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Home My WebLink AboutBld-19-006801 .yket. lJmce US Jiuy . 0 Permit# C 1 —H m L Amount �L./ 1 � • ,� r � "`"�"^'�c a `i+Permit expires 180 days from issue date 8 C✓—1 q / 0Qti ... EXPRESS BUILDING PERMIT APPLICATIll E C E _ ID _, TOWN OF YARMOUTH ig Yarmouth Building Department JuI`i ' 3 ?' - r 1146 Route 28 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: L ��.th,t? ill. , sire) YAv2-.?7l%, /Y'10 , -. ASSESSOR'S INFORMATION: Map: Parcel: OWNER: (/ir...z)Li,j) l iftzei/ S,r, ,75--' NAME PRESENT ADDRESS TEL. # Email Address: CONTRACTOR �i%��J? fil9._� ,.�� r �J`�,^�2f�''(%>1�f7� •i - C1' �� '�' V NAME MAILING ADDRESS TEL# Email Ad�"s's�' ( esidential Commercial Est.Cost of Construction$ 6/��J‘0 a` Home Improvement Contractor Lic.# /a:Pj''119 Construction Supervisor Lic.# O6,-?...$-, -2- Workman's Compensation Insurance: (check one) I am the homeowner I am the sole proprietor I have Wo k f5ss Compensation Insurance Insurance Company Name: 7/2A )Zc'r4 Worker's Comp.Policy# Ae?"/0)4 7y2 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 6, Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation 6 Old Kings Highway/Historic Dist. (V)Replacing like for like *The debris will be disposed of at: f /9�,}02Ci1,.97A/ 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 revoc 'on of mya license and for rosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: ( �./ ,/'/, 1 Date: .5 24.5 /t e Owners Signature(or attachment) ( . Date: Approved By: ' / Date: 6L� Building Official(or designee) Zoning District Historical District Yes No Flood Plain Zone: Yes No Water Resource Protection District Within 100 ft.of Wetlands: Yes No Yes No - The Commonwealth of Massachusetts 1=. t Department of Industrial Accidents = 1:= 1 Congress Street,Suite 100 . _'•till,=_ 8 • Boston,MA 02114-2017 • ,.,s` • www.mass gov/dice aw Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. . • TO BE FILED WITH THE PERMITTING AUTHORITY. • Applicant Information Please Print Legibly Name{Business/Organization/lndlvidual):_ ,,,/ite7/././/4b acyx �a., ...- . Address: JC}t✓A71/OJye,e5-72 ,Z79 - City/State/Zip: G/ YJA /%i O2 f/ Phone#:(5-- p'-992 -J 2.F Are you an employer?Cheek the appropriate box: • 'Type of project('required): 1 I am a employer with ".. employees(full and/or part-time).' 7. 0 New construction 20 tam d Sole proprietor of partnership and have no employees working forme in 8. ®Remodeling any capacity.(No workers'comp.insurance required.]. 3.Q I am a homeowner doing all work myself.(No workers'comp.insurance required.,t g• Demolition 10 0 Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that ail contractors either have workers'compensation insurance or are sole MO Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and 1 have hired the sub-contractors listed on the attached sheet 13.�Roof repairs These sub-contractor have employees and have workers'comp.insurance.: • • 6,12 We arc a corporation and its officers have exercised their right of exemption per MOL e. 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 anew affidavit indicating such. tContrectors that check this box must attached en additional sheet showing tile 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 fob site information: Insurance Company Name: 7 ,t7P/522577, • ' Policy#or Self-ins.Lic.#: r2,?f#‘562 y2 2. Expiration Date: 7////9 •Job Site Address: ' .c[a/tL e/3 .. �C//J City/State/Zip: 1//,�,////`,y, '. /iC� . 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 a 152,§25A is a criminal violation punishable.bya 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: ,�� '—� 4 Date: ��/Z�� ' ` Phone it: t.Y 1P 942 5-2 p Official use only. Do not*'rlie in this area,to be completed by city or town offciaL 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#: . V\lIIIIIaV 1,YV Cia,V,v,.,•a,..s+a••.,,.•.r•.aa.s r%/,..Yrr.,u»nrhn..r,///i ri:--'141.J•ndemr//1 Division of Professional Licensure offi nsumorAffairs&BusNTRA°gut°ttoo Board of Building Regulations and Standards , HOME IMPROVEMENT CONTRACTOR Construction Supervisor TYPE:Corporation 100497 03/2 CS-063537 Expires: 10115/2019 a r ,.T DAVID COX,INC. .r DAVID R COX -, PO BOX 401 - 7 OAVID R.COX 6 SOUTH YARMOUTH MA 02664 - - 19 LAVENDER LN W.YARMOUTH,MA 02673 Undersecretary Commissioner .• kl.c R CERTIFICATE OF LIABILITYi DATE(AeM/DO YYYY) • ..--" INSURANCE 07/12:2018 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 INSUREA(S)) AUTHORIZED REPRESENT AMIE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(lee)must 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 Mary Connor SULLIVAN GARRITY& DONNELLY INSURANCE AGENCY INC ,FYn �508)453-2586 fez Wit, AI�$: kathleen.geddiSCSSOina.com 10 INSTITUTE RD INSURER'S)AFFORDING COVERAGE - WC r WORCESTER _ _ MA 01609 INSURER A; TRAVELERS INDEMNITY CO OF AMERICA 2586E INSURED INSURER a: DAVID COX INC INSURER C; INSURER 0; PO BOX 401 INSURER E: S YARMOUTH MA 02664 Iruaan r COVERAGES CERTIFICATE NUMBER: 290863 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 LNrgR --~�" 1Assa lilts pbudV E �LICY EX I - r'�`- - TYPE OP INSURANCE jNsn I wve POLICY NUSISSR, rNntwawvvin tMr,un UNITS 'COMMERCIAL GENERAL LIABILITY f EACH OCCtJRRENGl3 �$ ----.I i DAMAGE I O RtiT£D 'i 1I CLAIMS-MADE f OCCUR I PAPAW(Eli 000 T,r, j,,,.,L? MED EXP(Any one person) 1$ !----.'_ __ N/A PERSONAL S ADV INJURY .$ 'L AGGREGATE LIMIT APPLIES PER ! GENERAL AGGREGATE - i HPOLICY E ICY F.--]LOC ? PRODUCTS.COMP/OP AGO $ OTHER: ` i AUTOMOBILE LIAINUTT ,fEMB 61N4L�1Mn t$ socklinn ANY AUTO ' BODILY INJURY(Per person) $ I�'—.ALL OWNED SCHEDULED N/A I l BODILY INJURY(Per accident! $ AUTOS AUTOS NON-OWNED 1 PROPERTY 6AMAo€ $ _�,i HIRED AUTOS yj AUTOS Per widen.) I } I S LMaREt.LALIAR '�OCCUR EACH OCCURRENCE I$ r'EXCESS UAa I CLAIMS-MADE N/A j AGGREGATE _ I$ r i DED i RETENTIQN I i g p 1 I ~ WORKERS COMPENSATION Y! I X; 8'fATUTE I I ER* AND EMPLCYERB'UABIUTY A IoCPPFIICERWE REXCLU01107 auTlvr wA WA , WA 6HUB910X742218 07/16/2018 07/16/2019 I E L'EACH ACCIDENT is 100,000 ,I(IMyyennnda bMil RN) ; i E.L DISEASE-EA EMPLOYE S 100,000 DESCRIPTfON OF OPERATIONS below F E.L.DISEASE•POLICY LIMIT 1$ 500,000 1 1 f N/A DESCRIPTION OP OPERATIONS/LOCATIONS/VEHICLB8 (ACORO 101,Additional Remarks Belleau*may be attached I more space Is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization Is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts, This cetiiftcate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue tine of this certificate of Insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.ma$s,gov/Iwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street AUTHORIZED REPRESENTATIVE MA 02601 L`'�.../l l.ti ^f HyannisDaniel M.C y,CPCU,Vice President-Residual Market-WORIBMA (01988.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD