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Bld-20-000481 •O�..Y,4 Office Use Only U!i:.t) • Amount4 Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: g ©(-i 3 er S•1-1/4Titto Li--1A I IA't-j 0 Ze7� ASSESSOR'S INFORMATION: Map: ;8 Parcel: /2� oVs OWNER: V`e4 /411-e-tt)41Pie/ -�1 49 �vrI dJ. ( i PRES ADDRESS L. # CONTRACTOR:3"'S11 l`- JC C> S9 (�' . �C� t�a' �]�� NAME �G ADDRESS TEL.II esidential 0 Commercialrc Est.Cost of Construction$ I ctio i Home Improvement Contractor Lic.# T�D0 Construction Supervisor Lic.#l�&' ),,3,3�, Workman's Compensation Insurance: (check one) G I am the homeowner ❑ I am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: TrIVekr3 'I j>1.§\ Worker's Comp.Policy# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 1 Replacement windows:# Replacement doors: # Roofing: #of Squares 16 ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: s e3 EA co It4Y) S Location of Facility I declare under penalties o perjury ,:t 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 den- or revo�tion of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: � N.,� . 4 Date: h., Owners Si:,attire(,/ a ch , nt) -eil �� d��II i Date: Approved - 4*_a 4-44i Date: 7 Building t..ror. si Yi r EMAIL ADDRESS: . ''/,7Zoning District: - Historical District: ❑ Yes 7 No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: I Yes No 1. Yes I No SI.._. ,per The Commonwealth of Massachusetts Department of Industrial Accidents Ermitinnff. 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. Applicant Information �, Please Print Legibly Name (Business/Organization/Individual):All C'w(v an51(i- tt) Address:a Omen Brevic City/State/Zip: S YrindA, m oat6 11 Phone#: 799- ) ?9 / Are you an employer?Cheek the appropriate box: Type of project(required): l I 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. Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]r 9. ❑Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 El 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 5.0 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.EI We are a corporation and its officers have exercised their right of exemption per MGL a 14.Q 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. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employee& Below is the policy and job site information. ----(ci �in5 Insurance Company Name: I VVer$Policy#or Self-ins.Lic.#: W CJ 1 54 '(-41 Expiration Date: V l W1 aC/ Job Site Address: /< 'ervristr tat c/ City/State/Zip: Vcrw.41m'J,. 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 her•,y •A 1.0 under t e 'ns and penalties of perjury that the information provided above is true and correct Signature: Date: ghb/) 7 Phone#: 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#: Ac RD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DOIYYYY) 04/23/19 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 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 rights to the certificate holder in lieu of such endorsement(s). PRODUCER CON1Al.T NAME: JIM HINDMAN Schlegel&Schlegel Ins Broker PHONE/ .EMI: 508-771-8381 FAX No): 508-771-0663 34 Main Street E-MAIL West Yarmouth,MA 02673 ADDRESS: schlegelinsurance@gmaii.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: NGM INSURANCE 14788 INSURED INSURER B: TRAVELERS ALL CAPE CONSTRUCTION INC INSURER C: 27 DANCING BROOK ROAD INSURER D: SOUTH YARMOUTH,MA 02664 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 AOOLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MMIDD/YYYY) (MM/DDJYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 FED CLAIMS-MADE X OCCUR PREMISES EaEN occu occurrence) $ 500,000 MED EXP(Any one person) $ 10,000 A MPP4794A 04/04/19 04/04/20 PERSONALSADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY n PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident) ANY AUTO BODILY INJURY I Per person) $ — OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ _AUTOS ONLY ^ AUTOS ONLY (Per accident) $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ s WORKERS COMPENSATION AND EMPLOYERS'UABIUTY S PER OTH- ER B OFFICER/MEMBE EANY XC UDED'ECUTIVE YyN N I A WC-1642241 04114/19 01/14/20 E L.EACH ACCIDENT $ 100,000 (Mandatory in NH) EL DISEASE-EA EMPLOYEE $ 100,000 Eyes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101.Additional Remarks Schedule,may be attached it more space is required) CORPORATE OFFICERS HAVE ELECTED NOT TO BE COVERED UNDER THEIR WORKERS COMPENSTION POLICY 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 ACCORDANCE WITH THE POL Y PROVISIONS. YARMOUTH MA ATTN:BUILDING DEPARTMENT AUTHORIZED REPRESENTATIVE ©1988-2416 CORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACOR Commonwealth of Massachusetts kg,/ Division of Professional Licensure Board of Building Regulations and Standards Consitrri lStSPPrvisor CS-102675 ° r L,pines:05/06/2021 JUSTIN M J `�, 27 DANCJ . . j SOUTH YARI)UTH Commissioner .7Z &mi.naauwt./ato/.,&-a,3¢chtJe/4 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:•Corporation Reaistration Expiration 188058-' 06/12/2021 ALL CAPE CONSTRUCTION-INC JUSTIN M.JACINTO 23 RIDGEWOOD RID ORLEANS,MA 02653 Undersecretary