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Home My WebLink AboutBLD-19-3382 01. g g ce Use Only O mo '� H Amount Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 - (508) 398-2231 Ext. 1261 /�� ✓CONSTRUCTION ADDRESS: 3 1 /' fp Geer qd wati/ 4h cmivrh' ,r, ASSESSOR'S INFORMATION: • Map:. Parcel: VOWNER.: 1jpLow t° rptrlai-J J( dPPL(' y �d NAME PRESENT ADDRESS TEL. # CONTRACTOR: Rtm/Are. S /S (/il Pole il3! Wei hhffpf ca t+ Cet'9ei cf+3 NAME MAILING ADDRESS TEL.# 1212esidential 0 Commercial - Est.Cost of Construction$ h Q'€-' - U8 t/ Home Improvement Contractor Lic.# (72. 0 9 le Construction Supervisor Li c.# (7 9T8 / —1 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor CA-leave Worker's Compensation Insurance V Insurance Company Name: s rker's Comp.Policy# WORK TO BE PERFORMED Tent — Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares L.S ( Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. (,1)Replacing like for like Pool fencing *The debris will be disposed of at 141714,0(/% ''y CC 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 revocation of my license and for prosecution under M.G.L Ch.268,Section 1. ✓Applicant's Signature: R rN/} (L o, ) 1/4 Date: (2 _ 14 Owners Signatu (or attachment J Date: Approved By: 11? 4' V PP .S Date: Building Official(or designee) EMAIL ADDRESS: Zoning District: RECEIVED Historical District 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No • Water Resource Protection District: Within 100 ft.of Wetlands: L±Eco42o1JDEC8 ❑ Yes ❑ No 0 Yes ❑ No BUILDING DEPARTMENT By .___ ✓' The Commonwealth of Massachusetts it=, = '/ Department oflndustrialAccidents War .4 1 Congress Street, Suite 100 MIL= ' Boston,MA 02114-2017 zc,;. 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): Address: City/State/Zip: Phone #: 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. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. Demolition 4.❑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.❑Plumbing repairs or additions 5.0 I am a general contactor and I have hired the sub-contractors listed on the attached sheet 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.; 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 contractors must submit a new affidavit indicating such. :Contactors 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: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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 DR 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: Phone#: 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 McLsachusetts 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 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." 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 contract 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 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 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. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia Client/I:38860 2EXCELBU ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MMDDNYYY) 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(les)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: Dowling&O'Neil Insurance Agy PHONE 508 775-1620 FAX 5087781218 (A,D.No,Ext*an No; 973 iyannough Road Ea1An. P.O.Box 1990 ADDRESS: • INSURER(S)AFFORDING COVERAGE NAIL f Hyannis,MA 02601 INSURER A:NGM*a,n aCsepS, 14788 INSURED NSURERB:Amedme E* Mens I.,nna Gsawa 11104 Excel Building Systems Company,Inc PO Box 436 INSURER C: Forestdaie,MA 02644 INSURER Dr INSURER E: 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 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 ADOLISUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR VIVO POLICY NUMBER PaCleerrn MMOD/rryn umws / A GENERALUABRm MPO2774T 02/22/2018 02/222019 EACHOCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABRITY PRA MISEneam DnMCO) $500,000 CLAIMS-MADE'n OCCUR MED EXP(My one person) $10,000 P — PERSONALSADV INJURY _ 51,000,000 — GENERAL AGGREGATE s2,000,000 GENLAGGREGATE LIMIT APPLIES PER PRODUCTS-COMPgP AGO $2,000,000 POLICY PRri Jai- f w I LOC $ A AUTOYOBILEOABIITY M1O2774T 12/0W2017 121092018(EC:M°.mNEE%51NCLELIMIT $1,000,000 ANY AUTO BODILY INJURY(Per person) $ — AUTO ED X SCAUTOSEDU.ED BODILY INJURY(Per accident) 5 X HIRED AUTOS X AUTOS ED PROPERTY DAMAGE $ $ UMBRELLA W1B _ OCCUR EACH OCCURRENCE _$ EXCESS LIAR CLAIMS-MADE AGGREGATE S DED I RETENTION$ $ B COMPE PLOYERS'NSA ON WCC5005009182017A 03/05/2018 03105/201• XSTAT "eu RI- AND YIN ANY PROPRIETORPARTNER/EXECUTIVEE.L EACH ACCIDENT s500,000 OFFICER/MEMBER EXCLUDED? n N/A II )yeeaendatory In NH) EL DISEASE-EA EMPLOYEE $500,000 describe under DESCRIPTION ON OFF OPERATIONS below E.L DISEASE.POLICY LIMiT s500,000 • DESCRIPTION OF OPERATORS/LOCATIONS/VEHICLES(Much ACORD 101,Additional Remarks Schedule,If more pace M 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 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTOR2ED REPRESENTATIVE I •.NI..a , c.Caire. ` 01988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/0.5) 1 of 1 The ACORD name and logo are registered marks of ACORD SS205646/M205644 RPCC1 ice-\ The Commonwealth of Massachusetts �_= Department of Industrial Accidents v.s m.s ,p Office of Investigations E = — : 600 Washington Street Boston,MA 02111 "•z;,4' www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information `X/ •• ` , Please Print Le¢ibly Name(Business/Organization/Individual): 2iGet-) v `y�V\). \1 Say , h` Address: ' O't " iC, J 1 City/State/Zip: &Y1Ji. ed cub*y, Phone#: •11 S01 C7iy3 Are y6u an employer?Check the appropriate box: Ju{� 4. I am a Type of project(required): I. am a employer with 3 0 genial contractor and I employees(full and/or part-time). hav81iir d the sub-contracfors 6. 0 w construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. '- . 7. modeling . ship and have no employees • These sub-contractors have 8. Demolition workingfor me in anycapacity, employees and have workers' n :Yt 9. 0 Building addition [No workers'comp.insurance comp.insurance.: required] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work ' officers have exercised their 11.0 Plumbing repairs or additions myself.No workers'comp. right of exemption per MGL 12❑Roof repairs insurance required.]t c. 152,§1(4),and we have no • employees.[No workers' 13.0 Other , comp.insurance required] . 'Any applicant that checks box HI must also fill out the section below showing their workers'compensation policy informatlbh. p t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractor must submit a neW affidavit(ndieating such. :Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not thote entities have employees. If the subcontractors 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: - - Policy If or Self-ins.Lic.#: Expiration Date: , Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal 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 the violator. Be advised that a copy of this statement may be forwarded to the Office of: Investigations of the a insurance coverage verification," I do hereby certify \ a pains and penalties of perjury that the information provided above is true and correct , Date: I�3'''\n‘3'''\n‘., Signature'. Mg Phone#: .. 6� +FRO\ o\`kt3 Official usTonly'''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 Deparfineoti City/Fown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ' • • • • • Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construction Supervisor • CS-098849 Expires:06/20/2019 RENATO F DA SILVA P.O. • BOE I]6% 8"GZ•,; FORESTDALE MA 02844 Commissioner lenu,nor n,/NV,//%r/r&beer/,Ia'/�' Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR I; NFLr TYPE:Corporation Registration valid for Individual use only , Registration Ezoiration before the expiration date. If found return to: 182094 . 05/25/2019 - Office of Consumer Alfa . and Business Regulation 10 Park Plaza•Suite - EXCEL BUILDING SYSTEMS COMPANY INC. Boston,MA 0211ails RENATO DA SILVA / 8 JAN SEBASTIAN DR.STE 9 [�'—`""'G • SANDWICH,MA 02563 Notes• without signature Undersecretary • APPLICATION NUMBER *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one:this event is a: for profit non-profit event Check one:Food served Yes No Flame Spread Sheet of each tent must be attached.Provide a site plan with the location(s)of each tent Wood is being served at your event please obtain a health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm.Commercial events may require Fire Department approval. *WOOD/COAL/PELLET STOVES * Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles:front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date LICANT'S SIGNATURE Signature Date • 3 . ggi AU permit applications are subject to a building official's approval prior to issuance.