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Home My WebLink AboutBLD-19-003712/ r4; Office Use Only .y -t.�,AR.r - p�.: - O [Permit# ti D -...a+r' Amount " ••"p Permit expires 180 days from : issue date 1 EXPRESS BUILDING PERMIT APPLICATI LY C E ! t D TOWN OF YARMOUTH Yarmouth Building Department I Qty 19 2018 1146 Route 28 South Yarmouth,MA 02664 eU1 -- (508) 398-2231 Ext. 1261 �t a� _— CONSTRUCTION ADDRESS: 4-67 R 1 O G'i W Uc On. yi4 e �� IQ UO2 ASSESSOR'S INFORMATION: l /� Map: Parcel: OWNER. l cft/rCb 14h-QTIt #6cI eogwOvtkt yoftr&&'zrfO/-?.37 x101 NAME PRESENT ADDRF-SS TEL # Email ress: CONTRACTOR:j1Avt 0 11 t_?fl4 ,?6.341.si r k v 51J Mt,9 aa(7l= Jag-15(4.432- NAME MAILING ADDRESS TEL#�/ Email Address: Resid i /'al Commercial 1 G Est,Cost of Construction$ UV�1. 0-0 Home Improvement Contractor Lia it 1 i 9 6 Construction Supervisor Lie.it C) `l a/ is 9 Workman's Compensation Insurance: (check one) � / I am the homeowner I am the sole proprietor!� I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# • WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Rooms #of Squares 23 ( )C)Remove existing (max.2 layers) Insulation • Old Kings Highway/Historic Dist. ( i )Replacing, ek like for or�lik/e *The debris will be disposed of at V�M 01.4f l/N /"f ✓" (/ Location of Facility I declare under penalties of p. r that the statements herein contained e true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial o anon of y h'c se and fo pro _ on under M.G.L Ch.268,Section 1. 2-- Applicant's Signature: �" !'/V� Date: ' t ri 16 Owners Signature(or attachment) 1 ef�� Date: yr/ Approved By: a�ige - Date: 11' Building Offici (or designees • Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No F. ![ l_ Department oflndustrialAccidents + 1= 1 Congress Street, Suite 100 • Boston, NIA 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): Dery r p 1-1 - 46 fj Address: Pa . 'Cc's 177/ City/State/Zip: artr-L- 114 - o 0-5-76, Phone #: 50 8— 566 jC3 2 r Are you an employer? Check the appropriate box: Type of project(required): . I.❑I am a employer with employees(full and/or part-time).* 2.0 I am a sole proprietor or partnership and have no employees working forme in 7. ❑New RemolindelingICUoA any capacity.[No workers'comp. insurance required.] 8. ❑ g 3.0 I am a homeowner doing all work myself[No workers'camp.insurance required): 9. El Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on property. 10 El Building addition ensure that all contractors either have workers'compensation insurance or are solI will proprietors with no employees. 11.❑Electrical repairs or additions 5.1 l am a general contractor and I have hired the sub-contractors listed on the attached sheet 1 ❑Roof repairs repairs or additions These sub-contractors have employees and have workers'camp.insurance.? 13.0 Roof 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 ill 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: Policy#or Self-ins. Lic.#: / a Expiration Date: Job Site Address: w / 141,14 wooLl d rj, Ci /State/Zi :� t Attach a copy of the workers' compensation policy declaration page(showing e policy rlumber�ir� date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to 31,500.00 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 :overage verification. L do hereby cert' nde ins and penalties o 4rjury that the information provided above is true and correct Si•nature: / �J---/ /� l Date: 6C Phone#: — Official use only. Do not write in this ea 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 • •M 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 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 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 WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Information Page WC o0 00 01 Atlantic Charter Insurance Company VDAC NCCI Co. No. 29211 Policy Number WCV01243703 1. INSURED: Prior Policy Number WCV01243702 Robert Tyndall Producer: Tyndall Roofing Miller McCartin, Inc. DBA Dowling &O'Neil PO Box 1093 PO Box 1990 Forestdale, MA 02644 Hyannis, MA 02601-1990 Federal ID Number 999100972 Business Type: Sole Proprietor Risk Id Number: SIC 9999- NONCLASSIFIABLE ESTABLISHMENTS• Other Named Insured:See WCE106 Other Work Places See WCE107 2. POLICY PERIOD: The Policy Period Is From: 07/15/2018 To 07/15/2019 12:01 A.M. Standard Time at The Insured Mailing Address 3. COVERAGES: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here:MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500,000 each employee C. Other States Insured: Part Three of the policy applies to the states, if any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B D. This policy includes these endorsements and schedules: See WCE105 4. COVERAGES: The premium for this policy will be determined by our Manual of Rules, Classifications, Rates& Rating Plans.All information required below is subject to verification and change by audit. Code Premium Basis Total Rate Per Estimated Classifications No. Estimated Annual $100 of Annual Remuneration Remuneration Premium See WC 00 00 01 Minimum Premium: Deposit Premium: $550 $7,194 Total Estimated Premium $9,085 Interim Adjustment: Annually Surcharge(s) 395 Servicing Office: Total Premium and Surcharge(s) $9,480 25 New Chardon Street Boston, MA 02114-4721 Jr)c 2,'�2 W; Pei-4- Issue Date 06/29/2018 Countersigned By: `Cu Date Copyright 1987 National Council on Compensation Insurance - Form:100mvnt4 • • Commonwealth of Massachusetts ! r Division of Professional Licensure Board of Building Regulations and Standards Const`{Ictff6ri ISupervis or CS-046189 EX ires: 10/29/2020 DAVID H WE88 L,.t • 179 TEATICKET HIGHWAY, EAST FALMOUTH MA 02536 Commissioner C/L P nenenuralil CMC*of Consumer Alf Mrs A Business Regulation • HOME IMPROVEMENT CONTRACTOR TYPE:Individual Assitrzatithe Dzirmign 1/9766 si-06/22/2020 DAVID WEBB.- °, t s DAVID H MJ 179 TEATICKET HIOHWAYe "' + EAST FALMOUTH,MA 02536 Undersecretary .1 • Commonwealth of Massachusetts `®it Division of Professional Licensure Board of Building Regulations and Standards Constnjctbn lSdpervisor CS-046189 Epires: 10/29/2020 DAVID WEBB '-'- / 0 pt 179 TEATICKET HIGHWAY' EAST FALMOUT MA 02536 {" Commissioner C ""' .916; weu Ofiof Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual • Begjetrati��- 114.0 'E Expire/ DAVID WEBS, "" d. DAVID H.WEBS --c-== 179 TEATICKET HIGH WAY,, �Cn EAST FALMOUTH,MA 02536 Unde- • • w;la:znz • ek*4 TOWN OF YARMOUTH , 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451 - • Telephone(508)398-2231 Ext. 1292-Fax(508) 398-0836 Il®C RAC •E. 012 KING'S HIGHWAY HISTORIC DISTRICT COMMITTEECc OV�® DEC 192018 DEC 18 2018 TOWN APPLICATION FOR • yriruwtlulrl SOUTH YARtiCOUTH, Attl CERTIFICATE OF EXEMPTION OLD KING'S HIGHWAY Application is hereby made for the issuance of a Certificate of Exemption under Sections 6 and 7 of Chapter 470 of Acts of 1973, as amended, for the proposed work as described below and on plans, drawings, or photographs accompanying this application. Type or print legibly: • Address of proposed work: &1 I is rr, io- 0 t'/172 v,,,, .r ap/Lot# 44 Owne s): (�tciariarrO /,*A ilt/1fl7 Phone#:4S()S9 - 75'7-07101 All applications must be submitted by owner or accompanied by letter from owner approving submittal of application. Mailing address:fp'9 Ralf a—,4—ea Pe yriv4 aAa o.-ii /�O/LT M 4- Year built Email: t tee- N1~77 at /N • " 'i 'referred notification method: Phone Email T t o CO lir, Agent/Contractoc DA-yr0 . 14 t v„.7.44---736 Phone#: Jd 9- 543 — 332T-4 Mailing Address: (2?". OOX LII ( lF„1=4-1- it4- 09-,y 36 ' Email: Dt wtc f3 r?7 5 9 6 r//-«, Preferred notification method: !V Phone Email Description of Proposed Work(Additional pages may be attached if necessary): NL W /2ct C/ rJcy G / 2v SA To /-ice— ria_.. o& �-7✓O Li Signed(Owner or agent): P-2-4.2.-t--C4 eg Date: /2 l r > Owner/contractor/agent is aware that a permit may be required from the Building Department.(Check other departments,also.) > This certificate is good for one year from approval date or upon date of expiration of Building Permit,whichever date shall be later. For Committee use only: Date: i2—j8---i O ” Approved _Approved with changes_ _Denied _ Amount e9e, Reason for denial: APPROVED • cash/cK#: 2566 DEL 19 2018 Rcvd by: 46-47 YARMOUTH OLD KING'S HIGHWAY. Jz r9/2,c)/ S77- 65;24_,A4.774 Date Signed: ( Signed: Vie �(�-L�l3y APPLICATION#: V5.2017