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Home My WebLink AboutBLD-19-2909 Office Use Only I . Permit# f 'oZ. J i y Amount urD _ c-(7..' Permit expires 180 days from - issue date EXPRESS BUILDING PERMIT APPLICATI e} p"lc1-f:41 I lt TOWN OF YARMOUTH RECEIVED Yarmouth Building Department • 1146 Route 28 NOV 13 2018 South Yarmouth, MA 02664 _ . (508) 398-2231 Ext. 1261 Bun' . - _ sr, CONSTRUCTION ADDRESS: /' er f f q P. C)rt U e ASSESSOR'S INFORMATION: ` , • Map: y�Parcel:r / Xi- OWNER: �-�Vf, GO late H Ncn fat.Ge Dr We ifkmd✓I y NAAME //�� PRESENT'ADDRESS (/�� Vitt', TEL.L,#tT� r� ��/ CONTRACTOR: l�f.QW ?vt �,6A1 a t-CC MAILING ADDRESS/[ A Si YQI-, \ P' ` 6 C L 7 residential rYY 0 Commercial Est.Cost of Construction$ /�(�7/ Jae Home Improvement Contractor Lie.# /36erclo Construction Supervisor Lie.# �— 0?6� a Workman's Compensation Insurance: (check one) 0 I am the homeowner/'+ 0 I am the sole proprietor (I have Worker's Compensation Insurance aQQ ? C �jy Insurance Company Name: (c4M MO,s.L c^t f Worker's Comp.Policy# M/M-R 1 ^1°( / / WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # oofin: .#of Squares 'r ( Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dis1t.�( )Replacing like for like Pool fencing 'The debris will be disposed of at y ar 'C( / Location of Facility I declare under penalties of perjury that 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 deni cation of tic e d for prosecution under MG.L.Ch.268,Section 1. Applicant's Signature: h..-“,--/ Date: 4407707- Owners Signature(or chment) '" t . / . - - Date: /l (a(( r p� .s l// Approved By: P+s, 1) j ,..�� Date: // - A'7.-•'/i.-.wilding Of£ci or de ignee) 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 j ►�^—�a_49 Department oflndustrialAccidents Congress Street, ite _' f 1 Boston, IA 02114-2017 0 %1?'" www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. • TO BE FILED WITH TUE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): ST ecJ 1 1il (ck v Co /,i_c Address: o 4t /a'-17 G Igve City/State/Zip: d bv1 p U—f"c M 1 �oZ�` hone #: SO r Qvo 3 RZ(7 Are you an employer? heck the appropriate box: Type of project(required): 1.0 I am a employer with t' employees(full and/or part-time).* 7. ❑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. I am a homeowner doing all work myself. t 9. ❑ Demolition ❑ ys [No workers'comp.insurance required.] 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. 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.adl 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. 14.0 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. 1-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: tr-,yt',O-t s /� '7 C Policy#or Self-ins.Lic.#: ale lEQ P,P0(6- ?) Expiration Datee: c.?// - — —,,,♦,CQ Job Site Address: /y l', ,9,P cOA oc City/State/Zip:KM- ' aPPICA'° '2 Attach a copy of the workers' compen ation policy declaration page(showing the policy number a.d 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 hereb • $ 0-r th pains a • aerial/es of perjury that the information provided above is ue and correct Sionatur: /7 t_ Date: lc? Phone#: r i- yolo ?V? 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): I. 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 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 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 contacting 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 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 I-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia . _ ri ,..._-------------------_- 1 -(92e%frnmoietnetrid ofoilauceda,fretts Office of Consumer Affairs&Business Regulation 1 HOME IMPROVEMENT CONTRACTOR TYPE:Individual i 699ltrilitigl;1 g 9312.AM 136840-,-Efy.s.-i 09/03/2020 DAVID GREW ,- T:rtiii= ,.:: 7 - lnu,;- i'[..-';.;,::-,--•,,:e ; DAVID A.GREW i-. -—_:-,, • aLCCQ/1---\ 438 WEIR RD r YARMOUTH,MA 02675- . Undersecretary ii r , , . —_----_----__-- 0, Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-076458 Construction Supervisor DAVID A GREW 1 438 WEIR ROAD YARMOUTHPORT MA 02675 -cf Expiration: Commissioner 0610112019 • A`E? CERTIFICATE OF LIABILITY INSURANCE DATE,�2)16 THS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER TI-IS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER TIE 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 poliey(l es)must be endorsed. If SUBROGATION IS WAIVED,subject to the terns 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 NAME: Gammons Adams Insurance PHONE FM( (508) 587-5362 385 West Center Street *a�PHI- (508) 587-5640 e.co West Bridgewater, MA 02379 ADDREss: cadams@gammonsinVERAGE e.com INSURER{S)AFFORDIMO COVERAGE NAICi IraIURERA:State Auto Insurance Co "SUMO INSURERa: Grew Building Company, LLC II URE1c:Arcadia Insurance Company 20 Atlantic Ave INSURELD: Yarmouthport, MA 02675-2525 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDNG ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CEPTFICATE MAY BE ISSUED OR MAY PERTAN,THE INSURANCE AFFORDED BY TIE POLICIES DESCRIBED HEREN IS SUBJECT TO ALL THE TERMS, EXCLUSONS AND CONDITIONS OF SUCH POUCIES LISTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAMS LTR TYPE OF INSURANCEADDLLIISUER POLICY EFF PWCY DO' UMTS INSRI Wm POU PCY MUMBEt IMWEOYYYY) (NPAND/YYYY) A GENERAL LIABIL'Y B082687872 8/13/17 8/13/18 EACH OCCURRENCE $ 1.000.000 DM/AGE COERCIAL GENERAL LIABILITY PRFMISESFaE NTED MMNEoccnencel $ 300.000 CLAIMS-MADE 1-1OCCUR1EDOPOM/ore paam) $ 5.000 PERSONnLSADV INJURY f 1.000.000 GENERAL AG GREGATE S 2.000.000 GEM AGGREGATE LMT APPLIES PER PRODUCTS-COW/OP AGO $ 2.000,000 n POLICY n,Eo- n LOC $ AUTOMOBILE LIABILITY COF,EINED SINGLE LIMIT (Ea accident) , S ANY AUTO BODILY INJURY(Per person) $ A.LOWIED SCHED(AED BODILY INJURY(Pr accident) I HIRED AUTOS _ NOAWNED AU (Per accident)DAMAGE f . f URSIELLA LIMBOCCUR EACH OCCURRENCE $ ECERS LAS I CUIMS-IMDE AGGREGATE S DED RETENTION$ $ C WORKERS COMPENSATION MA ARP301677 3/22/18 3/22/19 WC STATU-i EAR.4 OFR AND EMPLOYERS'LIABILRY ANY PIR.EIIOREXQ.LURIE?ECUTNE Y'� NIA E.L.EACH ACO CE NI $ 100.000 OFFICE RMEUZI RExQUDEDT _J FlyarenN,,abry In NH) E1.DISEASE-EAE.PLOYEE S 100,000 DESCRIPTIONCFOPE RATIONS below E.L.DISEASE-POLICY L MIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHCLES(Mach ACORD 101,AEOMIorr/Remarks Schedule,If mare spa YnaarW) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TIE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED N Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. Yarmouth, BDL AUTHORED REPRESENTATIVE Linda May @ 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The AC CRD Tame and logo are registered marks of ACORD Phone: Fax: E-Mail: tholland@creativeformltd.com