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Home My WebLink AboutBld-20-0001071 „s.' '70 -Pennit# p ,.fir.ib'• H `Amount SV '` f M 3 . J NATT 0 ' .,.' ..5`Permit expires 180 days from ,. h (1l— 0 I 01( issue date EXPRESS BUILDING PERMIT APPLICIfialf 1 V E D TOWN OF YARMOUTH Yarmouth Building Department f AUG 27 2019 1146 Route 28 South Yarmouth,MA 02664 B U i ' gin_ N T (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: , L o �A , / • ASSESSOR'S INFORMATION: �/ / 'SOç.i Map: Parcel: OWNER:5d4 l Elw1c1 >S 3 W,�1gG UERC• `Sa /737/G,-NAME PRESENT ADDRESS TEL. CONTRACTOR:a2n{;Qv',N W\e,I=F L I=!2 L1s..nioc,r ,110-11O ) ei: CD S o8.-PV6.1:dr E MAILING ADDRESS 1.,r( rf r ,..,,A , TEL.# 17411.esidential 0 Commercial Est.Cost of Construction$ t!', O 00, U 0 Home Improvement Contractor Lic.# 18 9 00-7 Construction Supervisor Lie.# 0 .?3 0 Ct. Workman's Compensation Insurance: (check one) CJ I am the homeowner ❑ I am the sole proprietor tiave Worker's Compensation Insurance Insurance Company Name:Sp,g ` ,- ll-E Sib E Worker's Comp.Policy# . . pi)(F t -c or ESr D e J"is: WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# a Replacement doors: # 1 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: S`3- y.co. 6 0 kY1..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 denial or revocation of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: ;2 (�/��— Date: a J aV 1/ t Owners Signature(or attachment) ,10/44_0/, i/ e4_ Date: f Z Cy/ 1 Approved By: L. --Grp / Date: - ).� 19 Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: Ci Yes No Flood Plain Zone: r Yes L No Water Resource Protection District: Within 100 ft.of Wetlands: Yes 17 No a Yes C No The Commonwealth of Massachusetts Department of Industrial Accidents = a= 1 Congress Street,Suite 100 ?ct=4 Boston, MA 02114-2017 www.mass.gov/dia �Jyt> Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individua[): J3 �a wu er-yr.2i -1A.,r1A— Address:67 ) C � p� City/State/Zip: ri 1\ 9iZA (7 31 Phone#: 5 or ?4/6- 1 �a r Are you an employer?Check the appropriate box: Type of project(required): rErram a employer with I 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.] 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. El Demolition 10 Q 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 11.0 Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.0 I 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.* 13.0 Roof repairs 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. 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. l ` Insurance Company Name: (co tzt) °!O Policy#or Self-ins.Lic.#: cQ C,0 c9 'J 01 Expiration Date: c,2— 0f 'w CS o"7i2lrc aoiar P► �_a3 - ap Job Site Address: 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 the pains and penalties of perjury that the information provided above is true and correct. Signature: ( Date: g/ 7//t Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: PermitlLicense# 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#: ...., .,. WatliglittOw"...-=4'1 --.4•-1 44- •'•.- ".,44: .44_ 7- ,_ _ _.„.,,, , ' ::':: —4('Dj.,7,'r r:),e nee owe,orea/a ryc...71(adaez4-44e ,,, , zi Office of-Consumer Affairs&HOM IMP Business Regulation , : * E ROVEMENT CONTRACTOR --, .___TYPE:Individual ...,.. 7 , 4 .: -,Lanitwo &comma! i 4 1E4aq' 12/03/2019 II • . JOAQUIN WHEELER 411 . ;..: I ... c_y_Ce•-ci.7.--, . JOAQUIN T.H WHEELE ,7' ' - 21HEMLOCK HOLLOW-RD 1 - BREWSTER,MA 02631 Undersecretary ; . . tt, ,,:.:,..„, i.,wevoLnibrnno..nowprxeai.ifesith 9.sitiolnassachusetts ; :.7.1,...51t.:..._,,,,..._. ,i1:1p:and_Standal.ds :;q$31-rii.-af*Old:hill Regidi ae . 1 L,cerTre su - -... • .;-,,, . rvis -••-....,„,.: . , --' CS-062309 • - . ._ e.39:),res: 03/19/2020 4 -- i JOAQUIN T WHEELER,:74; 4! ; 21 HEA4LOCKttOLLOW* ,_,---.7 1 BREWSTER MAL-p_2631 --'' N.- I, Commissioner • . • ACORD DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 08/26/19 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 poiicy(les)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 rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: FIRESIDE INSURANCE AGENCY INC (A/C.No. (508)487-9044 ac.No►: (508)487-0649 #10 Shank Painter Cmn POB 760 ADDRESS: fresideinsurancethotmail.com Provincetown,MA 02657-0760 INSURER(S)AFFORDING COVERAGE NAIC N 1781345 INSURERA: SAFETY INS.CO. INSURED INSURER B: FALLS LAKE NATIONAL INS.CO. WHEELER CONSTRUCTION INSURER C: JOAQUIN T WHEELER INSURER D: 21 HEMLOCK HOLLOW RD INSURER E: BREWSTER,MA.02631 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. INSR TYPE OF INSURANCE ADOL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER (MDD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 A BMA0024879 02/01/19 02/01/20 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident $ AUTOS ONLY AUTOS ) HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER 0TH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 B OFFICER/MEMBER EXCLUDED? Y NIA WC500-0071850-2019A 02/23/19 02/23/20 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) EXCLUDED FROM COVERAGE IN WORK.COMP.POLICY:JOAQUIN WHEELER,OWNER CARPENTRY WORK AT 3 WASQUE RD. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF YARMOUTH THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN HALL ACCORDANCE WITH THE POLICY PROVISIONS. 1146 ROUTE 28 AUTHOfaZED TATIVE YARMOUTH MA. 02664 / 1. ®1988 15 ' ORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks o C• -D