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Home My WebLink AboutBld-20-000170 e• '7 ''Permit# s, O ° 50 4 C —� OE" S. $ *Amount MATT S[,� i Permit expires 180 days from f 131.NC ✓ )0 issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: I Co el Pq,w K a-A n G w;lam-} 17v, ASSESSOR'S INFORMATION: Map: Parcel: OWNER: S+e Se—ty 4.I( /7 O/d ia411. ,1 Sit. 11/e s 1-j2eM7if o 7 70 77`f'Z qy-Z s 3 i NAME PRESENT ADDRESS TEL. # CONTRACTOR: IQ 1 U (i i / dolt o Z- �j. 50./1p(,t,v,[)% / b 7)'6 3 5-0 76 S/4/0 NAME MAILING ADDRESS TEL.# esidential 0 Commercial Est.Cost of Construction$ /f /,Sv Home Improvement Contractor Lic.# I/IY6 774' Construction Supervisor Lic.# 6-5 i 6 7 l 6 Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor 1:11 I have Worker's Compensation Insurance Insurance Company Name: -TJ-A✓E L4_S Worker's Comp.Policy# &/u1 - vois '7 - 19 WORK TO BE PERFORMED 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: 7231././y1 O.f ) '✓ 4-'ii 0 i'I12r, 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: ,c,,, tti..c /2 Date: Owners Signature(or attachment) ,v Date: 7 j///L-o/f Approved By: 177Date: 7' —�Z-77 Building Offici or d ' ee) EMAIL SS: Zoning District: Historical District: ❑ Yes QI No Flood Plain Zone: Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes LI No ❑ Yes ❑ No The Commonwealth of Massachusetts Department of Industrial Accidents e/t= n 1 Congress Street, Suite 100 c'' Boston, MA 02114-2017 —��,s 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): 5-111.6./. Address: 7 5. .^dw� �vi', s:.it.�w! MA- G-s( 3 City/State/Zip: (w.ti%✓i &Z 56 3 Phone#: 7 76 c/ 4f o Are you an employer?Check the appropriate box: Type of project(required): i.e am a employer with v 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. 0 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. ❑Demolition 4.0 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. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and Maya hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance.t 13.El Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[:Other Si 06.2�} 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *My 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. lithe 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: 1ctiv'C ICirc Policy#or Self-ins.Lic.#: (p T l/9 - 47//t/'/1/j—A - /, Expiration Date: U _2 S- Z Job Site Address: j G / f ea,✓k&n " lkkv f I7✓. City/State/Zip: V Kr i V i 1 t MA 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: Phone#: S' 7 76, 5/ 47, C) 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.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ItCommonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construction Supervisor CS-107966 Expires: 10/24/2019 RICHARD DENARDO 2 S SANDWICH ROAD SANDWICH MA 02563 !I.:*-..',..'"' Commissioner C26- ,, r iAsS�� TTs ° > -= A. us. tt , ' � - �d r, ;2 k 4/y8 r . 4 v 1 ,i5 D"NARDO, 3'15. e 1r y�..� 2 M1 om 1- -4 }5�«�n�o'; ._10/24/86 ._9-Z Kv-ivno-z-mbeeebil,v ' 4- Office of Consumer Affairs and Business Regulation 10 Park P{ Suite 5170 Boston, Masiattiusetts 02116 Home Improveme i tractor Registration 7 = . Type Corporation Registration: 188680 SMARTER HOME INC. Expiration: 08/20/2019 2 S. SANDWICH RD. SANDWICH, MA 02563 C., 2oMf� Update Address and return card. 1Office of Consumer Affah&eus:ness Regulation HOME IMPRO,MENT CONTRACTOR Registration valid for individual use only Ty orporation before the expiration date. if found return to: ;a= - Expiration Office of Consumer Affairs and Business Regulation :';aP 10 Park Plaza-Suite 5170 z i 8/20/2019 Boston,MA 02116 SMARTER HOiINC = RICHARD DE 'KW 2 S.SANDWIC 6�- /77/1,-/eK, SANDWICH,MA' �6i ' Undersecretary Not valid without signature AccurO)" I LIAM MauuwITT Ti CERTIFICATE OF LIABILITY INSURANCE 07/11M9 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 pollcy(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 NAME: Deoliveira Insurance Services PHONE �I: 508-477-3023 FAX Not 508-638-6463 800 Falmouth Rd. MI : joe@dinsinc.com UNIT101-A Mashpee,MA 02649 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: SAFETY INSURED INSURER B: Smarter Home Inc. INSURER C: 2 South Sandwich Rd. INSURER D: Sandwich,MA 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. L7R TYPE OF INSURANCE SR IN$�WVD POLICY NUMBER MM/DDMYYY) (MMIDWYYYPY) UNITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE 10 RENTED CLAIMS-MADE Ei OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 10,000 — A — BMA0029131 05/24/19 05/24/20 PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY❑78-- El LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINEDISINGLE LIMIT $ 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 IJAB _ OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED 1 RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE❑ N/A E.L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L DISEASE-EA EMPLOYEE $ DESCRIIPTIO OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space le required) RESIDENTIAL SIDING AND TRIM CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN TOWN OF YARMOUTH ACCORDANCE WITH THE POLICY PROVISIONS. 1146 ROUTE 28 V SOUTH YARMOUTH,MA 02664 AUTHORIZED REPRESENTA r r c, 988-201• _,-...-,: ORPORATION. All rights reserved. APADfl.2e 11111 Rff14% Ms Arnim nomn enrl Inns ova.rniehewnel enorIre of APADfl