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Home My WebLink AboutBLD-20-1067 ^Oi,Y -- Office Use Only s '- Permit# (p - '1.' . -_;Amount `e• MATT M CS � _ E O (�bj ,'Permit expires 180 days from II . ;,::...• DO) a 1� s issue date ..... RECEIVED_ EXPRESS BUILDING PERMIT APPLICATIOP _. .._.____-1 TOWN OF YARMOUTH AUG 16 LU I Yarmouth Building Department 3 1146 Route 28 ;LI!:r.:N r)F.Is RTr--,:rIT South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: ; C Ate.( R P`1 L"I Sa.- r I4 .%/.i s' r LA ASSESSOR'S INFORMATION: Map: //(a Parcel: S OWNER:JQ PTouie D p- W CAAA/J /1 / g -7 7 3 -a "v' NAME l PRESENT ADDRESSTEL. # CONTRACTOR:i R) 1 i is. Q�!7 ceAN g.r-nR y (,,Ai S ``$e✓/2h I? 68 tCl I Zoe NAME MAILING ADDRESS TEL.# gaesidential 0 Commercial Est.Cost of Construction$ 70 4c� V Home Improvement Contractor Lic.# C 0 11 Construction Supervisor Lic.# 0 Li o Li Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor have Worker's Compensation Insurance Insurance Company Name: A,,,A ju(J'tu.4 I Worker's Comp.Policy# WORK TO BE PERFORMED ikt, a G Z .0� 14s /(o xra AO. Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: `/-4 RAA.uJ'�� 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 denial or revocation of my license' se and for prosecution under M.G.L.Ch.268,Section 1. /Cp Applicant's Signature: r I Vo N— -A L I-5 Date: b i Owners Signature(or attachment) 4 l LA 14 Q - -- Date: Approved By: � . Date: %— )1‘6—i`\ Building Official(or designee) 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 ❑ Yes 0 No The Commonwealth of Massachusetts Department of Industrial Accidents _�A 1 Congress Street, Suite 100 .44 _ 4- Boston, MA 02114-2017 :..• www.mass.gov/dia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/Individuai): 1`-d�' \ A I Address: J1 CP j,/ City/State/Zip: S `A e.1, j_c 4 Phone )Zc ' Are you an employer?Check the appropriate box: Type of project(required): l 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 8. E Remodeling any capacity. [No workers'comp.insurance required.] p� , 3. I am a homeowner doing all work myself. 9. emoIition ❑ y [No workers'comp_insurance required.]' `�� 10 E Building addition 4.0 I 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.E 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.Q 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. tContractors 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: A (,/(A ,AA .%,I u AL, Policy#or Self-ins. Lic.#: Expiration Date: I f'h Job Site Address: Zed CetAX,/[?.t2{2-y 1.-A7 City/State/Zip: c L,,�4.44,(u 7T'LtAkk- 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 certi er the pal nalties of perjury that the information provided abo e is tr e and correct. Signature: Date: Z I Phone#: S 3 4 4 / Z o5 Off cial 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 Phone#: Contact Person: VU HUIwn,wcann UI maaaaunuaeua Division of Professional Licensure Board of Building Regulations and Standards Co nstrnce6r1'Supervisor • CS-044847 x Wires: 07/05/2021 TROY A WA1 S 87 CRANBERRY • SOUTH YARM UTH + � H4 Commissioner Clite C6710/01a/JoCteAtaea Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Individual TROY WALLS Registration: 105179 87 CRANBERRY LANE Expiration: 07/15/2020 SOUTH YARMOUTH,MA 02664 Update Address and Return Card. SCA 1 0 20M-05/17 !?%�c /inm4, wait of"'jlauacAase/ Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. If found return to: RegJstratiorl: Expiration Office of Consumer Affairs and Business Regulation 105179 07/15/2020 1000 Washington Street-Suite 710 TROY WALLS Boston,MA TROY A.WALLS 6.e.c,2 87 CRANBERRY LANE SOUTH YARMOUTH,MA 02664 r N vali ithout signature Undersecretary ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 05/16/2019 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. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer any rights to the certificate holder in lieu of such endorsement(s). PRODUCER MCI The Hilb Group of N.E.dba PH NE508 775-1620 FAX Dowling&O'Neil Insurance Agy �E-MAIL Eat): (Arc,No): 5087781218 P.O.Box 1990 ADDRESS: Hyannis,MA 02601 INSURERS)AFFORDING COVERAGE NAIL INSURER A:NGM Insurance Company 14788 INSURED INSURER B:Associated Employers Insurance Company 11104 Troy Walls dba Walls Construction &Remodeling INSURER c: 87 Cranberry Lane INSURER D: South Yarmouth,MA 02664-1007 INSURER E INSURER F: 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. NOTWITHSTANDING 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 HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILf18�R TYPE OF INSURANCE IN VWBDR POLICY NUMBER (Ti ')MIDDYYY (MWDDDD//Yrl POUCY Y) LIMITS A X COMMERCIAL GENERAL.LABILITY MPK1492X 09/14/2018 09/14/2019 EACHA OCCURRENCEETR $1,000,000 CLAIMS-MADE X OCCUR PEREMES�Ea o Duane) $500,000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY No X JECOT X LOC PRODUCTS-COMP/OPAGG $2,000,000 OTHER: $ A AUTOMOBILE UABIUTY M1 K1492X 09/17/2018 09/17/2019 (Ea amderDi1SINGLE LIMIT $1,000,000 ANY AUTO BODILY INJURY(Per person) $ — AUTOS ONLY X SCHEDULED BODILY INJURY(Per accident) $ AUTOS PROPERTY DAMAGE $ X AUTOS ONLY X ALO S ONLLYY (Per accident) UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION WCC50050095872018A 11/05/2018 11/05/2019 X p2TUTE OTH- ER AND EMPLOYERS'UABIUTY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? Y N/A (Mandatory In NH) E.L DISEASE-EA EMPLOYEE $500,000 If DESCRIscribe under PTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) "Workers Comp Information*" Proprietors/Partners/Executive Officers/Members Excluded:Troy A.Walls,Sole Proprietor Burke Job#055843389 Insurance coverage Is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of Insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ®1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD #S2358191M235816 RPJX1