The URL can be used to link to this page

Home My WebLink AboutBLD-19-002280 •O�,,Yd Office Use Only e 44,! Permit# - --- r O . �, Amount S 0— `, NM..r ; , t`..ao* c(d Permit expires 180 days from II issue dabA te )g"/) EXPRESS BUILDING PERMIT APPLICATI I N TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 OCT 1 6 20-111. South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 B U I 77, as7r- W_Ir �/ ar CONSTRUCTION ADDRESS: .3 9, Co P_LI?N ASSESSOR'S INFORMATION: • Map: Parcel: OWNER: GCgrg Vo,vuwRn/ 38 Gktiriti way s yA-ioury see-76o-yogi NAME PRESENT ADDRESS TEL # CONTRACTOR:TvOj Reit,(0,/(ti .5-20 d'07- sr Der/spar C)9 6 fr 770 6 NAME MAILING ADDRESS /04L 0 2!3 7G Residential 0 Commercial Est.Cost of Construction/7000 Home Improvement Contractor Lie.# / C.2 Vt y Construction Supervisor Lic.# 091 76_5-- Workman's Compensation Insurance: (check one) `� 0 I am the homeowner//)� 0 I am the sole proprietor C71 have Worker's Compensation Insurance /7 Insurance Company Name: E/C Worker's Comp.Policy#WCC1/45—bO.5?)► o262Zo/$f}' WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares /2. SQ Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. (t...)‹eplacing like for like Pool fencing *The debris will be disposed of at e 't D S At, PrN/NiS 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 m j.,. e and for,.t se ution under MG.L.Ch.268,Section 1. Applicant's Signature: - Date: /4A7 e Owners Signatu (or attachment) / - Date: Approved By: ter Date: /!/ . /,7►/pA Buildin: •m al(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 R of Wetlands: 0 Yes 0 No 0 Yes 0 No _Lc The Commonwealth of Massachusetts EuyDepartment oflndustrialAccidents Iratiiit4�- 1 Boston, MA 02114s Street, - 100ite 2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Pleaserint Legibly Name (Business/Organization/Individual): ge7JCOJ/ir /g/ (TODD 19 tyt/radar) Address: ,c f)jppr ar, City/State/Zip: ,1Z wN/Spc2T Mo- o2639 Phone #: sr-Oe_ 6 9.se- 770 6 Are you an employer?Check the appropriate box: Type of project(required): I. I 'I am a employer with X 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. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall work myself. t 9. ❑ Demolition ❑ y [No workers'comp.insurance required.] 4.0 I am a homeowner and will be hiring contractors to conduct all work on m property.ro 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.E]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.: 13.0 Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E other SllylNG 152,§1(4),and we have no employees. [No workers'comp. insurance required.] *Any applicant that checks box#1 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 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. Insurance Company Name: 4-e vc / Policy#or Self-ins.Lic.#: frvec 27d o/62(.2 to/ $4 Expiration Date: Z7� ? Job Site Address: 36 6 letrEiV INP-9 City/State/Zip:5• Mgme Ty /13- 0266 y 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 and r the pa'• and penalties of perjury that the information provided above is true and correct Signature: Date: /0�//t Phone#: Sofi 6Bf— 7706 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 1 Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: A • •v. 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 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." 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, §250(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract 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 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 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 38 Green Way South Yarmouth in accordance with the General Contractor and Owner Agreement dated September 914 , 2018. The work is scheduled to begin on or before September, 2018 and to be completed on or before December 31, 2018. (-1_ ,) Gly Owner: Rene Donovan Date • • en t' ?F. Donovan Date • tness : �, Kim. • :ourgea, HECH Program Manager Date ,¢ ...f- •,...,-•472. r0 s ,sums . /o�f(n. n 'Office of consumer Mal Irf a Ba.In.se e4 = HOME IMPROVEMENT CONTRACTOR II I 44fi F`., TYPE:Corporation ' It _ ,11 01/23/2019 d '� Y RANCOURT INC`._-f':' a 'i' TODD AANCOLiRT ITS Q� 520 Depot • St —i' �]�� y Dennisport,MA 02639; ..` Undersecretary ;''. l'*- ; } ! • 111 .. -4 Commonwealth of Massachusetts. - IlL>Nision of Professional Licensure Board of Building Regulations and Standards ' :;��- -- Construction.,SU*M4°r-I &,2 Farpil, t� ,-`4444...-:e ; I A _ pry res OLIk i2' 0': rCSFA-049265 lG - It r -- ri TODD M RANCOURT 1 . 4 . 1 f 520 DEPOT STi3EET f ,mac c i , S"- DENNIS PORT MA 02630' `S Commissioner _ .— x Client#:41809 2RANCOURTIN ACORD„, CERTIFICATE OF LIABILITY INSURANCE DAT0/YYYY) 1o/17/2nnots 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 -8 REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. 14- IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to u 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 Dowling&O'Neil Insurance Agy PHONEFAX (NC,No,Ext):SOH 775.1620 (AIC,No): 5087781218 973 lyannough Road EMAIL P.O.Box 1990 ADDRESS: • INSURER(S)AFFORDING COVERAGE NAMe L Hyannis,MA 02601 INSURER A:AYOCIeIN FmPlgere Insurance Company 11104 • INSURED INSURERS: 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 SUBJECT`TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. - - LTR TYPE OF INSURANCE ADDLSUBR POLICY EFF POLICY EXP JIVER WV!) POLICY NUMBER -fMM/DD(YYYY11MMIDD(YYYYI-, LIMITS GENERAL LIABILITY EACH��EET $ TO EoOCCURRENCE COMMERCIAL GENERAL LIABILITY PREMISESREaoicrunence) $ _ CLAIMS-MADE 0 OCCUR MED EXP(My one person) $ PERSONAL B ADV INJURY _ $ • GENERAL AGGREGATE ' $ — G�ENL AGGREGATE LIMIT APPLIES PER: - PRODUCTS.COMP/OP AGO $ _ I POLICY 7 .nr [1 LOC f AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ - , ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident $ _ AUTOS _ AUTOS — NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOSUTOS (Per acdden() $ — s. $ UMBRELLA LIAO OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS-MADE AGGREGATE $ — _DED RETENTIONS f A WORKERS COMPENSATION WCC50050162622018A 07/22/2018 07/22/2019 X wcV,IT1" gr- '''' AND EMPLOYERS'LIABILITY TORY I IMrtq FR Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L EACH ACCIDENT • $500,000 OFFICER/MEMBER EXCLUDED] N N/A . (Mandatory In NH) E.L DISEASE•EA EMPLOYEE $500,000 II yet desaibe under is • DESCRIPTION OF OPERATIONS below EI.DISEASE"POLICY LIMIT $500,000 • DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more 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 SHOULD 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 -.. C'C 01988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S221154/M221151 RPSW1