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Home My WebLink AboutBLD-19-4053 py_r_R Office use Only 1 .A: ! O Permit! • ., Cat �dg C SO O • H. Amount _N 1 �, �•,. Permit expires 180 days from ' >"xi.:-.•' BO-tq, ry)yUS3 issue date EXPRESS BUILDING PERMIT APPLICA • C E 1 V E D TOWN OF YARMOUTH Yarmouth Building Department JAN 0 9 2019 1146 Route 28 South Yarmouth• , MA 02664 d u'�''" rr, .. 'i ENT '77 (,5-08) 398-2231 Ext. 1261 �j� �— CONSTRUCTION ADDRESS: /,7 , ..9 4_ 1 .'^t 4- . 74,1,H rin ASSESSOR'S INFORMATION: yt /^ Map:. Par-ceel:, n OWNER: IA L�.A- C iMfI G e C� .51- Ft '- 4U, . ,�+ PRESENT ADDRESS TE . # CONTRACTOR: (/t{Hv/0 q /�L-•(.�A.(C.-Fia` IAO�gt:✓ Nc'Y67 CA S` fl^ �� a77 9511 NAME MAILING ADD -SS TEL-11( $Residential 0 Commercial Est.Cost of Construction$ _cog 7 y0. [v/y Home Improvement Contractor Lie.# I 53C79.1 Construction Supervisor Li c.# 10. 9 10 7 Workman's Compensation Insurance: (check one) ' 0 I am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: (Q1/? Worker's Comp.Poiicy#(,(rC cr_. (e'-goIg se? „tol$4 WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# I ? ` Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like ' Pool fencing *The debris will be disposed of at: V� /w- // Location of Facility I declare under penalties of perjury :t the statements 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 revo A ion oJj` icense and forprosecution under M.G.L.Ch..268,Section 1. Applicant's Signature: I'm' CA"./ . D/ D��i, / Date : y Owners Signature(or attachment) ,CAJJ cP. Date: 01-(((CS- / 9 Approved By: Buil• g Off 9ee)' E DRESS: Date: /--/°.--./7 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 of Massadhusetts I _N. , _ / Department ofIndustrial Accidents =f11= 1 Congress Street, Suite 100 o',=_ ® Boston, MA 02114-2017 vitc, .� 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): ela Uez—e_________ Address: ZoA 4, & Fc 2 0 City/State/Zip: 5_, / Phone #: 5Caa 37 Q591 Are you an mplayer?Check the appropriate box: Type of project(required): 1 I am a employer with 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. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp. insurance required.]r 9. E] Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on m property.P *Y• 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 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.* / 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.D Other N<rLQw/YX 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-contactors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 1 I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site Infurmation. �[ �i i Insurance Company Name: �//�.as , Policy#or Self-ins.Lic. #: ,(.[/tom 5flciS0/his g9 D-O/ i Expiration Date: 0 et/ 3C)//7 Job Site Address: / 7 ,11441 Civ • 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 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 Signature: / _ O/ act / Phone#: —Call ,-.31,5 t - 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 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." 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 checldng 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 bum 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. # 617-7274900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia A m CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDYYY� 04/05/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELYOR 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 rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT Larissa Camba NAME: Leonard Insurance Agency,Inc • u/c0 i o Fztl, (508)428-6921 i CA Net: (508)420-5406 683 Main Street E-MAIL larissageonardagency.com ADDRESS: Suite B INSURER(S)AFFORDING COVERAGE NAICI Osterville MA 02855 INSURER A: Atain Specialty Insurance INSURED INSURER B: The Commerce Ins.Co. 34754 C&F Remodeling Inc. INSURER O: A.I.M Mutual Insurance Company INSURER D: 20 Captain Noyes Road INSURER E: South Yarmouth MA 02884 INSURER F: COVERAGES CERTIFICATE NUMBER: Master 18-19 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. ILTR TYPE OF INSURANCE NSD WVDD POLICY NUMBER IR POLICY EFF POLICYEXP(MOLICYEFF (POLICY EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCES 1,000,000 I OCCUR DAMAGE TO REN 100,000 CLAIMS-MADE Ej PREMISES(Ea occurrence) $ MED EXP(Any one penton) $ 5,000 — A CIP353487 04/18/2018 04/18/2019 PERSONAL AADV INJURY $ 1,000,000 G�EN-T.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2000,000 POLICY 0 128: 0 LOC PRODUCTS•COMP/OP AGG $ 2000,000 — OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ — (Ea accident) ANYAUTO BODILY INJURY(Per person) $ 250,000 — B — OWNED se SCHEDULED RVM277 01/18/2018 01/18/2019 BODILY INJURY(Per ecddentl E 500,000 AUTOS ONLY. AUTOS se HIRED Si' NON-OWNED PROPERTY DAMAGE $ 250,000 AUTOS ONLY n. AUTOS ONLY (Per eccideM) $ UMBRELLALIAB OCCUR EACH OCCURRENCE _ $ _ EXCESS UAB CLAIMS-MADE AGGREGATE $ _ DED I RETENTION$ $ WORKERS COMPENSATION PER I....el OTH- AND EMPLOYERS'LIABILITY YIN STATUTE 0,1 ER C. ANY PROPRIETOR/PARTNER/EXECUTIVE NIA VJCQ-5005018589-201BA 04/30/2018 04/30/2019 E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? Ej (Mandatory InIn NH) DISEASE•EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD WI,Additional Remarks Schedule,may be attached If more space Is required) — • CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ConSerV Group Inc ACCORDANCE WITH THE POLICY PROVISIONS. 110 State Rd Apt? AUTHORIZED REPRESENTATIVE r�-•� Inn! -_1�I1,,., Sagamore Beach MA 02582 IY7W L 'r''"N^' C1• �,WTNxJw I ®1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD �(�� { a. ]OUO!SS!WWOO 1 ' �� f 5,53[11 �S * ': , ' &N s-Il''o W 21t�/A H1f1OS s V e �fy 21 S IAl N Nl�fldtf0 °Z ,,, , --,,,-: . .sir,...: ` ' t'5,ti/0f13f1Jt� H SO721�do" ^ t. v 4 z , b -" , :e tis 1 ' 610Z/SZI80 sa' i! 3 ` _�� - LOLPOC SO d ter: , x :_ , ;, JOS!&I3dnSfu -r7 suoe Y �: sp;epuels pue suolfeln6aa Suip11n8 ;o p�eog ,Z `` ainsuaorf Ieuoissa oid JO uorslnIQ sllasnyaesseyi Jo_ylieannuowwo0 ® k4; Ai �,�O�gJ3�JUf� 1o9Zo„VW `Hlnowab l 's ct:.,t, .c5 a s3AoN NItlldVO OZ �� ,./1:1,-2---,Voaid' Lloid -HSo1WO x yx }i, _ zt �`t O�II SNI?JOOW32i d l O -„`t q,; LZOZ/LO/LO ,�.__Z6L69L= M1'_s, uolle�Iax3 UP13e?35I4ad 4 HOlOV211N00 1N3 W3I%O2Id W 19 WOH uofHO_L a ssauisn8 g s/.ge;�yJawnsuo3 Jo aDUJO ", T `�r-vj .wrr�t":2,/ , ✓. -;-"" ✓,t W' iLllJ/J *7 C .440