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Home My WebLink AboutBLD-19-1747 ,h • 1 • OT Y"V? ,Office Use Only i AO I Permit# 011.' C _5O— N 'SI ' 'Amount s-� Permit expires 180 days from , issue dale rath-I9-0011(17 EXPRESS BUILDING PERMIT APPLICATION- RECEIVED TOWN OF YARMOUTH Yarmouth Building Department I 1146 Route 28 SEP 2 4 2018 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 4.'0BUIL ' 'l� ? ' ) By. CONSTRUCTION ADDRESS: 1/ /11 Ld+-te UnnerwFh 1 %AT- Oaw 4 ASSESSOR'S INFORMATION: Map: QZ6 Parcel: 20 OWNER: 6 iur t'2nr ftezlry /V (:ttcf3 �o64re“ “4Q DZo72 7B/35f/-yam NAME n PRESENT ADDRESS TEL. # CONTRACTOR: /Maid/ (lop, /Ysss fazed sT, S7 occ7oK wrD. 02072 767-3W—5/83O NAME MAILING ADDRESS TEL# Residential 0 Commercial Est.Cost of Construction$ (/Coot) Home Improvement Contractor Lie.# /(09104 3 Construction Supervisor Lie.# CS—09/i7/ Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor g 1 have Worker's Compensation Insurance Insurance Company Name: Federal \njtronce Cf11Y1pnt 4 Worker's Comp.Policy# non 4%t Rnas WORK TO BE PERFORMED • Tent Duration (Fire Retardant Certifica .ed?) Wood Stove Siding: #of Squares , Ofr Replacement windows Replacement doors: # Roofing: #of Squares • ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. `I( )Replacingtlike for _like ' Pool fencing *The debris will be disposed of atTF&.A ) C� lacivta t't aS{.D bJ At- &ay Cues ?a. v\lAfrra...th 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 revocationp f my license an�d�o/r prosecution unde/r M G.L.Ch.268,Section 1. /7�y1f �7 Applicant's Signature: on U--e.4174'�"v l Date: [//O / /` Owners Signature(or attachment) ` -• $ r y y�-1"Tnr*tt. Date: lQ/�( ii S Approved By: ,+rte!- , p Date: / � —/g Buil. g O `ml(. designee) seP'IL ADDRESS: actt ies- Zoning District: CAg-8E0S'c9'V f/ Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes C No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No r The Commonwealth of Massachusetts _ett Department oflndustrlalAccldents = 1 Congress Street,Suite 100 _EN Boston, MA 02114-2017 %AZ: www.mass,gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH TUE PERMITTING AUTHORITY. Applicant Information /� Please Print Legibly Name (Business/Organization/Individual): ,41,42l v/ /l..ogio, Address: /( S [pc-id 5 ( - City/State/Zip: n606lLTmc(ma- Ocb72-Phone#: 7e/—r3Yl ' y800 Are you an employer?Check the appropriate box: Type of project(required): am a employer with Aro 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.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[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 contractors either have workers'compensation insurance or arc sole 11.0 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 13,❑Roof repairs These sub-contractors have employees and have workers'comp.insurance? 14. Other W clout ger�eXe 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. (�] i Vt 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 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 number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andfob site information. _ Insurance Company Name: iflif[ral \I1"i tTlflfp. Q'k11paal Policy#or Self-ins.Lie.#: 00541)0q�t'Q l Expiration Date: Q I')OI la - q ISO 119 Job Site Address: ///%-e/, Lang City/State/Zip: ) s"4-0071-t a ozegy 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cera r the pains and penaltie of ury that the information provided abov is true and correct Signature: �� _ '" • " .' t/ 1(2.623 Date: 9. 41 i/ S Phone#: 7(?/'3 9 I -yam Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permlt/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: • • • • Mf ele rommonweala a`'©'tfauaeAiautA Office of Consumer Affairs 6 Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:IndMdual 'r Registration= gxoiration • 169643 _ 02/25/2020 SCOTT PIMENTAL SCOTT PIMENTAL'1: <_••_7:, 125 CURRIER RD. EAST FALMOUTH,MA 02536 Undersecretary M ®, Commonwealth of Massachusetts Division of Professional Board of Building Regulations and Standardsure COnstryiCtiyn$o jJeNISOr CS-091917 • Lrd�ires:05/09/2019 SCOTT G PIMENTAL -a 125 CURRIERTjD E FALMOUTH Mq 02536"� Commissioner Cele r 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 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 contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting 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 bum 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 ACORIS CERTIFICATE OF LIABILITY INSURANCE GATE(MM DDA YYY) `„/ 9/20/2018 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 have ADDITIONAL INSURED provisions or 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 Boston-Alliant Insurance Services,Inc. PHONE Stephen Turner FAX 131 Oliver Street,4th Floor (AIC. Xt'617-535-7200 (ANC,No):617-535-7205 Boston MA 02110 ADDRESS: sturner@alilant.com INSURER(S)AFFORDING COVERAGE NAIC 0 INSURER A:Executive Risk Indemnity Inc 35181 INSURED MWLLC-01 INSURER B:Federal Insurance Company 20281 A.A.Will Corporation 145 Islandd Street INSURER C:Allied World National Assurance Company 10690 Stoughton, MA 02072 INSURER D:Water Quality Insurance INSURER E:Allied World Assurance Company(U.S.)Inc 19489 INSURER F: COVERAGES CERTIFICATE NUMBER:853126310 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 MI ADDL SUER POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER (MDDIYYYY) (MN MD/YYYYI A X COMMERCIALGENERAL LIABILITY 54309528 9/30/2018 9/302019 EACH OCCURRENCE 51.000000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $100000 MED EXP(My one person) $5,000 PERSONALS ADV INJURY $1000,000 GENT-AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE 52000.000 1POLICY X Ter. 0LOC PRODUCTS-COMP/OP AGG $2.000000 OTHER: $ B AUTOMOBILE LIABILITY 54309527 9/302018 9/302019 COMBINED SINGLE LIMIT 51009000 (Ea acradent) _ X ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ C X UMBRELLALIAB X OCCUR 0310-9519 9/302018 9/302019 EACH OCCURRENCE _ 120.000000 EXCESS LIAB CLAIMS-MADE AGGREGATE 520,000,000 DED RETENTIONS S B WORKERS COMPENSATION 54309529 9/30/2018 9/302019 x PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANYPROPRIETOR/PARTNERIEXECUTNE NIA E L.EACH ACCIDENT $1,000,000 OFFICERMIEMBEREXCLUDED7Ej (Mandatory In NH) E L.DISEASE•EA EMPLOYEE 51,000000 8 Yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 E Contractors Pollution Liability 0310-9515 9/30/2018 91302019 Each CIMMAggregale 15.000.000 D Vessel Poluton Liabddy 52-82099 9/30/2018 9/302019 Each Occ.IAggregale 15.000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached H mon space Is required) Evidence of Insurance CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, A.A.Will Corporation 145 Island Street AUTHORIZEDREPRESENTATIVE Stoughton, MA 02072 ©1988.2015 ACORD CORPORATION. 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