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Home My WebLink AboutBLD-19-004039 11/13/2818 05:19 15884281578 ELL.D$ OD PAGE 02f: !ram WM Wait • Ames 5 �‘4. tc, Am �t taoetysaeae 13Lb - lG -trice • EXPRESS ilIIILDING PERMIT APPLICATIOPR E C E I V E D • TOWN OF YARMOUTH Yarmouth Building Departmeat JAN 09 2019 - 1146 Route 28 • South Yarmouth,MA 02664 . BUJ I ' y . �T�^�NT tof. (508)398-2231 Ext. 1261 By. "`-1-- CONSTRtTGTIONADDRRS3: 1.04 .Pi ItAGJ5.fi 94' YrurrntiAnW b2��4 ASSESSOR'S INPORMADON: Map: Pezcck • E_OWt�R+i 1'V*I Ice co-a crois (0(1 'tct \Avast_ R9 9Wv,1' ' " NAME s - ci PRE9 NrADDRESS ItL t CONIRACfOB:Afl •1J icAtos s Rksa�t ntJlJJO tt xstr v)Aade5or 2.6-t es hes sTinuitirs reweas.\s+�5 Mnr-WtADDRESS MArete.'v tvl.1lG TELitut L orfs ictermsl at • ncoromem Estc oCoonmedoas CS- '°i fleet Dome Issprevemeat Contractor Iia#t(D3125 Cosutractlon Sopervtvor Ida F (P).DD W Wozkmmes Compeasado,Inataence (check one) o ism the bosaeow wma I/I Ica the sale proprietor n I tine Worker's Campeasation Iaanmmm . Icsomace Comptroller= Wo:txe'tCoop.Policy# • • WORK;TO DE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Sung. N of Squares Rephe meat windows:# Replacement doors. # Roofing: #of Square . ( )Remove etstoag'(max.2 layers) Insulattoq Old Kings IIlbtway/Hlstoric Dist ( )Rephrnng Lice tbrh'ks Pool feneta "raedrhdewine d&posedrisk Sim EICCO 'U•sposdl —1DJsvv()SAG/ Loaf=ttFtcdty Idedaemderpenal=.1miry that the rbada woodoedaetrine cesectSxbrztatm lank' sad bdscttaadassait esaybi .atorts) flWit coos:for• n: orzevocaaoaern ltaeser$la MAL.Ch. 3ctita L A 5aurs Sipa= . _ AA P_ O�tensi=nttre .►��I Q , APPoce4ET ern�A 7-9-77 Otbdd '!`f!,. ROOAI. ZoalP;District • TismdealD arku o Yet 0 No FloodPizioiaoe; 0 Yep 0 No Wats Raomce Protection Dtamct Volt 100 it.of We Indr OYee. ONo OYes O No • 1. 1 n `I The Commonwealth ofMassac/tusetts ��, II,..1.7.41 ; �(I Department oflndustrialAccidents on= 1 Congress Street, Suite 100 t4:wit—r- a • Boston, MA 02114-2017 %,�.4 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): .TA v C 1 S S . ELL-I N UJOac-1j} 4O4S% `R aul, Y Revhtldeit Address: (0 0 rro�-zte r vJ AiCity/State/Zip:lv]A�gqars\an) Mk ma oa64$ Phone#: • So< 36-1 C (055 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. 0 New construction 214.1 am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling • any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself[No workers'coin p.insurance required.]r 9. ❑ Demolition 4.❑I am a homeowner and will be hiring contractors to conduct an work on my property. I will 10 0 Building addition ensure that all contactors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 5.E1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 12. 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 a 14.94 Other V i rs�D lD 152,§1(4),and we have no employees.(No workers'comp. insurance required.] 2 e el o..e m�"k •Any applicant that checks box#1 must also fill out the section below showing then workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contactors 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 employes 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. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address:tllO \GY.VstfJSt,'RArri(yr/]dr/n Mg City/State/Zip: o.(•ry]at. MR 02(o(otj Attach a copy of the workers' compensation p licy declaration page(showing the policy nu_nber 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 DR for insurance coverage verification. I do hereby ;51 under the pains ��and �penalties of perjury that the information provide above is true and correct Sinnatuur •• o. ��tt nr -'( Date: D`1 2— 2-0 ( > Phone 5(') 3(07 �,G, cs ' 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 CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: • • ; i*• • 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 contact 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(7)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 • • requirement 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 advisedlhat this affidavit may be submitted to the Department of Industrial • Accident 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 Accident. 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 bot om 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 I 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 r..' Commonwealth of Massachusetts r rm IDivision of Professional Licensure Board of Building Regulations and Standards Construction Supervisor • ConstruCfc f'Sv Unrestricted-Buildings of anyuse group which contain _ 'Supervisor tessthan 36,000cubic feet(5s1cubic meters)otenclosed CS-101454 , _ , - Espires:01113/2021 space a •t,rr,...h.m., _ • X04,0 h� „ .. tall sr 1 4^ JAMES 5ELIJNWOOID f 1 rl1 gk M I FRAZER NEAT , i/ zt".,z•^ � . 1 MARSTONS MfLIS MA 0251$, ` "`. - ' TE 1 Failure to possess a current edition of the Massachusetts ( Commissioner State Building Code's cause to revocation of this license. { For information about this license I Call(617)7274200 a visit www.mass.gov/dpl h 71/, 'Irbfm,Awow(d IT.{tla.”4NiOIt.' Mies of Cons smnmais&Business Regulation . HOME WPROVEIIENT CONTRACTOR '1 '�. TYPE:4sfl/dual ja. =K ReoGhadon ExMrutton Registration valid tor i+dividmduse arty t` '. , .. ,, 163725 07M6,2019 ' . before the expkatlon date. If found return to: JAMES EJJNWODD, ' . .., ... Office of Consumer Affairs end Business Regulation D/13111. P NORTHGRO4JBOWING AND REMODELING 10 Pair Plaze-Sults 5170 _ Boston,MA 02116 JAMES 5_Er JRAYDOD . J.CC 66 FRAZiER WAY • 2 -� / ^iif l A tSTOt13 MILLS, ALS 02548 Undersulytya7 6,......L. �A sada alL • Not valid without signature