HomeMy WebLinkAboutBld-20-001623 •
01;.YqR ,Office Use Only
1FP)O Amount
c- `Permit expires 180 days from
..:; .. issue date
EXPRESS BUILDING PERMIT APPLICAT t
ED
TOWN OF YARMOUTH .. '
Yarmouth Building Department I
1146 Route 28 SEP 2''1 201`,' '.
South Yarmouth, MA 02664 E -1
- ;S
(508) 398-2231 Ext. 1261 l
CONSTRUCTION ADDRESS: I Pe rhrttp,r CA-re-Li
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: G.t0.-14-rd 4-641o,a,te I2i,ti3O / GkSS,..no r G✓,y 'ne. to 2 22 3 2_ .
NAME PRESENT ADDRESS / TEL. #
CONTRACTOR: (.e - i ,e,,t� ' Ma lad 2te I S _ ienn:s ,'-'4 0246 0. S�8 �-3�'v B?-
NAME MAILING ADDRESS TEL.#
residential 0 Commercial Est.Cost of Construction S e2-42,-0
Home Improvement Contractor Lic.# I ?'l3(I Construction Supervisor Lic.# (I 3 la?-
Workman's Compensation Insurance: (check one)
0 I am the homeowner 0 I am the sole proprietor �I have Worker's Compensation Insurance
Insurance Company Name: 41M /4 v iv4.4- Worker's Comp.Policy# cm,/( (.E 14 u
WORK TO BE PERFORMED
Tent -_,1 ". Duration 4' (Fire Retardant Certificate attached?) Wood Stove :�/
Siding: #of Squares L Replacement windows:# 4 Replacement doors: # dir
Roofing: #of Squares Ca ( )Remove existing*(max.2 layers) Insulation
Old KingsH wa Ste►`" a akel cingINS A
ig� y istoric Dist. ( Re} acing 11 f like Pool fencing
*The debris will be disposed of at: (fa oa`('L ) v►•
'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 revocation of my license for.prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: C)4 , Date: [ /2 c f/24,1 of
Owners Signature(or attachment) ` J Date:rA.--09
e
Approved By: Date: / ' 2 �i
Building rat i ) EMAIL AD SS:
Zoning District:
Historical District: ❑ Yes C No Flood Plain Zone: C Yes C No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No , 0 Yes 0 No
•
The Commonwealth of Massachusetts
''_- ;;—'/ Department of IndustrialAccidents
e'= 1 Congress Street,Suite 100
c i_ Boston,MA 02114-2017
www moss gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Anolicant Information Please Print Legibly
Name(Businessiorganizaation/tndividua1): A.es „1 j,,, Fi,, [,vi G L C
Address: ro (2,„ , S.
City/State/Zip: s. QQ ;, `n o,z.c� (4.6 Phone#: (5-s) 7-' 3- — yQ 8
Are you as employer?Check the appropriate box:
II Type of project(required):
1. 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. Q Remodeling
any capacity.[No workers'comp.insurance required.] 9. Demolition
3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]t
10 ❑Building addition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contactors either have workers'compensation insurance or are sole MO Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing
5.0 I am a general contra for and I have hired the sub- ors listed on the attached sheet oof repairs or additions
r
sub-contractors
have employees and have workers'comp.insurance.: 13.Q Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other
152,41(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box fit must also fill out the section below showing their workers'ton 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 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: .iEr,cam I-Ic r 4i
Policy#or Self-ins.Lic.#: &ol(3 alters* Expiration Date: 3f 12 f 2t7
Job Site Address: 1 ��.r/�,���_ L.a� City/State/Zip: 4/54,,,,,14•c ref f- 02 Co -5
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 S1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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 candy under the pains and penalties of perjury that the information provided above is true and correct
Date: 5/2 til-l.m I q
Phone#: ('côci 73% c/vg
Official use only. Do not write in this area,to be completed by city or town of fuiclal
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#:
NOTICE OF ASSIGNMENT
tSIPLOVER: COMBO LD STATUS OF EMPLOYER
LR3 BUILDING & FINE FINISHES LLC 001136966 Limited Liability Camp
17 ASHEINS DRIVE
SOUTH DENNIS, MA 02660 COVERAGE GROUP
1202759
Coverage under this assignment
The Waiver of Our Right to applies to Massachusetts
Recover from Others Endorsement operations only. For coverage
is available on Pool policies. outside of Massachusetts, contact
Contact your agent for details. the appropriate Pool or Plan for
that state.
AMGE COMPANY:
sMOUR
AGENT AAA NORTHEAST INSURANCE AGENCY INC AIM MUTUAL INS CO
Nina LaFauci
PRODUCER: 110O ROYAL LITTLE DRIVE 54 THIRD AVENUE
PROVIDENCE, RI 02904 P 0 BOX 4070
BURLINGTON, MA 01803-0970
(781) 270-8822
AGENCYIEON: 540971805
CLASSIFICATION OF OPERATION CLASS ESTIMATED RATE ESTIMATED
CODE TOTAL ANNUAL PREMIUM
REMUNERATION
CARPENTRY - RES DWELLINGS NOT EXCEEDING 3 5645 $58,600 7.10 $4,161
STORIES IN HEIGHT
CARPENTRY-RES DWELLINGS EXCEEDING 3 STORIES OR 5403 $0 7.64 $0
COMM STRUCTRS
ROOFING IOC & YARD EMP, DRIVERS 5545 $0 35.68 $0
EMPLOYERS LIABILITY 100/100/500 9845
STANDARD PREMIUM $4,161
EXPENSE CONSTANT 0900 $338
TERRORISM CHARGE 9740 $18
TOTAL POLICY MINIMUM PREMIUM $500
•
TOTAL ESTIMATED PREMIUM $4,517
DIA ASSESS. 3.83% $159
TOTAL EST. PREMIUM PLUS ASSESSMENT $4,676
MULLIN/ITEMS& Annual PIM IUM: $4,676
THIS IS NOT A BILL
CQINMS
Coverage effective 12:01 AM on 03/12/19.
Add endorsement WC 00 03 10 to this policy. A sole proprietor, partner(s), or member(s)
of an LLC has elected to be covered as an employee.
DATE OF NOTICE: 03/13/19 PREPARED BY: Paulette Hoffman
EXT 514
* * VO3+UNTARY DIRECT ABED * *
a
•
The Workers'Compensation Rating and loon Bureau of Massachusetts
101 Arch Street•Boston,MA 02110
(617)43O✓9060- FAX(617)4394055•www.wcrthnia.org
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wea
Comns'n
:,
j Division of Professit nal Lcensure
'LRegulations stud Standards ,
Board of Bu tiling
Cons f i rvisor
-. s: 02/2 2 322
C-1' 3102
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