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Home My WebLink AboutBLD-19-1383 .yqR =.,mmc.,,uy ^r 3 LPerron ��/'� -i + :� C .-AmoaW ` 0 j * Qt i J nwrr Permit ..,w,��,.�� • � issoe da`- 180 days from 1 EXPRESS BUILDING PERMIT APPLICATION�� l 3 TOWN OF YARMOUTH - Yarmouth Building Department RECEIVED 1146 Route 28 South Yarmouth,MA 02664 - SEP 05 2018 (508) 398-2231 Ext. 1261 ntr CONSTRUCTION ADDRESS: 23 .Pl7/i3�7'/O0 t'n ,. ..:261 it ASSESSOR'S INFORMATION: Map: Parcel: OWNER: /S'.p/oe ,e>/.ejY 25 A er/-15l,zZ)A NAME /J PRESENT ADDRESS TEL. ft Email Address: CONTRACTOR: . 22J-',e2 ( 2)( //D Tai Sa/eg. sal-f 17`tSiig NAME MAILING ADDRESS TEL # ' Email Address: Resi a al Commercial Est.Cost of Construction$ 76/000d° Home Improvement Contractor Lie.# /4,4149 Construction Supervisor Lir..# Off,Si..5 3 Workman's Compensation Insurance: (check one) / I am the homeowner I am the sole proprietor I hM Workds Compensation Insurance Insurance Company Name: '?1J,.012/ 2M:,..5 Worker's Comp.Policy#_l/R 9/4Y.7922- WORK 792ZWORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares S3 - (L/Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like *The debris will be disposed of at YP.e."]!;///9715/ Location of Facility I declare under penalties of perjury that the statements herein contained are tine and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or of my license annddd f proseendon under M.G.L.Ch.268,Section 1. Applicant's Signature: .0 /.�.(L/��A�„�S / Date: 9�1��1c/ Owners Signature(or arta ern) Date: 9A,11 le Approved Br -- Date: ` -- /rC- Build' Official(or des* ee) • Zoning District Historical District Yes No Flood Plain Zone: Yes No Water Resource Protection District Within 100 ft.of Wetlands: Yes No Yes No • lIr: (L).\. The Commonwealth of Massachusetts sc•^= s�_, ,.1= DepartmentoflndustrialAccidents `eel= ?c,_ 1 Congress Street, Suite 100 _ _ Boston, MA 02114-2017 ,,,,—,.F www.mass.gov/dia mass.gov/alta \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant In`ormation , Please Print Legibly Name (Business/Orgalization/[ncividual): ,_fWjii0 rem___Z jtc Address: ifilfilineea a_ '44' City/State/Zip: Lt/Y.o/2- /2/4/ Phone#: 647-,yam-5279 Are you an employer?Check the appropriate box: Type of project(required): , I. ii amt employer with ? employees(full and/orart-rime .• P ) 7. 0 New constriction 2.0 i cm a sole proprietor or parmerthip and have no employees working for me in 3, Remodeling any capacity.[No workers'comp.insurance required,] ].G]t am a homeowner doing all work myself.No workers'comp,insurance required.]t 9. 0 Demolition '4.❑I am a homeowner and will be hiring contactors to conduct all work en my property. I will 10 El 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 5.01 em 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.: 6.0We are a corporation and is officers have exercised their nen 14.❑Other rpo ght of exemption per MGL c. 152,01(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checia hex k1 must also fall out the seetion below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work end then hire outride contactors 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 enddes have employees. If the subcontractors have employees,they must provide their workers'comp.policy number. 1 am an employer that it providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 7":1,494Z1tl;C Policy#or Self-ins:Lic.#: /A fir/�X3299t Expiration Date: jII,,/G.9 Job Site Address: 2,? .P,77,cyrizYoL) City/State/Zip: ..�/�,l//Z. /l e lj 2667 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 da hereby certify under the pains and penalties of perjury that the information providedabove is true and correct. Signature: 4.44tjC". / Date: 9//� Phone#: cf '7-9dt -SJR Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. Cityrrown Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: • 614.' a nronv eal/E(lb!(mw./.eta Mike of Consume.iuMW:a Duf hen Regulation HOME IMPROVEMENT CONTRACTOR • Registration valid to Individual use only PE Caoccation beton the expiration date- 'found return to: Re ath Fl Meta Office of Consumer Affairs and Business Regulation 100447 - 03/242020 10 Park Plaza-Butte 5170 DAVID COX,INC. - Boston,MA 02116 • DAVID R.COX 612-Car- 19 LAVENDEFI LN W.YARMOUTH.MA 02673UndotaeCfetaty , Not valid without si nature Consnonwnfih of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards • • ConstruCtt6li l$dpgrvisor CS-063537 a Ely ires: 10/15/2019 DAVID R COIF t 1 PO BOX 401 % I R � CERTIFICATE OF LIABILITY INSURANCE I °"'E'""°""'"' 07/10/2017 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 SY THE POLICIES SELOW. 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 hoidr I.an ADDITIONAL INSURED,the polley(a[)must be endorsed. If SUBROGATION IS WNVED,subject to the Mon[and vondltlons of the policy,attain paOdes may require an endorsement A stalemerd on this certificate don not easier rights to the oelt leele holder In lieu of such endorerant(s). FRoouaq "`,:`R Ks Seen Coddle NORTHWOOD ESHBAUGH INSURANCE AGENCY INC Mut me)771-1632 Fes--•- '"""- -ri4aLba 610 MAIN ST lo: KaOUan.Gedllle�egdNs._ .___________ _ .Sone NSI AFFORDrCCOMASE__- IUICe HYANNIS _ MA 02601 �rsuwpt s: TRAVELERS INDEMNITY CO OF AMERICA - 256.6 -- eYUIle • M'J Pr _ -- -- DAVIDCOXINC ErrRranc: ---- -- ---- -• PO BOX 401 NEMER o: . Swami/Tx MA 02664 ram F;_ I- COVERAGES CERTIFICATE NUMBER: 171517 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF NSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD CERTIFNOTWITHSTANDING REQUIREMENT, ICATE MAYMAY PERTAIN,THETIINSURANCE AFFORDED The POLICIES DESCRIBED HEREIN IS SUBJECTPTO ALL THE TERMS. EXCLUSIONS AND CONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLANS. LAr Trus 011rrerlRAllet ASDLaun- atm .___...____,._. - -___ ►m Ann FOXY NUMBER IYYOOAyryl �---•_- -WITS COleaiaCIA&.GENERAL wont: - ^•-1 EACH OCCURRENCE _._ N/A PERSONAL EARN INJURY $ GEAGGREGATE ppUMoIT.ARR.IES PER: GENERAL AGGREGATE --..-- --•- R'77N7.POLICY L• T ❑LOC rl0aets•MWCOWa►ACM s _._.,._ _ OTHER $ AUTOYO1aa LMSIUTS CONNEDIVNOLE UWT e - _, ANY AUTO BOWLS INJURY-IPA:Anon) [---.. .J_.- ALL OWNED —'° EOM= .- tyros _ Ar r WA 'ONLY INJURYMeesNe.n A -.--._ _._ �_HAND AUTOS Auto O ureRWAa s ...] OCCUR EACHOOWIRRENCB _ .�... SIMS UM cwreawDE N/A __ DEC IVETENTION$_ pp _------'t ..._.__.._. WORKIRSCONOMISATION Abe rMtO waIu1S �. - l� - 'x1 FT/H,TUTE I at.�_ AN IBTOMA TNIASP t[CUTM EL.EACH ACCIDENT [_100;000'-_.�-- A conw[RaxcLweDv NA GAA 6HU8810X742217 07/16/2017 07!1812018 - - - ---_. yyrrr,,� is.o EL.DISEASE•EA EMPLOYEE $ too,o00 _ PFBCNP710.1 er OPEMTION$Sc.. E.L.DISEASE•POLICY LIMIT S 500,000 _ N/A OrscIr1IOM Of OFMATCN5 I LOCATION,I YOCU$IAMB IEE.Arrow!Rweb SWPw4 my MMM/RNr a ewe SwpeM) Wotan'Combination benefits will be paid to Masseehunene employees only.Pursuant to Endorsement WC 20 0308 8,no authorization is given to pay deinns kr benefits to employees N alates Other than Massachusetts If the Insured NIM,or has hired those employees outside at Massachuistrs. This as ecate of Neurones shows the poky In torts on the dots that this certificate was issued(unless the expiration date on the above poky precedes the Issue dale of this certificate at Insurance). The stent at this coverage can be moneorsd deify by accessing the Proof of Coverage-Coverage Verification Seerdr tool at war.mate.pevf*tlMrortara-ampneesoMnvgetn onst CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION OATS THEREOF, NOTICE WILL BE DELIVERED IN Town of BarnstableACCORDANCE WITH THE POLICY PROVISIONS. 200 MSN M AMCOR=,ORcMNTATNe Hyannis MA 02601 N.''. • f..,. �. Daniel M.Camay.wly,CPCU,Vice President-Residual Market-WCRIBMA C'1888.2814 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD L