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HomeMy WebLinkAboutBLD-19-4063 •! Office Use Only ! Of'4,4,,_ 1k. • Pemut# 4 9 O �"Milt;'� � Amount 3'„•...r $ Permit expires 180 days from .r,.:gra: a • issue date Fii --lq-QNC(o3 EXPRESS BUILDING PERMIT APPLICA a §C E I V E D TOWN OF YARMOUTH Yarmouth Building Department - JAN 10 2019 _ 1146 Route 28 South Yarmouth,MA 02664 atm_ "l . •'a r (508 98-2231 Ext. 1261 A . J CONSTRUCTION ADDRESS: / .it2o • iOxt' GJV ✓t't i ASSESSOR'S INFORMATION: • Pt, /) • Map:tom' Parcel: OWNER: La ei__ N �� PRESENT ADDRESS f�j ►'/nom//A ,�,���TEEL. #7,2e.-;-7‘q CONTRACTOR: NAME //t4tO. 4 4 M�J�LC/ ADDRESS !/ /K.l" aZ/YE4 ❑Residential ❑Commercial r'�/ TN�i Est.Cost of Construction$ n� y Home Improvement Contractor Lic.# /655 Construction Supervisor Lic.# (/fd,7t39 Workman's Compensation Insurance: (check one) 0 I am the homeowner ,/,c0 I am the ole proprietor I have Worker's Compensation Insurance /� 41 Insurance Company Name: t42t ijr , rh,5, Worker's Comp.Policy# ��� �//U / • WORK TO BE PERFORMED • • • Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares /0 ( Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing "The debris will be disposed of at: �`/tSA�/J t}'Z� 6 ii 40-6-/l Location of Facility I declare under penalties of perjury that the statements herein canc.,ed 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 revocation o�•,'license.•- or,.)-ecution under M.G.L Ch.263,Section I. r /4/;" Applicant's Signature: Arireitt— / Date: Owners Signature(or attachment) 41'�/%J%�/ Date: / yt� Approved By: -��e� a Date: / �C i/ Bu. 41-0/cial(sr designee) . 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 ❑ No J__= The Commonwealth of Massachusetts .) —`a—_ Department oflndustrialAccidents �t ra iel_ , 1 Congress Street, Suite 100 =SFE Boston, MA 02114-2017 � s www mass.gov/dia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant InformationPlease Print Legibly Name (Business/Organization/Individual): J�1/ /Ir Gv. �fi t�o'�ig3 Address: fig $'d h� ! 14" y City/State/Zip: ( jtI— 0;1435 Phone#: j - 0)o� 8O?5I Are you an employer?Check the appropriate box: Type of project(required): {. am a employer with r employees(full and/or part-time)." 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall work myself. t 9. 0 Demolition ❑ y [No workers'comp.insurance required.] 4.❑I am a homeowner and will be hiring contractors to conduct all work on my proPty e I will 10 ❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 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 These sub-contractors have employees and have workers'comp.insurance, 13.0 Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGI..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 =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 wo kers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: tr G . l ' /, L.5 , 4'ii�37 Policy#or Self-ins.Lic.#: /t� 0C/<.f ���/// Expirat•on Date: / Job Site Address: /2/90 / ' , ( C?v'1 City/State/Zip: r-4 Attach a copy of the workers' corn sensation policy de aration page(showing the policy nplb4er 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. Ido hereby cerafy under the pains and pena •esom s erjury that the information provided ahoy is Date: tru and correct Signature: /V ! /1/ Phone#: a—•CJ 0 r--.".7 7 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 m: • 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,§250(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 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 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Employers Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 (800) 876-2765 NCCI NO 40959 POLICY NO. WCC-500-5006114-2018A PRIOR NO. WCC-500-5006114-2017A ITEM 1. The Insured: Michael Deluga DBA: Village Craft Building&Remodeling Mailing address: 568 Santuit Road FEIN:'-"'2146 Cotuit,MA 02635 Legal Entity Type: Sole Proprietor Other workplaces not shown above: 2. The policy period is from 12/23/2018 to 12/23/2019 12:01 a.m.standard time at the insured's mailing address. 3. 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 3.A. • The limits of liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates Code Estimated Per$100 Estimated No. Total Annual Of Annual Remuneration Remuneration Premium INTRA 000355380 . . INTER SEE CLASS CODE SCHEDULE • Minimum Premium $500 Total Estimated Annual Premium $3,474 GOV GOV Deposit Premium $899 STATE CLASS MA 5645 State Assessments/Surcharges $3,122.00 x 3.8300% $120 Thispolicy;includingall endorsements, is hereby countersigned by �`-'� .. -r 11/26/2018 • Authorized Signature Date Service Office: Malcolm&Parsons Insurance Agency Inc 54 Third Avenue. P 0 Box 527 Burlington MA 01803 Stoughton, MA 02072 WC 000001A(7-11) • Includes copyrighted material of the National Council on Compensation Insurance, used with its permission. U Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards • ConstruttltSft'SOpervisor =f 1 CS-050234 4 Epires: 07/09/2020 MICHAEL DELUGA "+ - • 668 SANTI NT RD { ..1/., COTUIT MA 02636 �` Commissioner c%- n. Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual pxDiretion ' 109!9 51 ,, 07/16/2020 MICHAEL DELUGA D/B/A VILLAGE CRAFT BUILDING&REMODELING MICHAEL DELUGA """`_J COSTUIT RD. U T.MA 02635 Undersecretary Registration valid for Individual use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation One Ashburton Place•Suite 1301 Boston,MA 02108 Not valid without signature ...