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Home My WebLink AboutBLD-19-003717 rY - a Qffice Use Only :eiR i O4 Hi !Amount Permit expires 180 days from : :;. w; . : - - • LL issue date EXPRESS BUILDING PERMIT APPLICAiI'IO�L =!°!-_Ir TOWN OF YARMOUTH s Yarmouth Building Department DEC 19 2018 1146 Route 28 __ South Yarmouth, MA 02664 BUILUWC UEPHRiMENr By: ____ (508) � 398-2231 Ext. 1261 / CONSTRUCTION ADDRESS: l f;`�-A'9/ 4/ 9 /J e ,ns-2/ -///J ASSESSOR'S INFORMATION: • �/� Map: ^ Parcel: /// /�p y) OWNER: !' t cL �{/1.Q/' i� �e/ 72 -I at4_41_,✓ / tS b 76z? � NAME • RES DRESS TEL. # CONTRACTOR: ilk (LA/}u� 6az� - ` NAME MAILING KESS TEL.# / Reeldential 0 Commercial Est.Cost of Construction S ! no cp n Home Improvement Contractor Lic.# I Q U1. 11ZD Construction Supervisor Lic.# G T 060 0 0 J1J Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am(j le pr rietor ❑ I have Worker's Compensation Insurance Insurance Company Name: 61^ Worker's Comp.Policy# Cn /D (jX b- ✓-//y k WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 5' Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist.7,_...,-,44( )Replacing like for like 1 Pool olol fencing "The debris will be disposed of at L/ •�__.) /- H Location of Facility I declare under penalties of perjury that the statements herein contained are true:•.co ect to the best of my knowledge and belief I understand that any false answer(s) will be just cause for denial or revoca:: . myli� e and for. .secutio. . .er M.a L.Ch.268,Section 1. /7 Applicant's Signature: 4 .4 / Date: 1..5 -e-e_ D /7 Owners Signature(o attachment) / S�� Date: Approved By: -�.�.. / Date: 1/C A-1 -- Building Official(or • EMAIL ADDRESS: 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 a The Commonwealth of Massadhusetts -;/ �� .-=-. e"- �/ Department of Industrial Accidents (,ri111_ 1 Congress Street,Suite 100 =4t. 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/Individ ): yC - I � / Address: 12 D l cr��,t ,e),--.— )ti .,r` --� cartig__ .�riT-{�� 6g1 City/State/Zip: Q? � Phone#: �d / 3 76( Are you an employer?Check the appropriate box: Type of project(required): 1 aid I am a employer with_et employees(full and/or part-time).* 7. 9 New construction 2.91 am a sole proprietor or partnership and have no employees working for me in 8. 9 Remodeling any capacity.[No workers'comp.insurance required.] 3. [am a homeowner doingall work myself r 9. ❑Demolition ❑ ys [No workers'comp.insurance required.] 4.91 am a homeowner and will be hiring contactors to conduct all work on my property. I will 10 9 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.9 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.9 I ant a general contactor and I have hired the sub-contractors listed on the attached sheet 13.❑Roof repairs c These sub-contractors have employees and have workers'comp.insurance) Q 6.9 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.9 Other $ !)t ✓/ 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-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 ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: bin-Ci—.4"Policy#or Self-ins.Lic.#: 9 p 'V °/Cier>2.- 1A5-3g 7/I Expiration Date: as--./7-7p7 Job Site Address: G/ - Q 1� Q 11.44s...City/State/Zip: 17 Ove Attach a copy of the workers' compensation policy declaration age(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 Sisnature: 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 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 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 • Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retuned 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 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or I-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia • ACCPRCP CERTIFICATE OF LIABILITY INSURANCEI °A'E(MW°"'"Y"' 11/06/2016 '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. 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 CON TACT John MCShera Marshall K Lovelette Insurance Agency Inc NAME: 398 Main St MIL (506)775-4559 FAX • ' West Yamouth,MA 02673 E-MAIL ExeI IA/c.No):(508)775-4577 ADDRESS: John s..loveletteins.com INSURER(S)AFFORDING COVERAGE NAIC f MSURER A: Nautilus Insurance Co. 17370J INSURED Healy Brothers Construction Corp The Hartford 72 Old Main Street INSURER s: A0095 South Yarmouth,MA 02664 INSURER C: ' MSURER D: 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 ADDL SUER LTR TYPE OF INSURANCE INS0 WVD POLICY NUMBER POLICY EFF POLICY EXP A J COMMERCIAL GENERALIABILITY NN850791 110 /2018) YYn IMAM 01/09/2018 01/09/2019 EACH OCCURRENCE s 1,000,000 CWMS MADE OCCUR PREMISES RENTED $ 100,000 �— MED EXP(Any CVO person) 5 5,000 PERSONAL&ADV INJURY s 1.000,000 GENLAGGREGATE UMrrAPPUES PER: GENERAL AGGREGATE S 2,000,000 POLICY❑JT T [J LOC PRODUCTS.COMP/OP AGE, f 2,000,000 OTHER. § AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (EaANY AUTO BODILY INJURY OVMED BODILY NJURY(Perperem) f SCHEDULED _ BODILY INJURY(Per AUTOS ONLY AUTOS aoddem) § HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY PROPERTY f f UMBRELLA UM OCCl1R . EXCESS UAB EACH OCCURRENCE § — CLAIMS-MADE AGGREGATE § DED RETENTION f — B WORKERS COMPENSATION § AND EMPLOYERS'LABILITY YIN 6S60UB5B97516918 05/17/2018 05/17/2019STATUTE �R� ' brob ANY OFFICER/MEM �EX�CLUDDED EDUfNE ❑ NIA E.L EACH ACCIDENT f x•100,000 (Mandatory In NH) rc yyBBse dasmlba unser E.L.DISEASE-EA EMPLOYEE $ 100.000 ' DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT § 500,000 DESCRIPTOR OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Ramada Schedule,maybe attached If more space Is required) 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. 1148 Rt 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE Njece. JIO1 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD