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Home My WebLink AboutBLD-19-2894 Y ueaumyy� ^�j r AR`a0 ^ �gbe2 C ( . `,¢ Amount 5(�— Ca.: � �, c� • - h Permit expires 180 days from . Issue date RECEIVED EXPRESS BUILDING PERMIT APPLICATI I TOWN OF YARMOUTH NOV 13 2018 Yarmouth Building Department 1146 Route 28 Bun. I1 r South Yarmouth,MA 02664 -a" - 0 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 7`' 1/ILLAG/f eL/4 YA�im//j/ ®Q ASSESSOR'S INFORMATION: Map: Parcel: OWNER: 77W/12715 / 27•0;77/9 NAME PRESENT ADDRESS TEL # Email Address: CONTRACTOR: D,Ofr 2 eat 1°7, w S•7' yA/1 ,_cagy'-94 2 -S-2-77. NAME MAILING ADDRESS TEL# ' Email Address: Residential Commercial Est.Cost of Construction S d f Home Improvement Contractor Lie.# /0, +VP Construction Supervisor Lk.# Q/3_5342 Workman's Compensation Insurance: (check one) I am the homeowner I am the sole proprietor Iorker's Compensation Insurance Insurance Company Name: 7. ?27nrL 0--45 • Worker's Comp.Policy# . frefrimee 94�LZ WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares /0 Replacement windows:# Replacement doors: # Roofing: #of Squares ( ✓ )Remove existing*(max.2 layers) Insulation ✓/ Old Kings Highway/Historic Dist. (Replacing like for Re 'Aim/ref cow e c2 y2 4". Gzymi 'The debris will be disposed of at 1/4o/1..ARZ> W Location of Facility I declare under penalties of perjury that the statements herein contained are tme and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or rev on of my licenseandfor prosecution under M.G.L Ch.268,Section 1. Applicant's Signature: � .[/ r Date: ill0c 0v/item Signature(or attachment) /' Date: Approved By: Date: M.-/1 Building Official(or designee) • Zoning District Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District Within 100 ft.of Wetlands: Yes No Yes No • 2 tie a-trrnmonwearzn of Massachusetts Department oflndustrialAccidents • a =WET*: 1 Conacress Street,Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH [til±,PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Jj�j//� 4, /c Address: -Zi , , / / el City/State/Zip: zeAyd� yy� 07 c' Phone #: ,5752-9GZ—S 2_ Are you an employer? Cheek the appropriate box: Type of project(required): loam a employer with employees(full and/or part-time).* 7. 0 New construction 2.0 I am a sole proprietor or partnership and have na employees working for me in any capacity.[No workers'comp. insurance required.] B• �Remodehng 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. [11 Demolition i.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will10 0 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 i.❑I am a general contactor and I have hired the sub-contractors Ion the attached sheet employees and have workers'comp. .in surmrcat 1.3.❑Roof repairs These sub-contractors have 3.0 We area corporation and its officers have exercised their right of exemption per MOL c. 14.❑Other 152,31(4),and we have no employees.[No workers'comp.insurance required.] .ny applicant that checks box ill must also fill out the section below showing their workers'compensation policy IlLfa Laotian. iomeawners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have ployees. If the sub-contractors have employees,they must provide their workers'comp,policy number. urn an employer that is providing workers'compensation insurance for my employees'. Below is the policy and job site formation. surance Company Name: /,..e347/24I,79.,...9-77, dicy#or Self-ins. Lic.#: l/' c?e'-1t997, Expiration Date: #J/9 b Site Address: 4ra% City/State/Zip: #.4 tach a copy of the workers' compensation po a cy declaration page(showing the policy number and expiration date). ilure to secure coverage as required under MGL c. 152, §25A is a criminal violation pnnichahle by a fine up to S1,500.00 d/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 y against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance erage verification. 'o hereby certify under the pains and penalties of perjury that the information provided above is'true and correct "nature: _ •! � . 1I Date: // one#• v Uwe gl� 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 t Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. • Pursuant to this statute, an gmployee 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, §25C(6)also states.that"everystate 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 contacting 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), addresses) 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 Of$rials • 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 511 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 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 r 4 'I • . '� 1d• CERTIFICATE OF LIABILITY INSURANCE °"""'"°"'"e THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIOHTS UPON THE CERTIFICATE HOLDER.1THIS 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: ,E Ie artleaMs holder Is an ADDITIONAL INSURED,the polloy(Ies)must be endorsed. M o SUBROGATION IS WAIVED,subject t , the tams end ounditiona af UM onSRcats holder In SU of such en M({ll0Y,certain� requirelICIMI May an endorsement A statement on thiscertificate does not center rights to the PRCOUCNI / jigraM.r KaDEeen Caddis_ NORTHWOOD ESHBAUGH INSURANCE AGENCY INC soe)T71.1aT2 _ FAY- 640 MAIN ST tan Kath1e°n' ° ^�CO'R _ 540AI ----• DsuRER{1UFaROeapgYERAOE_ __ _ �we!HYANNIS HYA _MA 02601 RAWPea A: TRAVELERS INDEMNITY CO OF AMERICA 23668 _ DAVID COX INC aMlwRe' T� ..._.- 111111111111 .wRVRe: __ — --- aaUeD1P: ___.-._ -_._.-- POBOX401: mutter s _-_ . 1 i S YARCOVERAGES MOi1TH' _, .MA INelalElr r, I CERTIFICATE NUMBER: 171517 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF NBURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR C ONOnON OF ANY CONTRACT OR OTHER DOCUMENT FAIN RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICES DESCEBE° HEREIN IS SUBJECT To AU. THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED SY PAS)CLAIMS. ewe a/are{Ir1ArrCa AOouwei" POLICTHF aMEiIwe a AI.LWKRY nae we: RUN MUMMER MMDOYYTYI Air_- MRM..._.._ _. . EACH OCCURRENCE j CLARIS ADE EOCCUROCET671ERIII5•_ f.—.._ ._.._..._.. �ENBEM.fEe.mem.,�, 3 -- NEO IFNA,Y AntEwP!'L -s....... . .__ ._. . .. WA PERSONALAACVIWURV $ _ _ _ oEIHLADPRerdArjEPPUpeMO�rtAPPLES PIA: GENERAL AGGREGATE E_ _...I POLICY L�l{C7 LOC PRODUCTS.COAigPAOO { - `--_ 011ER __ ISI MRDYOW12LIAaILRT $ COMBINEDSNGLE UWT 11 -- u ._—_.._._ _ANY AUTO eOdLr PaARerlvt_ WARDr—soca; . _ ___._ToAUTOS WA NON-OWNED • soccer INJURY(Per eedlPq s _+---_ _—HMO AUTOS Aura --. ._.---- { IlrreaaUAlido OCCUR EACHOCCIIMENCa { IXCSULMS , cuaa+uos WA ._.. �ocaEOArE { DEG I I Retemorr{_ wanes coargJAs 1N - pE { AMPeMPlerele'L1AayJrT Y x1ETATUR I .169....-__ A Orn :n wea°a RTNE nva IVI WA WA EL EACH ACCIDENT .....S..100‘000___�._�- Ns BHUB910X742217 omenwaq 07/162017 07A812pt8 --------- EyyPe�A,OMaeeuWr E1.OI{EAEE-EA EueLOVEE 5-100,000 DrkwilT1DN of OPERATION{erect EL.DISEASE-'DUCT LIMIT { 600,000 SVA a{DRFTIDM OF OPeIA11018 I LOCARda1YWNICLM IACONO MI,Mnnean:eM ed.ay ma,r:aedied andw ipso w ngd,R{i Workers' Wr1efln'Compensation benefits WI be pay to Massachusetts enployees only.Pursuant to Endorsement WC 20 03 08 B,no authorization Is given to pay me employees in Stare other than Massadsmetts If the insured Wrw,or has hired those employees outside of Massachusetts. This osnlAeate of Inewanoa shows the policy 1n force on to date that Ws certificate was Issued(unless the'Oration date on the above policy precedes the Issue dale of this CemBeae of Insurance). TM REM c(this coverage can be monitored dolly by accessing the Proof of Coverage-Coverage Verification Search tool at wew.mass.gov/WdAvalcersoomponsettallneestlooportei. CERTIFICATE HOLDER CANCELLATION Smuts ANY OF THE ABOVE DESCRIBED PouuES BE CANCELLED BEFORE THE EVIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN Town of Barnstable ACCORDANCE W1111 TIM POLICY PROVISIONS. 200 Main St AUTNOR¢mREPRWEARATRa Hyannis MA 02601 L,,i' (,, c Daniel M I M.Crow*,CPCU,Vice President-Residual Market-WCRIBMA ®1558-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo we registered maks of ACORD • Ma of Conner bee a O ashoso OreMMlsa - HOYE 11PROIRSEHT CONTRACTOR Regheretlonyalld terk dlvklull use only TYPE Cstioratim Before Vie aspiration dale.i iwnd Mum sn la BostiOntoo Eamioi . Offload Ca ourafMRan and Brakrsss Regulation 100497' • Oa2wazo 10 Pak qua-SuffsM70 DAVID COX,INC. ` BostonIIA anis o 19 LAVENDER LH W.YARMOUTH.MA 07873 Not valid without commonwealth of Yassathusells \ . � Division of Professional Licensure Board of Building Regulations and Standards Constr4 1I6i1%idpgrvisor CS-063537 14,pires: 10115/2019 k _ s (AMR Ca- ''•-f/ ^ . PO BOX401 / - SOUTH YARMrtu 61IAA 02451s*- r . 10/W.(3Ut _ -- - - Commissioner C • • • • •