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Home My WebLink AboutBLD-19-002411 01"y Office Use Only • k..:, 0 Patna :,' 4 .1tJ AmouaC2D ivc� ." Permit expires 180 days from .1.•# 8 (J).— I c"1 —C1);L1 if `issue date RECEIVED EXPRESS BUILDING PERMIT APPLICATI N TOWN OF YARMOUTH OCT 23 2018 • . . , - .,Yarmouth Building-Department 1146 Route 28 BUIL Beggar/MT-1—T South Yarmouth,MA 02664 w By: (508)398-2231 Ext 1261 : cr -7 ( i CO--- CONSTRUCTION CONSTRUCTION ADDRESS / y CED4 rc 5 3/4 Ain. ASSESSOR'S INFORMATION: n Map: 37 Parcel: / $J -iC / 7-y-f6 -f;9 OWNER: A�/2✓p A/4 A.# Y 77 0[1 I�DR5 < C4/73Tt�J CE 0A/7-0 ` // NAME. r / PRESENT ADDRESS— TEL # CONTRACTOR: D-T COM Fa?" ' 7a 8a1/4_?3/ /sir-2 02-4 7 g sec c.z ra -PiG r% NAME MAILING ADDRESS TEL# 0 Residential 0 Commercial Est Cost of Construction S 842 a O Home Improvement Contractor Lie.# /G 3 Z-5:5' Construction Supervisor Lie.# CS - )ev2.L71' Workman's Compensation Insurance:'(check one) _ ❑ I am the homeowner ❑ I am the sole proprietor O1 have Worker's Compensation Insurance Li-)C ) &a`r I 1 Insurance Company Name: cc.— Worker's Comp.Policy# WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) , i ' ; Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares it (a)Remove existing*(max.2 Tacerse).•. „ ,, ,Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like ' Pool fencing *The debris will be disposed of at: ,4 n7. 0 Q "7-1i1ltl 5 pA'i� Location of acaity 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 licensensnnseand for` Y 1 prosecution�utunder M.G.L Ch.268,Section I. Applicant's Signature: 5/ 2 t Dater ' 2.Z 0 C-�/r Owners Signature(or attachment) Date: Date: Approved By: Sara. . Date `G -- 23/a Building Or" :al . •!sign EMAIL ADDRES' Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes ❑-No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No __ �\ The Commonwealth of Massachusetts —— f Department o De artIndustrial Accidents 12=::171=. P?Fail= 1 Congress Street,Suite 100 _€ __ c : Boston,MA 02114-2017 `:..,,-- www.mass.gov/dia • - (Porkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. 'Applicant Information Please Print Legibly Name(Business/Organizatlodandividoal): filo 7r C'o,t/S TrZL/Ln a As )ev e--- ' Address: 1:16; IS ao& 731 City/Stateizip:flf Q zG ' r Phone#: $.o r a to 74.0-C An yes employer?Cheek the appropriate box: ' Type of project(required): 1. i am a employer with C employees(full and/or partrtime).e 7. 0 New construction 3.0 lama sole proprieax or part iership and have no employee-working for in '. 8. ❑Remodeling • • aty apaci y.(No workers'comp insurance required] 3. I ani a homeowner do' all woik • ` ',9. ❑Demolition .. i. , ❑ ung royale(Wo workers'comp,—manna required.]t � . : • 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. l will 10 ❑Building addition enure Net all contractors sidle;have coon?as'compensation inwaar ce«arc sole - t 11.0 Electrical repairs or additions proprietors with no anployea. 12.❑Pymbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet , These sub-oamaimn have employees and have workers'comp'nuance.: 13. of repairs 6.0 We Si a cap«etion and Its officers have exercised their right ofexemption per MGL c.,' 14,❑Other 152,{1(4),and we have no employees.fhb workers'comp.insurance required] *Any applicant that checks box Ill must also fill out the section below showing their workers'compensation policy information. t Homeowner who submit this affidavit indicating they are doing all work end then hire outside contractors must submit a new affidavit indicating such. :Contactors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether ornot those entities have a employees, If the nab-oo t on have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation Insurance for my employees Below Is the policy andJob site Information. Insurance Company Name: A e--"IP 1 A Policy#or Self-ins.Lie.#: 1✓C-r1 SX,$r;Sf -12— Expiration Date: C/ /S/Ref Job Site Address: 17 Aerial". d A". S r- stra a%�,r City/State/Zip: 794 Attach a copy of the orken'compensatio 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: �i�� / Date: 2.2 acr, X Phone#: Sc V- 2.5rSem 8 C 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#: • • • I • • • • Commonwealth of Massachusetts - ®1 Division of Professional Licensure Board of Building Regulations and Standards • , ConstrggC t611-ISdp,,rvisor CS-102647 U s E'pires:03/03/2019 ' PATRICK J COFFEY �1 d-t -f'• PRATT 153 LOVELLS ANE t 114; :' y P.O BOX 731 ,-' 30 I CONSTRUCTION CO. MARSTONS MILt8MA 0264it3. nO/SS A0` •1� BUILDING&REMODELING CONTRACTORS Commissioner �'L t— PATRICK COFFEY c 508.280.4688 coffey7Qmsn.com o 508.420.9333 153 Lovers Laie/Box 731 f 508.420.9733 Massone Mils MA 02648 . Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration ..„.3b.—^"_; 11 Type: Corporation PRATT CONSTRUCTION COMPANY,LLC . j 1 Registration: 163855 P.O.BOX 731 `F, Expiration: 08/22/2020 MARSTONS MILLS,MA 02648 y 'L'A q 44e os 3 20M-05/17Update Address and ReturnCard. Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Cprooraticn before the expiration date. If found return to: Reglstratior'\ Exoiratiort Office of Consumer Affairs and Business Regulation 163855.-_ ✓.08/22/2020 1000 Washington Street-Suite 710 RATT CONSTRUCTION COMPANY,LLC Boston,MA 02118 4TRICK COFFEY \ 1 i3 LOVELLS LN UNITp I% ; ARSTONS MILLS,MA-02648 Undersecretary Not valid without signature October 22, 2018 Yarmouth Building Department , c/o Yarmouth Town Hall Yarmouth, MA 02664 Re: 14 Cedar St. South Yarmouth,MA 02664 I To Whom It Concerns: I authorize Patrick Coffey, Pratt Construction to pull a building permit for reroofing my house at 14 Cedar St.,South Yarmouth MA. € Thank you. a Sincerely, • t Nancy Ayoub AACCICI IaINSURANCE a Berkley Company WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 01 B 01 15 Issuing Company:Acadia Insurance Company 290 Donald J. Lynch Blvd Marlborough, MA 01752 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY RENEWAL INFORMATION PAGE NCCI Carrier Code No.: 33391 Policy No.:WCA 5258951 - 12 Previous Policy No.: 5258951-11 1. Name Insured and Address Agency Name and Address 07131 Pratt Construction Company, Inc. (508)676-1971 PO Box 731 HUB International New England, LLC Marstons Mills, MA 02648 P.O. Box 3220 Fall River, MA 02721 Other workplaces not shown above: Refer to Name and Location Schedule FEIN:270354389 Risk ID No.: Bureau File No.: 301701 Entity of Insured: Corporation POLICY PERIOD 2. The Policy Period is from 06/15/2018 to 06/15/2019 12:01 AM Standard Time at the insured's mailing address. COVERAGE 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part two are: Bodily Injury by Accident$ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All states except ND, OH, WA,WY and states designated in item 3.A. of the information page. D. This policy includes these endorsements and schedules: See "Schedule Of Endorsements" WC 00 00 018 01 15 Includes copyrighted material of The National Council on Compensation Page 1 of 4 Insurance,with their permission.