The URL can be used to link to this page

Home My WebLink Aboutbld-20-002504 1 Office 12se()ob. df 45' ., • ; .r:t. Penne- ,017/...::, SD,..— i . •,'"1,4, Amount "krA,1•1A:rTAS I, C VE/::"1,,e -:r4 Permit expires 180 days from [ ;,(.1 -7-1) —2>S0q issuc date EXPRESS BUILDING PERMIT APPLICAT ON TOWN OF YARMOUTH RECEIVED Yarmouth Building Department ! 1146 Route 28 1 OCT 30 2019 South Yafiliouth. MA 02664 L (508) 398-2231 Ext 1261 By CONSTRUCTION ADDRESS; °3 0 9 R.T ( A \fit t i1/4./toci ft,‘ i\A PC ASSESSORS INFORMATION: Map: Parcel: OWNER: D 6 not(..\ct F0 I -to A..) .3 0 ct r+ 604 "Viev.A -1-? 1-11 7 — 2 z-`—a — 7°' 7 NAME PRESENT ADDRESS TEL # CONTRACTOR: T054‘41 114554* PO, goe 12-1 Vlironiroti— NAME MAILING ADDRESS SS 41 itl Residential 0 Commercial Est Cost of Construction$ il ago C) qn L....."" Home improvement Contractor Lie.# 13 (9...)7J Construction Supervisor Lie.sit C ""'"'//3 5'57-- Workman's Compensation Insurance: (check one) - I am the homeowner y I am the sole proprietor -- I have Worker's Compensation Insurance Insurance Company Name: DMA,40 t Dual Worker's Comp.Policy* W4'5'00 500"i5 E-2015 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 1 Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( 116 Replacing like for like Pool fencing *The debris will lie disposed of at. '1/4/A-li•-", o 14 ON. tor S Ro 3 Pk-1 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 sin:swats) will be just cause for denial or revocation of " prosecution under M.G.L.Ch.268.Section 1. Applicants Signature Date: /0/3/4 CI Owners Signature(or a ehaiart) 0\ittA,or Draw Approved By A9 - Date /0—i/'—/I'' Budding 'upir)".". EMAIL S Zoning District Historical District Yes No Flood Plain Zone: Yes No Water Resource Protection District Within 100 ft.of Wetlands: Yes No Yes No The Commonwealth of Massachusetts Department of Industrial Accidents IRI= a 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Annlicant Information '� 'L Please Print Legibly Name(Business/organization/individual): J o S 4jv c, !�is 55J Address: 'P. 0 , /30) 12`o n City/State/Zip: l ti r W7 on►S12c(4-A t4' Phone#: (54)0 3 (9 U --01 to z Are you an employer?Check the appropriate box: Type of project(required): 1 kl 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. D Remodeling any capacity.(No workers'comp.insurance required.] 3.❑I am a homeowner doing all work myself.[No workers'comp_insurance required.]t 9. ❑Demolition 4. I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contactors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other I>�§I(4),and we have no employees.(No workers'comp.insurance required.] *Any applicant that checks box#1 must also fiil 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 contactors 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 thrills providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: pcW/ Vt 0(1 Pc ' ��yy —0��YZOtei�- 14Izv Policy#or Self-ins.Lic.#: ��.�J�V� Expiration Date: Job Site Address: 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 under the pains and 'es of perjury that the information provided above is true and correct Signature: Date: /D 1?///l Phone#: Sb - �<o G—O f (to Z_ 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: • Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other Iegal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials PIease be sure that the affidavit is complete and printed legibly. The Department has provided a spar,-at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 • Boston, MA 02 1 1 4-20 1 7 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia ",'i aa4apun ZL9a0 b1N`labdSlNNVAH 23l XO8 t d . ,,.2-2-\ 119SS d9'8 Vf1HSc-1(' -• I 113SSV9 '9 t•fHSCf OZOZ/4Z/LO 55E9Et uoiWeJldx3 Uol}e.;slbaa Ienpinlpul adA1 I HO. 3Vtl1No31N3493AO*Id W1 3L lO1-1 uoiteln5e8 ssaulsnB 1g safety Jawnsuo3 to at l?i;} sl/JrmfJBPrv1 f �7frra rruazuura aaf� Commwlth sacs `it Division on of ea ProfessionalofMas Licensurehusett Board of Building Regulations and Standards Constr4$t Srl%Upervisor CS-113552 ti 1 Quires: 05/25/2023 JOSHUA B BOSS- 11, 1 :1 PO BOX 128 ' = " W HYANNISP' Mp<j•,j,f!}' i ()/ti1:11)1 \ Commissioner Client#:36429 2BASSETTJO ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE DOMO """Y) 3/04/2019 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 POUCIES 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 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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER glarCT The Hilb Group of N.E.dba Mw.EA;r� Fa775-1620 5087781218 Dowling&O'Neti Insurance Agy P ' ' .P.O. NO)' ADDRESS: Box 1990 Nsurierks)AFFORDING COVERAGE Niue II Hyannis,MA 02601 MnsuRs%a:NGM insurance Company 14788 NSA sawRER B:Associated Employers Insurance Company 11104 Jushua-B.-Bast INSURER : P.O.Box 128 c West Hyannisport,MA 02672 RMURER D MSURER 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 AU.THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAIDCLAIMS. ADOLSUBW LTR TYPE OF INSURANCE MR END POUCY NUMBER f11MiD�D11f Y)�IwYDD/Y LINTS A X COMMERCIAL GENE LIABILITY MPJ2966M 03N=1/2019 03111►2020 EACH OCCURRENCEU� S 1,000,000 CLAIMS-MADE X OCCUR PAWN ocwnenoa) $500,000 MEDEXP(Any one pawn) S10,000 PERSONAL NM ADV INJURY S 1,000,000 GENT.AGGREGATE UMMT APPLIES PER: GENERAL AGGREGATE S 2,000,000 POLICY X JG-CTT I X LOC PRODUCTS-COI PIOPAGG S2,000,000 OTHER: - S AUTOMOBILEUABm IL COMBINED rr S ANY AUTO — — BODILY INJURY(Per person) S OWNED A ONLY _ SCHEDULED BODILY INJURY(Per a:ddeM) S PROPERTY AUTAmos — OS ONLY EYLY (Per )DAMAGE S S --USIBREUJ4uAri !xY YR EACH OCCURRBCE S EXCESS UM CLAMI&MADE AGGREGATE $ DED I RETENTIONS S B WORKERS COMPENSATIONWCC50050078582019A A1l04f2019 01 R °TH- AND EMPLOYERS'LIABILITY " ' ' X STATUTE ANY PROPRIETORIPARTNER/EXECUTNE YN EL EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.T.DISEASE-EA EMPLOYEE'S'�,000 DESCRIPTIONlci"OF OPERATIONS below EL DISEASE-POLICY MST1$500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be*Hashed N more space is required) Certificate holder is named additional Insured for general liability when required by written contract. Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained In the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POUCY PROVISIONS. ,.AUTHORIZED REPRESENTATIVE 01988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD #5231447/61231436 RPJX1 �I; ro p o 5 .Y Page# of pages\ 1 -3'o3hLic & St't ti, lfyunn fro(4--.A4 4, 0110, PROPOSAL SUBMITTED TO: JOB NAME JOB# pon ha Fti14'0 vl ADDRESS JOB LOCATION 3o9 ri- tiA )arnE I DATE DATE OF PLANS Yq(mO4� �'A• ARCHITECT PHONE# FAX# \ N1)--27y--2o-72 .:a hereby submit specifications and estimates for: --..._..-_......._.._--.... ..-. ..-..._-_........ _.._.._...._._......_.. — Jf V A- e + - - _ PA r L` r e 14,4 Ced l' s id,- a 1/ - __CleCiil_-. / e propose hereby to furnish material and labor-comple in accordance� ith the above specifications for the sumc� of: \ I4 ao sA 4,-,ii �.4.,y✓c i/ Dollars with payments to be made as follow er o x vU Ld SJc,r I00 e n j-4' n►S L Any alteration or deviation from above specifications involving extra costs Respectfully AZ,), ?1(' will be executed only upon written order,and will become an extra charge submitted over and above the estimate. All agreements contingent upon strikes, \accidents,or delays beyond our control. Note—this proposal may be withdrawn by us if not accepted within days. ° tcceptance of Jropotar The above prices,specifications and conditions are satisfactory and are / /.40,4 hereby accepted. You are authorized to do the work as specified. Signature Payments will be made as outlined above. /� "' eeiziziL Date of Acceptance Signature I /4- A-NC3819/T-3850 09-11