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HomeMy WebLinkAboutBLD-19-003596 • O e Use Onl 0gnryR / 7-� l 3 'j, t 244' j 'I irp� .' '. Amount ..-. ....kill"a.cr' • Permit expires 180 days from j • ;rgr a:.,. issue date - e. EXPRESS BUILDING PERMIT APPLICAION. z t TOWN OF YARMOUTH � 1 Yarmouth Building Department DEC 13 2018 i 1146 Route 28 South Yarmouth, MA 02664 ur..ou�%uec-r < i.. id (508) 398-2231 Ext. 1261 I aY • CONSTRUCTIONADDRESS: 23 Letl.-e,,.„,,r Qe 34,vnoJf, (J' 07ccs • ASSESSOR'S INFORMATION: Map: Parcel: OWNER ice-i I,Jc+s0i 23 L4kewode of Yrwu)'11, NAME / PRESENT ADDRESS p t TEL. # CONTRACTOR el-7;" /c, e4fl n, , uADDRESS Bross F( GtM � YW" - pit- NAME MAILING id Residential ❑Commercial/ 2 Est u Cost of Construction$ 7)2SD _ Home Improvement Contractor Lic.# I 'I 3 o$3 Construction Supervisor Lic.# If 3.5-/ Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor dI have Worker's Compensation Insurance C, Insurance Company Name: £A Worker's Comp.Policy#CSS/ U/i 07 z tvv37 2/tY WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 2 6 ( ove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( ))Replacing like for like Pool fencing 'The debris will be disposed of at yti rM �, / OJ I % hit 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 voc of my license and for prosecution under M.G.L.Ch.268,Section 1. ` Applicant's Signature: - Date: 12 11 ? Il / t[ Owners Signature(or attachment) Date: Approved By: t/.� Date: 11.-11.- I Building Official(or designee EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 R of Wetlands: 0 Yes 0 No 0 Yes 0 No • .r � The Commonwealth of Massachusetts • `✓ a Department of Industrial Accidents • ==ra= 1 Congress Street, Suite 100 VIE_ 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): •-11-6/ iP4-W, y Address: $ '1 /—order groat, R2 City/State/Zip: ycrMo) - lti.A' 62a-, Phone#: Sv cr 7id Z7oZ Are you an employer?Check the appropriate box: Type of project(required): I. 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. 21 Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall work myself t 9. ❑ Demolition ❑ y [No workers'comp.insurance required.] 10 ❑ 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 • 5.0 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.❑We are a corporation and iu officers have exercised their right of exemption per MGL c. 14.D Other 152,§I(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 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. A Insurance Company Name: C a//T' Policy#or Self-ins.Lic.#: CS59 u/' O2z t-ftti7) 7/V Expiration Date: ?Jc/jr+it ]S Job Site Address: 23 ��i AJC " o)el es City/State/Zip: y /rykllt4 t' c 201 j 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: 12(a /. Phone#: SO ,E- 760 2-207 1 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#: n. 6,1 • 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, expresser 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 contract 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 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 • Accident 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 • • • • A CERTIFICATE OF LIABILITY INSURANCE DATE(M^3DI 16/18 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THS 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 policyiles) 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(e). PRODUCER CONTACT NAME: JULI MCDOWELL • Schlegel 4 Schlegel Ins Broker most FAX (508) 771-0663 34 Main Street E �ArLa E.P (50 III) 771-8381 INC.Not: eAss: schlegelinsurance@gmail.com West Yarmouth, MA 02673 INSURER()AFFORDING COVERAGE NAIL* ,_ ..._. _ . INSURER A:MOUNT VERNON INSURED INSURER B:CNA TIMOTHY KEATING DBA KEATING HOMER C: CONSTRUCTION INSURER D: 54 LOWER BROOK RD INSURER E: SOUTH YARMOUTH, MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDCATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTFICATE MAY BE ISSUED OR MAY PERTAN, THE INSURANCE AFFORDED BY TI-E POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDTIONS OF SUQI POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY EFF POLI CY E%P_ ..____ LTR TYPE OF INSURANCE INSR VND POU CY NUNEER (MM/CONYYY1 (LNrDdfYYY) LIMITS A GENERAL LIABILITY GL 2548741 3/20/18 3/20/19 EACH OCCURRENCE $ 1,000,080 X COMMERCIAL GENERAL LIABLLITY PRFFMMISFGESIFaa O camnencal $ 500,000 CLAaSNADE 13ZI OCCUR - EEO 171P(Ary onepesm) $ 10.000 PERSONALS ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLES PER PRODUCTS•WMP/OP AGG $ 2,000,000 • —1 POLICY n weltI TI ice $ AUTOMOBILE LIABILITYCOMBINED SINGLE LIMIT (Ea accident] $ MY AUTO BODILY INJURY(Per xenon) $ ALL WI*LI SCHEDULED BODILY INJURY(Per accidem) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS _AUTOS _ (Par accident) $ UMBRELLA LOB _OCCUR EACH OCCURRENCE $ • EXCESS LOB CLANS-MACE • AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION 6S59U130224N37214 3/9/18 3/9/19 TWCYIAR ma- AND EMPLOYERS LIABILITY ANY PROPRIEIOR/PARTNEILEXECUTNE YINEL.EACH ACO CENT $ 100/000 OFFICER/EMBEREXCLLDED4 E NIA (MaMabrylnNH) E.L.DISEASE-EA EMPLOYEES 100,000 o e desmpe under DESCRIPTION OF Of'ERATONS below E.L.DREASE-POLICY LMR $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Math ACORIA 101,Ahfifiana(Rarrado Schedule,If spa a nq/rW) TIMOTHY KEATING HAS ELECTED TO BE COVERED UNDER HIS CURRENT WORKERS COMPENSATION POLICY • CERTIFICATE HOLDER CANCELLATION • SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED N ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE • • ©1988-2 0 COR ORPORATION. All rights reserved. ACORD 25(2010/05) The/CORD name and logo are registered marks of A 0 D Phone: Fax: E-Mail'