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Q Type Demolition Other Speciy: :i Brief Description of Proposed Work: .__.4 Section 7-Use Group and ConstructionType i ` j f Building Use Group(Cheek as appfieapable) Construction Type A" ASSEMBLY: ❑ ^A-i Q A-2 Q A-3 ❑ '' IA` Q " 1 B BUSINESS ❑ -_ 2Ay Q" y .i E E7]UCATIONAL Q 2a' ❑ .•. H`HIGH HAZARD ❑ a ,' Q 'b I:<:.INSTTMIONAL Q : 41 Q :42 Q 43 Q 3B ❑ M MERCHANTtE ❑ 4 ❑ R RESIDENTIAL Q R-1 ❑ !R,2 ❑ R-3 Q:'. SA r' Q S i STORAGE ❑ S-1 Q --54 Q" Sa ❑ 'i ❑ - SVEQFYc • .. M MIXED USE ❑ ` SPECIFY: - ,. '. _,_,__ S SPEOALUSE ❑ SPECIFY: Complete this section If existing building undergoing renovations:additions and/or change In use.' Existing Use Gawp: . proposed Usa Group Existing Hazard Index 780 CMR 34 Proposed Hazard kids:.780 CMR 34 :v Section 8 Building Height and Area j .. __ Building Area Listing(A applicable) _ . _ .Propos ' ,� NumEar d lipoyl m as a 5 € Include basemml level :7 t _ Roor AneperRmr(sl) .� Total Area AB Floors(sf) t Total Height(It) Section 9-STRUCTURAL PEER REVIEW(78OCMR 11011) Independent Stnlcbaal Engineering Strube:al Peer Review Required Yes____.. " No �:: ' SECTION 10a OWNER AUTHORIZATION-TO BE COMPLETED WHEN k OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ,as Owner of the subject property, hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. _ $' " Signature of Owner Oats ,:i 3014 OVER .t mi nr'Xniv SxWu' u+f'eNWL±4iu.M.iW.a.0"..0 e.va " .ry.++..-tw�MM.w'.40 w+'va.6x#owrriieu:k..wccuwbrkawsuaw w.wn.rV1,4,41 w Sw..x...itat:wfinr.W...ahgauwGuwr The Commonwealth of Massachusetts v- -••=------- • � , Department of Industrial Accidents u _-1: Office of Investigations -- - 600 Washington Street • • N_r`` -- Boston,MA 02111 •www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Nae(Busi❑ess/Organization/lndividnal): .1iv _, r _ Address: 2_ &e, vii< ,,,,A„/ i'` lTcA�o( G opt!S '. • Ci /State/Zi.: . 141,41.,_. p et- tt , _ ' Phone#: &e's 3C. 'i ; Are yqv an employer?Check the appropriate box: 4. I am a Type of project(required): I. I am a employer with y ❑ general contractor and I s have hired the sub contractors 6. ❑New construction employees (full and/or part-time). 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contactors have 8. 0 Demolition working for me in any capacity: employees and have workers' 9. ❑Building - [NO workers'comp,insurancecomp.insurBuilding addition required 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their . 11.0 P ing repairs or additions • myself[No workers'comp. right�§1(4), exemption per MGL 12. Roof repairs insurance required.]t: c. 15 1 4 ,and we have no _ 3a.❑ I am a homeowner acting as a employees.[No workers' 13 Other general contractor(refer to#4) comp.insurance ), 'Any applicant that checks box it must also fill out the section below showing their wotktxs'w mpensatiallsolicy t Homeownm who submit this affidavit indicating they am doing all work and then hire outside comncton must submit a affidavit indicating such. :Contractors that check this box must attached ea additional sheet showing the name of the sub-contactors 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: ' -r;.14.t j Le p,..› ......MA-1 Policy#or Self-ins.Lic.#: I 11-2..„.` I �e y7 3 / Expiration Date: t o y /7 Job Site Address: //) o'7 nk.`y— 2. C City/State/Zip: '1" Attach a copy of the workers'compensation policy declaration page(showingthe policy � � �I Failure to secure coverage as P g number and expiration date). g required under Section 25A of MGL c..152 can lead to the imposition of criminal penalties of 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 a• . t the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of s . ', . rust.:... : ;,r ; Ido here. •. • of perjury that the information provided ab, els tint d correct rr i....2 a t 40,E ll a • 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 nspector 6.Other Contact Person: Phone#: • "i ,: '•'r'9, TOWN OF YARMOUTH 2- 4.0BUILDING DEPARTMENT • ` E� '5 y 1146 Route 28,South Yarmouth,NIA 02664 CZCZ—oasg 508-398-2231 ext.1261 Fax 508-398-0836 BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G.L. Chapter 40,Section 54 and 780 CMR,Chapter 1,Section 111.5, [hereby certify that the debris resulting� from the proposed work/demolition to be conducted at OG'7 1 vF Z C S Yjd.✓tivty Alt titter Work Address Is to be disposed of at the following location: S+V 9-�CU Said dispos - hall be a licensed solid waste facility as defined by M.G.L. Cha 11, Sec.on 150A. //k—/ Si: of Application Permit No. • Massachusetts Department of Public Safety V: Board of Building Regulations and Standards License: CS-073981 Construction Supervisor - • ,c'; MICHAEL F DRISCOLL 2 CHRISTOPHER HALLWAY YARMOUTHPORT MA 02675 xpiratiOn: Commissioner it/11/2018 To: Page 1 of 1 2018-11-05 11:28:44 EST 186654431 84 From:Anne Sanzo • ' TLHITCH-01 ASA= 'Aco oR CERTIFICATE OF LIABILITY INSURANCE tf sATE1MM/2018 r( �� f 11Ig8i2016 THIS CERTIFICATE. IS ISSUED.AS A MATTER OF INFORMATION ONLY.AND CONFERS NO RIGHTSUPONTHE 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,tho 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.License#.1760662 '-.. • NaNTACT HUB International New England ."• - '- PHONE- E•MAILa Eq):(5081945-0446 - _.� I(Arc,ngLl5D8)945-9136 ) '. 2650rleans Road �.'' ' '--' - " '• ' - .- 1 North Chatham,MA 02650 ADDRES6• INSURERISI AFFORDING COVERAGE NAICa INSURER A;Travelers Property Casualty Company of America 25674 • • .. INSURER B T L Hitchcock Construction INSURER C; • 1 2 Quinns Way INSURER B.: _- I Mashpeo,MA 02649 INSURER E: INSURERF: .:.''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. NOTIMTHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VAIN RESPECT TO WHICH THIS CERTIFICATE MAYBEISSUED 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. I�rry TYPE OE WSURANCE INS SULK� POLICY NUMBER POLICY Err POLICY EMP LIMITS -- IMMIDDlYYYYI IMIDOWYYYY1 COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE IS —_J CLAIMS-MADE n OCCUR DAMAGE 0 RENTED _EU 471 MED EXP(Anv onepw,w,I $ PERSONAL a ADV INJURY S tSL AGGREQt EpLgIMo-IT ..abaEALOGS:RPGATE I5 POLICY[ spCi LOC - I PRODUCTS-COMP/OP ACO IS -_.... OTHER. COM $ AUTOMOBILE LIABLLRY - TESALNEE,ill SINGLE LIMIT i S • — ANYAUTO BODILY INJURY tpe serum) S OWNED SCHEDULED `I • _ AUTOS ONLY AUTOSpFL ��NNEEpp BODILYOINJURY(Per acCvdl S _ AUTOS ONLY ADIOS ONLY IPn ecaaenIDAMAGE S S UMBRELLA LIAO OCCUR -' EACH OCCURRENCE S EXCESS LIAR CLAIMS-MADE . AGGREGATE S DED 4 RETETIONS . I N 5 A WORKERS COMPENSATION PER DTH• AND EMPLOYERS'LIABILITY � STATUTE ER ANY PROPRIET(lftlr'ARTNERIEXECUTIVE I (,NI 7PJUB1K64731818 10109/2018 10!09/2019 1,000,000 i����Idatary ii a EXCLUDED? 1 1 NIA FI FBGH ACCIDENT $ 1,0001000 (Wnr)alory n E.L DISEASE'-EA EMPLOYEE S Ifyea de,wtemiler 1,000,000 -_,-DESCRIPTIONQ[`OPERATIONSbAcw E DISEASE-POLICY UNIT S ii DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES(ACORD101,Additions;Remarks Schsdula,mar be attached If move space II required) • 3 i v ... . CERTIFICATE HOLDER CANCELLATION • .. - `• ' - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATIONNCE DATE THEREOF, NOTICE WILL BE DELIVERED IN . . - ..., 1146 Route 28 ` - ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 02664 .. AUTHORIZED REPRESENTATIVE tVAP// ACORD 25(2016/03) (1 ©1988.2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD