bld-19-006729 ,
.y Office Use Only
PI tte
* 0 Permit# ,
0 `,4, . H Amount 5
s.t., cam. Permit expires 180 days from
sue date
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28 t ,",V _ .; tt
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: /S / +.1.uTUGKQT A.5-
ASSESSOR'S INFORMATION:
/�
Map: O 3 3 Parcel: 1zg.
OWNER: GiZ.SLa/4 i f fr.M..,.cw /S NAvTucr.or . .e yt yLvodN .A4. 417 -.MB-card
NAME ( � PRESENT ADDRESS ' TEL. #
CONTRACTOR:A,t�,,, jtk./, -( ii /la*i r s ill.. L.1-�►rnelirrf 44. O.2S3t Saes-VS--SUS
NAME MAILING ADDRESS TEL.#
ISCResidential 0 Commercial Est.Cost of Construction$ /(7 .e
Home Improvement Contractor Lic.# /43 8.6 Construction Supervisor Lic.# G$S.3
Workman's Compensation Insurance: (check one)
I am the homeowner lc.I am the sole proprietor I have Worker's Compensation Insurance
Insurance Company Name: — Worker's Comp.Policy# -----
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares A l_ V Replacement windows:# Replacement doors: #
Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
'The debris will be disposed of at: iheir.lyAt / i�.�ouTe.I- hio-h.# ( r s�.+Te .
Location of aciiity
I declare under penalties of perjury that the s ements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s)
will be just cause for denial or revocation y license rosecution under M.G.L.Ch.268,Section I.
Applicant's Signature: Date: gr.r/1$/1
)(
Owners Signaturr,(ar attachment) Date:
‘?
Approved By: Date: J 'p,r1 /q
Building Official(or designee) EMAIL ADDRESS:
Zoning District:
Historical District: _ Yes No Flood Plain Zone: Yes No
Water Resource Protection District: Within 100 ft.of Wetlands:
Yes No Yes No
05/29/2019 14:20 15085398165 DJGCO PAGE 01
.�+41ti Office %ly
\ Permit/
ABM
Parch woks 189 drys Bee
• bane due
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Deportment
1146 Route 28
South Yarmouth,MA 02664
(508)398-2231 Ext. 1261
CONSTRUCTION AM OS: / /V4 kiTtazaa aT
ASSESSOR'S 1NPORMATtON:
Mop: Q$, Parcel: 426
OWNER: tnatn.piL,f Ark>e�.r�,.. Ar 88•�_ ,✓ tt. 417- M-card
CONTRACTOR: �.
N r1. ;m1 r o ...
ICResittentlel 0 ConnesW Eat.Coat of Ooaaauetioo S 1/4A00
Hems Improvement Contractor Lk.M MMUS Coastrrctioa Supervisor Lie N, .O31;10
Workman's Compe tssdan brauestoe: (Chants one)
ci i am the homeowner St I am the sofa peplos 0 I Awe Worker's Compensation insu ante
plwtenoe COMM Nano: Worker's Comp.Palley. ..-�—
WORK TQ E PERFORMED
Test Duration (Fee RNtardwtt( rtlllcate Nescafe) Wood 8tovt
Siding: M of Squares ,,1 0 Replace tent windows:S Replacement doors: el
Roofing: II of Squares ( )Rimtove uidettng'(aim 2 layers) Iosaladoq
OW Mop I Igllway1Hlstorle Dist ( )Replacing like lbr like Pool ehada'
•nts esbrle will be disposed stet: _ as atkallott••••earrit- r ,. _r4r�,.
LemI deohne mks penalties otpat f eq that the . kai euadd se
ooe trod wl sonect to the ea[of orr tnowio4ee and tithe( I .J. d eel any Mee easem(a)
will be Met muse be denial er .. Iloon MAL Ch.Mt,&Won I.
Ieaaoere t� �a•I!7 Dear: irk /f
Oera0fal�aetal'a(or eaaakalaa� .1 /..j / �� 0010:, � , fit
Air
Dec
Baado f min(or on** ADOttas8:
E•nirW Dtatrie:
Historical Dia rkt Q Yea 0 No Mood Ploin Zone: 0 Yes G No
• Water Rasotras Pros:dian District; Within 100 0.of Wcttattds:
C Yes C No l7 Yes 0 No
The Commonwealth of Massachusetts
Department of Industrial Accidents
%11= 1 Congress Street,Suite 100
t WIDE
1 I-`= 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 1411.A..y
Please Print Legibly
Name (Business/Organization/Individual): A4 j Address: /2 ,4ertepr�l
City/State/Zip: t<. F;a...-knt,.re ( ,..r4, 02534 Phone#: S49 -qgS -8365
Are you an employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with employees(full and/or part-time).* 7. ❑New construction
2.ETI am a sole proprietor or partnership and have no employees working for me in
8. 0 Remodeling
any capacity.[No workers'comp.insurance required.]
3. I am a homeowner doingall work myself. t 9. ❑Demolition
❑ y [No workers'comp.insurance required.]
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. 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
•
These sub-contractors have employees and have workers'comp.insurance.t 13.❑Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El 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.
3Contractors 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: �r
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: /.S /U4••.,TUCt AVE. City/State/Zip: $ y4/1•.od7.74, rL4
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 and penalties of perjury that the information provided above is true and correct.
Si ature: Date: J/24//f
Phone#: SOR-4BS-B3GS
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#:
PERRAA2 OP ID:JL
Ak C-C,RCP CERTIFICATE OF LIABILITY INSURANCE 04/25IDD/YYYYI
4/25/2019
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(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
Paul Peters Insurance Agency PHONE Aaron Perry FAX
680 Falmouth Rd. ( lC No.Eati:508-985-8365 (A/C,Not
Mashpee,MA 02649- ADDRESS:
John J.Lynch,IV —
INSURER(S)AFFORDING COVERAGE NAIC/
INSURER A:SURPLUS SERVICES
INSURED Aaron Perry INSURER 8:
12 Meredith Dr
East Falmouth,MA 02536 INSURER C:
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
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 ADDL SUER POLICY EFF POLICY EXP
1NSR WVD POLICY NUMBER (MM/DDIYYYY) (MM/DD/YYYYI LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
A X COMMERCIAL GENERAL LIABILITY NN977612 10/28/2018 10/28/2019 pREM SES EsENTED ocarrence) $ 100,000
CLAIMS-MADE X OCCUR MED EXP(My one person) $ 5,000
PERSONAL&AOV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000
TO POLICY F Firei LOC $
AUTOMOBILE LIABILITY (Et�EDiSINGLE LIMIT $
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS
ROPERTY
HIRED AUTOS AUTOS NON-OWNED (PER ACCIDENT)DAMAGE
UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $
EXCESS UAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ $
WORKERS COMPENSATION WC STATU- 0TH-
AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? NIA
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $
H yes,describe under
DESCRIPTION OF OPERATIONS.below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it more space Is required)
Re: 15 Nantucket Ave, South Yarmouth MA
CERTIFICATE HOLDER CANCELLATION
0000001
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Gregory Atkinson THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
9 rY ACCORDANCE WITH THE POLICY PROVISIONS.
15 Nantucket Ave South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE9.41- e--
John J. Lynch,IV 9464®1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
T' E Individual
t _
Expiration
-D8/28/2019
AARON PERR.5ik:w _
AARON PERRY si r, 1
45 BRAEBURIN
E. FALMOUTH`lh1A '
Undersecretary
Commonwealth of Massachusetts
® Division of Professional Licensure
Board of Building Regulations and Standards
Constrvahni tOpervisor
CS-085300 4 ires: 08/06/2020
•
AARON J PERRY *
12 MEREDITI4OR
EAST FALMOUT.F,MA. 36
Commissioner
L..