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HomeMy WebLinkAboutBLD-19-003265 I Office Use Only : of c'''lk 1 , •2•. b e S. • a Fennel i p �'TM I,'� N Amount n � it Permexpires 180 days from [3Lb -s Iq _Obi'1/_,(' I issue Permit , EXPRESS BUILDING PERMIT APPLICAT O I TOWN OF YARMOUTH NOV 27 2018 Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 a ui i �+ Fit l T (508) 0398-2231 Ext. 1261 `/ CONSTRUCTION ADDRESS: --4 to LM berG4c-� (24-1, W•T • ASSESSOR'S INFORMATION: Map: Parcel: OWNER: NLCAA lMAtnntk Gantt; -4(0 Lr�4, otr t a 94 �� . 505(- 5- 1205 NME PRESENT ADDRESI TEL. # CONTRACTOR: Cake Roos ..A 96 A nes l�. 5 'Demos k(.o2(oGo liti-,209-0211 NAME MAILING ADDRESS TEL.it Ei esidential ❑Commercial Est.Cost of Construction$ 3 f rc9 600 Home Improvement Contractor Lie.# I 13 (a Construction Supervisor Lie.# CS //al-4S Workman's Compensation Insurance: (check one) ❑ I am the homeowner//�� ❑ I am the sole proprietor g'I have Worker's Compensation Insurance Insurance Company Name: A(n010 AL_ Worker's Comp.Policy# G.tq YJ37 L16G'0 I CI WORK TO BE PERFORMED ' . Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # 3 Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic (Dist. (�eplacing like for like Pool fencing �T *The debris will be disposed of at 4/M oukL DOA"..D Location of Ilacility 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 revocation o y license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: ,/ / t Date: L L (21 I i V Owners Signature(or attachment) !II - / /11 I Date: b( If al/0 Approved By: r1 al(or designee) EMAIL ADDRESS: Date: / (42Bir:, ti 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 • The Commonwealth of Massachusetts a - ►�= __�,�_�/ Department oflndustrialAccidents '� ==el= .0 1 Congress Street, Suite 100 Fr Boston, MA 02114-2017 sktarza www.mass.gov/dia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information `` Please Print Legibly Name (Business/Organization/Individual): l_AQGS;dt CotskvQt.I'01 S cfl3 Address: 1)30 Lon, Dona bry City/State/Zip: cot,, Mce...otli ... 02(009 Phone #: "3'34- 9n -9(o34 Are you an employer?Check the appropriate box: Type of project(required): I.if am a employer with e{ employees(full and/or part-time).* 7. 9 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. [vj'kemodeling any capacity.[No workers'comp.insurance required.] 3.❑I am a homeowner doing all work myself.(No workers'comp.insurance required.]t 9. ❑Demolition 4.0 I am a homeowner and will be hiring contractors 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.❑ Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0 Roof repairs These sub-contactors have employees and have workers'comp.insurances 6.9 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.9 Other 152,11(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 contractors 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 /� Insurance Company Name: A PI OT 0 A 1_. Policy#or Self-ins.Lie.#: 11 007 03i y G 1p a O 1 CS A- Expiration Date: 10 — 1 3'— 3 0 j q Job Site Address: 7(o l..urr+bcr-.1 e C v r PA 1-l-1 City/State/Zip: t f AfmocB h fliA 0a47 3 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 the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: kk 12'3"11ff Phone g: 9-a9 —p.-09- OZ,g 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/I'own 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. Puisuant 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 a joint 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." MOL 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, §250(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 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 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. # 617-7274900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia A40R®® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDwYYY) 4esme/ 11/27/2018 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 CONTACT NAME' John McShera MARSHALL K LOVELETTE INSURANCE AGENCY INC INC No Far (508)7754559 FAX (AC.No): EMAIL john@loveletteins.com 396 MAIN ST INSURER(S)AFFORDING COVERAGE NAIOS WEST YARMOUTH MA 02673 INSURER AI AIM MUTUAL INS CO 33758 INSURED INSURER B: CAPESIDE CONSTRUCTION SERVICES INC INSURERC: INSURER D: PO BOX 782 INSURER E: SOUTH YARMOUTH MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: 341651 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. INSR ADDL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSO wvo POLICY NUMBER (MM/DO/YYYYI (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY - EACH OCCURRENCE S DAMAGE TO RENTED CLAIMS-MADE El OCCUR PREMISES(Ea occurrence) $ _ MED EXP(My one person) $ _ N/A PERSONAL tADV INJURY $ GEN'L AGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE S —1 POLICY n JET fl LOC PRODUCTS-COMP/OP AGG $ OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea sodden() ANY AUTO BODILY INJURY(Per person)— S ALL OWNED SCHEDULED _AUTOS _ AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per wadent) S _ $ UMBRELLALIAB _ OCCUR EACH OCCURRENCE S EXCESS UAB CLAIMS-MADE N/A AGGREGATE S OED RETENTIONS S WORKERS COMPENSATION X PER 0TH- ANDEMPLOYERS'LIABILITY YIN STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTNE E.L.EACH ACCIDENT $ 100,000 A OFFICEFUMEMB REXCLUDEDT I� N/A WA AWC40070374662018A 10/12/2018 10/12/2019 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE 100,000 H yes,tleevibe OF O - DESCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101.Additional RemerLs Schedule,may be attached If more space Is required) Workers Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization Is given to pay claims for benefits to employees in states other than 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 at www,mass.gov/Iwd/workers-compensation/Investigations/. 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 ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Rt28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 `D,pDaniel M.CroVey,CPCU,Vice President—Residual Market—WCRIBMA ©1988.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD d ' l�Si.. ( YlIN4NrYnYY'iVY'i YrXJ f�t� ::AFy _�a uA�e�i� anM Return- C Office tit Consumer Matra IS. rlusinose Regulation HOME IMPROVEMENT CONTRACTOR ' t • TVA fndiT CO _ Registration valid for Individual Fes:L i� before the expiration date-;t1 found us.Stu c alartr i .. .Ex t0 • Office of Consumer Affairs end Buskins to : 1 CARLooUSQUI:T e , Bost n:MA 02118 het.Sults ftp Rpt`In ;;-. 'R `t Boston;M: -. „ .t8 TRU ,TIt7N. � ti�y� Rzt Plw T,�Vj 46 AGNES RO Z=5 SOUTH DENNIS. MA 02860 Undersecretary Not valid Without signature .7:;-",';'-ti."" ...„' _ .' " ''' s s Commonwealth of Massachusetts . � ' 'cnn„ ion of Professional Licensure . z ; ' �:- Board of Building Regulations and Standards ,t Constrijctl nISii.'Per or • y ' I. Aires 03!29!2022 CS 712745 .. ' U e ,a 1•. CARL. ARTHUR BOUSQUEt .a `- .±i6 AGNES RD=' ` °: . t r S DENNIS MA 02660 ,s �. . commissioner : p� N9 K£ ? ✓x b F > � y E _ S l't� - 3 F _ 1 �� \F y t ..0 ^. x