Loading...
HomeMy WebLinkAboutBld-20-001784 _ a ' O A t ce use only o . _Amount "z : Gosi Permit expires 180 days from A 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: tf', j1,f 6p I9/)/)(' ,"? 541 )4 Q ASSESSOR'S INFORMATION: Map: Parcel: OWNER: J4 ; Z.0Lv6GG NAME PRESENT ADDRESS TEL. # CONTRACTOR: . /?l17k? /dQ 9a✓ )/4e NAME MAILING ADDRESS TEL.# Residential ❑Commercial Est.Cost of Construction$ /41 tt 10 Home Improvement Contractor Lic.# /i 9-?^ Construction Supervisor Lic.# e96 3� Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor `l? I have Worker's Compensation Insurance Insurance Company Name: 7',,AU21j,j ' Worker's Comp.Policy# &891/e,"\-1qZ z. 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 viimaiveaor7`7 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 rev 'on of my license and fog.rosecution under M.G.L.Ch.268,Section 1. 11 1 Applicant's Signature: d / �11 Date: ✓t / 27 /Y Owners Signature(or attachment) o / Date: Approved By: // Date: to Building Official(or designee) EMAIL ADDRESS: Zoning District: a r Historical District: 0 Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No4647 Water Resource Protection District: Within 100 ft.of Wetlands: ;1 C) )111 Q 0 Yes 0 No 0 Yes 0 No g' The Commonwealth of Massachusetts r 41 Department of Industrial Accidents 1 Congress Street, Suite 100 It j, 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): 3+1/1i/<j Address: /1 LAP S L,v City/State/Zip: 4 . y,O12 v. 2,Z93 Phone #: c —g&2 ;s2 Are you an employer?Check the appropriate box: Type of project(required): I1'I am a employer with employees(full and/or part-time).* 7. ❑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. I am a homeowner doing all work myself 9. ❑ Demolition ❑ _ y [No workers'comp.insurance required.]t 10 Building addition 4.❑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.❑ Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 6.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 1-,.DRoof repairs These sub-contractors have employees and have workers'comp.insurance.= 6.❑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. +Contractors 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. Tnsurance Company Name: 7/2.A1/1r2.(5)2,S Policy#or Self-ins. Lic.#: b'6'9/0,e /2 2, Expiration Date: 7fl/ f Job Site Address: Z °.7. �/ ,G? /1%G.?-5./ City/State/Zip: 5 ye 4 6 7' 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 un r the pains a penalties of perjury that the information provided above is true and correct. Si nature: _ � Date: /Ø/i Phone#: 6'6 9G t J Official use only. Do not write in this area, to be completed by city or town off ciaL 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#: c%/„•`4w,rumnrrrnvr//l,:'.c'/l.rri.r.✓irrrr//d Division of Professional Licensure Office of Consumer Maks&BusinessReyulatiae HOME IMPROVEMENT CONTRACTOR Board of Building Regulations and Standards TYPE,Corporation Construction Supervisor 100497 03/2412020 CS-063537 Expires: 10/15/2019 DAVID COX,INC: DAVID R COX PO BOX 401i -- DAVID R.COX SOUTH YARMOUTH MA 02664 .; 19 LAVENDER IN W.YARMOUTH,MA 02673 Undersecretary Commissioner l DAVID-2 Op[DI LAN ACC) CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) ,,.. 07/1 6 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 pollcy(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 rights to the certificate holder in lieu of such endorsement(s). PRODUCER 508-771-1632 CNACT SG&D Insurance Agencies,LLC PHONE No,Ert):508-771-1632 I FAX,No): 540 Main Street,Sulte 9 Hyannis,MA 02601 fiMass: INSURER(S)AFFORDING COVERAGE NAIC ill INSURER A:Travelers Insurance Company 723 _ (�Q INSURER B,Norfolk&Dedham Mutual Ins. 23965 tN.Tili. Sl{d GOX I 1C ..Box M INSURER C arIT10Ut , A 02664 1 INSURER D: INSURER E: INSURER F: COVJRAG S 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: ADM SUER POLLCY NUMBER 1 POLICY EFF POLICY EXP 1 raldtproorrrimLIMITS J TR i TYPE OF INSURANCE ydsD W VD A COMMERCIAL.GENERAL LIABILITY ` EACH OCCURRENCE I $_ 1,000,000 1 CLAIMS-MADE 7 OCCUR 630-1481 M79B-19-42 03/14/2019 03/14/2020 DAMAGE OE R ENuErrDe xel ,; 300,000 X `Business Owners y MED EXP(Inv one verson) i$ 5,000 ---I __—i 1 PERSONAL&AOV INJURY $ 1,000,000 I L GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE +$ 2,000,000 �X 1I POLICY�7—1 P r LOC PRODUCTS-COMPIOP AGO $ 2,000,000 II �J J OT,Eft $ { COMBINED SINGLE LIMIT B I AUTOMOBILE LIABILITY i IEa axider,tl $ '_ANY AUDIO 91561469A 04/19/2019 04/19/2020 BODILY INJURY(Per person) $ 250,000 OWNED x SCHEDULED i 500,000 AU��T��OEp ONLY _ AUTOSN N p I BODILY INJURY(Per accdenp _ AUTOS ONLY ._ AUTOS O Y PPROPEacr,RTYRAMAGE I$ 100,000 1T 1 I } UMBRELLA UAt3 — OCCUR I EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE j I AGGREGATE $ j DEpD� RETENTION$ I . I-s A I AND EMPLOYERS'COMPENSATION I X STATUTF I I ER Y!N 16HUB-910X742-2-19 07/16/2019 07/16/2020� 100,000 f�p7,14R MingR EXCLUDED/ECVTIVE '— N/A " I E.L.EACH ACCIDENT $ _ I(I ces. ct in NH) i E L DISEASE•EA EMPLOYEE $ 100,000 II yyes.describe under 500,000 DESCRIPTION OF OPERATIONS below j E.L DISEASE.POLICY LIMIT $ 1 1 l i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE_HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main St Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD