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Home My WebLink AboutBLD-19-001695 & LA_ r P-efr,„ RECEIVL.__1 // I SEP 21 2C:'.1 CAN v s h C e CA- L/ BUILDING DEPA /2,,emav c ; LAr Ox po R Qe //a--i4\ +— Veoz — 1 � .. E,�Y W Office Use Only . O 9R e . /. .0:£ .. ,, o, 3Permrt# ,D C ru O YMrI ;Amrnmt C + . ._,� r,� '}Permit expiry 180 days from - issuedate 1 BLD — 19- Dbt Q- EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 SEP 20 2018 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 By itsear -' i T(p CONSTRUCTION ADDRESS: 7c 4,40//tZ R2'ae . si xae ASSESSOR'S INFORMATION: Map: ' Parcel: OWNER: PAWL A'475-A?X) t F GAw1'M e . NAME PRESENT ADDRESS TEL # . CONTRACTOR: W iz/XU CaZ /4V Ed/ RESS So e sc7TEL-gti2- —L'C22 NAME MAILING ADDL4esidential 0 Commercial , ��Est Cost of Construction S/1/1,1 Arne Improvement Contractor Lie.# /4/799-7- I.eonstruction Supervisor Lie.N /L9(353-7 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor velhave Worker's Compensation Insurance t//Insurance Company Name: 792491/mzrA5 Worker's Comp.Policy# OR tWete 94/72 WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 2'45-- ( )Remove existing"(max.2 layers) Insulation Old Kings Highway/Historic Dist ( )Replacing like for like Pool fencing 'The debris will be disposed of at YiOQinin9T,S° 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 revoc n of my license and for prosecution under M.G.L.Ch.268,Section 1. 00.c." Applicant's Signature: (ee Date: Owners Signature(or attachment sr `Date: Approved By: Date: 9 'Tjj' din ci (or designee) , I ADDRESS: Zoning District. Historical District 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 R of Wetlands: 0 Yes 0 No 0 Yes 0 No =Tr—r— The Commonwealth of Massachusetts ,� e�=sit=r Department of Industrial Accidents int= 1 Congress Street,Suite 100 _ 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 Leoibl' Name (Business/Organization/Individual): cnj/7,e9 c 2t l aiti Address: /91.,vh/averir7r•, LA, City/State/Zip: .,ypy1,f.710 0174,93 Phone #: cra7—fdt15-27, Are you an employer?Check the appropriate box: Type of project(required): l.12I am a employer with 3 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 • capacity.[No 8. remodeling any ap icy. workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself9. ❑ Demolition mys [No workers'comp.insurance required]t 4.0 I am a homeowner and will be hiring contractors to conduct all work on my 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 5.0 I am a general contractor and I have hired the sub-contractor listed on the attached sheet These sub-contactors have employees and have workers'comp.insurance.: 13.❑Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL e. 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 affidavit indicating they are doing all work and then hire outside contactors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contactors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide thee workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: 7/..:'7l/ena-7?-.j Policy#or Self-ins.Lic.#: tjQ 9zete 9 1/22 Expiration Date: 0///7 Job Site Address: 2t�,i"j2/I/pjdob'f- '' City/State/Zip: 4,1/az /%t erZie LLy 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 the pains and penalties of perjury that the information provided above is true and correct Sienature: it: Led ! Date: 9r / j Phone#: 0-7791‘i.1. e<On J 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 persiin 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-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 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 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 t M ACCORD'oCERTIFICATE OF LIABILITY INSURANCE 1 °""""" �' °°" THIS CERTIFICATE IS ISSUED AS A MATTER OFINFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDSR 1 TMS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POUCIES 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 certtfcMe holder Is en ADDITIONAL INSURED,the polky(Iss)must be endorsed If SUBROGATION IS WAIVED,subject to the tans,and Sorditlona of The po6Gy,certain polls,nay require an endorsement, A statement on this cernit:ate does not confer rights to the aeetlRcets holder In Hsu of such rtdrwnenl(s). mown grit` Kathleen Geddis NORTHWOOD ESHBAUGH INSURANCE AGENCY INC Met. (sot)771.1632 640 MAIN ST ICEthisrl.Geddisaspolns coal --_ -- - IlammtplAnomwocovmAaE __ ruK• HYANNIS _ i MA 02601 .snn A: TRAVELERS INDEMNrTY CO OF AMERICA _ 25666 DAVID COX INC mea: ------------ -_ PO SOX 401 awn. - • S YARMOUTH . MA 02664 .-�."-- -' EBIIRm F: I COVERAGES CERTIFICATE NUMBER: 171517 REVISION NUMBER: THIe IS TO CERTIFY THAT THE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING MY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WM4 RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTNN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 18 SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POUCIEO.LIMITS SHOWN MAY HAVE BEEN REDUCED SY PAC CLAIMS. EIRIEBIE•T5 TWO CRYMIPIAMCEwon,- POU(,NW161 ,..n� -- yen_ :.._._.___. _ _ c'—'ICA SEeQrAL LMRLRY -1 EACHOCCURRENCE E I CLArbMADE 0OCCURammetratbareersona.._s �LW[OrCEY6TIERTEtl•-.•- -._ — - _- -MED LEP WIcestriaA1.. _$ .._.... -- ._. WA PERSONTLE ADEIIUORY $ OE''''R7777KAOOREGA7[UNITAPPIue PEA: GENERAL AGGREGATE $ -_-_ POLICY a]n ❑LOC PRODuf:TS`eOASMOPEOO f .------- OIHEI t AUTOIIDeRlWMLm =SINGLE E _ NW AUTO ."' 0.-.- _._._.-._-.- LI--••TT W00.YNRRRYwrern E __ AUTOALL S SON° IIiiy WA WWI 1As0 INJURY e(P V eetlEmn E _ _._ • HIRED AUTOS �AUTD PROPERTY rte- s RNLLSA IW — OCCUR EACH OCCURRENCE _ E •- NRslKas IJAM 6LAAtlsMDE WA AOOREOATE _ .E .__-•_ _..-^ OW I 1 gimmicks --'--"_ AND NOLCOfitsew N $ ANpeYROYEp'L4eWTT' x61.61 m.L.). H'--_- A µ�F YMRAu naDLwe m�"v E rw WA WA eHUBet°X742217 07/16/2017 07/1612018 EL.TACH ADwDENT „ _s_100�000_ -_— E��ww,,��eMRbayM El.DISEASE-EA EM?LOYEE f 100.00° --- OMR/ANON r OPEMvONS wkr, EL DISEASE-POLICY LIIMT 5 500,000 _ _ WA , unarm OP OPOMTYNts I LOCATIONS/WHOLES 15/ZORDMT,A.MINNI1 Reerb Samba mai be OWNS Sam won iseanYq Waters'Coripeneetbn benefits ME be paid to Ma athunetls snpbtea only.Pursuant to Endorsement WC 20 0306 B,no authorization roNen to clime for benefits to employees In mss than an Mecsel3Rusetts t the Insured Nese.or has hired those employees outside of Maach seta. pay This certficate of insurance shows the policy In tap on the date that ads&Man wes Issued(unties the expiration date on the above policy Precedes the Issue dale of this estMeate of Insurance). The statue r this oovrsgs can be monitored daily by accessing the Preet of Coverage-Coverage Verification South tool et www.mess.pov/wdbA'orkers-compauataRRnvestlg Bonet. CERTIFICATE HOLDER CANCEWTION ammo ANY OF THE ABOVE DESCRIBED POUCIES ea CANCELLED BEFORE THE IMPUTATION DATE THEREOF, NOTICE WILL BE DELNERID N Town of Barnstable ACCORDANCE wrtHTHE FDLIerPROVISIONS. 200 Mein SI AOmOR®RerHIMOITATNE Hyannis MA I 02601Dank!M.CraArey,CPCU,Vice PresPresident-ResIdual Market-WCRiBMA O 1866.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Wounamemala ofQ/6.m craw AM office of Consumer/asks&19ustriass nagufason ' HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Canoration before the expiration date. V found return to: 8 ion E7ml131098 Office of Consumer Affairs and Business Reputation 100497 - 03/242020 10 Par[Plaza-Sults 5170 DAVID COX INC. Boston,MA 02116 /�/./// DAVID R.COX •��//!L /VC / 19 LAVENDER LN W.YARMOUTH.MA 02673 Not Valid withoutsl nature Undersecretary Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards . • COnstruetMit ISSpSrvisor • CS-063537 r =a F.Apires: 10115/2019 L DAVID COX- '•-/ - PO BOX 401 .t• %, ', SOUTH YARMOUTH MA-0266%t } �. i Commissioner art • • • • ••