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Ijsgouiajlo aw.Iouag lmdag yon.gsuoJ o,L uormojjddyuuuadSuomi" )INIa 08L'aPoD2u11311na ale;S suasngoesseY4 9E80-86E-805 Xe3 19Z) in I£ZZ-86E-805 Z6t12-1299Z0 VW`ginonue t I4110S `8Z olno)I 91211 C: . ,' ;uawpudaq Zuipimg q;nouusAio umo,I, imsRIaa DMIQ'II 11 -A'IMO A'III4ili3 OMI w awO • . 3/5/0/ . • • . . .. • SECTION 5:.CONSTRUCTIONSERVICES . . 5.1 Construction Supervisor License(CSL) n f`3O W 6 to rof t; 31v v ut License Number Exp' do Date Namelolf CSL�II�Iolder 03 HI 14,11, tii&, ArtaList CSL • Type(see below) 0 No.( and Street ,/ A .Type... ., .. Description U o(Ct L Y/1,r nA n u Fru 0,2664 R Unrestricted(Buildings up el ing cu.R) City/Town,State,ZIP / M Masonry 18t2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding • SF Solid Fuel Burning Appliances 1p- Digi�F-OPS9401 r( C{f.OVV P.dfI, i i itr.0 I Insulation Telephone V l)Emtiil address D Demolition 5.2 Registered Home Improvvement Contractor(HIC) C0 A l0• I3eoror, an,Vlur ) l {'LC•• HIC Registration Number Expira.tthMite HICCoraNam r HIC Registrant Namp DYf,{l, (1(.YL VC.t G �d nvi eU( gran yid(EnaladdressaYmAti ..}� OU�Oi� Mit)/-Jnl9 ty/Town,State,ZIP Telephone SECTION.6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6)) •. • Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes X No ❑ . .SECTION 7a:OWNER AUTHORIZATION;TO BE COMPLETED WHEN • OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT . . • I,as Owner of the subject property,hereby authorize 6 nei me, l Il CLV CJ, I , to act on my behalf,in all matters relative to work authorized by thiuilding permit application. °forgo CnLi.n.aq. Na.h rt tji enroll io�t3 Jii Print Own/es Name(Electronic Signature) 1, 1, ate • • • • • SECTION 7b:OWNER'ORAUTHORIZED AGENT DECLARATION • By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information • contained in this application is true and accurate to the best of my knowledge and understanding. P�oorg� "Pc v-5 Print Owner's or Authorized Agent's Name(Electronic Signature) fDat • 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A Other important information on the HIC Program can be found at www.mass.aov/oca Information on the Construction Supervisor License can be found at www.mass.gov(dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" • The Commonwealth of Massachusetts Department oflndustrialAccidents S171111--= 5 1 Congress Street, Suite 100 _a11=a Boston,MA 02114-2017 8. www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electriclans/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information r7� �7- Please Print Legibly Name(Business/Organization/Individual):1Il' t.o r3 c.' CL Q,v Lf, -1-VI.C. Address: t33 IVov+k, /(5111, tri reef. City/State/Zip:J,Yarht.0(L.+.1k), ft\ 0 a GG y Phone#: 6oP-t3 1 i{- O t32, Are you an employer?Check the appropriate box: Type of project(required): 1. am a employer with Il") employees(full and/or pan-time).* 7. ❑New construction 2.01 am a sole proprietor or partnership and have no employees working for me in g. Remodeling any capacity.[No workers'comp.insurance required.] 'rLy 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. Demolition 10 Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ❑ 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 5.0 lam a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs 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 MGL c. 14.❑Other 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. A II� ,,( �.p. ,{y.. Insurance Company Name: ' tisoCla .1:,[7,� 'TI&,uAet{'i(Al '1 a.lrrl• rQ. tee, Policy#or Self-ins.Lic.#: W CC �o o b' O(4'3a q azo at t Expiration Date: 31s If 9 Job Site Address: 13 Itl1lCKCh zl r, City/State/Zip: S. YaYlf 6IAa! 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 th ins and penalties of perjury that the information provided abovecorrect pis true and Signature: •pDate: 16 il.3''Q Phone#: 5 o A - 3`f'f' O f C7aJ 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#: • 0ttetR,i, TOWN OF YARMOUTH o BUILDING DEPARTMENT I''4 y 1146 Route 28,South Yarmouth,MA 02664 e�< ,,,,3'`� 508-398-2231 ext. 1261 Fax 508-398-0836 BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.C.L.Chapter 40, Section 54 and 780 CMR,Chapter 1, Section 111.5, thereby certify that the debris resulting from the proposed work/demolition to be conducted at 13 M n c 1Ct;A.z i c Qo a.d, d Y Work Address Is to be disposed of at the following location: J'4 Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. Ipp/ Signature of Application Permit No. 4. Final payment shall not be due until the Contractor has delivered to the Owner a complete release of all liens arising out of this Contract or receipts in full covering all labor, materials and equipment for which a lien could be filed, or a bond satisfactory to the Owner indemnifying him against any lien. If any lien remains unsatisfied after all payments are made,the Contractor shall refund to the Owner all moneys the latter may be compelled to pay in discharging such lien, including all costs and reasonable attorneys'fees. 5. If the Contractor defaults or persistently fails or neglects to carry out the Work in accordance with the Contract Documents or fails to perform any provision of the Contract, the Owner, after seven (7) days' written notice to the Contractor and without prejudice to any other remedy he may have, may make good such deficiencies and may deduct the cost thereof from the payment then or thereafter due the Contractor or, at his option, may terminate the Contract and take possession of the site and of all materials, and may finish the Work by whatever method he may deem expedient, and if the unpaid balance of the Contract Sum exceeds the expense of finishing the Work, such excess shall be paid to the Contractor, but if such expense exceeds such unpaid balance, the Contractor shall pay the difference to the Owner. PERMIT AUTHORIZATION By signing below, the Owner(s) authorize George Davis, Inc., to act on Owner(s) behalf relative to the work to be performed at this address. Project Address: 13 MacKenzie Road;South Yarmouth, MA 02664 Our signatures indicate that we have read,we understand, and we accept all provisions of this agreement. Do not sign this contract if there are any blank spaces. Owner 8• / � gate Nancy t son Owner 04:614' (.06 Vw Date do -113 eorge Colina Contractor /��Date q'dg . it George Davis, President George Davis, Inc. Initial Initial Page8of8 • • rV3e tnentonarea///e /(a n e. uac%aela Office of Consumer Malts&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corporation before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs end Business Regulation 160164 ' 07/01/2020 One Ashburton Place-Suite 1301 GEORGE DAVIS,INC. Boston,MA 02108 GEORGE F.DAVIS \p_l-i(�-,,, 33 NORTH MAIN STREET C..)'—""'�d SOUTH YARMOUTH,MA 02664 Undersecretary Not valid without signature • i, • Massachusetts Department of Public Safety - Ni f Board of Building Regulations and Standards • s License: CS-056130 - • Construction Supervisor • GEORGE F DAVIS 33 N MAIN ST !1 • S YARMOUTH MA 02664 •/Ay.921-60 Expiration: Commissioher 03/01/2019 • • • • • • • • • • • /� GEORDAV-01 KMELCHER ACORO' CERTIFICATE OF LIABILITY INSURANCE DATE(MM DO YY Y) kw./ 03/05/2018 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 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 tights to the certificate holder In lieu of such endorsement(s). PRODUCER FiiniA0T Gwen Vosburgh Mason&Mason Insurance Agency,Inc. ON (A/C,No,Es):(603)356-3392I lA�.Na):(603)356-9290 458 South Ave. E-MAIL Whitman,MA 02382 ADDRESS'g`Nen@mmins.com INSURER(S)AFFORDING COVERAGE NAIC R INSURERA:Western World 13196 INSURED INSURERB:NGM Insurence Company 14788 George Davis,Inc. INSURER C:Associated Industries Insuranc 33 North Main St INSURER D: South Yarmouth,MA 02664-3437 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 EXP TYPE OF INSURANCE (NSD SVND POLICY NUMBER IMMIDDy I IEFF MMAIDY/YYTYI LIMITS A X COMMERCIAL GENERAL LIABIUTY EACH OCCURRENCE E 1,000,000 CLAIMS-MADE n OCCUR NPP1477087 01/12/2018 01/12/2019 DAMAGEES fEe TORENTED $ 100,000 PREMISoaunerlcel MED EXP(Any one person) S 5'000 PERSONAL ADV INJURY _3 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE § 2,000,000 POLICY n PRO- fl LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: ECT E DeaiidenXSINGLELIMIT E 1,000,000 B AUTOMOBILE LIABILITY (Ea _ANY AUTO _ M9M28491 10/26/2017 10/26/2018 BODILY INJURY(Par person) $ _ _ AUTOSAONLY X SCHEDULED pBpOODILY INJURY(Per accidene $ X AUTOS ONLY X AUUTOS ONLY (Perreandnt)AMAGE § - _ UMBRELLA LIAR _ OCCUR EACH OCCURRENCE E _ EXCESS LIAB CLAIMS-MADE AGGREGATE E DED RETENTIONS § C WORKERS OYERS COMPENSATION X STATUTE ERH WCC50050143902018AYiN 03/05/2018 03/05/2019 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT E (pM�anC0atpry n :EXCLUDED? N N/A 'f yes,dory In NH) E.L.DISEASE-EA EMPLOYEES 500,000 If yas,RIPTION OF O 500,000 DESCRIPTION OF OPERATIONS below E.I.DISEASE-POLICY LIMIT § DESCRIPTION OF OPERATIONS I LOCATIONS(VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is rewind) Office Copy CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE George Davis,Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 ACCORDANCE WITH THE POLICY PROVISIONS. 33 North Main St. South Yarmouth,MA 02664-3437 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 01-.2. y TOWN OF YARMOUTH • • . -21-r -�y HEALTH DEPARTMENT PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET To be completed by Applicant: Building Site Location: 13 (! Cl. 941.7 l G 7.0QiL J'0 Llit,h., ya_rI/X.0C t Ju Proposed Improvement: IL tit i vo t C s c en t lt, -P Lon r hcak,. N o tit r u rt u v-a L @killed. Iykttycol 0.18r)C Oily: Applicant: 6 CO rl t, ZCLVIf ILCn. Tel.No.: Sop-agii-0&3,2, Address: 3,3 Wortfu ttalu .. ..NJ utLYft lknutk i Date Filed: 10/4iifi '•Ifyou would l l•likee-mailnotification of sign off please provide e-mail address: Owner Name: Toile, Onl.im, di NOaf, dirt/ m.) Owner Address: Sam, Owner Tel.No.: Age• 39 t-a t1 RESIDENTIAL AND/OR COMMERCIAL BUILDING HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements For Septage Disposal and other Public Health Activities. Please submit three (3) copies of plans, to include: (1.) Site Plan showing existing buildings, water line location, and septic system location; (2.) Floor plan labeling ALL rooms within building (all existing and proposed)— Note:Floor plans not required for decks,sheds, windows, roofing; (3.) If necessary, Title 5 application signed by licensed installer with fee. REVIEWED BY: '424 / DATE: / ' T' r? PLEASE NOTE COMMENTS/CONDITIONS: ?i&CiG✓1 dt°G Iaz 4/ TOWN OF YARMOUTH `rix, g REVIEWED FOR BUILDING AND ZONING CODE COMPLI• 1 ANCE. ERRORS OR OMISSIONS NOT RELIEVEf WS et/rt C M ICANTLFROM THE RESPONSIBILLIITY OF AS BUILT' THE DATE:I—Q--S- 1gam- cs TV'!244b Existing — tlU1CDING OFFicW o }— U i I i >.// I �\ 0 o 1 L. ' . �_ dl 1 I E] o fo- r a, in // N r bci Q ' u Ln al I� 4 ".`m I I------ E1:711 Zee � m ,� E I 2462 —L__ '[ r- mI :2-1 o s N Z 3 ‘5mvi X 81 112" X Cxisti g 2: fl--- `[ m .Ela Q o of X 811/2" vwn o l6 Y N C V } Existing Proposed to f , romp z 2nd Floor Bath DATE: replace existing tub in same location _ 10/1/2018 update existing sink and toilet in same location Yarmouth Health Department replace tile floor APPR 11 VED SCALE: Name Date SHEET: Pg-7