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Home My WebLink AboutBLD-19-1348 '• �, i Office Use Only . .'of q 'pi.• gyp. • iPermit* hi ' t; ! C , O R` kl a Amount •_� -c ' ` Permit expires 180 days from = _i, issue date 3cb-lq --Do(34 ? EXPRESS BUILDING PERMIT APPLICA -I! TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 SEP 05 2018 South Yarmouth, MA 02664 (508)398-2231 Ext. 1261 ctUILDING DEPARTMENT tlY' CONSTRUCTION ADDRESS: 3 3 SA C)) 14 171 ASSESSOR'S INFORMATION: Map: Parcel: OWNER L/SA !/A Le C 6/7. 7/0- 577,5! NAME PRESENT ADDRESS TEL. # CONTRACTOR: 'remit frfay.mit 77st 0 2.g Kas,-nnen > S'/- 95?— &/2 5 NAME MAILING ADDRESS sem.., 9tr c c TEL.# $'Residential 0 Commercial Est Cost of Construction$ 706,5 -- sr .II aa, Home Improvement Contractor Lic.# �✓��%rI." Cf�I Construction Supervisor Lic.# �-7 Workman's Compensation Insurance: (check one) • J 83`/ O SO7 / 0 I am the homeowner 0 I am the sole proprietor VI have Worker's Compensation Insurance /� r 9g86a Insurance Company Name: , lIF L > 6c, E/ Worker's Comp.Policy# /�1/ / WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares ,Q` t/ (x)Remove existing'(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing •The debris will be disposed of at _p(1a7 7 Tie ill LEif Ilib'lnnterr p/SfOCAL ) Location of Facility I declare under penalties of perjury that the statements herein coats. . 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 revory j se and for...secution under M.G.L.Ch.268,Section 1. Applicant's Signature: - / Date: _CVP L— Owners Signatu. (or attaehme, ) Date: Approved By: yle Date: t r'/Ol BuddingOffici• (or. cue- 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 of Massachusetts e � / Department oflndustrialAccidents AI 1 Congress Street, Suite 100 ? _ 1= Boston, MA 02114-2017 • ikt " ;, 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): pc-rot f14'e3 n74.4-7-7"c, Address: Zai 60.4-12.4c1 2/> City/State/Zip: 5.41-x,4wc,/ /274 Phone#: SOF-Cfl- j'pes o 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 2.0 I am a sole proprietor or partnership and have no employees working for me in $. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall work 9. ❑Demolition ❑ myself[No workers'comp.insurance required.]t 4.0 I am a homeowner and will be hiring contactors to conduct all work on my property. I will 10 ❑ Building addition ensure that all contactors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5;211-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.,®'Koof repairs 6.0 We area corporation and its officers have exercised their right of exemption per MGL c. 14.0 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 workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: //Q(zee;EG Policy#or Self-ins.Lic.#: /7/P7— egg 6(/ Expiration Date: 0543 7 Job Site Address:33 -59CH&xi if j/J /4.014 are/ 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 under a pain and pen, 'ds of perjury that the information provided above is true and correct Signature: Date: — C1 Phone#: 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, eirpress 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, §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." Applicant 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. # 617-7274900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia • .) I ACO CP . CERTIFICATE OF LIABILITY INSURANCE DA o )tainar YY" 18 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. 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). PRODUCER `w°n"M'r JIM HINDMAN Schlegel&Schlegel Ins Broker l E port 508-7714381 I FAX 508-771-0663 34 Main Streetra a Noy West Yarmouth.MA 02673 lemm S: eoh(egel rMurellaxeg eiLCOm INSURERS)AFFORDING COVERAGE NAIL I INSURER A: NGM INSURANCE COMPANY 14788 INSURED INSURER B: AIM MUTUAL Adllson Segolinl INSURER c: DBA SEGOLINI CONSTRUCTION INSURER 0: 117 Minton Lane W Barnstable,MA 02888-1818 INSURER E: INSURER F t 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. NOTWTTHSTANDING 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 HERON IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDrTIONS OF SUCH POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS R POUCY ME OF INSURANCE ltl� (N WM POLICY NUMBER DIYW rouCYEIP LTR " 1 DI YYTYI limns X COMMERCIAL GENERAL LUBIUT/ EACH OCCURRENCE S 1,000,000 IDAMAGE TO REN a ED CLAIMS-MADE X OCCUR PREMISES(Ea ocaJnerMe) S 600,000 MED ERP(Any ens Panni) S 10,000 A MPT8486U 05/07/18 05/07/19 PERSONAL It ADV INJURY a 1,000,000 ''--GEENLAGGRE YE LaETAPIPIES PER GENERAL AGGREGATE I 2,000,000 POLICY LiJC LTJ LOC PRODUCTS-COMP/OP AGO 1 2,000,000 OTHERS AUTOMOBILE LIABILITY ft MBBNEb)INGLE UMIT $ ANYAUTO BODILY INJURY(Per mewl) S CANED —SCHEDULED BOOBY INJURY(Par accident) $ _AUTOS ONLY AUTOS HIRED NOMONNED PROPERTY DAMAGE a AUTOS ONLY _ AUTOS ONLY (PBT acc anD a UMBRELLA LJAS - OCCUR EACH OCCURRENCE S —UCESS LAB CLAMS-MADE AGGREGATE I DED I I RETENTIONS S WORKERS COMPENSATION PER IN' AND EMPLOYERS'LIABILITY STATUTE I I EH B OFFICANY ERMREMBE EXCLUDED? CUTIVE YN❑ NIA AWC-400-7026025-2015 05123/18 05/23/18 EL EACH ACC IDEHT $ 100,000 (Mandatory in NM) EL DISEASE-EA EMPLOYEE S 10,000 • O ESCRI M 0OPERATIONS below EL DISEASE-POLICY LIMIT $ 600,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Sokwdot.,may be attached Moron apse Is mune) ADILSON SEGOLINI HAS ELECTED TO BE COVERED UNDER HIS CURRENT WORKERS COMPENSATION POLICY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN SEGOLINKOFIOTMAIL.IX)M, ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORED RE'-•',,: 5 I ® ... 2016 ACORD CORPORATION.All rights reserved ACORD 25(2018/03) The ACORD name and logo em registered mart • ACORD • - 1P7 ebnCIM • • --‘60/ii\a`O e- S1- . i eCir Ir`-kfrib . ) reth (ore t‘antm - hcot (occt1 _ x-_33 sicrivo room , West YariMOIS MAR4 — qn - C-016/ 7/. - .rtyr • A • Commonwealth of Massachusetts • • ®; Division of Professional Licensure :S, Board of Building Regulations and Standards ConstrUCtt dpe f;'yp or fres: 04/12/2020 CS-025077 • PETER CMEOMARTINO4 'T = "{ • 29 BOARDLEYJ D - (Y- SANDWICH MA.02563 .% �'•� ti(�KcI_h�J x. Commissioner C ormanweal/A olb lfaaadaJeld Mee of ConsumerAlfairs B Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Peoistration= Fxolratlon 115831 ., ':-04/192020 PETER MEOMARTINO f L .`- • PETER C.MEOMARTINO �2,LA� 29 BOARDLEY RD .. U '� SANDWICH,MA 02563 Undersecretary