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Home My WebLink AboutBld-20-002033 •Y9R ' 4' 6 j Permit# r i S yO ', H i Amount t"A wwrr� ,, cseJ) ' ftIetat.o's .'' j Permit expires 180 days from =+ ' issue date I3(at)—..2D--ao33 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146Route28 Oil 1 i 201 South Yarmouth, MA 02664 / (508) 398-2231 Ext. 1261 cAC�4 �7 CONSTRUCTION ADDRESS: // /5ra,cj 571- ASSESSOR'S INFORMATION: Map://_ Parrccel:: / / / OWNER: 4 �-t��f'�� // !?rl,,r�'^1 %� l r l 7 �� 7e , N / PRESENT ADDRESS TEL. # CONTRACTOR: G 7 �//l�► /7 ✓r' r,4 c S� ,S �,jl �.J NAM /� NIAILINGADDRESS TEL.# ❑Residential ❑Commercial Est.Cost of Construction$ 3 OD D Home Improvement Contractor Lic.# / /5-7, 4.7G Construction Supervisor Lic.# CS— DG /4--C,_.S—Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I,am_the sole proprietor 'ave Worker's Compensation Insurance PA Insurance Company Name: 1' ► ,1`"Gr�A-trl-}- '3 Worker's Comp.Policy# (dlX'U o 3 IP 1111 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares _ Replacement windows:# 3 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: ,,GyV�,/ �5��*-v c�7:�i��' /' 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 n of cense and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: 7 Date: / .;�r Owners Signature(or attachment) 22_4' 7} / Date: / �/, 0 Approved By: , Date: $ I I — 5 Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes E. No Water Resource Protection District: Within 100 ft.of Wetlands: Yes 0 No ❑ Yes 2' No '� The Commonwealth of Massachusetts Mai= Department of Industrial Accidents _�fel- 1 Congress Street, Suite 100 _ _a4_ Boston, MA 02114-2017 •-, ,,;�5 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): r-/-„).w. % �� iP i6'- Address: /,7 ..)---9 , �_ 4/>/�,�I .e9(- , v/ e.. / 3 City/State/Zip: s..074 - iyy p-2s Phone #: ; —0J`_ --"r-...S 0 Are you an employer?Check the appropriate box: Type of project(required): 1,I am a employer with employees(full and/or part-time).* 7. ❑ New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. E 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.]` 4.❑I am a homeowner and will be hiring contractors to conduct all work on mYP property.e 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 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp. insurance.t R1Ia are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 52,§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.Insurance Company Name: Me_X G-tn`1-3 V LA I _. n Policy#or Self-ins. Lic. #: G kO3 I I-1 t I Expiration Date: Job Site Address: 1 �Jt(Ct - )( 8- V--8 City/State/Zip: 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 der the ns and penalties of perjury that the information provided above is true and correct. !/ Signature:`;r e- Date: �'-s' Phone#: t 5-‘C.�fdd 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#: Office of Consumer Affairs& Business Regulation- Mass.Gov Page 1 of 2 Commonwealth of Massachusetts (. J Division of Professional Licensure •1 Board of Building Regulations and Standards Const`utti Sri%tuwvisor ii Mass.gov CS-061665 ,pires: 07/01/202' t r, WILLIAM E FARRI c •, r 17 JAN SEBASTIAN '- !,i E 13 SANDWICH 4 02663 t ' i :A 'rr'' 11 Commissioner Office of Consumer Affairs and Business Regulation (oCABR) HIC Registration Complaints Registration # 115356 Registrant FARRINGTON BUILDING & REMODELING, INC. Name WILLIAM FARRINGTON Address 33 BOARDLEY RD. City, State Zip SANDWICH, MA 02563 Expiration Date 06/08/2020 Complaints Details No complaints found for this registrant. You can also view arbitration and Guaranty Fund history. Back To Search Site Policies Contact Us https://services.oca.state.ma.us/hic/licdetails.aspx?txtSearchLN=115356 8/10/2018 :Hub International New England To:Farrington 09:53 10/11/19 ET Pg 2-2 �CORO® CERTIFICATE OF LIABILITY INSURANCE DATE(MMNDIYYYY) 10/11/2019 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 TIE 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(ies)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 NAME: Kathleen Tausevic h HUB INTERNATIONAL NEW ENGLAND LLC ( No.Extl: (781)792-3298 FAX No): ADDRESS: kathleen.tausevich@hubinternational.com 600 LONGWATER DRIVE INSURER(S)AFFORDING COVERAGE NAIC# NORWELL MA 02061 INSURER A: AIM MUTUAL INS CO 33758 INSURED INSURER B: FARRINGTON BUILDING&REMODELING INC INSURER C: INSURER D: 17 JAN SEBASTIAN DRIVE SUITE 13 INSURER E: SANDWICH MA 02563 INSURER F: COVERAGES CERTIFICATE NUMBER: 459905 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 TYPE OF INSURANCE IINN S yD° VD POLICY NUMBER nsdv POLICY EFF POLICY EXP LIMBS (MM/DD/YYYY) uo/YYYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL BADVINJURY $ GENL AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ POLICY JEC LOC PRODUCTS-COMP/OPAGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) UMBRELLA UM OCCUR EACH OCCURRENCE $ _ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY X STATUTE ER"- ANYPROPRIETORIPARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 500,000 A OFFICER/NEMBEREXCLUDED? N/A N/A NIA AWC40070322682019A 03/14/2019 03/14/2020 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached N more apace 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 certificate 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 date 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.mass.gov/Iwd/workers-compensation/investigations/. CERTFICATE 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 6A AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 Daniel M.Cr y,CPCU,Vice President—Residual Market—WCRIBMA 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD ®:Hub International New England To:Farrington (15083980836) 09:48 10/11/19 GMT-05 Pg 3-3 FARRBUI-01 MWOLF ACORO" CERTIFICATE OF LIABILITY INSURANCE DATE 10/11IDDiYYYY) 0H 1/2019 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 temis and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer lights to the certificate holder in lieu of such endorsement(s). PRODUCER License#1780862 cab ►CT HUB 600 International r Drive Fi1ss w England PHONE (A/C,No,Ent):(781)792-3200 FAX ) Norwell,MA 02061-9146 (A1C No):(781 792-3400 : INSURERS)AFFORDING COVERAGE NAEC/ INSURER A:Main Street America Assurance Company 29939 INSURED INSURER B: Farrington Building Sr INSURER C Remodeling,Inc. 18 Dewey Ave. INSURER D: Sandwich,MA 02653 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD YyyD POLICY NUMBER JMMIDD/YYYY) (MIYIDDIYYYYI LIMITS A X COMMERCIAL GENERAL LIABIUTY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR MPT4217R 3/13/2019 3/13/2020 DAMAGE TO RENTED 500,000 X PREMISES(Ea occurtence) $ MED EXP(Any one person) $ 10,000 PERSONAL SADVINJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PODGY JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE UAB�iTY COMBINED SINGLE OMIT [Ea accident) $ —ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED _AUTOS�RE� ONLY AUTOS yy Ep BODILY INJURY(Per accident) $ AUTOS ONLY AUTO ONLY (PerracRcrdent)AMAGE $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS(JAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ AAN D EMPLOYERS'COMPENSATION YIN PER EERH ANYQ� �PR��OPREIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFRCER En BER EXCLUDED? N I A (Y dat 1 Ili) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY UNIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (A CORD 101,Additional Remarks Schedule,may be attached If more apace 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 Yarmouth ofo a ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE z9,9 ACORD 25(2016/03) O 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD