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Home My WebLink AboutBLD-19-002240 Office Use Only { ot''rak "� 'rO Permitil /-� 0 �, H Amount IOb— ,- " 'Permit expires 180 days from :" T , A-19-C q oissuedate EXPRESS BUILDING PERMIT APPLICAT C E f V E u TOWN OF YARMOUTH Yarmouth Building Department OCT 1 6 2018 1146 Route 28 South Yarmouth,MA 02664 BUILDING UE a�kT1aEN7 (508)r 398-2231 Ext. 1261 '' l/ BY ----- --- __ CONSTRUCTION ADDRESS: 14' /go/o ssa c Li t/se �j-v I Ly Wr r/7rMOt) - ASSESSOR'S INFORMATION: Map: Parcel: OWNER: Q4 s y /it c- Ak nnG scL 64 Anessca cievn th A.Ve_ ¶-09- 6:53- 0304 AM PRESENT Y�L1p .IADD'RE�'SYS 1 IUe�I`f�LTTEL D�� I��'— CONTRACTOR: NAME - r1' C^' 11-1 Td T(( gYiai h TEL a O.Residential 0 Commercial Est.Cost of Construction S 3h 1(3 Home Improvement Contractor Lic.# I g 7 tire) Construction Supervisor Lic.# 1,74;9-7./ Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 4 I have Worker's Compensation Insurance Insurance Company Name:f O(`d►ier r.e. "TAS ci f 0.dt CC. Worker's Comp.Policy# MA Ar ) Se 31 9? f WORK TO BE PERFORMED Tent _ Duration 1 t✓ (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares l 8 Replacement windows:# y Replacement doors: # • Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ()<)Replacing like for like Pool fencing •The debris will be disposed of at: YcreAua. TOw.wA. DU P"'p. Location of Facility I declare under penalties of perjury that the statements herein spitained are true and correct to the best of my knowledge and belief. 1 understand that any false answer(s) will be just cause for denial or rev. ation •1 my i me and M.G.L.fol oosecution under M.G. Ch.268,Section 1. /` f 'yJI /Ji aWPPlicant's Signature: ,4 \ ♦ A " `` Date: 7/r // it )(Owners Signature(or attacbmea ••res. �-`-tet a ,' 's Date: g /14/118 Approved By: V ../mac . Iir. Date: I0'16' ii 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: ❑ Yes 0 No ❑ Yes 0 No The Commonwealth of Massachusetts 'E -- a Department oflndustrialAccidents -i3tril_ 1 Congress Street,Suite 100 =i5'_�__ ,�- Boston, MA 02114-2017 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): ifl KI& ifer Address: 9 Loi kt— 'd. -]�j-2/4/ City/State/Zip: OfGV1.(>tCk Ith ar•1. hone#: 7/ / -1q2ce Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or pan-time).• 7. ❑New construction 2.1em a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]: 9. ❑Demolition 4.0 I aa homeowner and will be hiring contractors to conduct all work on my property. 1 will 10 0 Building addition m ensure that all connactors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees, 12.❑Plumbing repairs or additions 5.fam 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 14.®Other S d t tq 6.0 We are a corporation and its officers have exercised their right of exemption per MGI.e. 152,I1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that chrctrc 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. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Comm tree fit 2f rcc.n.c.¢- Policy#or Self-insLie.#: MA Ar P 10 31 �(� Expiration Date: a — Job Site Address: (/�K /MA55a(IN/ S AUC'. City/State/Zip: t, s . . . ..; 0203 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 t e pains and nalties of perjury that the information provided above is true and correct "Signature: 12 6 4e fir► Date: Triy.-pl( Phone#: 771-W1 6- ('1Z5 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 S.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 brrai,se 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 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 -i ,�% ,.. _. Giemsa of 404$ Lgm sw WM1 lKsoaegt ioarq of Ply Rs9 +ens sI fisnWrpf_ Const *tOnOnt11p�jy1fOt C$-0 273➢ f400k.-�, , N+ '"es;06//OR020 • � •:f4�'' � l ic'E5: 1 ,} le .� • Construction Supervisor :-Restricted to: Unrestrided-Buildings of any use group which conta ✓ less than 35,000 cubic feet(991 cubic meters)of enclosed space. • Failure to possess a current edition of the Massachusetts - State Building Code is cause for revocation of this license. DPS Licensing information visit;www.MASS.GOWBPS , Registration valid for individual use only ' before the expiration date. It found return to: i ^''.cOfticeofConsumer Affairs and Business Regulation 4` ' a.;10 Park Plaza=.Suite 5170 r • +eoeton,MA 02 6F ^ � r � n 1 S yYL rt• �r. outs 1 • i Utat�Uf@ • 2. « J...m1 ELIZOND OP ID:PS .4CORo' CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/1'YYY) 4....----- CERTIFICATE 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 508-385-2454 cater E.J.McGrath Insurance Agency Edward J.McGrath Insurance PHONE 508-385-2454 FAX 5083855991 P.O.Box 1003 SAN:,No,Eat): (/VC,No): Dennis,MA 02638 Pram E.J.McGrath Insurance Agency INSUREWSI AFFORDING COVERAGE NAIC P INSURER A:Mount Vernon Fire Insurance Co INSURED Major Minor Construction Co. INSURER B.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 EPP POLICY EXP ITP INSD WVD ,IMM/DDM'YY1 IMMDDWYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000.000 NEW 10/05/2018 10/05/2019 DAMAGE N TO RETED CLAIMS-MADE X OCCUR 100,000 — MED EXP(Any one Denson) S 5'000 PERSONAL S ADV INJURY S 1,000,000 GEN'L AGGREGATE pL{I�MpAPPLIES IT PER: GENERAL AGGREGATE 3 IJEC2,000,000 POLICY T LOC PRODUCTS-COMP/OP AGG S 2,000,000 OTHER' S AUTOMOBILE LIABILITY IEe COMBINED NSINGLE LIMIT S ANY AUTO BODILY INJURY(Per demon) S OWNED SCHEDULED - AUTOSONLY AUTOS WN BODILY INJURY(Per scddenil S AUTOS ONLY _ AUTOS ONLY (Pr 000jdentl GE S S — UMBRELLA LIAB — OCCUR EACH OCCURRENCE 3 EXCESS LIAB CLAIMS-MADE AGGREGATE S DED RETENTIONS S B WORKERS COMPENSATION PER X 0TH- ANDEMPLOYERS'LIABILITY Y/N STATUTE FR MAARP303199 01/17/2018 01/17/2019 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT S 4ManOdetoryln NH)EXCLUDED? Y MIA E.L.DISEASE-EA EMPLOYEE S 1,000,000 N yes describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT S 1'000'000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached N mon apace M required) CERTIFICATE HOLDER - CANCELLATION YARMT01 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 S Yarmouth,MA 02664 AUTHORIZED REPRESENTATME E.J.McGrath Insurance Agency I ACORD 25(2016/03) ®1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD