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HomeMy WebLinkAboutBLD-19-002646 i Office Use Only I ZOg•Y'4R,r . ■ , : �., Permit# paX1 - - Amoumtc2Ol•(SU iti.N_,.,t,'m r.Mrd: Permit expires 180 days from ,a . :e rw: ::.. issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OFYARMOUTH . RECEIVED Yarmouth Building Department 1146 Route 28 NOV 01 2018 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 seuitem rsr -Nip C "" se ...?_•—_±.—...?_•—_±.—_________...?_•—_±.—...?_•—_±.— CONSTRUCTION ADDRESS: 8 2.- tpp?,ft(kM 6 4 , J mini eaez--s^ ` ASSESSOR'S INFORMATION: / • c�Map: Parcel: OWNER: 0 ac '3e(l iWo L7€c '<.9-4);ve t__ Sr //445).2 a-5 - �a NAME �. PRESENT ADDRESS �� L. # CONTRACTOR: LrAtiC� c ij5b t ?[� it c h7s , nr w0'(1 Cab . SD a P3')�5' NAME v MAILECG ADDRE�SQ' TEL.# 0 Residential 0 Commercial Est.Cost of Construction$ •.5r 500 Ofa Home Improvement Contractor Lic.# ' 5 3 4 cti Construction Supervisor Lie.# Cs G /O WD 9 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 II'��am��the essole proprietor 0 I have Worker's Compensation Insurance ISO �i Insurance Company Name: �"C.JG( _ Worker's Comp.Policy# WeC £Oo6D ,taiSt�i 10/$A- WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares ^r19 Replacement windows:# Replacement doors: # Roofing: #of Squares la ( x)Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing/ *The debris will be disposed of at \/4Il novo,f-,L A NS,�J^ 5 ,A-77 a./v (j'� ' Location of Facility I declare under penalties of perjury that the statements herein contained are true and correct to the best of my Imowledge and belief. I understand that any false answer(s) will be just cause for denial or revoc.,:.n of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: t it /�J, �/ Date: c) Owners Signature(or attachment) w �/ Cil.& Date: /d/ 7// i'mm." Approved By: / Date: /� /� . Burl , tal(o•designee) 4,4? • I 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 _�' The Convnonwealth of Massachusetts �u_,. t � / Department ofIndustrial Accidents " =::,elE I Congress Street;Suite 100 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): (asP, _ Acs' Address: ' J �-S0 City/State/Zip: Phone #: S C8 3 3Z 15711 Are you an employer?Cheek the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. 9 New construction 2.�� I am a sole proprietor or partnership and have no employees working for me in $. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 3.9I am a homeowner doingall work [Not 9. ❑ Demolition myself. workers'comp.insurance required.] 4.❑I am a homeowner and will be hiring contractors to conduct all work on my 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. 12.0 Numbing repairs or additions 5.❑I am a general contactor and I have hired the sub-contactors listed on the attached sheet. 13.0 Roof repair These sub-contractors have employees and have workers'comp.insurance.: 6.❑We area 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. (� Insurance Company Name: SCOL'CA, Policy#or Self-ins.Lie.#: WCC .Sea SI) Se . -O 1(. l- Expiration Date: e K Lt3 [f 9 Job Site Address:_ g a_ ft&VJ.. 5kJ City/State/Zip: -S 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 un c,_ the pains and penalties of perjury that the information provided above is •tie and correct. Signature: - Date: / ( S Phone#: SCM 9 Sin' 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 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,§250(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 contact 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 checldng 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 I 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 Commonwealth of Massachusetts 171 Division of Professional Licensure Board of JldingRegulations and Standards ConstrJ Mrf iI ¢rvisor CS-104107 �. g . csy ires:08/25/2019 ibe-: r}CARLO FIGUEIROA _ _2G CAP YES pp - rSOUTH YARO1TH Commissioner �iie ;in mote mot/1/sic)iiiimiteke etice at Ccrsume.r Attaiis 8 i ;, ,.HOME IMPROVEMENT CONTRACTOR },/ iRe Is±r_Hc Ira±Io C u F REMODELIN+G IN Ot/07I2079 . Carlos Fladeiroa .‘.-74 Jtainl Noyes Rd 1 & armouth,MA 09604 C` �`" ' . . Undersea +_:, ' . ACORD® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYVY) 04/05/2018 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(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 CONTACT Larissa Camba NAME: Leonard Insurance Agency,Inc PHONE (508)428-6921 ,seer.No): (508)420-5406 (A/O.No.FSI): (AIC 683 Main Street E-MAIL larissa©leonardagency.com ADDRESS: Suite B INSURER(S)AFFORDING COVERAGE NAIC Osterville MA 02655 INSURER A: Atain Specialty Insurance INSURED INSURER B: The Commerce Ins.Co. 34754 C&F Remodeling Inc INSURER c: A.I.M Mutual Insurance Company INSURER D: 20 Captain Noyes Road INSURER E: South Yarmouth MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: Master 18-19 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 ADDL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WWI POLICY NUMBER (MMIDOIYYYY) (MMIDD/YYYY1 LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 DAMAGE TO RENTED 100,000 CLAIMS-MADE OCCUR PREMISES(Es occurrence) I MED EXP(Any one person) $ 5,000 A CIP353467 04/18/2018 04/18/2019 PERSONAL b ADV INJURY $ 1,000,000 ��GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 JAI POLICY !Pr LOC PRODUCTS-COMP/OP AGG S 2,000,000 �7I OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S _ (Ea accident ANY AUTO BODILY INJURY(Per person) $ 250,000 B OWNED Ne SCHEDULED RVM277 01/18/2018 01/18/2019 BODILYINJURY(Per accident S 500,000 AUTOS ONLY AUTOS _ XHIREDNON-OWNED PROPERTY DAMAGE AUTOS ONLY x AUTOS ONLY (Per accidem) S 250,000 S UMBRELLA UAB OCCUR EACH OCCURRENCE _ $ EXCESS UAB CLAIMS-MADE AGGREGATE S DED RETENTION$ $ WORKERS COMPENSATION PER 0TH. AND EMPLOYERT LIABILITY YIN STATUTE ER ANV PROPRIETOIVPARTNERIEXECUTNE E.L.EACH ACCIDENT $ 500,000 C (MendaRIMEMBEREXCLUDEDT N❑ NIA WCC-5°05018588-2018A 04/30/2018 04/30/2019 (Mandatory N NH) Et.DISEASE•EA EMPLOYEE $ 500,000 I1 yes,describe under 5000°0 DESCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached N more space Is required) • CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ConSery Group Inc ACCORDANCE WITH THE POLICY PROVISIONS. 110 State Rd 7 AUTHORIZED DESCRIBED POLI44 A�,�, r-1 1/1..,,,,,1//1,n Sagamore Beach MA 02582 !�7W�"''e-^ Cj• QA(I'w"_ ®1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD