HomeMy WebLinkAboutBLD-19-002493 spL.O use eOnly ,
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t•....o••'�:.d Permit expires 180,days from
- issue date •
EXPRESS BUILDING PERMIT APPLICATI•
�� [ y E D
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28 ! OCT 26 2018
South Yarmouth,MA 02664 �.,.,1C��
(508)398-2231Ext. 1261 Bt �f7v�°efArhfry+� 1
417 per 6A }
CONSTRUCTION ADDRESS: � y�11�M�l�C�} �e 1
ASSESSOR'S INFORMATION: r •
Map: Parcel:
(4*.1110 70CoeNI°e 'RNST' c,$ 30.13
OWNER: NoLJtws y-� ff PRESgcni, ecMA ozss9 $-ZZ/ - o97(n
ADDTEL. #
CONTRACTOR S. Lt9"sarq CD . 322 -q q*cr PSD- �a8-41 b2 - 13�.C/
NAME iG. Y13Lra 0474'•` f• G L536 #
❑Residential Dt mercial Est Cost of Construction$ 3 S O O O .�
Home Improvement Contractor Lic.# f E lit , , Construction Supervisor Lie.# (S O f 8 6. 7 I
Workman's Compensation Insurance:;check one) /
0 I am the homeowner B'I am the sole proprietor 0/I have Worker's Compensation Insurance
Insurance Company Name: &40e . eye
'I 5 •c . Worker's Comp.Policy# WW C-so_ 5) ' U7jg_
WORK TO BE PERFORMED 2M8A
Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares Replacement windows:#30 Replacement doors: # /
Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation
Old Kings Highway/Historic Dist ( Mceplacing like for like Pool fencing
'The debris will be disposed of at tryurj,IE• l elu.]! 14Ate, T �-
V !spas".'
Location of acility
I declare under penalties of perjury that the :t9metts 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 o ..y license and for j.secution under MG.L Ch.268,Section 1.
Applicant's S. emit:_ t 4' Iii• Date: / ZZ
Owners Sig tun(or a .hme.1`La_,�. 772f!`i/7EE Date: e 2 /ea
Approved By: /�/ = _ - - Date: ,p • �-f� 'I
Building•i•-•.. •, �,_:r� EMAIL ADDRESS:
•
Zoning District
Historical District ❑ Yes ❑ 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
* `� The Commonwealth of Massachusetts
'I) 'gyp" a= t
vL.E Department of Industrial Accidents
t =ifi1_ 1 Congress Street,Suite .100
=N 1i •
Boston, MA 02114-2017
,"�•etz,. 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): __J . MA L���'-n ay r
Address: 32 Z �F�Ske /`
City/State/Zip: /C / �/ OZCr
��NDW n M Phone #: 12g Z ^ i— /
Are you
—
Areyou an employer?Check the appropriate box:
� Type of project(required):
1.0 I am a employer with ,C/ employees(full and/or part-time).•
7. 0 New construction
2.�am a sole proprietor or partnership and have no employees working for me in
any capacity.[No workers'comp.insurance required.)
8• remodeling
3.❑I am a homeowner doing all work myself(No workers'comp.insurance required]t 9. ❑Demolition
4.❑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 are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.0I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub contractors have employees and have workers'camp. insurance.* 13.❑Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGI.c. 14.0 Other
152,§1(4),and we have no employees. [No workers'comp. insurance required.]
'Any applicant that checks box#1 must also fill ora the section below showing their worker'compensation policy information.
t Homeowner,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'camp.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: /' jcs/7. "g /L/. ' /17G. C .
Policy#or Self-ins.Lie.#: W Wt—gyp^,Sip/d 5799 "z/Sir Expiration Date: 3.A042'
Job Site Address: yy7 RT tip- lv410ic ftp-/ City/State/Zip: /44-- 02270
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 c .fy' u -r thh tai d aides of er• ry that the informazion provided above is true d correct
Simlature: /f(`'' Date: l4/Zv/ 8
Phone#./&--e2 V '/‘Le- /&7 /
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 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 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."
Applicant
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary, supply sub-contactors) 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
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 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
r• ' Boston, MA02114-2017
Tel. # 617-7274900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 02-23-IS wwv.mass.gov/dia
. Co'
of vqR
• �_- G TOWN OF YARMOUTHIRECE8/ED
F' $ 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451
Telephone(508)398-2231 Ext. 1292-Fax(508)398-0836 OCT 5 2018
OLD,KIIG'S HIGHWAY HISTORIC DISTRICT COMM! H&aNcsHHI/ H
i EClcl = GHWAY
OCT 09 2018 APPLICATION FOR
CERTIFICATE OF EXEMPTION
TOWN CLERK
ApplicatbotiftriprAThrigdenfortviNe issuance of a Certificate of Exemption under Sections 6 and 7 of Chapter 470 of
Acts of 1973, as amended, Mr the proposed work as described below and on plans, drawings, or photographs
accompanying this application.
Type or print legibly. I,I/ yr / 1
Address of proposed work: gel `// Pet 4 Pi b A /� int Map/Lot#
Owner(s): . (A Y11r1011, IR-1&Sta .,COALRwfe.. #rtlegi * Phone#: 5o3- ZZ/ —0r17(,
All applications must be submitted by owner or accompanied by letter from owner approving submittal of application.
Mailing address: Pa'Et:X So 13 Yockse-c"c 7/1A 07S$4 Year built 1752 4 1972
Email: In tie nn on 4'L pel/nett 1 .c. Y» Preferred notification method: Phone , Email
Agent/Contractor. ft 5/�CO M fs)}r/ L-t_� Phone#: -I '3.743•�s GE+
Mailing Address: rO2ra&J 2A. PP--epi _eLf.--/ D I I'6 3
Email: s ._. 6 .- Preferred notification method: Phone (/Email
co
The Project includes the replacement of windows, re-shingling the building,the replacement of the main
entry door and frame on the Union Street side and the construction of rain guards over the Union Street
entry door and the South facing side entry door.
The Building consists of two distinct parts:the Historic building fronting on Route 6A built c 1752 and
the Addition at the rear built in 1972.The overall intent is to maintain the current features of Building.
(Continued on additional sheet)
T
Signed(Owner or agent): Gfitw� �!(LtASbe Date: /0/5 fi
> Owner/contractor/agent is aware that a permit may be required from the Building Department(Check other departments,also.)
> This certificate Is good for one year from approval date or upon date of expiration of Building Permit,whichever date shall be later.
For Committee use only:
Date: /0-.5-/ Approved _Approved with cha 99ppRtio v
I- L
Amount dO Reason for denial:
OCT — 9' %118
Cash/ �7�tb I I
Rcvd by: X i/ - YARMOUTH
OLD _
Date Signed:/0/912.0a Signed: t-go. air APPLICATION#� 8 _ £ 1 7 0
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Failure to possess a current edition, of the lass ► se is
State Building Code is cause for revocation of this license.
For;information about;this license r,:
Call (617) 727-3200;orvisit www.Knass.govldpT
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before the expiration date, it found return t�. A
( Rico of Consumer Affairs and Business Regulation '
1000 Washington,Street - Suite 710 .,
.
• tore MA 02110
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�°►�Ro® CERTIFICATE OF LIABILITY INSURANCE °A1`0-23 8YY)
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 LONTACT DENNIS SHINE
Capital City insurance Agency,LLC PRONEFAX
870 Oaklawn Ave 401.569.0786
INC Na EMP (NC,No):
Cranston,RI 02920 E-MAIL
ADDREss: DENNIS@CAPCITY-INS.COM
INSURERS)AFFORDING COVERAGE NAIC I
INSURER A: EMC INSURANCE
INSURED John McCarthy INSURER e: ASSOCIATED EMPLOYERS INS CO
322 Acapesket Rd INSURER Ce
East Falmouth,MA 02536
INSURER'):
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 ORCCONDITION 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 OP INSURANCE ADOLSUBR POLICY EFE POLICY EXP LIMITS
LTR INSIOND POLICY NUMBER ,(MMIDOIYYYY) IMM/DD/MY)
A J COMMERCIAL GENERAL LIABILITY 4X60780 9/9/18 9/9/19 EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE VI OCCUR -DAMAGE
R M�SEEST.OLEa�ocanal_. S 300,000
MED EXP(Any one person) $ 5,000
—
PERSONAL It AIV INJURY $ 1.000,000
—
GEM AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s 2,000,000
1PRODPOLICY u PRo-T I I LOC 2,000,000
JEC
UCTS•COMP/OP AGG S
I
OTHER: $
A AUTOMOBILELIABRJTY 4X60780 9/9/18 9/9/19 COMBINED SINGLE LIMIT s
(Ea accident) _
ANY AUTO BODILY INJURY(Per person) S 500,000
-- OWNED j7SCHEDULED BODILY INJURY(Por eaMenQ $ - 500,000
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE a 500,000
AUTOS ONLY AUTOS ONLYfPertSCFM110
$
UMBRELLA LIAR _ OCCUR EACH OCCURRENCE s
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DEO RETENTION$ -
5
WORKERS COMPENSATION PER
Eµ
T
TH-
AND EMPLOYERS'LIABILITY YIN
ANY OFFICER/MEMBER ECUTIVE ❑ NIA EA.EACH ACCIDENT $
(Mandatory In NH) Et DISEASE•EA EMPLOYEE S
N yyees.describe under
DESCRIPTION OF OPERATIONS DDIdw - E.L.DISEASE•POLICY LIMA $
DESCRIPTION Of OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may De attached N more space Is required) .
CERTIFICATE HOLDER CANCELLATION
Neel Hannon
320 Circuit Ave SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Pocasset,MA 02556 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
®1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
~• Client#:117951 JOHNMCCA
ACORDT. CERTIFICATE OF LIABILITY INSURANCE DATE(MWDIXYYTY)
• 10/23/2018
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 pollcy(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 any rights to the certificate holder in lieu of such endorsement(s).
PRODUCER NAppMEACT Hollie Archetto
Starkweather&Shepley ti o,sxt):401 435.3600 I FAX,rale 401 431-9351
PO Box 549 .M"'Lharchetto tarshep_com
ADDRESS: __ _..._.__..
Providence,RI 02901-0549 INSURER(S)AFFORDINGCOVERAGE NAICII
401 435-3600 INSURER A:Associated Employers Ins CO/AIM 11104
INSURED INSURER B:
John McCarthy INSURER C I
322 Acapesket Road
INSURER D:
East Falmouth,MA 02536
INSURER 5:
INSURER i:
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 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.
Mk FASOCRIB POLICY EFF POLICY EXP LIMITS
LTR TYPE OF INSURANCE IIy$R WVDI POLICY NUMBER (MMIDDIYYYI)IMMIDD/YYYYI _....
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
CLAIMS-MADE n OCCUR DPMMaII _nc. a
MED EXP(Any on person) .f
PERSONAL a ADV INJURY S
GENt AGGREGATE UNIT APPLIES PER; GENERAL AGGREGATE I
POLICY I )JEEl LOC PRODUCTS•COMPIOP AGG S
OTHER:
AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT
SEF acgdenn 3
_ ANY AUTO BODILY INJURY(Per person) S
O,+ lyD �'SCHEDULED BODILY INJURY(Par accident) I
AUTOS ONLY AUTOS PROPERTY DAMAGE
AUTOS ONLY _ AUTOS ONLY - (Per accident) f
E
UMBRELLA LIAR OCCUR EACH OCCURRENCE S
—
EXCESS UAB — CLAIMS-MADE AGGREGATE f
DEO ( RETENTION S $
A WORKERS COMPENSATION 'WCC50050169982018A 03/0812018 0310812019 IsuTIITE tilRµ
AND EMPLOYERS'LIABILITY
ANY PROoPRIETORS+ARTNERIEXECUTIVE Y I N E.L.EACH ACCIDENT Si 00,000
OFFICERR EXCLUDED? NNIA
IMSMetory ry In In NHNN) E DISEASE•EA EMPLOYEE s100,000
II Yes,CleStliti•ION under EL DISEASE-POLICY UMR E5O0 OOO
_ DESCRIPTION OF OPERATIONS below , -. ---- —I--- —C_.
DESCRIPTION OF OPERATIONS(LOCATIONS I VEHICLES(ACORD Wt,Additional Remarks Schedule,maybe attached If more span Is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE
Neel Hannon THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
320 Circuit Ave ACCORDANCE WITH THE POUCY PROVISIONS.
Pocasset,MA 02559
AUTHORIZED REPRESENTATIVE
m 1988.2015 ACORD CORPORATION.All rights reserved.
ACORD 25(2016103) 1 of 1 The ACORD name and logo are registered marks of ACORD
#512067591M1206754 HEK