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Bld-20-000534 cif,YgRrd Office Use Only ' ! • Permit 0 ll'.. H lAmount ` MATTACM ESE W>yg1E0h9 :.� _ c� `il l e aS� C h t r ki @ l i Ve >Coin iCS) Permit ex1. pires 180 days from /� l issue date B LI)-2D--53 4 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH "armouth Building Department 1146 Route 28 South Yarmouth, MA 02664 '/ (508) 398-2231 Ext. 1261 C ' °? ISM CONSTRUCTION ADDRESS: (0 R6M. ASSESSOR'S INFORMATION: Map: Parcel: OWNER: S( in 0 11 e. Sc Rai eel San, e sbn-- `)-2 I -(t9'1S NAI'V )) I PRESENT// ADDRESS TEL. # CONTRACTOR: Shayh e � l.U, f CV I cowl,non 5 w 2 - s 7---sg- NAME MAILING ADDRESS TEL.# esidential El Commercial Est.Cost of Construction$ -�/ 0'° Home Improvement Contractor Lie.# / & 6 r7 f Construction Supervisor Lic.# f©� r Li Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor ' I have Worker's Compensation Insurance Insurance Company Name: A4 Ian 1-+ G C// eL fL 67 Worker's Comp.Policy# (j1ft2-"�/ ©I Lt 3SIC7© WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 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: / ' a,I/i L l iI1 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 cation of my lice d for prossL�u/tion under M.G.L.Ch.268,Section 1. %f Applicant's Signature: ��1. -- 3t 1 1 Date: Owners Signature(or attachment) 6.'e eA A Cl. Date: Approved By: v,__l... L/ Date: ) - 30 — I 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: 0 Yes 0 No 0 Yes 0 No `� The Commonwealth of Massachusetts Department oflndustrialAccidents i -LA 1 Congress Street, Suite 100 1•1=4:FININ Boston, MA 02114-2017 1.1 SNP5O www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (B,!Fint.;97/07.7.nizatf ii131547-1-4:6=t; ga Eft ell Address: 1 �� V ui1 i � ei �55 City/State/Zip:& e w4�C( 0 943 I Phone #: a31 --355 3 Are you an employer?Check the appropriate box: Type of project(required): I.Vm a employer with employees(full and/or part-time).* 7. New construction 2.1:I am a sole proprietor or partnership and have no employees working for me in 8. — 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.]I. _ 10 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will — ensure that all contractors either have workers'compensation insurance or are sole 11.[ Electrical repairs or additions proprietors with no employees. 12.Q 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.; '11 D 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. ther T�5 l/ 1 152,§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. 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: Al /&(,4 I e GI L .e Policy#or Self-ins.Lic. #: U C V 0 I -1 15ToO Expiration Date: ^D e Job Site Address: 36 RO6 e L City/State/Zip: IQr,v©o 4 Attach a copy of the workers' compensatidn 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 nder the pains a nalties o perjury that the information provided above is true and correct. Signature: Date: 1 3-67—/ Phone#: 3-f 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#: }TOME OWNER WEATHERIZATION WORK PERMIT: PLEASE COMPLETE AND SIGN THIS FORM AS THE APPLICANT HOMEOWNER. I .. 01.0NE cGtU1O a►t hereby consent to and agree that weatherization work may be done by the Weatherization Program of Housing Assistance Corporation on the property located at The weatherization work done will be based on programmatic priorities and availability of funding and it may include all or some of the following measures: Weather stripping; air sealing; attic& basement insulation; exterior wall insulation; ventilation measures In consideration of the weatherization work to be done at my home I agree to the following: 1. I give permission to Housing Assistance Corporation to access the property with such equipment and materials as may be necessary to perform weatherization. 2. The Housing Assistance Corporation reserves the right to inspect the fuel or utility bill for the weatherized unit on an ongoing basis for no more than five(5)years after the weatherization work is completed. I have read the provisiojif this agreem t and give my consent. Home Owner signatureYriUvkt jime ,il Home Owner email: Date: 5)71(1 i t Agent:(Signature) Date: Agency Approved Weatherization Company All Cape Energy Alternative Weatherization Cape Cod Insulation Cape Save Cazeault Frontier Energy Solutions Lohr Home Improvement Agency Signature: ' *---2 ... Date: 61.-) 111 For Natural Gas Customers I have received the National Grid Discount Rate Application form from my auditor. Customer Initials Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construction Supervisor Specialty CSSL-103842 Expires: 02/23/2020 SHAYNE DEWITT 161 COMMONS WAY BREWSTER MA 02631 Commissioner l C��ie'ryn manweallA ofc.f(&taeAusettt . Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration EMBALM 166888 08/09/2020 SHAYNE DEWITT ' D/B/A ALL CAPE ENERGY SHAYNE DEWITT 161 COMMONS WAY BREWSTER,MA 02361 Undersecretary ACO aI CERTIFICATE OF LIABILITY INSURANCE °"'E`""°°""'"' 02/13/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON TIE CERTWICATE HOLDER. THIS CERTIFICATE DOES NOT AFRFIMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER TIE COVERAGE AFFORDED BY THE POLICES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORED REPRESENTATIVE OR PRODUCER,AND THE CERTIRCATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL NSURED,the polcy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies nmy require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such eodorsemerht(s). PRODUCER 00241-001 RaPci Mier McGartin,Inc.DBA Dowling&O'Neil Insurance Agency Wife.Erdl: (508)775-1620 (Ag.ma, (508)778-1218 PO Box 1990 Hyannis,MA 02601-1990 RISME:NA AFFORDING COVERAGE NEC I INSURER A: Mantic Charter Insurance Company VDAC 44326 INS MOB: ALL CAPE ENERGY,INC. INSURER PO BOX 1492 INSURER D BREWSTER,MA 02631 INSURER E: INSURER F COVERAGES CERTFICATE NUMBER: REVISION MJMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED 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.LINTS SHOWN MAY HAVE BEEN REDUCCEELDDCyyBYYID PA pCLANS. TYPE OF INSURANCE POLICY NUMBER (2 N[1/M QM) M% LIMITS GENERAL LIABILITY EACH ONCEDAMAGE E COLOAE RCIAL GENERAL UABXITY - PF .S�RENTED carreee) CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GENL AGGREGATE UNIT APPLIES PER: PRODUCTS-COMP/OP AGG $ f""CY I 1`oc AUTOMOBILE LIABILITY (Ea accidene COMB!!®SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ Au_maw ALIT �® BOXY RUURY(Per accident) $ MEI AUTOS (per DAMAGEAUTOS $ UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS UAB CLAIMS MADE AGGREGATE $ DED RETENTION$ $ ratignOCRNMAIM X TO vS EAR Y/N WCV01435800 2/7/2019 02/07/2020 EL EACH ACCIDENT $ 500,000.00 A tW4Ybm9 N NIA EL.�-Y-EA©PLOYEE $ 500,000.00 Policy Coverage EntRVIM OPERATIONS below SYS� MA OF EL DISEASE-POLICY LIMIT $ 500,000.00 DESCRIPTION OF OPERATIONS I LOCATIONS/VE ICLES(Attach ACORD 101,Additional Remarks Sidedri,I more apace Is required) CER71ACATE HOLDER CANCELLATION SHOULD ANY OF TIE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPILAT1ON DATE THEREOF TIE 155UBIG COMPANY WLL ENDEAVOR TO NAIL NOTICE WALL BE DBNERED BI ACCORDANCE WITH THE POLICY PROVISIONS. AUTHOR®REPRESENTATIVE isieintsiel.glet... 01988-2014 ACORD CORPORATION.AN rights reserved. ACORD 25(2014/01) The ACORD name and logo are marks of ACORD CERTIFICATE HOLDEROPY