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Home My WebLink AboutBld-20-001135 F Y Vmt:C use vl/uy / sy..,;'.' 01V-OO ff .a. 1 ` `Amount I f "`" ;"'f;d r Permit expires 180 days from issue date 1 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH -:: l ...E 1) 1 Yarmouth Building Department "" �` 1146 Route 28 J1�1 71 South Yarmouth, MA 02664 A(JU �,' - ,f,..i5T, (508) 398-2231 Ext. 1261 1 ,,,, ___ _ _ ------ CONSTRUCTION ADDRESS: 1 LA➢11I1gif7i- 1e 1) )7,i/X- `- } ASSESSOR'S INFORMATION: -- Map: Parcel: OWNER: %&&Z eger '4zpioleo .0660 J.5 Ke4_ NAME PRESENT ADDRESS TEL # Email Address: CONTRACTOR:1 -Pid/'A& 01°d ' ') ___ NAME MAILING ADDRESS TEL# Email Address: esidential Commercial Est.Cost of Construction$P dia te Home provement Contractor Lic.# /a, Construction Supervisor Lic.# �� Workman's Compensation Insurance: (check one) I am the homeowner I am the sole proprietor I hav�,rker's Compensation Insurance Insurance Company Name: Tzmi 2r75 Worker's Comp.Policy# e/19/ae—PyZO WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 4) (//)Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like *The debris will be disposed of at 1/iKei ?" 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 an for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: ✓e Date: 7i //�///Jj Date: ✓ Owners Signature(or attachment) I� `f - ` Approved By: 6t✓ Date: �/7 Buil ' (or ignee) Zoning District Historical District Yes No Flood Plain Zone: Yes No Water Resource Protection District Within 100 ft.of Wetlands: Yes No Yes No �.Ummonweaun of Massachusetts , ti- / Department oflndustrialAccidents �l= 1 Congress Street,Suite 100 _-�1= , Boston, MA 021I�201 T www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly lame (Business/Organization/Individual): _2).,7,12/O -7V// address: /9 ZAus4N, )I r L,0 .ity/State/Zip: �/ J'�r12. .fJ D x`ti� Phone #: re you an employer? Check the appropriate box: Type of project(required): ❑I em a employer with - employees(full and/or part-time).* 7. ❑New construction ❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.(No workers'comp. insurance required.] ❑I am a homeowner doing all work myself. 9• El Demolition [No workers'comp.insurance required]r ❑I am a homeowner and will be hiring contractors to conduct all work on my prop 10 [] Building addition arty. i wiIl ensure that all contactors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions ❑I em a general contractor and I have hired the sub-contractors fisted on the attached sheet ta These sub-contractors have employees and have workers'comp.insurance.; 13. Roof repairs We are corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,.11(4).and we have no employees.(No workers'comp.insurance required.] y applicant that checks box ill must also fill out the section below showing their workers'compensation policy information. rmecwners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. enactors that check this box roust attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have loyees. If the sub-convectors have employees,they mat provide their workers'comp.policy number. n an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site 'motion. srance Company Name: 7.-24U e,�j713.j icy#or Self-ins.Lic. #: ty'490/4r99,7z Expiration Date: 7//(,/2 Site Address: 7Li19 V4ii i€40 City/State/Zip: !.Y;741` 1i7 6 t ach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). lure to secure coverage as required under MGL c. 152, §25A is a criminal violation punish Able by a fine up to $1,500.00 /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 against the violator, A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance erage verification.. a hereby certify u the pains and penalties of perjury that the information provided above is true and correct. atnre Date: 0..r/f lie#: Z f� )lcial use only. Do not write in this area, to be completed by city or town officiaL 2tty or Town: Permit/License# Issuing Authority (circle one): Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Other l'ontact Person Phone#: • _ DAVID-2 OP III LAN DATE(MMOD/YYYY) • AC CERTIFICATE OF LIABILITY INSURANCE 07/16/2019 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 policy(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 50B-771-1632 gaiE"FACT SG&D Insurance Agencies,LLC ) 508-771-1632 F i Aixc,No, 540 Main Street,Suite 9 Hyannis,MA 02801 ass: - INSURERISI AFFORDING COVERAGE NAB a INSURER A:Travelers Insurance Company �723 ____ _ -- INSURER B:Norfolk&Dedham Mutual Ins. 23965 _ pR 0X f. INSURER C armout ,MA 02884 INSURER D: 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 I 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. 1 OL SUER POl ICY NUMBER POLICY EFF I POLICY EXP LIMITS TYPE OF INSURANCE rNcn wyp WNTnD Y�IMPAMMVYYY) A i COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 300,000 ; fiAADE n OCCUR �680.1461M796-79-42 03/14/2019j 03/14/2020 PREMISES iEa occurrunc $ X ; Business Owners I I MED EXP(Any one penan) $ 5,000 ~I PERSONAL E ADV INJURY $ 1,000,000 „t f rl.AGGREGATE LIMIT APP_,LIDS PER. I GENERAL AGGREGATE $ 2,000,000 X POLICY I i,Tef L.00 I PRODUCTS-CCMPIOP_AOG $ 2,000,000 , S QT�R, — t COMBINED SINGLE LIMIT B AUTOMOBILE LIAa1LRY I_ (Ea acciderrtl $ ANY AUTO /91581469A 04/19/2019 04/19/2020 BODILY INJURY(Prx person) I$ 250,000 t OWNED SCHEDULED j E BODILY INJURY(Per occident);S $�� ,-- AUTOS ONLY X AUTOS I PROPERTY DAMAGE I�� NOB-OWNED I (Peraccrdent) $ 100,000 `— AUTOS ONLY __ AUTOS ONLY j I i } 1 $ UMBRELLA UAB OCCUR EACH OCCURRENCE 4i EXCESS UAB w_ CLAIMS MADE I — AGGREGATE _ r DED_ I RETENTION$ I S A WORKERS COMPENSATION X STATUTE I ER AND EMPLOYERS'LIABILITY Y/N I6HUB-910X742-2-19 07/16/2019 07/16/2020 100,000 A FC R I TOR/PARTN R/EXECUTIVE n IN/A E.L.EACH AGGIDf NT $ pp�� hat EXCLUDED'? yes,Mory n I—'1 I E,L,DISEASE-EA EMPLOYEE $ 1 oor0_o_ If yes,describe under 11 _,-,�,i DESCRIPTION OF OPERATIONS below + E.L.DISEASE-POLICY LIMLT $ 500,000 I 1 I I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more fpau is r quired) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Barnstable THE ACCORDANCE iWITHTHE POLICY P ON DATE THEREOF OVISIONSE WILL BE DELIVERED IN 200 Main St Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) E 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD f l.o. 1unwedw,r". ••• ••�-��••� f��p fConsumer on f/rpN��+Mr��r��/(�+'.AIut�R9ti Division of Professional Licensure OffiHO f Consu CO ess Regulation Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR TYPE:Corporation Construction Supervisor 100497 03/2 CS-063537 Expires: 10/15/2019 DAVID COX,INC. K , W DAVID R COX , z PO BOX 401 DAVID R_COX SOUTH YARMOUTH MA 02664 19 LAVENDER LN W.YARMOUTH,MA 02673 Undersecretary Commissioner CL