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Home My WebLink AboutBLD-19-2904 Y. - _ i Office Use Only oF• gR s 14r 'zso. 'Permit# O � N -Amont /ago 00 e •_Nl 1. s , Permit expires 180 days from I. `issue date 61b-lG- 0�1Mr REcEiveD . EXPRESS BUILDING PERMIT APPLICAT O TOWN OF YARMOUTH NOV 13 2018 Yarmouth Building Department 1146 Route 28 ter __rut a i ma r South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: l7 /ap&ANF L" vie, / ef aelo WA, in A ASSESSOR'S INFORMATION: • !� Map: Parcel: OWNER gRlr^Mf lieeogG /ff FThetAt 4v2-• /3-:azDfile4 67 e/ c/P NAME PRESENT -' , ADDRESS CONTRACTOR: • A ,. OP / L �/,i . 97% °a V I, NAME el MAILING as DRESS TEL# • pesidential 0 Commercial Est Cost of Construction$ c?q, a-alp Home Improvement Contractor Lic.# / SO 3p [ Construction Supervisor Lie.# 0 l ? 697 Workman's Compensation Insurance": (check one) "CT I am the homeowner I am the sole proprietor 0 I have Worker's Compensation Insurance 50--a Q Insurance Company Name: rLeft ef t$ Worker's Comp.Policy# 4 (I$ ,r a s-1 V WORK TO BE PERFORMED Tent _ Duration �� (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares / ' Replacement windows:# p �S O Replacement doors: # a Roofing: #of Squares 9 ( 'Remove existing* (max.2 layers) Insulation N > �d Kings Highway/Historic Dist ( )Replacing like for like Pool fencing - r E co "The debrisbris will be disposed of at ,.i JC 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 o 'cation of my license and for on under M.G.L Ch.268,Section 1. _ Applicants Signatu - . et Date: Owners Signa. re(or attachment) Date: I 1- 13 - a Approved By: .,•••••C-et" Date: 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 (fr S The Commonwealth ofMassaclrusetts I!=- �= t Department o =7,431:= � p flndustrialAccidents s ==e= � 1 Congress Street, Suite 100 1.-910_—= 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): q J l iI('pW�7)o13L /, & sf-Rvcn' n n Address: �Muig City/State/Zip: Ca' eit/Y1Path Phone#: 'f5f^7/F -01? f 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 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ,Q-Remodeling any capacity.(No workers'comp.insurance required.] 3. I am a homeowner doingall work myself r 9. Demolition ❑ ys (No workers'comp.insurance required.] 4.0 I am a homeowner and will be hiring contactors to conduct all work on my property. I will 10 Building addition 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 I am a general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance.; 13. Roof repair 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 contactors 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: t ' \4VR L Policy#or Self-ins.Lic.it: 4P KUip !K 3 a as s ( Expiration Date: Job Site Address: a I, I l/ —\ ,0/0/ � ►^r,CCity/State/Zipk/ • rt atf'rl Attach a copy of the workers compensation policy declaration page(showing the policy number Yiy' Yid 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 c-e; under the pains and penalties of perjury that the information provided above is true and correct Signature: ii Date: // z!/ 8` Phone#: rel/ �� /?'— 0 1 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#: • 10 ie • 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 ajoint 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, §25C(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 contacting 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 Accident. 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 I-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.rnass.gov/dia T� ��o Wpoinwooicoea to d/Q%ooac�et? qa Office of Consumer Affairs and Business Regulation "�� 10 Park Plaza-Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Type: . Individual ROBERT B. DUNPHY Registration: 180935 Eviration: 02J01/2079 3 Harbour Hill Run South Yarmouth, MA 02664 • Update Address and return card. Mark reason for change. SCA I 0 20M-05/11 n R a.i-... n a.....wt n ems..'........... n i..N rx.l Commonwealth of Massachusetts l®1 Division of Professional Licensure Board of Building Regulations and Standards Construction„Sit 404or,1 & 2 Family a • CSFA-069294 li Ejtpires: 09/1412020 i ROBERT B DUNPHY kk' .;'' - . ,„, . 3 HARBOUR HILL RUN„./ `• SOUTH YARMOUTH MA 02661c.": • Commissioner Page 1 of 2 http://web.mail.comcast.net/service/home/—/?auth=co&1oc=en US&id=274101&part=2 1/20/2015 4/acv22 c r mss carbonless am . . NC3822 3 PART • CONTRACTORS INVOICE oti3stR-i— 7)1/IL( ?fir WORK PERFORMED At • a ? AA.44 L4r /f eCZ fi 1 uta rf- yisoriP h /5. 4R/Yl pcifli YOUR WORK ORDER NO. • OUR BID NO.' • rR.19 r Si?CP- F -1711b1t1 a_ Las trio, • • • te• net Is guars to be as specified,and the above work was performed In accordance with the drawings and specifications e d for the a a work wa completed in a substantial workmanlike manner for the agreed sum of ..�1 Dollars($ O ° )• a 0 ❑ Full invoke due and payable by: kfa�dhDay Year. 11/L3/201U 11:84 /817498822 JOHN J. LAMB INS PAGE 92192 oA d CERTIFICATE OF LIABILITY INSURANCE DATE`�"IDD"Y'" 11/132018 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 poiicy(iee)must 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 CONAMEI Jeanne McPhaI JOHN J LAMB INSURANCE AGENCY INC PHONE.Ertl: 061)749-6960 1JVC,Np): ADDRESS: keriny@jlambInsurance.com 24 NORTH ST INSURER a(lAFFORDING COVERAGE NAIGF _HINGHAM • MA 02043 INSURER A: TRAVELERS INDEMNITY CO OF AMERICA 25688 INSURED INSURER a; DUBLIN CONSTRUCTION INC INSURER C f INSURER O: " 2 HERSEY STREET INSURER E: SO YARMOUTH MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: 337092 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. INBR ADDL SUER POLICY EFE POUCTEXP LTR TYPE OF INSURANCE NEL WYG PDUCY NUMBER pdMIDDPYYYY) IMwoorrinEW, Lan COMMERCIAL GENERAL LABILITY EACH OCCURRENCE S 71 CLAIMS-MADE n OCCUR DAMAGE IT H6NTE0 ' PRFMGES 1(EaN NTvmncel S MED EXP(Aar oa4 pareen) G N/A PERSONAL A ADV INJURY G GENt.ADOREDATE UMR APPLIES PER: GENERAL AGGREGATE $ POLICY0 Te-sr n LOC PRODUCTS-CONPXIPAGS B OTHER: G ALTOMODLSLIABILCY COMBINEDSINGLE LIM/ B (Er AOdnen° ANY AUTO BODILY INJURY(Per pew) r — AU.OWNED —SCHEDULED AUTOS —AUTOS N/A BODILY INJURY(Per occident) I HIRED AUTOS _NOTOeW� -PROPERTY QAMAOE r (Per actldeM s UMeREUA LPN HOCCUR EACH OCCURRENCE S EXCESS LIen CLAWS-MADE N/A AGGREGATE $ DEO RETENTION$ $ _ WORKERS COMPENSATION XSTATIRE I EOR AND EMPLOYERS LIABILITY Y/N _ A O FICERMEMBERF_ARCC uDERD?� N/A NIA 6HUB1K83222518 - 09(292018 0929/2019 UTIVE EL.EACH AccIDENr s 100,000 (Marddory In NN) EL DISEASE-EA EMPLOYEE r 100,000 II yes.describe under DESCRIPTION OF OPERATIONS Doles EL DISEASE-POLICYUMR G 500,000 N/A DESCRIPTION OF OPERATORS/LOCATIONS/VENIC.EB(ACORD 1O1,Additional Ramerks Schedule,nor be attached if mon space is required) Workers'Compensation benefits will be paid to Meseaohusetta employees only.Pursuant to Endorsement WC 20 03 08 B,no euthoraetion is given to pay claims for benefits to employees in states other then Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of Insurance shows the policy in force on the date that this certificate was Issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool al www.mass.gowlwd/workerscompensationrnvestigetionsl. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLJCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BR DEUVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTTHHOR�IZZFED REPRESENTATIVE .So Yarmouth MA 02664 'i �' % OSnia M;Gl• y,CPCU.Vice President—Residual Market—WCRIBMA G1988.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD • a ri NOTICE ' g NOTICE TO ( 'isr-ra TO EMPLOYEES = =5..- A EMPLOYEES r e� 0,,, - gV 6 The Commonwealth of Massachusetts - DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114 — 2017 617-727-4900 — http://www.state.ma.us/dia As required by Massachusetts General Law,Chapter 152,Sections 21,22&30,this will give you notice that I(we) have provided for payment to our inured employees under the above mentioned chapter by insuring with: THE TRAVELERS INSURANCE COMPANIES NAME OF INSURANCE COMPANY P.O. BOX 1450 MIDDLEBORO. MA 02344-1450 ADDRESS OF INSURANCE COMPANY (6HUB-1K63222-5-18) 09-29-18 TO 09-29-19 POLICY NUMBER EItECTIVE DATES JOHN J LAMB INS AGCY INC 24 NORTH STREET - , aa. �Nf�ME�OF T7.Ci T�p�i7 IeAm�e ay ,r . MA 02043 ' u/so-woz n L vas D W 3 3kSYWA 'P C nlarPue ss PP ES e ue �o uo ai S PHONE# ,=_—_, DUBLIN CONSTRUCTION INC 2 HERSEY STREET SO 02664 f O HW 'tg A wog ' �:-MA 0266 r10lUJB h0 EMPLOYER ADDRESS µ' inn iyl1 6L03/4020 :uoRe,!dX3 ARdNna •s la3sOb 3= cteoaL :uoreiis!6eu �. :,.... [.. EMPLOYER'S V4ERSMPENSATION OFFICER(IF ANY) DATE The above named insurer is require Lif scevSofamEnhaiajories arising out of and in the course of.;-4-1,,, — employment to furni$ly, egg1 II jp#.18 .11istiteal}9et'dd n accordance with provisions of the Wor ets' mpensation Act. A copy of the First Report of Injury must begiven toy' ,— P J rY �+ - injured employee. The em to a ma sel- t %i o , - so ?� of the servt - W provided by th aGi' ri��f.fe,q/,- , !; t�Vag,�r�e rea s ngEa and reasonab connected to the work related inji . In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS • TO RE POSTED BY EMPLOYER