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Home My WebLink AboutBld-20-001454 .O�.y�R Office Use Only e O q Permit# C z - p Amount `C` w.,T.cM cs �1,4°+w.+��9 c6'd Permit expires 180 days from W....Z(.7'(q CAL A issue date EXPRESS BUILDING PERMIT APPLICATION __. TOWN OF YARMOUTH i 7 E i1 5 ..a Yarmouth Building Department 1146 Route 28 , 3Ef 1 ; 2019 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 'r;`- ,r pi,�-i , 7, CONSTRUCTION ADDRESS: 61 I 0(eon f ue so(.c t-A )r n`Oc.,_ h ASSESSOR'S INFORMATION: Map: Parcel: OWNER ..;. n Max Z, 11, 911 Orecv, l(i e- AME ) PRESENT ADDRESS TEL. # n CONTRACTOR: NAME Oh n '- 'O CI, o ec J ,.,v ADD 6/6t v /-di Lief,' `-i y'G�TBL.# 7 7 y ". 7P - Sio s) Residential 0 Commercial Est.Cost of Construction$ MOB O o d Home Improvement Contractor Lic.#/9e2$ .98 Construction Supervisor Lic.# (c — O 7 1// f Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor '$I have Worker's Compensation Insurance Insurance Company Name: 1)p t✓it'nicsi J-On,'/ Worker's Comp.Policy# 1,,/C6(-TO v 56 /P.V9 9aO/So 4 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares /q ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at J- Location of Facility I declare under penalties of perjury that the statements herein cont " 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 an for p cution under M.G.L.Ch.268,Sec' 1. Applicant's Signature: I ., (..,) Date: q-/3 - / q t Owners Signature(,/ttachment) Date: q'/3-/p Approved By: �(ir Date: Ck —"/ '15 Building O cial(or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No _ . The Commonwealth of Massachusetts rk -► - t1 Department of Industrial Accidents .1 1 Congress Street, Suite 100 • 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 PIease Print Legibly Name (Business/Organization/Individual): W -d.3 n e.0 14-0 f in C J_--m re/ve—hero - 'I Address: I-I yo, 1.,,/cu Lit/ City/State/Zip: Lenn._�ror-4- ('M- o.06 3 4/ Phone #: 7 7y a 7,9 - 3/v,y Are you an employer?Check the appropriate box: Type of project(required): LE❑I am a employer with employees(full and/or part-time).* 7. E New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required. 8• ❑ Remodeling 3.0 I am a homeowner doing all work myself ] 9. ❑ Demolition y [No workers'comp.insurance required.]t 4.❑I am a homeowner and will be hiring contractors to conduct all work on mYproperty. I will 10 ❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 6.Tfam 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.�'Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E' 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 ararhed 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 ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 30i.! / /Ar ci- On.'e Policy#or Self-ins.Lic. ,4: (A/Li 5066 cc) l Lap le 6 Expiration Date: Job Site Address: q L, C1 et, at,._ City/State/Zip: ,S6,(.4.A I/ia ttfaji, /4/1# pgc4y 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: oj4a-�- � � Date: q'/.�-// Phone#: 771y- 27� _/G�' 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#: Commonwealth of Massachusetts �P Division of Professional Lit ensure Board of Building Regulations and Standards Construction Supervisor CS-071114 Expires:08/20/2019 RICHARD W GURNEY ,% 19 REDWOOGLANE EXT ' HYANNIS MA 02601 Commissioner CAL Construction Supervisor ti . Unrestricted-Buildings of any use group whic*contaia less than 36,000 cubic feet(991 cubic meters)of enclosed space. . Failrre to possess a current edition of the Massachusetts State Budding Code is cause for revocation of this license. For infornwtion about this license Call 017)727-3200 or visit www mass.govtdpl .j Y%//l'iininf,W4' .,/✓/�i�Jiii-Rile//• . Office of,artsnr;sr Affairs 4 Piatness Regutr ttan tiO;a i`PYi•iO' AE t;INTRACTOti Registration valid for individual use only • - •i VPd� c,.., before the expiration date. If found return to: • t Office of Consumer Affairs and Business Regulation Reoistr i 4. 1'UPlailIM 182828, =,._0J/28/2019-, Boston,MA 02116 10 Park Plaza-Suite 5170 _ . . JOHNATHh"`,*MINER JOH A I elf-N WP.ON!f 7C`3 HYOik WAY Lit: � DEfNNISPC;r.: ,.}A,02639 .- f - ;•. - : *Undeltecrelary Not valid ut signature Client#:763053 2WAGNERHO ACORD CERTIFICATE OF O1AR!!!TV IMQ110 A!!r•c I DATE(MMIDD/YYYY) THIS CERTIFICATE IS ISo::_=:L...-____.._____ . CERTIFICATE DOES NOT AFr:. _ __._._._. ..:.:_.: 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(les)must be endorsed.If SUBROGATION IS WAIVED,subject to 4"..Mr..-'J---JW-......et'L---u-.. --M'..^-•Mi.u.-.-..«...d.w-..-_J-^.--.-wi A ..t ww ibis-w.tifie.te does not confer rights to the t(s). nCr i.......an .A V..a..i... auuce A a 9Y alo,Ext►;508 775-1620 wc,No 5087781218 973 lyannough Road Ems P.O.Box 1990 INSURER'S)AFFORDING COVERAGE NAIL I Hyannis,MA 02601 „o„� 14788 SOURER A: ""."r'^.`-`. 1 - - INSURED Nam!--- 1 John VY:.---_ INSURER:.. 3 Hydaway Lane Dennisport,MA 02639 INSURER D INSURER E: INSURER F: I: ---_-":`!UMBER: _ . _.. ?OLICY PERIOD 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 pRpED�UyCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INSRA gR SUER POLICY NUI ER (MWDWYYY 1(IM�D YYY)I LIMITS A GENERALLIABILRY MPT998C'. 02l1""- .- --- •-- _ .._---- 1 e4........ed._ r X COMMERCIALGE"'r^•LL..' PRf- CLAIMS-MADE n^".. " I MED EAr i..., I ,--- PERSONAL S ADV INJURY 81,000,000 GENERAL AGGREGATE $2,000,000 GENL AGGREGATE UMIT APPUES PER: PRODUCTS-COMP/OP AGG $2,000,000 f—1 $ ^^�ICY I I tea__... X LOC ( :_.. - SINGLE UMIT $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS (Per accident) $ UMBRELLL L^ occ:ui. EACI I^ r..- EXCESS 1 I I I CLAi -6 .. . w� .. AGGKL ..� f :_ I.ia $ DED RETENTION$ $ B WORICERS COMPENSATION WCC50050188942018A 05/21/2018 05/21/2019 X T1oRVTUMrrs ER H- AND EMPLOYERS'LIABILITY ^" owIETORIPARTNER/EXECUTNE Y/N ^ E.L EACH ACCIDENT s500,000 ( _ 3__ EXCLUDED? y N/A -'NH) -I- __ ___1rLOYEE $500,000 3f - , '90,000 DESORPTION Or L _. :.__ Insur_-:: :---::--- .. .. . - NoL.. o coverage provided by the policy provisions. i......w.......................i,.•ir•A...e a..au..4..�.w.. _...ism..»s wi.....iww.. :M...,is,...8.-ntions and endorsements. -ON SHOULD ANY BE CAELLED Jesse Downing THE EXPIRATIONF E DATE D THEREOF,AVEE NO ILCEIES WILL BE�DELIVEREDORE IN 619 Main Street ACCORDANCE frr" T•.. •.•.• ...................... Harwic!:,!'a. "^-._ )1988-2010 ACORD CORPORATION.All rights reserved. A"..lan•.e ewnAnerir,) A -r 2 = Ani.en-^._:: .---_ -'_i_-sd marks of ACORD .._-_. _._..__;:7583 NS2 Meghan Wagner From: Meghan Brown <meggles 019 10b@yahoo.com> Sent: Friday, September 13, 2 :39 AM To: Meghan Wagner 4 y%^ M k .Y .xi t - .�. FP lit,k X » . a ux a .� , ., '- ;--, ',:::,7.14,4„,;4;,1,,,ktAttc x 1