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Home My WebLink AboutBLD-19-001457 + Yea ce use rimy •ed jog "R -19DD/ 7 . . ..ste. ! C i O ••Qn!I 4 ¢AmountucctrmarXi, e P . yPermit expires 180 days from .. (issue date ; EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508)398-2231 Ext./1261 02- ,�� „7 CONSTRUCTION ADDRESS: i LI ASSESSOR'S INFORMATION: • Map: �` �YfC�1 Paarcc�el: p ¢ OigNER: //►a 9-44`G 14" 'E PZ4 elT ADISRESS O - `�T9/#Q e77 CONTRACTOR NAME � t lkOr4` c*eAVAI) 0LL a S 4 5v l 776S7:66 MAILEN DRESS kesidential 0 Commercial �7 Est.Cost of Construction S 4ti&t Home Improvement Contractor Lie.# /2 1S ?6 Construction Supervisor Lic.# © €a RCS" Workm7g Compensation Insurance: (check one) U" I am the homeowner 0 I,amt the sole oprietor 0 I have Worker's Compensation Insurance/' Q /,t �j J� /�j n Insurance Company Name: TAJkS.4 i^'Q{y L� Worker's Comp.Policy# l9 J b 6 Ug� T 2t7 �e 7 l'�` WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares cz Replacement windows:# Replacement doors: # 'Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( ))Replacing like for like Pool fencing y -- �i 'The debris will be disposed of at \ /`. L 1 Y Location of Facility / I declare under penalties of perjury that the statements herein contained are true and correct to th best of my knowledge and belief I understand that any false answer(s) will be just cause for denial or revoc on my license and for prose .n under • G.I.Ch. ••,Section 1. Applicmtt's Signature: d ••C (� I Date: �o /( / W 5) Owners Signature(or attachment) L_ir1At'A-� (/ , Date: Q Approved By: /�� - / Date: 7—///EJ +• (or designee) • S'DRESS: 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 ofMassadhusetts cDepartment of Industrial Accidents te= 1 Congress Street,Suite 100 f= Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A.alicant Information Please P int Legibl Name (Business/Organization/Indi 'dual): WaarfalLTHMII Address: • ,_e `! UL% City/State/Zip: At Phone#: CO s . C• ( Are you as employer?Check the appropriate box: Type of project(required): a employer with employees(full and/or part-time).* 7. ❑New construction 2.❑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. I am a homeowner doingall work 9. 0 Demolition ❑ myself[No workers'comp.insurance required]t 4.❑I am a homeowner and will be hiring contactors to conduct all work on my property. I will 10 0 Building addition ensure that all contactors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contactor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance: 13.❑Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption14.❑Other per MGL e. 152.§I(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'compensaton 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 mlher. I am 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.#: S • `:c — 9/ 6� ? Expiration Date: S l /2' Job Site Address: A- S ( CIA City/State/Zip: H9gg 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, ander .. j a[n: of perjzt , „ the information provided above is true anddccorree it Sierlature Date: L1 ,56,5621 -��ITT• 1a6 Phone '. � 2 9 L 1 ` 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.CityiTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: J . • 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 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 advisedthat 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 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 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. # 617-7274900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-I5 www.mass.gov/dia PR CERTIFICATE OF LIABILITY INSURANCE DATE iiM/DEIG8 I RTIFItATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS ICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED SENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. rANT: If the certificate holder is an ADDITIONAL INSURED,the pollcy(ies)must have ADDITIONAL INSURED provisions or be endorsed. IODATION IS WANED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on tifioet•don not confer rights to the certificate holder In lieu of such endorsement). coma John McShera Marshall K Lovelette Insurance Agency Inc NAME: 396 Main St NI, E„I. (508)775-4559 FAX Not 775-4577 West Yamouth,MA 02673 ADDRESS: iOhn@Iovetetteins.com INSURER(S)AFFORDING COVERAGE NAIC e INsuRER A: Westrern World Insurance Company 17370) Healy Brothers Construction Corp INSURER B: 72 Old Main Street South Yarmouth,MA 02664 INSURER C: INSURER D: INSURER E: INSURER F: ICES CERTIFICATE NUMBER: REVISION NUMBER: TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD IED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS ICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, TIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. .TYPE OF INSURANCE ADOL SUER POLICY EFF POLICY EXP INSD WVD POLICY NUMBER IMM/OD/YYYYI IMMIDDIYWYI LIMITS COMMERCIAL GENERALLIABILT' NN850791 01/09/2018 01/09/2019 EACH OCCURRENCE • S 1,000,000 CLAIMS-MADE OCCUR DAMAGE 10 RENTED °100,000 PREMISES la occurrence) S MED EXP(Any one person) S 5.000 PERSONAL a ADV INJURY S 1,000,000 I.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 POLICY JPRO-EECT U LOC PRODUCTS-COMP/OP AGO S 2,00Q000 OTHER: S )MOBLE LUBILitt COMBINED SINGLE LIMIT S (Ea occldeno ANY AUTO BODILY INJURY(Per person) S OWNED —SCHEDULED AUTOS ONLY _ AUTOS BODILY INJURY(Per ersiaetn) S HIRED NON-OWNED PROPERTY DAMAGE S AUTOS ONLY _ AUTOS ONLY (per accidenll S UMBRELLA LIAB — OCCUR EACH OCCURRENCE S EXCESS DAB CLAIMS-MADE AGGREGATE S DED RETENTION S S KERS COMPENSATION PER 0TH- EMPLOYERS'LIABILITY Y/N STATUTE ER PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT S ERAIEMBER EXCLUDED/ ❑ NIA theory In NH) EL DISEASE-EA EMPLOYEE S describe under Z.RIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S ION OF OPERATIONS I LOCATIONS I VEHICLES IACORD/01,Additional Remelts Schee.,may be attached N mon space Is Required) ICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Rt 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE - A. pC atc- ®1988-2015 ACORD CORPORATION. All rights reserved. 3 25(2016/03) The ACORD name end logo are registered marks of ACORD aMassachusetts Deparintentof Public Satety , `• ;-VIP Board of Building Regulations-and Standards':kf License: CS-060855 Conntructicri Supervisor • `•MICHAEL A HEALY 72 OLD MAIN ST - SOUTH YARMOUTH MA 02664 - . • • • , 015a`— • Expiration: ' • Commissioner _ • 11/22/2018 Cc.720 Crommoi;romfrif,0 70/110 1.10 4141//6 Office of Consumer Affairs&Business Regulation ,-• { HOME IMPROVEMENT CONTRACTOR .;-.,TYPE:Corporation -, Aeglstratlorl FxnlratIon ,ec- • 181360.,. 03/24/2019 HBROTHERS CONSTRUCTION,INC.• MICHAEL HEALY'=; ▪ ,',' 612-Cal - 72 OLD MAIN ST u SOUTH YARMOUTH,MA 02664 Undersecretary • • x ' •