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Home My WebLink AboutBLD-19-002281 Y se'Office Use Only re . ,z° IF 1 too '/9 db ZZ'.i J O -'WI '� H Amount 1 S I `-N .� .,�tefts,,,.*'g Permit expires 180 days from , •�ia�::.' • issue date , EXPRESS BUILDING PERMIT APPLICATI _ TOWN OF YARMOUTH RECEIVE , • Yarmouth Building Department 1146 Route 28 OCT 16 2018 f i South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 B uit ,v ; .r 1,- ,;, _ ! CONSTRUCTION ADDRESS: 3 5-2 4107-1 -J Otrauti La) I ASSESSOR'S INFORMATION: • Q Map: Parcel: � OWNER: eOPt)t2- Alli, tVTpa 35'2 ,ti q pyiv4l. PD77/�/ /" /r%7.70t2 NAME PRESENT ADDRESS TEL. # CONTRACTOR:1 ODD Pavy✓Rr 3,20 2 ePar Sl; DeAbvisPar al's 6 est 770.6 NAME MAILING ADDRESS Am 026 3 7 TEL.# • ,// O spiResidential 0 Commercial / Est Cost of Construction$ /9/ . 0O� 0 Home Improvement Contractor Lie.# I (o tu. / 64/ Construction Supervisor Lie.# 7 -F,<rCJI`f Workman's Compensation Insurance: (check one) 0 ygG2 'C 0 I am the homeownerfig/ 0 I am the sole proprietor VI have Worker's Compensation Insurance [/ Insurance Company Name: g/C. Worker's Comp.Policy#ttxtCJUSO!62.422W3/9- WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares /0 49 Replacement windows:# Replacement doors: # Roiling: #of Squares f e ( /Remove existing*(max.2 layers) Insulation ul41lQ/,/ V' p Old Kings Highway/HistoricDr-ist ( (,'Replacing like for like Pool fencing "The debris will be disposed of at rela.0)p ' /N - AL'Amij 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 liceee and for prosecution under MG.L.Ch.268,Section 1. Applicant's Signature: ��.��i /' Date:_ /01/7/e Owners Signa or alta 4j t �. Date: '' Approved By: /.l. / /� Date: /e9 ./7—/ R Bu+/g Official(or designee EMAIL.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 • _�� The Commonwealth ofMassadhusetts _=4 / Department oflndustrialAccidents —S! 1 Congress Street, Suite 100 st itl /9' Boston, MA 02119-2017 �.� 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): )71)'.JCO,./L //1/L • C-rob RPM/eocici) Address: ,c70 Vera" sr. / City/State/Zip: Deva/Spat /4 026 77 Phone#: 1/45-08- 6 gr Tpgd Are you an employer?Check the appropriate box: Type of project(required): I am a employer with employees(Ml 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. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ID Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on mYproperty. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.[ 13.❑'R00{repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL e. 14. Other Sit 6✓L 152,$1(4),and we have no employees, [No workers'comp.insurance required.] *Any applicant that checks box#1 must also fin 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 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'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Q / Insurance Company Name: /9//C- Policy#or Self-ins.Lic,#: ✓iCC1SOD,�l� /62(0 7 20/0 es Expiration Date: V2e./4 Job Site Address: '3,c 2 Ahia-r)7 i76n'MIr RD City/State/Zip: ye(4luJ/-Marr Ms p 2675 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Sirrnaturer Date: /D�7//�Q Phone#: SOS- �95-- 796(0 ! 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 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 grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MOL 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 advised that 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 1 Congress Street, Suite 100 r ' Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia Harwich Ecumenical Council for the Homeless, Inc. (HECH) Housing Emergency Loan Program General Contractor and Owner Agreement Attachment A NOTICE TO PROCEED To: Todd Rancourt, Rancourt, Inc.: You are hereby given authorization to proceed with the renovations at 352 North Dennis Road, YarmouthPort in accordance with the General Contractor and Owner Agreement dated October 16, 2018. The work is scheduled to begin on or before October 16, 2018 and to be completed on or before December 30,2018. /104 frg Owner: Bonnie Talamantez Date itnesse y: Kimberly our ,HECH Program Manager Date ,.. . . I . — • ;sciThe Cf.....,,,,,attA lataadarktOda . . _ i I 4. • Mae of Consumer Oflii"lii I eaSIDOSS RegilialiOn 1,1' litin _a • HOME IMPROVEMENT CONTRACTOR 1,r t 1; • ;C:,, TYPE:Corporation ii. • littlinog Emoteitsn .-- - ttlit-4562-464-- o1/23/20i9 1 RANCOURT INC...._2.-sr,,,,,,,, TODD RANCOUF1T-,1,„5200e post , 1 - Dennispott,MA 02539, . - . Undersecretary I • 14 '' 1 V • a ig 1 Ca• ! t V ;0046.0;;Iintsinewrons • I i Commonwealth of Massachusetts -. .. • •• Dtvision of Professional Licensure . ,4 i; Boald of Building Regulations and Standards • ‘.. 4•'' . ''' ConstruciionSiti4e14Aiei.1 8.,2 Fprpilk,%.,, L,,t,.. 4.,„...‘ • , -CSFA-049265 ::: ti•• ,-- ay ei;u4iit iv 0 7 '..11 ; 2, .,,,,y,- TODD M FtAlikOURT ,7-1I ,, .„, to 620 DEPOT ST13EET ':.•;''' ,-_, • '- -...-4/ • DENNIS PORT Mils. 02639 Cs• VO1-S‘ 1 sci AL „Lof Commissioner . • - .. I-i . • ' , • ClIent#:41809 2RANCOURTIN ACORD. • CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 10/17/2018 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 . [i,'' 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 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 PHONE 508 775.1620 FAX 973 lyannough Road ADD No,Ext: (ac,No): 5087781218 EMAIL P.O.BOX 1990 ADDRESS: H annis,MA 02601 INSURER(S)AFFORDING COVERAGE NAILS y INSURER A:Associated Employe Insurance company 11104 INSURED - INSURER B: Rancourt,Inc. INSURER C: ( PO Box 1062 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 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 SUBJECTWO 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 JNSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DO/YYYY)._ LIMITS GENERAL LIABILITY EEDACH��OEECCCTpURgRENCE —$ _ PR COMMERCIAL GENERAL LIABILITY EMISES(Eeociunence) S CLAIMS-MADE n OCCUR MED EXP(Any we person) S PERSONAL&ADV INJURY $ — GENERAL AGGREGATE 1 S GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ POLICY JEC PRO- [ l LOG - $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY(Per person) S 1 ALL OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS AUTOS NON-0WNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) S S UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE S DED RETENTIONS - $ A WORKERS COMPENSATION WCC50050162622018A 07/22/2018 07/22/2019 X TORYTUMTs $14}4 AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L EACH ACCIDENT s500,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE•EA EMPLOYEE $500,000 if yes describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,N mon 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. CERTIFICATE HOLDER CANCELLATION Town Of Yarmouth THE ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1146 Route 28 ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE I _,,4C -aa� 7 v ®19988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #5221154/M221151 RPSW1