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HomeMy WebLinkAboutBLD-19-002454 IY1 7..i. .7.41t; r 'R� 3 a� 5e/ . ` j U tl y z4 o /SLyN!/J Oa ] y .Q• i it $' 1AP mowta jraermit expires 180.days from I issue date . EXPRESS BUILDING PERMIT APPLICATION • TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 . l�2. (l (508)398-2231 Ext. 1261 • CONSTRUCTION ADDRESS: G�7 "` �(x�S � (• 'l Ms4-0-3`11. ASSESSOR'S INFORMATION: • . Map: Parcel: . n OWNER: l 712-ACE ��1(Aac 2 2-5 1A'tC.eer"S • stt1 AA O 2_61 5 NAME PRESENT DRESS Vn/,,,,,, TEL it CONTRACTOR: ca G nl C,- QV' 1 t i�.6 , tl( PVL Q try fs NAME` MAILING ADDRESS TEL it esidential ❑Commercial Est Cost of Construction$600.12‘) Improvement Contractor tic,# f2 -/57 Construction Supervisor Lie.# O /M7 Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I the sole proprietor ❑ I have Worker's Compensation Insurance 1 �y - �/ Insonate Company Name:' \(� Q k }� Worker's Comp.Policy# 6S 61 v b P(O OS D Off((g • WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 26 ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Histo^ric^Dolt ( ))Replacing like for like Pool fencing "The debris will be disposed of at` Qi�� l�!{IV�Y`��- �. V. 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 undersand that any false answer(s) Will bejust cause fo • mono. ofmy c prose utionunder MG.LCh268,Section 1. Applicant's Sift / Date: 1,0 -2.S - (rfi Owners Signature(or attachment) i ,^.. Date: 1,0'?S ' . Approved By: - Date: 0 Building Ow.Ar—Ace) - EMAIL SS: - EIVED Zoning District Historical District ❑ Yes ❑. No Flood Plain Zone: 0 Yes 0 No OCT 25 2018 Water Resource Protection District r Within 100 R of Wetlands: BO •'I r:E• RIME NT 0 Yes 0 No 0 Yes 0 No ar: __ >PA .frac The Commonwealth of Massachusetts .1y n_--�_ .t _ _ Department oflndustriafAccidents =e1_ 1 Congress Street, Suite 100 Boston, MA 02114-2017 bc.,o,s4* www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leoibiv Name (Business/Organization/Individual): w-t Il-Q4 vAG N V C- Address: C) +L u LM3 City/State/Zip:g4QAt.p,� pqS MA- �O1$hone #: So g 50 9 LGh ciQ Are you an employer?Check the appropriate bat Type of project(required): I. <am a employer with I employees(full and/or part-time).* 7. ❑New construction • 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. o Remodeling • any capacity.(No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself[No workers'comp insurance required]t 9. ❑Demolition • 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I wuL 10 0 Building addition ensure that all contractors either have workers'compensation insurance or an sole 11.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.01 am a general contractor and I have hired the sorb-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance? 13.[ Of repairs 6.0 We area corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152,§1(4),and we have no employees.[No workers'comp. insurance required.] 'Any applicant that checla box Il 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. tContactors that check this bax 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 and job site • information. Insurance Company Name: iiz JMPT 14 • Policy#or Self-ins.Lemic.#: hg-06 Deb CoS l (45 Expiration Date: • I 0 - Job Site Address: lS 4'{ca�5 t City/State/Zip. - ' C ' Attach a copy of the workers' compensation policy de oration 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 ' ` der the pains and ..•.> of perjury that the information provided above is true and correct Sismatur a l. Oth• Date: 1,0'2.tv ' 18" Phone#: 4,b'-(cS Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: PermitlLicense# 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 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 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,sounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §250(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; §250(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 • requirement 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 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 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 I Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 61.7-7274900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia ACORE) CERTIFICATE OF LIABILITY INSURANCE DATE 09n(MR/DO/Yr/VI o/DOYa n 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 pollcy(ies) 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 ACT NAME: Linda Sullivan DOWLING&O'NEIL INSURANCE AGENCY PHONE pip. (508)775-1620 FAX c.No): rMCM ADDRESS; Isullivantdoins.com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAICI HYANNIS MA 02601 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B KELLY ROOFING INC INSURER C: INSURER D: 8 RHINE RD INSURER E: YARMOUTHPORT MA 02675 INSURER F: COVERAGES CERTIFICATE NUMBER: 316737 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 OFINSUMNCE ADDLSUBR POUCYEFF POLICY EXP LIMITSLJRmen Iwo POLICY NUMBER IMWDO/YYYY) (MMNB'YYYYI COMMERCIAL GENERALUABIITY EACH OCCURRENCE S DAMAGE TO RENTED MAIMS-MADE n OCCUR PREMISES(Ea ocarrence) $ MED EXP(Arty one person) S N/A PERSONAL 8,ADV INJURY $ GEN'L AGGREGATE LIMR APPLIES PER: GENERAL AGGREGATE f POLICY f jEa D LOC PRODUCTS-COMP/OP AGO $ — I OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMB S (Ea ectoderm ANY AUTO BODILY INJURY(Per person) $ AOOWNEDSCHEDULED AUTOS N/A BODILY INJURY(Per accident) $ AUTOS NON-OWNED - PROPERTY DAMAGE S HIRED AUTOS — AUTOS (Per aakentl S UMBRELLAUAB — OCCUR EACH OCCURRENCE f EXCESS UAB CLAIMS-MADE N/A AGGREGATE S DED RETENTION$ $ WORKERS COMPENSATIONTH- AND EMPLOYERS'LIABILITY X STATUTE ER A OFFICER/MEMBER ANYPROPRIETOPEXRCLUDED?XECUTIVE WA WA WA 6S62UB8H08580918 05/10/2018 05/10/2019 EL EACH ACCIDENT $ 500,000 (MandatoryyeIn NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Add/Maud Remarks Schedule,may be attached I more apace Ia required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization Is given to pay claims for benefits to employees in states other than Massachusetts if the Insured hires,or has hired those employees outside of Massachusetts. This certificate of Insurance shows the policy In force on the date that this certificate was issued(unless the expiration date on the above policy precedes the Issue date of this certificate of Insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.govllwd/workers-compensatlon/investigatlons/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN David Bernstein Builders ACCORDANCE WITH THE POLICY PROVISIONS. 139 Nantucket Drive AUTHORIZED REPRESENTATIVE Chatham MA 02633 Daniel M.Cr y,CPCU,Vice President—Residual Market—WCRIBMA ID 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD • • &Ae WpoiWnOflWea cz/GA(aoocac/uroee& Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Type: Individual IL: • . ,(,1 Registration: 128957 - OLNER KELLY ' Expiration: 06/13/2019 8 RHINE RD ; ` 4 YARMOUTHPORT,MA 02675 ! i • _.. Update Address and return card. Mark reason for change. SCA 1 O 20M-05/11 ---...._._---���. / _._------rL Addr••• n o.newsti rl rmnlnvm•nt 0 Lend Card ,979 S*'mmcnu'rn/f%r/h(%aiiar enetui a.‘� Office of Consumer Malts&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only p e f TYPE:Individual before the expiration date. If found return to: Registration Expiration before of Consumer Affairs and Business Regulation OVER KELLY 128957_ . OW13/2019 10 Park Plaza-Suite 5170 �- Bostcn;MA 02116 f«.-The 1 OLNER M.KELLY - 11/4,Aj- I B RHINE RD. 6.1 �m—"� ' '� YARMOUTHPORT,MA 02675 undersec Not valid without signature % retary--.- ®f Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construction-StlpeMsor Specialty CSSL-099167 Expires: 09/28/2019 • • - OLIVER M KELLY .27 8 RHINE ROAD YARMOUTH PORT MA 02675• i'nll.1/4"110tt- i CAL- , � Jew • Commissioner V^"