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Home My WebLink AboutBLD-19-3103 Office Use Only d .Permit# _O-/ O � y Amount /CD- CO - U ' h h Permit expires 180 days from tIJ��(�"1 —bb31 b3 issue date .—._ RECEIVED EXPRESS BUILDING PERMIT APPLICA ION TOWN OF YARMOUTH NOV 19 2018 Yarmouth Building Department 1146 Route 28 Bui • ' n T South Yarmouth, MA 02664 BY (508) 398-2231 Ext. 12/ ;l61 '/ Q CONSTRUCTION ADDRESS: eo0 Plea sanf Sty South a "0tltL 0466q ASSESSOR'S INFORMATION: VVV • n // p / Map: Parcel: OSI. /03 (/. OWNER: Aftot zee e A20oRah. 4ertA a5 loo P(eaganf cct Sou I-Ac aGI/>Loc�fk 508 e69-673b NAMEQQQ / PRESENT ADDRESS ' TEL. 3l CONTRACTOR: IDr/Q/l- AR S 4 R. NAME MAILING ADDRESS TEL.# /Residential 0 Commercial e Est.Cost of Construction$ ZO,°O/ O • 00 Home Improvement Contractor Lie.# 1R5-7368 Construction Supervisor Lic.# 16 9l7 1 7 Workman's Compensation Insurance: (check one) 0 I am the homeowner �1 0 I am the sole proprietor 0 I have Worker's Compensation Insurance / /� Insurance Company Name:f-40-1`.4 cAM 1 LI Worker's Comp.Policy# 2_001 W6 y 2C WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached)ril Wood Stove 9 Siding: #of Squares Replacement windows:# 4 __— Replacement doors: # Roofing: #of Squares )Vitt ( )Remove existing* (max.2 layers) Insulation A)Jft Old Kings Highway/Historic Dist. ( )Replacing like for like T / Pool fencing ic *The debris will be disposed of at: / M V ' t 0 o - La&Y I ec 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 rtion of my liic and f r prosecution under M.G.L.Ch.268,Section 1. I I. (�� Applicant's Signature: / \ Date: I I 0 Owners Signature(or attachment) (,yt i1 cq (/p� 6�1,-,„ �d.Qri(, Date: /1/51/ Approved By: i .Aileaa - Date: /7/19 ---457---,,./9 �6 •!d : •ffici. (or designee) / MAIL ADDRESS: • Zoning District: Historical District: 0 Yes &No Flood Plain Zone: 0 Yes 4 No Water Resource Pro ction District: Within 100 ft.of Wetlands: 0 Yes )yNo 0 Yes � No The Commonwealth of Massachusetts "_g/ Department oflndustrialAccidents I, 1 Congress Street, Suite 100 Boston, MA 02114-2017 . —vs, www.mass.gov/ilia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): 13R (A n) IBA SEE R Address: L{6 M INAPETU )(E — WA V City/State/Zip: ' f QMw N4 4briT 620CPhone#: 5-01c — 36.7— I75q Are ou an employer?Check the appropriate box: Type of project(required): 1. l am a employer with I employees(full and/or part-time).* 7. El New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. RIRe:nodeling any capacity.(No workers'comp.insurance required.] 3. I am a homeowner doingall work myself t 9. ❑ Demolition ❑ ys (No workers'comp.insurance required.] 10 0 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.; 6.❑We are a corporation and its officers have exercised their right of exemption per MGI.c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp. insurance required.] 'Any applicant that checks box#1 must alsofill 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-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. PA-11/1/1 )` Insurance Company Name: A-11/1 1/ CA/V1 I LX/ Policy#or Self-ins. Lic.#: ?CD 1 W6 1-12-I Expiration Date: —I q / I9 Job Site Address:20 TLRAy4 )r Sr City/State/Zip: S. JA"A MaJTtl 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 under ains and penalties of perjury that the information provided above is true and correct Signature Date: 1I 115 / Ia Phone#: — )C7. 1151 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 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"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 contracting authority." Applicants r 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 certificates) 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 Ton 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 021.14-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia • Faf Q Office of ConsumerAffairs&Be inss rgul�on I J HOME IMPROVEMENT CONTRACTOR a TYPE: f onndivitlual E i xi } tiaa ,18506a a 04/18/2020 BRIAN BASLERi - ',7' BRIAN BASLER \ = ' 46 MINNETUXET WAy,_.;, YARMOUTHPORT,MA--02675 Undersecretary M ,ont assachu ttses De artment of Public Safety V. Board of Building Regulations and Standatds. License: CS-109619 Construction Supervisor } . .=Y BRIAN BASLER P.O.BOX 119 YARMOUTH PORT MA 02675Expl Ml ti Commissioner 09121/ti19 09/21/2019 • • CCMd CERTIFICATE OF LIABILITY INSURANCE DATE/` o°8" 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 pollcy(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 CONTNAMMEACT Dana McElroy Byrne Mark Sylvia Insurance Agency,LLC PPA, (508)957-2125 .Nor (508)957-2781 404 Main Street AD'DR'eEw /rASS . markgmarksylvlalnsurance.com INSURER(SIAFFORDING COVERAGE NAICS Centerville MA 02632 INSURER A: Farm Family Casualty Insurance INSURED INSURER B: Brian Basler LLC INSURER C. PO Box 119 INSURER D: INSURER E: • Yarmouthport MA 02675-0119 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. NO'TWTHSTANDING 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. INSRR TYPE OF INSURANCE ADCCS0B11 POLICY EF PoLicy EXP LTR wan No, POLICY NUMBER DoNnntfrPA ibiWnrurf n LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 _ CLANS-MADE a OCCUR PREMISES Piero RENTED } 100,000 MED EXP(Ann on) S 5,000 A _ N N 2001X0413 1/19/2018 1/19/2019 PERSONAL aADV RIJURY $ 1,000,000 GENL AGGREGATE LMT APPLIES PER GENERAL AGGREGATE $ 2,000,000 Jl I POLICY O!Teti too PRODUCTS-COMP/OPAGO $ 2,000,000 �TI OTHER � } AUTOMOBILE LIABILITY MINEeDSINGLE LINT $ — MYAUTO BODILY INJURY(Perpeson/ $ OVAED —SCHEDULED BODILY INJURY(PIN aeddfn) a AUTOS ONLY — AUTOS B _ HIRED NONOVd1E0 PROPERTY DAMAGE — AUTOS ONLY _ AUTOS ONLY INN aroMenll } _ UMBRELLA LIAB — OCCUR EACH OCCURRENCE $ EXCESS LIAR CLMMSMADE AGGREGATE B DED I RETENTIONS ppEEpp B wORNERS COMPENSATION I STATUTE I I FOR AND EMPLOYERS'LIABILITYANY �yY��/TNJ� A OFFICER/MEMBER EXCLUDED)PROPRIETOR/PARTNER/EXECUTIVE L'J NIA E.L.EACHACCIDENT $ 500,000 (MYansd,atory In NH) LT j N 2001W6424 2/9/2018 219/2019 Et DISEASE-EA EMPLOYEE $ 500,000 If unAr DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERAT1ONSJ LOCATIONS I VEHICLES(ACORD 101,Additional Remarks SMedule,may be attached N mote ince IS rewind). Carpentry 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 proVlded by the policy provisions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth Building dept ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Rt 28 AUTHORIZED REPRESENTA • I South Yarmouth MA 02664 Fat 5083980836 Email: 01988.2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD