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EXPRESS BUILDING PERMIT APPLICATI I , E C E
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28 OCT 16 2018
South Yarmouth,MA 02664
BUILDING DEPARTMENT
PDX) �r
(508)398-2231 Ext.
J 1261 -� By:
CONSTRUCTION ADDRESS: CeRl> 5i-
W4- f& P6, r 4-1.4, 0.26-7,5-
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ASSESSOR'S INFORMATION:
Map: ,/Parcel:
OWNER: 1_rats ra. jMn O A
a°
Cenitr 6
1 7lsn•rn,H, Pc'', A..L v o26$ ;—.1(9—
d— 367-23/r
NArj/� ,,� ,` PREESENIT�&DD ESS TEL a/,;r- //
CONTRACTOR: NAME C/(tAA)gi tel 021 h ILINkci I. �1 ILY1 �. TEL k �4YVjr&C
'Residential 0 Commercial ('l �'J r �(�66Mt,DDD RE Est.Cost of Construction s '3,000 �2Qp
Home Improvement Contractor Lic.# I p / V' 8 Construction Supervisor Lie.# 67 9-7�� ,
Workman's Compensation Insurance: (p&feck one)
❑ I am the homeowner VI am the sole proprietor Sri have Worker's Compensation Insurance
Insurance Company Name: ( frtM,(t" SA Sipco.n.t'ge Worker's Comp.Policy#Ad* pie a 301( C(G
WORK TO BE PERFORMED 7
Tent _ Duration sem (Fire Retardant Certificate attached?) Wood Stove
1
Siding: #of Squares 2. Replacement windows:# Replacement doors: #
Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation
x Old Kings Highway/Historic Dist. ()4)Replacing like for like Pool fencing
*The debris will be disposed of m: Year M&t1lti \Ory A. VuM19
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 lic,Etse and or prosecution under M.G.L.Ch.268,Section I. ��
Applicant's Signature: (' Date: Qg
%Owners Signature(or attachment) r Q _ Date: —! /iii i /
Approved By: t/...c. L / Date: /0 ea� 10Rp
Building 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
y The Commonwealth of Massachusetts
• ^� / Department ofIndustrial Accidents
I'it s Boston,Congress MA 021 100 Suite
14 -2017
5
r =`� 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): ?•4 13,10 p&0 I(P
Address: `�.� 1-(Cr cif I,
I
City/State/Zip: _„ J b .. Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with employees(full and/or part-time).* 7. 0 New construction
2.arrrn a sole proprietor or partnership and have no employees working for me in
any capacity.[No workers'comp.insurance required.] 8. ❑Remodeling
3.0 lam a homeowner doing all work myself[No workers'comp.insurance required.]t 9. ❑Demolition
4.0 i am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition
ensure that an contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5.l l lerem a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0 Roof repairs
`i'These sub-contractors have employees and have workers'comp.insurance?
6.0 We are a corporation and its officers have exercised their right of exemption per MOL c. 14. Other s 1�1►C>!
152,41(4),and we have no employees.[No workers'comp.insurance required.] o
'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 employee;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: 61 Airs yt.t e r Co -tads ri re.n re*
Policy#or Self-ins.Lic.#:/4r(-Ar P36 3t 99 Expiration Date: 5 I —(7- 201C(
PA)Site Address: 0 Ce..7Cr st YerrtnstA iffier) City/State/Zip:
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 51,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up t' $250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for' surance
coverage verification.
I do hereby certify under t e p ' and penalties of perjury that the information provided above Zr true and correct
Signature: (�/-4 the-- Date: 9'/7-- f
Done#: 77q a/('j-l 5-
Official use only. Do not write in this area,to be completed by city or town offidal
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 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, §25C(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 contracting 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
• • Boston, MA 02114-2017
Tel. # 617-7274900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 02-23-15 www.mass.gov/dia
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Board of Iron,RW
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Const uetton tOpsrvisor
CS-072739 .! ,s ftpirasi 081012020
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Construction Supervisor
Restricted to <,
Unrestricted Buildings of any use group which conte•.
• less than 35,000 cubic feet(991 cubic meters)of
enclosed space.
. 5':Failure to possess a current edition of the Massachusetts
State Building Code Is cause for revocation of this license-
CPS Licensing information visit:WNW.MASS.GOV'DPS v
6 ° , , Registration valid for Individual use only
before the expiration date. If found return to:
ym%. Office of Consumer Affairs and Business Regulation i
. -:: 10 Park Plaza*:Suite 5170" -; s `
Boston;MA 02 fi
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/•1 ELIZOND OP ID-PS
AcoR)U CERTIFICATE OF LIABILITY INSURANCE D 10/10/2018ATE )
lononola
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(les)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 508-385-2454 LoRtirCT E.J.McGrath Insurance Agency
Edward J.McGrath Insurance PHONE 508-385-2454 FAX 508-385-5991
P.O.Box 1003 LAIC,No,EA): (AIC,Ne):
Dennis,MA 02638 swim
E.J.McGrath Insurance Agency
INSURERS)AFFORDING COVERAGE NAIC N
INSURER A:Mount Vernon Fire Insurance Co
INSURED Major Minor Construction Co. INSURERe:Acadia Insurance Company
Minor Elizondo
126 Higgins Crowell Rd INSURER C:
W Yarmouth,MA 02673 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.
INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS
LTR INS° MND (MWDD/YYYY) IMMIDD/YYYYI
A X COMMERCIAL GENERAL LIABMY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE X OCCUR NEW - 10/05/201810/05/2019 PREMI$ESfEeEDCMcorrence) $ 100,000
MEDP(Any one Dentin) $ 5,000
EX
PERSONAL A ADV INJURY $ 1'808'888
GE 'L AGGREGATE fief
APPLIES PER: GENERAL AGGREGATE
JEC $ 2,000,000
POLICY T LOC PRODUCTS 2,000,008
OTHERO $
AUTOMOBILE UABIUTY ((EMaccciNdent) GLE LIMIT
ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED
AUTOS ONLY _ AUTOSUpN�pWwNNEEpp BODILY INJURYpD (Per accident) $
AUTOS ONLY _ AUTOSONLV (PRerew�nt)AMAGE
$
UMBRELLA UAB _ OCCUR EACH OCCURRENCE $ _
EXCESS LMB CLAIMS-MADE AGGREGATE $
DED RETENTION$ f
B WORKERS COMPENSATION PER
X RRTM
AND EMPLOYERS'LIABILITY MAARP303199 01/17/2018 01/17/2019 3 1,000,000
ANY PROPRIETOR R/EXECUTNE YIN E.L.EACH ACCIDENT
(Mandator In EXCLUDED? I Y I NIA 1,888,886
7 NH) E.L.DISEASE-EA EMPLOYEE $
It yes,describe under 1,000,000
DESCRIPTION OF OPERATIONS Delon E L DISEASE-POI ICY LIMB f
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may W attached If more space Is required)
CERTIFICATE HOLDER CANCELLATION
YARMTO1
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS.
1146 Route 28
S Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE
E.J.McGrath Insurance Agency
ACORD 25(2016/03) ®1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
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Home Improvement Contractor Registration Lookup
I
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To search by regkaatke amber,enter the reglsur atbn*umbIn the teatime below end click a 'Soar
I7I Seart by Registration Number p13/618 I Scarth
i
J
IYou nun tick the"Search Registrant'button to search by name or bodes.
Search by Registrant Company name I I Sew.Reyasaa
Q Search by Registrant last name I I
City/Town
State I I
Zip code I I •
Click on the registration number to view complaint history.You can also view arbitration and Guaranty Fund history.
The en Is cuneat as el Mondry,October 15,zees.
Search ResuRs
RegistrantName ('.RESPONSIBLE I -REGISTRATION 1 I ADDRESS !EXPIRATION DATE I STATUS
;rINDIVIDUAL F ' NUMBER , -e
Bnan Kinsella Kinsella Bnan 187678 21 UJBERTY TRAIL D5A29/2010 Current .
i HARWICH.MA 02645 i _.....
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