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Home My WebLink AboutBLD-20-847 Office Use Only Permit# p' -1 aD 2b� 7 Amcntnt6201, ,A'1 �4t o* �� 't Permit mites 180 days from ' issue date EXPRESS BUILDING PERMIT APPLICATI RECEIVED TOWN OF YARMOUTH Yarmouth Building Department 14 2019 1146 Route 28 South Yarmouth MA 02664 [ AUG By: (508) 398-2231 Ext. 1261 _— CONSTRUCTION ADDRESS: ez Cg,u E„a IT y/g4A-tetpw__ ASSESSOR'S INFORMATION: Map: Parcel: OWNER: £(JA4 Ott&zz (r 0 NAME PRESENT ADDRESS TEL, # CONTRACTOR: 1). 1't I I Q.11 PlarinSke le—. I Ge-x•inslon Let.44 e r CQPha=ll X 16'(�1' NAME MAILING ADDRESS TEL.# C esidential 0 Commercial Est.Cost of Construction$ te O O ' Home Improvement Contractor Lie.# 1 5 S g(Q 3 Construction Supervisor Lie.# (-)q SC( <1'I Workman's Compensation Insurance: (e one) I am the homeowner r am the sole proprietor have Worker's Compensation Insurance c� nsttranee Company Name: �1TIYci Vele r5 Worker's Comp.'.'olioy# (p I4uf I K o(D((4;0C)O WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares /0 Replacement windows:#,5c - .dos j Replacement doors: #` () + k00• i- �1 -- Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for Iike Pool fencing *The debris will be disposed of at: TO CL/A1 of y 'tM Cj(1 _.._...__.._ Location of Facility I declare under penalties of perjury that tl•statements ei. s ntained are true t • the best of niy I owledge and belief. I understand that any false answer(s) will be just cause for denial or-revocatif my'Ii s prosecution and• .268,Section I. Applicant's Signature: I / ' ` Date: � _• "- - . I/ s /c^ Owners Signature(or attachment) l- ..,/,4 . ' Date: r� r Z./ 7 Approved By: _ it��' Date: _.....,/'c�—f Building OM ' xi-Igoe EMAIL ADDR,aka Zoning District: Historical District: 0 Yes .1 No Flood Plain Zone: -i Yes 7 No Water Resource Protection District: Within 100 it.of Wetlands: El Yes U' No Yes 2 No . The Commonwealth of Massachusetts _* /, Department of Industrial Accidents —=i =. = 1 Congress Street, Suite 100 SA�,_ Boston, MA 02114-2017 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): (QJ A � " � S C C (X-C Address: /5— K( ' .4_, /-44-1./1---- City/State/Zip: \)d\-&04° 96 dLi 1144 Phone #: j ';-(k-C I L(7 , Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 3 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.] 9. ❑Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 0 Building addition 4.0I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 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.t 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑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: -> Policy#or Self-ins.Lie.#: Expiration Date: ' Job Site Address: '---2.-'---2.- Cf�� City/State/Zip: An Old�' ' Attach a copy of the workers' compensation policy declaration page(showing the policy n ber 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 �rtify`under he ai s an�enaltie. of perjury that -e info ation provided above is/zO ( e and correct Signature: i� `i Date: / Phone#: '}`—d '{.6 f 4? C Official use only. Do not write in this area,to be completed by city or to tcial. City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2. Building Department 3.City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: *t. commonwealth of Massachusetts Division of Professional Licensure Board of Budding Regulations and Standards Constr 4,11titnilti*Fryisor "4/ CS-095981 *ones: 10/25/2020 7 4: WILLIAM F •P4Pdsl, - to: HEK 15 LEXINGTOMj.M. , YARMOUTH PORT,k0 Ols),A-A4--167 Commissioner anzi9Ao-fri-itieex Y.."6 K7 die V:y1K Office of Consumer Affairs and Business Regulation 1000 Washington Street-Suite 710 Boston, Massachusetts 02118 Home improvement Contractor Registration Type: LLC Registration: 155863 PROJECT MANAGERS LLC 05/14/2021 15 LEXINGTON LN. Expiration: YARMOUTHPORT,MA 02675 : . Update Address and Return Card. SCA 1 0 20M-05117 Kimmet41"e24(e/.,ieea-ii,aehe4e-h4 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:LLC before the expiration date. If found return to: Realstraildh- - Expiration Office of Consumer Affairs and Business Regulation tkorsiz3L,.., 05114/2021 1000 Washington Street -Suite 710 PROJECT MANAGERS LLCIAI:f.- Boston,MA 02118 tr.:5•••=. 1-sf.:73 WILLIAM PLANINSHEIV--- -' 15 LEXINGTON LNE-5.:('' ge0/1"#(4-4". (1)(-11? YARMOUTHPORT,MA 02675 Undersecretary )valid without signature * PRODUCER 16 TRAVELERS FAX 877-634-3710 Date:03-05-19 Policy No: (6*18-1 K86160-0-19) Effective Date:02-25-19 PROJECT MANAGERS CC LLC 9 SALT MARSH LANE POCASSET MA 02559 , THE TRAVELERS INi)EMNITY COMPANY OF AMERICA has been assigned as the servicing carrier for your Assigned Risk Workers Compensation Insurance policy.We welcome you as a customer. We have received your application and premium.Your policy will be issued shortly. Please note that your binder is proof of coverage with cancelled or the policy is issued. In the meantime, should you find it necessary to file a claim,request a certificate,or communicate wall us,please note the following: For a certificate of insurance: For Claims Reporting: For Policy Services: Fax a written request to: 1-800432 7839 0-4443-4404 (877)336-6036 Tif TRAVELERS INDEMNITY COMPANY OF AMERICA The Claim Reporting system is a toll-free service that is available seven days a week, twenty-four hours a day. a Usage of this system has been proven to provide significant benefits, with the immediate assignment of a Case Manager,automatic production of the First Report of Injury form,and earlier resolution of employee claims. Safety and Low Prevention are critical concerns to any business.We have long been a pioneer in the field of ac- cs cident prevention,having the experience, resources and capabilities to provide a complete range of safety ser- vices.Your policy will include more details regarding these services. .r._ Please keep this information available. Reference the above policy number on any correspondence and have it available when contacting us or submitting correspondence. gm It is our pleasure to work with you.If we can be of service,please call. Sincerely, The Travelers = cc: f JRRAY & MACDOWALD INS 550 MACARTHWR2 BLVD BOURNE MA 02532 W2OM3G1O Page 1 of 1 OD1201