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Home My WebLink AboutBLD-19-003568 Y ce Dag Only vg• '9R aft c O •n4 8 N Amount '� 4 °"* c - Permit expires 180 days from •• • issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 p tW' (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: / I n it 3CC`r0OcL, CV\nk. } ASSESSOR'S INFORMATION: IIMap: Parcel: OWNER: O r\' o -11 . M1/4C<C-4 -1 t\r I I-' L1S� NAME PRESENT ADDRESS TEL. # CONTRACTOR:t _ �'> ms 1 MAILIN�UyP11 I( S�- W t & n--1- ...0 'm c �.pt(� e NAMEADDRESS TEL.# residential 0 Commercial Est.Cost of Construction$c� • Home Improvement Contractor Lie.# 1-19(00.g Construction Supervisor Lic.# /0167(o Workman's Compensation Insurance: (check one) 0 I am the homeowner Acn 0 I am the sole proprietor I have Worker's Compensation Insurance t�K� r� Insurance Company Name: te Worker's Comp.Policy# U)CC '-� •0- )11450 ot3I t WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove / Siding: #of Squares to 1 Lf Replacement windows:# � Replacement doors: # a Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. (Replacing like for like Pool fencing _r *The debris will be disposed of at: TOS, C7�- YeiNeedo, Location of Facility I declare under penaltie• • 1.erjury 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 de . A r vocation of my license and for prosecution under MG.L.Ch.268,Section 1. clots,Applicant's Signature: A Date: /o✓ 1t �(f I Owners Signature(or attachment) „ A` 1) ,„Ai ��;/-! Date: ) j a le /� Approved By: _ _ / Date: /i �2-T7 r•d. s Offi :al(or designee) / EMAIL ADDRESS: , 1thrnSnr-hof(12�'JJ ti 5 (y'c,\.own Zoning District: RECEIVED �E G, E ' v E D Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft of Wetlands: DEC 12 2018 ❑ Yes ❑ No ❑ Yes 0 No • 44:07-,A R 1 � I �� The Commonwealth of Massachusetts =s— _,yam_ Department ofIndustrial Accidents =ant_ 1 Congress Street, Suite 100 Boston,MA 02114-2017 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): Itn kr) Address: cAUjy\ City/State/Zip:k jj,(1l rnas}tiNK av< Phone #: 77C1 43S/ Ot34 Are you an employer?Check the appropriate box: Type of project(required): l.Yr-em a employer with I employees(full and/or part-time).* 7- 0 New construction 2.01 am a sole proprietor or partnership and have no employees working for me in $. oZRemodeling 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 0 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 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.: 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑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-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: - CT C Policy#or Self-ins.Lic.#:W'(t,'-$3p -5� /4-15( op —DO le Expiration Date: (('GO// / k 4X\ Job Site Address:k10 ('{v,) sk- City/State/Zip:l1alINCl 'Y Attach a copy of the workers' compensation policy declaration page(showing the policy number and 4xpiration 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 vio tor. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verifica I do hereby certi nder the pains and penalties of perjury that the information provided above is true and correct. Signature: ' l Date: /0//g,/if (y�`� Phone#: 17 —I dJb OdJ<�G 11 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#: /—Th JOHN-10 OP ID-Ti- ACORO' CERTIFICATE OF LIABILITY INSURANCE D OIY'/YY) k.....---- 1 1211112/11/2018 • 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(les) must have ADDITIONAL INSURED provisions or be endorsed. M 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 508-775-6060 Mr Bryden&Sullivan Insurance Bryden&Sullivan Ins Agency PHONE 508.775-6060 FAX 508-790-1414 88 Falmouth Road (NC,No,Errs: INC,No): Hyannis,MA 02601 tD'naiss: Bryden&Sullivan Insurance INSURER(S)AFFORDING COVERAGE NAIL a INSURER A•NGM Insurance Company 14788 378 UREA INSURER B:Citation 40274 Plum Home Building, LLC INSISTERC:Associated Employers Insurance West Barnstable,MA 02668 - - - ----- INSURER 0 INSURERS' 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 MOVE 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 POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. jNjR TYPE Of INSURANCE ADDLISUBR POLICY EFF POLICY EXP ,y yryn POLICY NUMBER /MM!DDIVYYN IMMIDDWYYYI LIMITS A COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE El OCCUR MP17064K 11/10/20181111012019 IMMAGETORENTED 500,000 DAMAGE TO RENsurtenrel $ X Business DWnB' MED EXP(Any one person) S 10,000 PERSONAL&AW INJURY_3 2.000.000 GERI AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 4,000,000 A I POLICY❑ga ❑LOC PRODUCTS-COMP/OP AGOG 4,000,000 �II OTHER: • S B AUTOMOBILE LIABILITY COMBINED SINGLE UNIT 1,000,000 !Fa accident) S — ANY AUTO BCLRYL 04128/2018 04/28/2019 BODILY INJURY(Perperson) $OWNED _ AUTOSE� ONLY a AAUUTTOSSWULNEEDp BODILY INJURY(Per accident) S AUTOS ONLY AUT0.5 ONLY (Per accident) S S UMBRELLA UAB _ OCCUR EACH OCCURRENCE S— _ EXCESS LIAR CLAIMS-MADE AGGREGATE S DED RETENTION S S C WORKERS COMPENSATION PER 011-1- AND EMPLOYERS'UABINTY 1TATIJIE ER ANY PROPRIETOR/PARTNER/EXECUTIVE �Y�/N� WCC-500-5011458-2018 1110212016 11102/2019 E.L.EACH ACCIDENT S 100,000 OFFICERAM)MBERI EXCLUDED? I r l N/A 100,000 enders nN E.L DISEASE-EA EMPLOYEE $ II yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY limn" $ DESCRIPTION OF OPERATORS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,any be attached Nonce space b required) Contractor-Certificate Issued for Insurance verification CERTIFICATE HOLDER CANCELLATION TOWNYAR 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 Rte 28 Yarmouth,MA 02664 - AU1mOOpRImDQR,EPRESENNTATIVE '�l I �-41--l.J- 1) ACORD 25(2016/03) 01988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Es'r'y--"Y°'"'s. ME a . c t a 2 I la it 4 ,_ . . , m C • O u a a �' it F N fi JS roc «JI s z 0 G j p �•)��v r Z o0 ! ! IL:.t A 12/12/2018 Office of Consumer Affairs&Business Regulation-Mass.Gov y a Mass.gov Office of Consumer Affairs gusiness RegUlation HIC Registration Complaints Registration 179608 Registrant Timothy P Johnson Name TIMOTHY JOHNSON Address 378 Plum St City, State West Bamstable, MA 02668 Zip Expiration 08/20/2020 Date Complaints Details https://services.oca.state.ma.us/hIc/licdetaiis.aspx?txtSearchLN=179608 1/2