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Home My WebLink AboutBLD-19-003826 (54 Country Avenue) .t.Y, RECEIVED !Office Use Only g Permit# o 'Aar p ay DEC 26 2018 ',Amount 351oD " 3 Permit expires 180 days from BUILDING DEPARTMENT ;1 issue date t- a-D—lG-vb3 A EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 54 County Rd, West Yarmouth MA 02673 ASSESSOR'S INFORMATION: Map: 83 Parcel: 22 OWNER: _ _ I CONTRACTOR Richard Tupper 546A Hi.gins Crowell Rd W Yarmouth MA 02673 (508)778-011' NAME MAILING ADDRESS TEL# 7 Residential ❑Commercial Est Cost of Construction S $s02 57 Home Improvement Contractor Lie.# Construction Supervisor Lie.# CS-069058 1(S434 Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor 5(1 have Worker's Compensation Insurance Insurance Company Name: AEIC Worker's Comp.Policy# WCC5005593012019A WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulatio( Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at NAUSET DISPOSAL Location of Facility I declare under penalties of perj 4., 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 den If my license and for prosecution under MAL Ch.268,Section 1. ��// Applicant's Signatu . Date: / r Owners Signature(IirATZIM1 Date: .099 Approved By: - , fing Official(or. signet) EMAIL ADDRESS: Date: /�.i1 �� 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 • RISE ENGINEERING • OWNER AUTHORIZATION FORM I, Gerard Desautels (Owner's Name) owner of the property located at: 54 County Road • (Property Address) West Yarmouth, MA 02673 . (Property Address) hereby authorize 1 P-Pi V ( c h S fit V G4'I0\/1 ( U' C' z c- (S bcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property.This form •s only valid with a signed ••ntract. e r Owner's Signature Date RISE Engineering,a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RISEengineering.com bp, A The Commonwealth of Massachusetts �a ,1 Department oflndustrialAccidents - Is Office of Investigations 111 III S, 1 Congress Street,Suite 100 or WIe 1 . Boston,MA 02114-2017 wwwmassgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business%organizationindividual): TUPPER CONSTRUCTION CO LLC Address:546A HIGGINS CROWELL RD City/State/zip:WEST YARMOUTH MA 02673 phone#:508478-0111 Are you an employer?Check the appropriate box: 4Typc of project(required): 1.❑Q .I am a employer+dth 8 0 lam a general contractor and 1 employees(full and/or part-time).• have hired the sub-contractors 6. 0 New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8, 0 Demolition working for me in any capacity. employees and have workers' 90 Building addition [No workers'comp.insurance comp.insurance? required.) 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a homeowner doingall work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152.§1(4).and we have noINSULATION employees.[No workers' 13.!! Other comp.insurance required.) *Any applicant that checks box*1 must also alt out the section beim showing their workers'compensation policy information. t Ilomeownen who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new a mdasit indicating such. :Contractors that check this box must attached an additions?ahem shoving the name of the sub-contractors and state whether or not those entities have employees. lithe sub-contractors have employees.they must provide their whrken'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Below Is the policy andJab site information. Insurance Company Name:AEIC Policy#or Self-ins. Lic.#:WCC5005593012018A Expiration Date:10/3/19 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 DIA for insurance coverage verification. I do hereht'certify r der the pains and penalties Sappy that the information provided above Is true and correct. e Signature: ., Date: Phone#: '50811178-011 1Offld0 luse 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#: e CERTIFICATE OF LIABILITY INSURANCE I /11/15/2018 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 policyges)must be endorsed. If SUBROGATION IS WANED,subject to the teens 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 Ashley Pain Eastern Insurance Group LLC PAN�CO�NyaPdf: (800)333-7234 IFAX 233 West Central St ' .MSL L1A�-t+9L ADDRESS;apalva8easterninsurance.Com Natick INSURER(9)AFFORDING COVERAGE NAIDS MA 01760 INSURERA Arballa Mutual Insurance Co. 17000 INSURED It3URERBArbella Protection Ins. Co, 41360 Tupper Construction Co LLC MSURERCDoston Insurance Brokerage Inc 546A Biggins Crowell Road 111111L. INSURER DJ West Yarmouth INSURER E1 NA . 02673 INSURER f: COVERAGES CERTIFICATE NUMBER:2018-19 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. (NSA_,_.— —.AtitiC LTRI TYPE OF INSURANCE pygn W.y�l POLICY NUMBER ,(PLO / VDDYYYY1 IMP D"YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH A EMI CLAIMS-MADEOCCn OCCURU6RRRENCE � f 1,000,000 ^MNE6ESEk1EtEtkonut $ 100,000 9520045200 one 11/1/2019 MED EXP(Any 4 person) f 5,000 PERSONAL a ADV INJURY f 1,000,000 GEN.AGGREGATE LIMIT APPLIES PER: a GENERAL AGGREGATE _ $ 2,000,000 POLICY0JPER0. Li LOC PRODUCTS.COMP/OP AGO f 2,000,000 OTHER Employee Benefits f A— UTOMOBILE LIABILITY SINGLE LIMIT f 1,000,000 B _ ANY AUTO BODILY INJURY(Per Person) f ALL OWNED —.. SCHEDULED AUTOS AUTOS 1020009389 12/1/2019 12/1/2019 BODILY INJURY(Paracaee5) S X HIRED AUTOS a AUTOS D I — AUTOSMED AM`GE f x UMBRELLA Lin OCCUR ANOPL S EACH OCCURRENCE f 1,OOOQ 00 B EXCESS LIAB — CWMS4fADE AGGREGATE S 1,000 000 OED x IRETENTION S 10,000 4600058369 11/1/2018 11/1/2019 $ WORKERS COMPENSATION pp AND EMPLOYERS'UABIUTY YIN STpTUTF i ERS ANY PER%IEMTORIPARTNERIEXECUTVE � a 1,000,000 OFFICERMMEMBER EXCLUDED? Di] E L.EACH ACCIDENT C (MyeNndeloy M under NH) WCC5005005593201 30/3/2015 10/5/2019 Si DISEASE.EA EMPLOYEE f 1,000,000 IDESCRIPOeT�ONOFOPERATIONSbelow EL DISEASE•POLICY LIMB f 1,000,000 ' 1 1 I DESCRIPTION OF OPERATIONS/LOCATIONS/VEMCLES(ACORD 101,Addmenal Remarks Schedule,may be aflchd S mote pate M remind) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF WE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Display Purposes Only THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE / R to Kayo, Kevin/APAI 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025nXHann esvopmwww71,ye:/4.7.444v4 ' Ogles of Consum&Attars&Business Regulation NOME IMPROVEMENT CONTRACTOR Registration valid tor lndMduelussonly • TYPE:LLC - Wont the nplrstlon data n found Mum to: Realetnnen • Affairs end Business Regulation 4. 178434 -• 04/115/20200 • • Place•Sults 1301 TUPPER CONSTRUCTION CO,LLC. Boston,AlA •'L RICHARD TUPPER ' • 546AHIGaINSCROWt1LA!) (, _ r W.YARMOUTH,MA 02873Und Not - Id without signatureersecretary . . Commonweenh of Messechusetts •4.: Division of Professional Lioenouts Board of Building Regulations and standards Construction Supervisor CS-060058 Expires 12131/2020 RICHARD S TUPPER ��1 646 AHIOMNS CROWELL ROAD: i4. I WEST YARMOUTH MA 01673 • Commissioner L'A". • BUILDING PERFORMANCE INSTITUTE,INC. 107 Hermes Road,Suite 210 CERTIFIED PROPESSIONAL Da9&NATION EXPIRATION DATE - Malta,NY 12020 ,sir (877)274-1274 Huildms AnalystAofsa;onal. sits/2mi f' wwwLpl.Orq 1 frA tjp iddj • Richard Tupper r Inn n BPI IDE 6040640 kSCCR;TIFiED PROFESSIONAL, 1 .. i1UlE M (SEE REVERSE SIDE FOR DESIGNATIONS AND memos DATES) } BUILDING PERFORMANCE INSTITUTE, INC. Tt