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Home My WebLink AboutBLD-19-4005 I ,. og'Y44 & - Office Use Only j ,4 ',2: r-! O' Denmt# 60— �— N 01 . $, !Amount 1 �°"""'�s'cd', _ _. Permit expires 180 days from issue date 9 8(1}-- q-DIS-War RECEIVED EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH ,JAN 08 2019 Yarmouth Building Department • 1146 Route 28 BUIL'.! li ' r South Yarmouth,MA 02664 By: (508) 398-2231 Ext.11/261 CONSTRUCTION ADDRESS: // f-7Fl.fa- 6./. c. Y/Yn-ivtoo7 ASSESSOR'S INFORMATION: / Map: Parcel: OWNER: e_. -)HLb 'L I I la L.p% r L/F3 - 5.22 - b 353 NANM PRESENT ADDRESS TEL. # CONTRACTOR: Cewr1GN6 (tomtits-Qvtod q , U/°i°T"ztaw^y/4 ,roarFrearg 7-2oz NAME MAILING ADDRESS TEL# ea 6 Residential 0 Commercial Est. HO Cost of Construction$ e Ol Home Improvement Contractor Lie.# /7 s' 5-7 S Construction Supervisor Lic.# C S - 09034 7 Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: OQM)1(&I 0 4 ouQCG Worker's Comp.Policy# • WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# 7 Replacement doors: # '0 Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation usil% 11O1d Kings Highway/Historic Dist. ( /Replacing like for like Pool fencing "The debris will be disposed of at Taloa g.3 et \/Athaevon tck L cation of Facility I declare under penalties of perjury .4 th .tements 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 re alio'- y license and for prosecution under M.G.L.Ch.268,Section 1. / Applicant's Signature: / Date: //0 19 Owners Signature(or attachment) �Z$vClkDate: p 111 • Approved By: / '. ' Date: 1 - (7"1-S Building Official esignee) 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 The Commonwealth ofMassacitusetts _ c/ Department ofIndustrial Accidents • — ii1= T 1 Congress Street,Suite 100 • • __a=-- 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 aeon/tote � Name (Business/Organization/Individual): ( fie /tote Ansi�ie�,�y Address: '1ti v d f.rl. Goof•t-ty Rp, ll�� City/State/Zip: DCc-+v res te. l Phone#: 'i '2-7A'L Are you u employer?Check the appropriate box: Type of project(required): I. I am a employer with 1ieaemployees(full and/or part-time).* 7. 0 New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. [ Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing an work myself. [No workers'comp.insurance required.]t 9. El Demolition 4.❑1 am a homeowner and will be hiring contractors to conduct all work on m property. I will 10 ❑ Building addition 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.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.0 We are a corporation and is 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#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-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. (1 Insurance Company Name: FILO G(NCP- 4 0 MC-t (— Policy Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: �I 42-e-L( (art, City/State/Zip: C. vtLwn� enn,4_ gVt)3— Attach a copy of the workers' compensation policy declaration page(showing the policy number an 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 co.y of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. / I do hereby certi' , the pal-,' and penalties of perjury that the information provided above i true nd correct Signature: _ Date: 81 9 Phone#: 5.0St & S-? 22p"— 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. Pu'rs - - ant 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( )states "Neither the commonwealth nor any of its political subdivisions shall enter into any contact 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}hat 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 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 c Commonwealth of Massachusetts kV/Division of Professional lkensure Board of Building Regulations and Standards Construt6`SPS^nsot CS.090367 Igi E3�ires:05/1412020 DAVID JBUE.JI$ I A " 1 30wtMASMFA,Ya I:s } HARWICH MA 0+ f f-. ;,+* � i .. tF37R'ciC� Commissioner . eh TISMM4pnakeeta �_ Ofike of Consumer/ftatrs&0usinaa R.ggulatlor 4 -` = , HOME IMPROVEMENT CONTRACTOR Ragistratlon valid for Individual usa Doty _:_* "-TYPE:Supplement Card before the explratlon data. If found return to: t, Emokilidn Office of Consumer Affairs and Business Regulation `.;..` ,; _ 020/2019 10 Park Plaza•Suits 5170 r= COASTLINE COIBoston,MA 02116N INC. / 3 Chipman A ;,_- r.:,' 141 7,-��,/ Sandwbti,MA 02,16-3--1- Undersecretary Not valid without signature M ✓A H COASTLINE CONSTRUCTION INC Construction Services Authorization Subject: Lorenz Windows Date: 10/02/2018 AUTHORIZATION All work will be completed in a professional and timely manner. Any alterations,deviations, or additional work scopes to those listed above, and which require additional fees not included herein, will be executed only upon written orders,and will become a charge over and above the proposal price. The total cost for the authorized Scope of Work is$11736.35 Timely payments are expected. Payments not received within ten days of invoicing will incur a 5%late fee. It is further agreed should it become necessary to hire an attorney in order to collect the amount due on this contract or to settle any disputes that may occur that the owner will pay for any and all legal fees that may be incurred in the collection process. This bid is final and supersedes all previous proposals and/or correspondence written or verbal. „ z� ll Contractor ' Date: / The above prices are as specified and conditions are satisfactory and are hereby accepted. You are authorized to do the work as described in the bid. Payments will be made as outlined above. Owner/Owners Rep:SZ4,27,Aja Date: /Spey/ • - *Please note that this proposal may be withdrawn by Coastline Construction Inc.if not accepted within 30 days. Prices are valid for 60 days and may be subject to change due to continual rising construction cost. P.O.Box 1599 • East Harwich,?La 02645 s P. (508)694/236 •F.(508)694.7261 joe Fccoastlinema.com •dacid e coastlinema corn Client#:44875 2COASTLINECOI ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDWYYY) 01/08/2019 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(ies)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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Dowling&O'Nell Insurance Agy PHONE 508 775-1620 (FA/MCC. 5087781218 P.O.Box 1990 jkIC,No,Eat): (AIC,No): 973 lyannough Road EMAIL ADDRESS: H annis,MA 02601 INSURER(S)AFFORDING COVERAGE NAICs y INSURER A:Admiral Insurance Company 24856 INSURED INSURER B:Associated Employers Insurance Company 11104 Coastline Construction,Inc. INSURER C: PO Box 1599 Harwich,MA 02645 INSURER 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 CONTRACTOR 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 TYPE OF INSURANCE ADDLSUBR POLICY EFF POLICY EXP JNSR WVD POLICY NUMBER (MMIDD/YYYY) (MMIDDIYYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY CA00002958401 02/01/2018 02/01/2019 EACH OCCURRENCE 51,000,000 CLAIMS-MADE LI OCCUR PREMI$ESYEaEMrPenoel s50,000 X BI/PDDed:5,000 MED EXP(Any ate person) $5,000 PERSONAL&ADV INJURY $1,000,000 GGEEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 R POLICY III JET fl LOCI PRODUCTS•COMP/OP AGO E2'000,000 OTHER: $ _ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ _ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) . S UMBRELLA LIAR OCCUR EACH OCCURRENCE S - EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION§ $ B WORKERS COMPENSATION WCC50050116682019A 01/15/2019 01/15/2020 X STATUTE FORH- AND EMPLOYERS'LIABILRY ANY PROPRIETORIPARTNERIEXECUTNEYIN E.L.EACH ACCIDENT $500,000 OFFICERIn R EXCLUDED? n NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $500,000 II be under DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached N mon space Is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of Insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION Town of Yarmouth SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1146 Route 28 ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 02664-4492 AUTHORIZED REPRESENTATIVE I '✓/....i. "7`C— O 1988.2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD #5227185/M227184 RPSW1