aft t e 13q ,i f!/') Expiration Date: H 2 f 7
lob Site Address: 44 Briar C t if City/State/Zip: Yet 42,,,(h A-41 Z Lj
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 certi under the pans and enalties of perjury that the information provided above is true and correct
Signature: a/ Date: tri—D‘l ^ I17
Phone#: SQ I A3'1.35g 3
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.
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 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 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 •
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.ocrov/dia
HOME OWNER WEATHERIZAT1ON WORK PERMIT:
. PLEASE COMPLETE AND SIGN THIS FORM AS THE APPLICANT HOMEOWNER.
I 5,V''t% 1 'O0wr"-, hereby consent to and agree that weatherization work
may be done by the Weatherization Program of Housing Assistance Corporation on the property
located at:
Gl 231/(-)it- C,2 fr gL&,
The weatherization work done will be based on programmatic priorities and availability of
funding and it may Include all or some of the following measures:
Weather stripping; air sealing; attic&basement insulation; exterior wall insulation;ventilation
measures In consideration of the weatherization work to be done at my home I agree to the
following:
1. I give permission to Housing Assistance Corporation to access the property with such
equipment and materials as may be necessary to perform weatherization.
2. The Housing Assistance Corporation reserves the right to inspect the fuel or utility bill for
the weatherized unit on an ongoing basis for no more than five (5)years after the
weatherization work is completed.
�s°i . o� 7
o�. 3C.
I have read the provisions of this agreement and give my consent. O/( 4-
Home Owner(signature) - _:
Home Owner email: Date:
Agent:(sIgnature) Date:
Agency Approved Wea erization Company
All Cape Energy Alternative Weatherization
Cape Cod Insulation Cape Save Cazeault
Frontier Energy Solutions Lohr Home Improvement
Agency Signature: 1 Date: ) 't I8
For Natural Gas Customers:
I have received the National Grid Discount Rate Application form from my auditor.
Customer Initials
•
Commonwealth of Massachusetts _
'.7 Division of Professional Licensure
Board of Building Regulations and Standards
ConstrUction.SU$&niisor Specialty
CSSL-103842 u• ' ''r ^- E�ires:02/23/2020 '
SHAYNE DEWITT, '-•a ' ' ,
161 COMMONS WAY .1 ' = '%-1
BREWSTER MA,02631 * r -
I 01W-1:10,*AS Li- 's'
r � la-..---s- 1.•i-
;
Commissioner
'^'
l/
C. re Wm'momenta eibitauadmie/11 .
OMee of Consumer Affairs 8 Business Reoula0on
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only •
TYPE:individual before the expiration date. H found return to: •
Fealstratiorl N LaSratIon Office of Consumer Affairs and Business Regulation
166088_—=i 06/09/2020 1000 Washington Street-Suite 710 ,
SHAYNE DEW ITT•F-..2,---.,-;.:-.H,'� Boston,MA 02110
DB/AALL CAPE ENERGYi=_ ' •
.,
iY t.,2.;-, is '.'
SHAYNE DEWI7T'=,C�:-'-i-E.:74;'� ��71/^/ �,/ ,
161 COMMONS WAY;=§34
BREWSTER,MA 02361:_x"' Undefsecrewary Not valid without signature
•
ACCPRO • CERTIFICATE OF LIABILITY INSURANCE• °"012
THIS CERTIFICATE B ISSUE AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDS) BY THE POLICES
SOW. TNS CBtTIRCATE OF INSURANCE DOES NOT CONSTITUTE'A CONTRACT BETWEEN THE ISSUING ONSUJRERW), AUTHOR/Mt
REPRESENTATIVE OR PRODUCER,AND TIE CERTIFICATE HOLDER.
IMPORTANT: If the uTUtieS holder ban ADDITIONAL INSURED,the,.. &yges)amt be endorsed. If SUBROGATION IS.WAIVED,subject to
the teras and conditions of the policy,certain p may ruins an endorsement A stateewA mthb Certificate does nal corder rights to the
rile hofda In In of such endorsement(s). - .
PRODUCER ACTmime Linda&divan
DOWLING&O'NEIL INSURANCE AGENCY , ,s (sob)7751620 I ram*
1 =um hulliven@doascom
9731YANN000H RD VISURERISHWORDI SCOVE AGE Nets
HYANNIS • MA 02801 RRsa3e A: ATLANTIC CHARTER INS CO 44326
INSURED USURER a:
ALL CAPE ENERGY INC •
Tsar..:
INSURER V: •
PO BOX 1492 MEUR R E s '
BREWSTER MA 02831 INSURER Fs
COVERAGES CERTIFICATE NUARBEW 233251 • REVISION NU EC
THS IS TO C811WY THAT THE POLICIES OF INSURANCE LISTED BB.W HAVE BESt ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATE). NO1VWHHSTANOBIG ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO VA-UCH THIS
CERI1RC ATE MAY BE ISSUED OR MAY PERTAIN,THE ASSURANCE AFFORDED BY THE POLICIES DESCRIBED MEIN IS SUBJECT TO ALL THE TI MMS,
EXCLUSIONS AND CONLITOHS OF SUCH POLICES LENTS SHOWN MAY HAVE Bim/REDUCED BY PAD CANS.
NM ADOLISUDIT •
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UMBRELLA oeaR EACHOCC OCCURRENCE NCE a
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. n-1.DESCRIPTICIIOFDPeUCTIONS/LOCATIOICHVBICLEIS(ADaoi m,Aee•s,r lY orke Se tli,,way naWSW.no Jonas wqureq .
Walters'CarpaISSOm benefitsNM be paid to Messsdumdls employees only.Rasura b EndonsenentV1C 200306 B.no authorization is given b pay
claims for benefits to employees H dales other than Ithissadiusetb Vele irssed hies,or has bled those employees outside dliassadawels.
This wtifca a of insurance dews the policy in force an the date that this certificate was issued(ams the expiration date on the above polo'peoedest e
issue dale of this oeSilbfe of insurance). The stars of coverage can be mated daly by accessing the Proof of Coverage-Coverage Visitation
Seardn kid vanwmass.govthravathersainpensatiarigoresligationst
ot
CERTURCATE HOLDER CANCERATION
SHOULD ANY OF THE ABOVE DESCRIBE)POUCIB BE MICELLE!)BEFORE
THE EXPIRATION DATE TIERIEOF, NOTICE WILL BE DELIVERED N
- DANCE WMTHE POLICY PROVISIONS.
• .. aUaa®REPR6ePrATive
I , Daniel a ConWey,CPCU,Vice President—Residual Markel—WCRBMA
• 619862014 ACORD CORPORATION. A2 rights reserved
ACORD 25(2014101) - The ACORD nine and logo se registered mals of ACORD
C8eH10:762494 MUMMER
ACORQI. . CERTIFICATE OF LIABILITY INSURANCE • DA1ENI XOTTI°
01/18/1018
INS CERIt-CATE6ISSUED ASAMATTIS OF INFORMATIONONLYANDCOIFEFsNORIGHTSUPONTHECEITFICATEHOLDBi1MS
CERTIRCAIE DOES NOT AFFIRMATIVELY OR NBGA11YE1.Y Amer,EXTEND OR ALIERTit COVERAGE AFFORDED BYRE POLICIES
BELOW.MS tat,. CATEOFl6iM WCEDOESNOTCONSTITUTEACONRGCTBETWEENINEISSLI GRAS),AUTHO .
REPRESENTATIVE OR PRODUCER,ANOMIE CEBDFIGRE HOLDER. .
t8ORTANT:M the eaMiesis holder b a ADDITIONAL MSLR IA the poteyf es)must be redeemed.M SUBROGATION IS WANED,subject to
U etems and eanadens ofthe policy,ambit Pestles meq ogee an endorsement.A_-ate eedathb retina to does not corder IIFtstothe
wake holder is lea of such aldeeamet(a).
MOONIER CONTACT •
'
Dow6Hg80?leBMwrmlceAgymetme50877s1e - 1 ma><5067/81218 •
973lyammugh Road EMAIL
P.O. ANDREAE
Box 1990
IIA 02W1 mmmE>MgARdl0mmO0IelAE NEC*
■SURE1A:�A+■�oS. 41297,
INSURED INSURER a:
A8 Cape Energy Inc.
ab ayne E.Dewitt ■mmm e:
Mayne .
PO Box 1492 - ,
•
Brewster, 02631 ■e■BRE: •
es■Ia F:
COVERAGE tats CAIS MttBEttr REVISION MUMMER:
THIS IS TO CERTIFY THAT TIE POLICES OF NSIEANCE LISTED BELOW HAVE BEEN ISSUED TOT1E INSURED NAMED ABOVE FOR TIE POLICY PERIOD
PLICATE" NDIWIB STANDNG ANY REDuRB6lf,TEEN OR CONDITION OF ANY CONTRACTOR MER DOCUMENT wmi RESPECT TO WINCH THIS
CERTIFICATE MAY BE ISSUED OR MAY PSLTAN, WE INSURANCE WORDED BY TIE POLICES DESCRIBED MIN IS ALT 10 Nl THE 1MMC, .
EXCLUSIONS AND COMMONS OF WI POLICES. LENTS SHOWN MAY HAVE BEEN ppREDUCED BYPAIDEasia .
seoustar
MIR AWE OFI NINANCE MISRPOEM RUMEN Ila�esnTYYI Uaim
A oe■ at.tIAan CPS2993246 01/12/2018 01/12/2019 EACH OCCURRENCE s1,000,000
X faann,LMEALENMITY °") DITTaxe) s1001000
a.AeISNAOE p.. IED DTOng maporn, s5,000
—
PEBOINLAACV PURIM $1,000,000
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•
OEZWIEN OF OPERANCINS/LOrJUIONSMEICES Nadu WOW/a.--- -Is_a Biri/R tea as InquIRNSS_-Certificate of of knura lee tar workers compensation w81 be issued by the carder. - ,
CERTFiCATE HOLDER CANCELLATION .
. SNOLLD ANY OF THE ABOVE DESe7IMED POLICES BE CANCELED BEFORE
THE DBNATTDN DATE T E RME, WILE NEL BE DELIVERED N
ACCORDANCE MITI THE POLICY PTOYISDP6
- AI■lee®eERONEIrtall,e • -
•
C 18862010 AOOFID CORPORATION.Al rights reserved
ACORDx0R01 ) 1 oft Thes ACORD lame end logo a.sgbteroamarks of CORD '
d'32M LSt