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Home My WebLink AboutBLD-19-3040 can ceUse Only A .FY : RECEIVED /9 30 CI y{: `� 9 ii -A 4. C' • Amour[ 1 c ^1 y` s NOV 16 2018 %. b�, j;Permit expires 180 days from f'issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH - Yarmouth Building Department 1146 Route 28 _ South Yarmouth,MA 02664 5088)/398-22231 Ext. 1261 unt444.4._ CO NSTRUCTIONADDRESS: t) VI I fiL000c `ten & /1 es�ASSESSOR S INFORMATION: nn�j Map: as Parcel:„.44 OWNER �4 ÜIC2G 1 ` I" GCb C—A o 710 I Y (alt - 5Oa - (la&—c U.. [L '�-• s Ema'' Address: CONTRACTOR: t1s e4 ,Mt � gdr" S1 /y1b Q4(h`ic. U MAILING ADDRESS /�l,l• �7. ik MI-# ' bcl(�.1/" Ema�`Mddree— esidential Commercial Est Cost of ConstructionL4 $ h i OCY3 ^� Home Improvement Contractor Lie.# /Co 2 2-3� Construction Supervisor Lia# l 1^ — ,opal,n J Workman's Compensation Insurance: (check one) I am the homeowner SS I am the s��15 proprietor _I .l have Worker's Compensation Insurance ' I p d Insurance Company Name: SSO C • (J' )IO�c�J A JJS 010-�✓orker's Comp.Policy# S OC OO S`i 4 a�(u /' WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares ' /D Replacement windows:* 1 Replacement doors: # c:,1_ Roofing: #of Squares 1 1 ( )Remove existing (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( Vieplacing like for like *The debris win be disposed of at 1 1 to—) CAS LC3o s 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 or rev ation of.. se for a on under Milt.Ch.268,Section 1. Applicant's Signature: J Il e t 1V �P Y/7yC • Date: (� SW- Owners //s Owners Signature(or attachment) / tit( D� ��% t+' r'— Date: 1)if s/!/� �j Approved By: � " �'i , , Date: /// /G B ' g tial(de 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 • The Commonwealth ofMassachusetts Department of Industrial Accidents It—re ilt Office of Investigations iii Iel— 1 600 Washington Street 1 Boston,M4 02111 ,j.� wmhnmass.gosVdia Workers'Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers Builders/Contractors/El sob es ApplInformation Pease Print Letr lv . C� Name Ous tianrlati • l #G C r C5 - rs . — Address: (2 L0 ev.;&— 4-Y City/State/Zip: (� IL. Phone#: Sod - .off'. Are you an employer?Check the appropriate box: - Type of project(required): I.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction employees(fall and/or partfime), have hired the sub-contractors 7. Remodeling 2.❑ I am a sole proprietor fir partner- listed on the attached sheet ❑ ship and have no employees These sub-contractors bate S. 0 Demolition wemployees and have workers' Building addition [�oyrlriag for me in any capacity. 0 o waters'comp.insurance comp.insurance: 9 r• 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ Iam a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions right of exemption per MGL 12.0 Roof • '. myself c.152.§1(4),and we bate no ii.i b insurann ce e required.]equired]I T employee.[No workers' 1 - comp.insurance required.) 1 S S • • *Any applicant tat checks box almost also fill out the cacao.below showing their wakes'compensation policy information — �tJ�� I nomenwaes who submit this affidavit indicating they are doing an work and then hire outside contractors amu tubmit a new affidavit at m , :Contractors that check this boa must attached an additional sheet showing the name of the sub-contractors and state whether at not those employees. lithe mbcwnaaas have employee,they mint provide their workers'comp.policy number. _ e I am an employer that is pros ding workers'co anion insurance for my employees. Below is the policy and fob site information. ..., /`/e)�� Insurance Company Name: rQL' • 11 ( . • I • ::on Date: 6 aPolicy#a Self--ins.Lie. -=Stab r r ,a.3 _ t /gyp 1� t Job Site Address& o 1 A-0't'"OO� City/State/Zip: hi - QJ��+ Q` Attach a copy of the workers'compensation policy declaration page(showing the policy number n expiration dates. Failure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of 1 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 against violator. Be a . that copy of this statement maybe forwarded to the Office of Investigations of the DIA for' utance coverage - cati Idohereby ceHifynn a 'ns andTS( 'that the info r tationprovidedabmvts Bean correct Siraat°re: / /_' Date: // J 'r menet co X - U CSS - a Q! i1 (( Official use only. Do not write in this area,to be completed by city or town official. • City or Town: Permit/License 0 Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone ii: 6 Client#: 16665 2MEAGHERCO `ACORD,„ CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 10/31/2018 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 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 C�INTACT N ME: Dowling&O'Neil insurance Agy PONNe,E„).508775.1620 (NC,No): 5087781218 973 lyannough Road E-MAIL ADDRESS: P.O.Box 1990 INSURER(S)AFFORDING COVERAGE HMCo Hyannis,MA 02601 INSURER A wnnaAeAnnlnsurannCompany 32859 INSURED INSURER B:AssocWd Employers Insurance Company 11104 Meagher Construction Inc. • INSURER C Timothy Meagher 776 Main Street INSURER D: INSURER E: Osterville,MA 02655 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 WTH 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. LTRY EXP R TYPE OF INSURANCE INSRL WVD POLICY NUMBER (MSUBR PM/00//YY EYYY) (MPM/0D//TTTY) LIMITS A GENERAL LIABILITY PAV0186320 /0/16/2018 10/16/2019 EACH OCCURRENCE 51,000,000 X COMMERCIAL GENERAL LIABILITY PR EMISES�Eaoaurrence) $50,000 CLAIMS-MADE xi OCCUR MED EXP(Any one person) 55,000 X BI/PD Ded:500 PERSONALS ADV INJURY 31,000,000 GENERAL AGGREGATE 52,000,000 GERI AGGREGATE LIMB APPLIES PER: PRODUCTS•COMP/OP AGG $2,000,000 AI POLICY I 'Ta- fl LOC $ AUTOMOBILE LIABILITY CEOMBISDI SINGLE LIMITCa $ ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED BODILY INJURY(Per accident) 5 AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS _ AUTOS (Per accident) $ UMBRELLA LIAR _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE 3 DEO RETENTION S $ B WORKERS COMPENSATION WCC50050054422018A 06/23/2018 06/23/2019 X TORVTAinlis ERH AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT 5100,000 OFFICER/MEMBER EXCLUDED? N NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE 5100,000 If yes,desmibe under DESCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT 5500,000 • DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Insurance coverage Is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained In the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION Town of BamStable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Dept. ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE TH614iids VE ,y ®1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S222476/M221069 RPSW1 CONSTRUCTION 776 Main Street Osterville, MA 02655 508-428-0458 Tim@Meagherinc.com r .. Commonwealthof Professional of Massachusettsl Licenu Division of Professional Licensure Board of Building Regulations and Standards Constrgtttt6ri`%`If pervisor CS-102260 7 Expires 11/05/2020 MICHAEL S MEAGRE 97 EMERALDL}AWNE a iaA.:' • f w MARSTONS MILLS MA 02648 C a . 'tf)r4, 1fl1L` w Commissioner l • Vroe'Fansrreonlora/eS e`o ftaosacAaeeaa Office of Consumer Attain&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:IndividuFvpll9SlOn f 41R 82, n 04/26/2019 M CHER CONSTRUCt"TION 1 '• MICHAEL MEAGHER JR. 776 MAIN STREET ,. OSTERVILLE,MA 02665- Undersecretary