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HomeMy WebLinkAboutBLD-19-3965 Office U e V ,ZrO Y,q k mj®s'! �y1 • 3 '6�I a -, ra' k Per � ,urr'In n 'Z'. 3 _he's, cvPermit expires 180 days from Issue date j EXPRESS BUILDING PERMIT APPLICATION `i - TOWN OF YARMOUTH _ ___ Yarmouth Building Department tT� nI 9 i 1146 Route 28 JAN 0 7 2e I South Yarmouth,MA 02664 r , E.Nar i nr.en T (508) 398-2231 Ext. 1261 e CONSTRUCTION ADDRESS: .3.-- AC& fl'n 3 6„PA SD ?PIT ASSESSOR'S INFORMATION: Map: Parcel: en- un/r=H _--OWNER: /POs/v2j/,A-r0z11 w) ,�'S-0,4- NAME PRESENT ADDRESS TEL # Email Address: cONTRACIOR;7,1,720 (.mak p4 y0/ ,fid y"2 /'ISI .07-9C2. -SZ91 NAME MAILING ADDRESS Tom.# Email Address: CRISireaat`) Commercial Est Cost of Construction$ 4.7/Ield Home Improvement Contractor Lie.# /809fl Co. upervtsor c. - ev , Workman's Compensation Insurance: (check one) _ I am the homeowner TI am the sole proprietor I have Worker's Compensation In 'ce / �j ^� Insurance Company Name: ` tflVEter-a Worker s •mp.Policy# ( )3 9 / l) /yz_z__ WORK TO BE PERFORMED \ Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares l< Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like *The debris will be disposed of at yit70.lQ/97711 Location of Facility I declare under penalties of perjury that , statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) willbe'ustcausefordenialorrevom license df• . •s:• ounderM.G.LCh.268,Section1. 1 Y �} Applicant's Signature: . Al/ ._/r l "1P Date: </�/9 n Owners Signature(or attachment)j. L / .fi-trv'-'.. t Date: y Approved By: / Date: / — D i'7n Building Offlerarlgnee) • Zoning District Historical District Yes No Hood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No f, .ac c ummonweaan of Massachusetts *4 a? . Department of Industrial Accidents • e INS . 1 Congress Street,Suite 100 7U Boston, MA 02114-2017 '•Gro. www mass.;ov/dia -4 Workers' Compensation Insurance Affidavit: Builders/Contractors/Eleciricians/Plumbers. • TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual . 7fitJ4/I/7'rat. G,fit'i Address: /9G,,iiz7zv Yg9. 4GY2 21/y/' City/State/Zip: a/ et /V,e; / Phone #:s$2J7-942- 32.-f Are you an employer? Check the appropriate box: Type of project(required): l.Zf am a employer with .7 employees(full and/or part-time).* 7. ❑New construction 2.0 1 am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp. insurance required.] 8. (Remodeling 3.0 I am a homeowner doing all work myself[No workers'camp,insurance required.]t 9. ❑ Demolition 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. 5.01 am a general contractor and I have hired the sub-contractors listed on the attached sheet 12.0 Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.: 13. Roof repairs 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 41 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 Dumber. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and Job site Information. Insurance Company Name: j��,i?j/m.7f2e.0 Policy#or Self-ins.Lic.#: A/.8 Q/Q,1L 2, Expiration Date: 009 Job Site Address: City/State/Zip: ,yj/Jef7/1 YVd9 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 der the pains and penalties of perjury that the information provided above is true and correct. Si•nature: ,' �_s / /f' Date: A Phone#: C5-07-94 2- t"5-24V 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 gmployee 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." MOL 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 ACORD" CERTIFICATE OF LIABILITY INSURANCE tATE(MMDOYYYY) 07/12/2018 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: \'HIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: it the certificate holder Is an ADDITIONAL INSURED,the policy(es)must be endorsed. H SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require en endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). CONTACT PRODUCER NAME; Maly Connor SULLIVAN GARRITY&DONNELLY INSURANCE AGENCY INC rzeo Esn. (508)453.2586 INC,No): ADn an ; kathleen.geddis©Sgdins.Com 1 10 INSTITUTE RD IRSURER(S)AFFORDING COVERAGE NAM• WORCESTER MA 01609 INSURER A: TRAVELERS INDEMNITY CO OF AMERICA 25666 I INSURED INSURER B: DAVID COX INC INSURER C: . INSURER D: PO BOX 401INSURER E: S YARMOUTH MA 02664 INSURER f: COVERAGES CERTIFICATE NUMBER: 290863 . 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 VNTH 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. ADOL SUBR POL1Cyy EPP POLILICCY EXP LIMIT I TYPE OP INSURANCE I Mien wV0 POLICY NUMBER (MINDS/MGMIMMAIWY IYYI I:. l COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS.MADE ❑OCCUR PREMISES occults* S MED EXP(My ale person) S �—� Woccults*occults*PERSONAL LADY INJURY $ IenN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ --,POLICY❑PEC 0 LOC PRODUCTS.COMPKIP AGO S I $ OTHER' COMBINED SINL,L LIMO AUTOMOBILE LIABILITY (Ea occident $ -- ANY AUTO BODILY INJURY(Per person) $ MN ALL OWNED SCHEDULED N/A BODILY INJURY(Per aod*sm) $ AUTOS —' NON-OV.NED PROPERTY DAMAGE S 1111 HIRED AUTOS _ AVrOs (Per aoadenil S , UMBRELLA WS — OCCUR I EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE N/A AGGREGATE _ S DEO RETENTION S , S WORKER*CONDENSATION X STATUTE ORT H ' AND EMPLOYEAS'WIBILITY . ANYPROPRIETORPARTNERAEXECUTIVE Y/N E.L.EACH ACCIDENT S 100,000 A orfICER/MEMBEREXCLUDE0T WA WA WA 6HUB910X742218 107/16/2018 07/16/2019 ( andatory In NH) E.L.DISEASE•EA EMPLOYEES 100,000 ryywaa*mate wilder �EaCRIPTIoe OF OPERATIONS b4*w - E.L.W nae-POLICY LIMIT S 500,000 N/A 1 I DESCRIPTION Of OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Rema*Schedule,may be amine*mote span Is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 0306 B,no authorization is given to pay claims for benefits to employees In states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of Insurance shows the policy In force on the date that this certificate was Issued(unless the expiration date on the above policy precedes the issue date of this certificate of Insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/iwd/workerc•compensatlonhlnvestlgations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY Of THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street AUTHORIZED REPRESENTATIVE • 1 Hyannis MA 02601 �-M'(, r,,.. Daniel M.CTo(T y,CPCU,Vice President-Residual Market-WCRIBMA 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name end logo are registered marks of ACORD • ?ILWAY fin/((0.ftvGaii4 4Ur1611YnWW11111 u.M.rsaa.-.luac..a -� Division of Professional Licensure Offke of Consumer Agars i Business RCgllfetisn Board of Building Regulations and Standards HOME WPROYEd(NT BttJ1 CONTRACTOR Construction Supervisor TYPE:Corraet�n - g . '. l 100497 - 03124/2020 CS-063537 Expires:1011512019 , a4. DAVID COX.INC... - -" - _.�i%` —rzz - DAVID R COX - "' tQ 1.y'a lei_'-._ • PO 60X401 +F DAVID R.COX - SOUTH YARMOUTH MA 02664 .~ 'C` 19IAVEM7ER W U W.YARMOUTH,MA 02673 UndersectetazY e Commissioner l/'- 4