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Home My WebLink AboutBLD-19-001989 a Office Use Only 1 / og.'VAR 1 : gi 1Permita .Ni ,� 4y Amount 0— i Permit expires 180 days from e >;=•' 3 issue date EXPRESS BUILDING PERMIT APPLICATI i►► JI Cfripv l a VI • TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 OCT 03 2018 South Yarmouth, MA 02664 • (508) 398-2231 Ext. 1261 Bui1SERTMENT '7 !! ti. leer _ ', CONSTRUCTION ADDRESS: G/ rr WCi rn(io/100.2. ICS ASSESSOR'S INFORMATION: L • Map: R_ Parcel:sJ OWNER: �/1G./ Casey 711f 1../nmoo"q C/78 'S Li 0, '• a 9 �/2 NAME / PRESENT ADDRESS TEL. # CONTRACTOR: Aa>Ll'w ti.4. y*cc 3 NY,I,, it LA/ 7?if -3 7e -Sit<r NAME -J MAILING ADDRES TEL# 16esidential ❑Commercial Est.Cost of Construction$ (,, 000 Home Improvement Contractor Lic.# /2(9-3 c1 > Construction Supervisor Lic.# ..S -0 7// /y C R.CAeL Vit,,,,< Workman's Compensation Insurance: (check one) 1' 0 I am the homeowner 0 I am the sole proprietor 'jI have Worker's Compensation Insurance Insurance Company Name: 0 n wI rni 42 0/1 e / Worker's Comp.Policy#L/(( coo co/8t7 s/„10 keg WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) , Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares /A ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dista ( )/Reeplacing like for like Pool fencing "The debris will be disposed of at c 6 ) /: kC o, 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 of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: el- n,(��-- Date: '0 -3- /41 Owners Signature(or ebment) 4., o_ _ Date: A.0 I— (3) /a— Approved By: Date: _,-1�fr Build , j.1 lord srgnee) E ADDRESS: 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 r The Commonwealth of Massachusetts `j _,_, _ / Department oflndustrialAccidents =rel= 1 Congress Street, Suite 100 -.14=41,7," Boston, MA 02114-2017 �ze.? 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 / • a • e - 1. A. . I Address: 3 (JycI& L.,/ay L 1 City/State/Zip: I pan,'Slonr I- MA O, C&7Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1.0 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. I am a homeowner doingall work t 9. ❑Demolition ❑ myself[No workers'comp.ntsurance required.] 4.❑ my P Pent• I wi71 I am a homeowner and will be hiring contractors to conduct all work onro 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. 5. I am12.� lambing repairs or additions a general contactor and I have hired the subcontractors listed on the attached sheet ese sub-cont-actors have employees and have workers'comp.insurance.: 13. Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 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'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. :Contactors 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-contactors 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 and job site information. Insurance Company Name: -one 4,./ I t1 a t^Y/)t_r! Policy#or Self-ins.Lic.#: id CC coo So(5 l t/3t9fpf} Expiration Date: v,s":70 I/ /Cl Job Site Address: 7y G✓r'{M pi)n oaf 12 City/State/Zip:61 a4 y.caer.k Mf 022-'/ Attach a copy of the workers' compensatfen 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. Signature: 4j �,e__ Date: /o ' 3—// - Phone#: 77q- 1 )4'-- 3f0 f1 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#: • :• • 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 advisedthat 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. # 617-7274900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia • r.. Commonwealth of Massachusetts Division of Professional Licensure • / Board of Building Regulations and Standards ConstroottOritOpervisor jr,spires:08/20/2019 CS-071114 < 4, ._754 : 2 • 'RIC H AR D IN GURNEY , 19 REDWOOD1ANE •!V HYANMS MA 02€01 , . 9,4 • Me Commissioner i •, Fewz.woneveaadydgezalaerewelt • .4; Ma' ta14.aitt:..tr Affairs 4:t.Vainess RegwAthan ‘-f HerlilitleiMPROVAIW.F?NTRACTok "c51 E7,1th:thikn • -‘4.A182828T-*,:s.:74R28/2019 - rs. JOHNAli-IAP,:triAdtlEe • Wijilti"Ei,11;•31 9 L' 3 ENDA WAY LHIP-.4 ..7,thriI. • 69-r-Ceee--. • ,DENNiS'P.DECri.i.4,:02b19 •, .0 L. t • Ap\ .. A .1±7 pndettecretary. -rst 9fiat) • leij:St teStriCtila)3Sed,00-0:eulintrngrUCtS Ori°1141n:cubiljUSPeraWre CgrrneiMIPerthilOar ealndentatiMedit • bie fee( . sPace. • . • scrttaBuie Ithn9 aurrencauset ecialfor ran of the Massa.e.husefts I For info„natan- abet • 1° °t ni"°Hills license, a tien Call Oln 727-3200 or visit www.magCsiSegowds ' Client#:763053 2WAGNERHO ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIODIVYYY) 08/16/2018 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(les)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: Dowling&O'Neil Insurance Agy PHON;,Eat);508 775.1620 FAX 5087781218 973 lyannough Road E-MAIL (A C,Na): P.O.Box 1990 ADDRESS: Hyannis,MA 02601 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:NGM insurance Compow 14788 INSURED INSURER B:Mondani rmpl Wen Insurance company 11104 John Wagner DBA Wagner Home Improvement 3 Hydaway Lane INSURER C Dennisport,MA 02639 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 MY 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 ADDLSUBR POLICY EFF POLICY EXP LTR INSR WVD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) LIMITS A GENERAL LIABILITY MPT9986V 02/12/2018 02/12/2019 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES(EaElogance) $500,000 CLAIMS-MADE a OCCUR MED EXP(My one pecan) $10,000 PERSONAL AADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $2,000,000 —1 POLICY IGI JF O 130 I LOC $ AUTOMOBILE LIABILITY (EO BBBIINEDISINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ — ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS _ AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ _ AUTOS (Per accident) $ UMBRELLA UAB _ OCCUR EACH OCCURRENCE _ $ EXCESS LIAB CLAIMS-MADE AGGREGATE _$ _ DED RETENTIONS $ B WORKERS COMPENSATION WCC50050188942018A 05/21/2018 05/21/2019 X WCSTATU- FRH• AND EMPLOYERS'LIABILITY TORY I IMITS FR ANY PROPRIETOR,PARTNERIEXECUTNEYIN E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? NIA (Mandatory In NH) E L.DISEASE-EA EMPLOYEE $500,000 Ifyes, IPTIOeunder DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT *500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained In the certificate of Insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. Insurance coverage Is limited to the terms,conditions,exclusions,other limitations and endorsements. (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION Jesse Downing SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 619 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Harwich,MA 02645 AUTHORIZED REPRESENTATIVE ..� —e-7 es ®1985-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 2 The ACORD name and logo are registered marks of ACORD 1/S217584/M217583 NS2