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HomeMy WebLinkAboutBLD-19-002275 s. % SECTION 5: CONSTRIICTZON SERer'74 ` \;, ' 5-1 Construction Supervisor License(CSL) on !or 1 TT�MAs E. _ License Expiration Daze • e. Name of CSLHolder List CSL Type(see below) . Irl - MostL 124. Type DescriptionNo.and Street U Unrestricted :endings up to 35,000 co.ft 50OW4 v 6.44- 1 WI{} Q f en\-- R Rest deed l&2Fami1YDWellin: City/Towo,State,ZIP M •.. RC Roofm• Cwerin: WS VTmdow and Sidor: sF Telephone ess .. D Demolition p Si Registered Home Improvement Contractor(MC) j�e�� 3-.17e)00 l Qv(.1.�/NG� C. ECRegi-stianNum etban E pirationDate au HICCompany Name orEC egtstrantNme .�)NA� dial ILLei^'� ins Mill . • No.and Sleet Cot.r{+acao� MnOil')l- cvY Y-e5 City/Town,State,ZIP Telephone GL e 152§ 25C(6)) SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M Workers Compeesati.onlnsurance affidavit must be completed and subm2tedwiththis application. Falicretoprovide this affidavit will.result in the a rugal of the Issuance of the bmading permit Sued Affidavit Attached? Yes K. No ❑ SECTION 1a:OWNER AVIEORI7.ATIONTORECOMPLETED WEE2i ' • OWNER'S AGENT ORCONTRP CTORAYPr>T'T BOR BUELDINGPERMIT - I, as Owner of the subjectprope ty,hereby amhorize a h'en's 6p-ins Li • to act Gamy behalf in all ma2rers relative to work arthorizedby this bmld^+g permit application. F-1-11-NK- 244Alt-t44 Dale Print Owner's Name(Electronic Si tae) SECTION lb: OWNER/OR Au'1HORIMED AGENT DECLARATION . Ey entering my name below,I hereby attest tinder the pains and pe+ryes of perjury That all of the information contented in this application is tree and accttate to the best of fay knowledge andmderstandlg• IW' it :7 Date Print Owner's or Atrthouzed Agent's Name(Electronic Sig:sine) NOTES: . contactor 1. An Owner who obtains abuildmgpermit to do his/her own Priv,or an owner �c eess to e steihdhon (not registered in the Home Improvement Contractor(HI ) ) t can be found at program or guaranty fund under M.G.L.c. 142k Other imports information on the EC Program www inas.eovlodeInformation an.the Construction Supervisor LicensecabefoundatwwwSSaov!ns 2. When substantial work isplanned,provide the information1u elow (mcludiaggarage,frmshedbasement/attics,decks or porch) GrGrostal living area a(sq.ft) Habitableroom colmt Num loving arcades ft) Number of-bedrooms NNaber of fireplaces_ Number ofbalf baths Type of ofbathroomssyms Number of decks/porches _-- Type of heating system Enclosed _Open Type of coaling system . _. . .. T _ _ The Commonwealth of Massachusetts y ___ �=C� Department of%ndrrst -talAcciderzts �� f =7411.--a- ;:r; " Z Congress Street, Suite 100 s i Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH lHbb PERMITTING AUTHORITY. Applicant Information _ -�^ . Please Print Leo-iblY Name (Business/Organization/Individual): fr( 3w �uILDINC—rt"J4 Address: (bbL� City/State/Zip: S'n,ra9+0,o¢cvc-t+ MA-0 IY)1— Phone#: Are yo a an employer? Check the appropriate box: Type of project(required): I. am aemployer with employees(full and/or parttime).' 7. ❑New construction ❑I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] $• ❑ Remodeling 3.0 I am a homeowner doing all work myself[No workers'compinsurance required"? 9. ❑ Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work an my property. I will 10 El Building addition _ ---ensure that all contactors either have workers'compensation insurance or are sole • 11.❑ Electrical repairs or additions proprietors with no employees. 5.❑I am a geneera! eonhacmr and I have 12.❑Plumbing repairs or additions a m-- d the sub-cont-actors listed on the attached sheet have employees and have worke[s'comp insurance? 13.❑Roof repairs These subral 6.0 we are a corporation and its officers have exercised their right of exemption per MGL e 14.❑Other 151•§1(4).and we have no employees [No workers'camp.insurance required.] *Arty applicant that checks bcoc#1 must also MI out the section below showing their wadies'w Y Elameowoers who submit this mpenact rs policy try atioa =Cormacmrs that check this boa��t���are doing all work and thea biro outside contractors must submit a new temployees. rm attached an additional sheet showing the name of the sub-ceonace:rs and stat whether or mot those�ting such. If the sub-co employees,they must Provide thea workers'camp,policy number. am= employer thorns proved tgworkers'compensation insrumtce for my employees Below it the policy old job site information. Insurance Company Name: 14C$j 1 A Policy#or Self-ins. Lic.#: L/Cf s--) (its .11 ` // Expiration Dale: .S'••�1:101 'Job Site Address: ll • ,04/VCW'� �Na 1 City/5t unzip jild �CITd /'1�t ()sczi 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 - :._url Sider son. and penalties of perjury that the hformaiion provided above is true cord correct �atore: h7..- I Date: 47')C-(1/ Phone*: •trei tS Official use only. Do notwrite in this area, to be completed by city or town offiaiaL City or Town: Permit/License# Issuing Authority(circle one): I. Board of Health 2. Building 0 apartment 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 5. Other Contact Person: Phone. • Information and lnstrucnons . Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation forntract ofhire, .employees. • Pursuant to this statute, an employee is defined as`...every person in the service of another under any co 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 chat'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" Applicant P lease 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 withtheircertificcaits)of o�erthanthe insurance. Limited Liability Companies(LLC)Cr Limited Liability Partnerships(LLP)with no employees members or partners, are not required to carry workers' compensation ins lance. If an LLC �e¢LLP of Industrial have employees, a.policy is required- Be advised Mat-this affidavit may be submitted to the Depvit Accidents for confirmation of insurance coverage. Also be sure to sip.and date thenot the DepdThe ament of should be returned to the city or town that the application for the permit or license is being requested, Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain aworkers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number oathe appropriate line. City or Town&Tidal! Please be sure that the affidavit is complete and printed legibly. TheDepartment has provided a.space a the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact You regarding applicant Please be sure to fill in the permitllicense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,aced only submit one affidavit indicating current policy information(if necessary) and under"Iob 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 bellied out each year.Where a home owner or citizen is obtainin g 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 Boston, MA 02114-2017 TeL # 617-7274900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 7 j. a.ss.govh$a n1 ^o�-Y� TOWN OF Y OU' r 01 ;) BUILDING DEPARTMENT ^^T 1146 Route 23,South Yarmouth,MA.02664 503-393-2231 eat. 1261 §i.. ta.n.®� HOMEOWNER LICENSE EE ?TION PLEASE PRINT: DATE: • • JOB LOCATION: NAME STREET ADDRESS SECTION OF TOWN "HOMEOWNER" NAME HOME PHONE WORK PHONE PRESENT MAILING ADDRESS CITY OR TOWN STATE ZIP CODE The current exemption for 'Homeowner' was extended to include owner—occupied dwellin ss of one or two units and to allow such homeowners to engage an.individual for hire who does not possess a license,provided t homeowner shall act as supervisor. (State Building Code Section 110 PS.13.1 Definition of Homeowner Pers on(s) who owns a parcel of land on which he/she resides or in :•ds to reside,on whichthere is oris intended to be, a one or two family attached or detached structure assesso • • such use and/or farm structures. A person who constructs more than one home in atwo-year period aha Tl no •e considered a.homeowner; such"homeowner"shall submit to the building official, on a form acceptable to the .wilding official,that he/she 012 T1 be resoonsible for ail such work performed under the builrline permit (Sec:•n 110 85.1.3.1) The undersigned 'homeowner' assumes respons .ility for compliance with the State Building Code and other applicable codes, by-laws,rules and re ulatio• The undersigned `homeowner' certifies rhe• he / she understands the Town of Yarmouth Building Department minimum inspection procedures and req. - .•ents and'that he / she will comply with said procedures and requirements. HOMEOWNER' S SIGNATURE APPROVAL OF BUILDING OH'lt ' INSURANCE COVERAGE: I have a current liability insur. • - policy or its substantial equivalent, which meets the requirements of MGL 2142. Yes No If you have checked yes, pie. indicate the type coverage by checking the appropriate box. A liability insurance policy . Other type of indemnity Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coveraggerequiredby Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement Check one: Signature of Owner or Owner's Agent Owner Agent h-hnrr..nwnr1jcee .. Cr:.:E Y TOWN OF YARMOUTH .y/ rig Sill BUILDING DEPARTMENT o `� `j 1146 Route 28, South Yarmouth,MA 02664 -" "��--....,,•��- 508-398-2231 eat,1261 Fax 508-338-0€36 • • BUJ I,DING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to MG.L. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section 111.5, , I hereby certify that the debris resulting fron the proposed work/denolition to be conducted at /6C Sexuvo -Lt, Work Address Is to be disposed of at the following location: 5-C GSLLb .Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Sectio 150K (2 qi_ r -a Signature of Application Date Permit No. • • AC R?t CERTIFICATE OF LIABILITY INSURANCE DA (NM DN""' 05/21!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: Y the certificate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. IfSUBROGATION 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 • NINE T 1 Darin NoguMm Integrated Insurance Solutions,LLC PNONE (508)370.0002 FAX (508)370-0758 Wc.No EMI: INC,No): 1881 Worcester Road ASU ESS:I dnoguoim©usagoncy.cam SUER 101 I INSURER(S)AFFORDING COVERAGE NAME Framingham MA 01701 INSURER A: Acadia Insurance Co NSURED INSURER a: From Bu!ding Inc. INSURER C t 172 Middle Road i INSURER D: INSURER Er Southborough MA 01772 INSURER F: + COVERAGES CERTIFICATE NUMBER: CL1852136176 1 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY 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 INSURANCEAFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LMITS SHOWN MAY RAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADOL SUOR POLICY POLICY EFS POLICY EXP LIMITS LTRJN'D.R&D IMWDDITYYYI IMWDMYYY) X COMMERCIAL GENERAL LIABILITY i EACH OCCURRENCE S 1,000,000 I CLAIMS-MADE ®OCCUR 1 DAMA(.ETO RENAL) tag Dgg PREMISES Ea Occurrence) T _ — MED EXP(Any mm epen) S 5'� A CPA5255607-13 05/28)2018 05/28/2019 _PERSOwuSADV INJURY F 1.000.000 CENLAGGREGATE LIMIT APPLIES PER: i GENERAL AGGREGATE „...I2.000.000 POUCY❑zei 0 LDC j PRODUCTS-COMP/OP AGO 62.000.000 OTHER 6 AUTOMOBILE LIABILITYCDARENED SINGLE LIMIT 6 1.000,000 i (isWM) _ PAY AUTO ODDLY S11Um/WWPoon/ I , A OWNED SCHFae 00 MAA5255602-12 05/28/2018 05/28/2019 BODILY MANY(Pe a:MeN) I AIRED ONLY ^ AUTOS NON-O x AUTOS ONLY x AUUTOSSOOrLLY (Per PROPERTYDAMAGEGE PIP-Basic 6 8,000 X UMBRELLA•LIASOCCUR 1 EACH OCCURRENCE 6 1,000.000 A EXCESS LIAO CUIFS.LIADE CUA5255603-12 05/28/2018 0528/2019 AGGREGATE s 1'x•000 I DED I I RETENTION 6 6 WORKERS COMPENSATION 1PER 0TH- AND EMPLOYERS'UASRITY I STATUTE I I ER A ANY PROPRIETORAARTNEFEICCUTNE TIN EL EACHACGIOENT dbM6500.000 oFFICERMENE eaxcLU0ED1 El NIA WCA5259148-12 06/282018 05728/2019 (Ms^ ,YWO 1 EA EL.DISEASE-FA ROYEE 6 5°°.°M1NMm E , smne under500.000 DESCRIPTION OF OPERATIONS below El DISEASE.POLICY LMR $ i I DESCRIPTION OF OPERATIONS I LOCATIONS I VESICLES IACORD 101,AddNIone Ro,ndm SRMduy my N.bold It men Awe Is?DRAMA) I I i l I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED N ACCORDANCE WITH THE POLICY PROVISIONS. • - AUTHORIZED REPRESENTATIVE I MA 01752 inc... 5)1888-2015 ACORD CORPORATION.All HAUS reserved. ACORD 25(2018/03) The ACORD name and logo are registered marks of ACORD , Commonwealth of Massachusetts ® Division of Professional Licensure Board of Building Regulations and Standards Const rUOtio0'Supervisor CS-053105 _ •i Wires:11110/2019 t .4 Yq ! F THOMAS E FINELLI j :" i € 172 MIDDLE RD ,-` +tS SOUTHBOROUGH MA 01772 i c.(... 1' .4 0 r c 1� j.,.-w Commissioner a > r !%4B Von tutenturaid tibilet1neiNNta Odic'of Consumer Mains L Business Regulation Registration valid for Individual use only HOME IMPROVEMENT CONTRACTOR before the expiration date. it found return to: ✓ TYPE:Cor amain r as i6on i'XDIraUOn Office of Consumer Affairs and Business Regulation10 Para Plaza-Suite 5170 s 118505 , 00/27/2019 ,/t/FINFILI BUILDING INC (2Boston,MA 02110 , THOMAS Ftp ,per So Rd. .' - Middle Rd Q Southborough,MA,01772 Undersecretary - Not valid without signature — — — --TOWN CF YARIViOUTi-i._ • REVIEWED FOR BUILDING AND ZONING CODE COMPL-- ' • ANCE. ERRORS OROK VSSIONSDONOT RELIEVE THE '- - - APPLICANT COMPLUNCE.OMTHE RESPON5181LI_TYOF'AS BUILT' .f.F., " • 6 - icienNG en ijv DATE IQ-/S'lB __ - BUILDING O FILE COPY. _ r r -N Gas exsnr - Raeeus 3 Foum,fine, . 1 )/Jl _ �� _ a were s - i2sr FLo©2.