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Home My WebLink AboutBld-20-20-00487 • •YiiA .._..� Office Use Only ' . :`; s. •% RECEIVED 4 U' y/ l• �.s Amount 8' l ,„„ Ecd4. JUL 2 5 2019 c� ve '3 Permit expires 180 days from ` 'issue date SIIIF'61 . :.ili• PARTM EXPRESS BUIL G PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 7 t%// 0 bUi6 I Yizr,600/-4 o 73 ASSESSOR'S INFORMATION: Map: 2 A Parcel: 51 (hr/S L/ -rr n� y— • j --3ER: QslgMnnEf�f �,D R>`S G��6 �1— NAME � PRE D S leri CONTRACTOR: /ft ��o 7X' ? 'Y Iie>,4 See $7/, d'-6,AME MAILING ADDRESS y/ .,"G TEL.# Residential 0 Commercial Est.Cost of Construction$ Y ' Home Improvement Contractor Lic.# / 72— ` Construction Supervisor Lic.# 6 5 C> ✓ o Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor I have Worker's Compensation Insurance / y Insurance Company Name: �� G 2- �� Worker's Comp.Policy# / 4/ 'gg 0-7 3 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: /✓ �J� /z ��S�of�� 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 fob denial or revocation of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature ) 07.2.01 ...../7S Date: 67./Z---� Owners Signature(or attachment) r � Date: °?/.�/ 5 Approved By: "si • Date: - `4Ci. "i Cj Building Offi 'al(or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No _ '\ The Commonwealth of Massachusetts _ Department of Industrial Accidents _�e- 1 Congress Street, Suite 100 r `- Boston, MA 02114-2017 �M .• www.mass.gov/dig Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information -/ PIease Print Legibly Name (Business/Organization/Individual): �� Or/yS Address: q5 /#7j/"& c1 ,i. ,{- / City/State/Zip per i,if,c Z 4 Phone #: 5-. 0 Y/'? 7 2 6 6 Are you an employer?Check the appropriate box: Type of project(required): LE 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. I am a homeowner doing all work myself 9. ❑ Demolition y [No workers'comp. insurance required.]` 4.❑ myProPertY•I am a homeowner and will be hiring contractors to conduct all work on 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.❑Plu ing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. oof repairs These sub-contractors have employees and have workers'comp. insurance.i 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑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. ;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: i ,1V c -2... _X Policy#or Self-ins. Lic. #: f Y" 7da Expiration Date: Y/% 7/Z8 Job Site Address:/7/ ' )4 Z6�y,'1b City/State/Zip: - ./ja1e-; U ?1 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 pen ties of jury that the information provided abov is true an correct. i Signature: Date: 7 ?-X'-- /, Phone#: So 8 0;' '1 • c 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#: ilisciztir CERTIFICATE OF LIABILITY INSURANCE DATE(MM1D°"'I'rY) 04/17/19 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 cerdflrate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terns 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). PACER NAE:E T JIM HINDMAN i Fax Schlegel A Schlegel Ins Broker m• L Bob-771-8381 1 ,No): 508-7714663 34 Main Sheet aooREss: schlegelinsurance@gmall.com West Yarmouth,MA 02673 INSURER(S)AFFORDING COVERAGE HNC A INSURER A: NGM INSURANCE COMPANY 14788 INSURED INSURER B: TRAVELERS MARCOS SILVA INSURER C: DBA EMERSON CONSTRUCTION INSURER o: 67 SEA ST APT II HYANNIS,MA 02601 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. LTR TYPE OF INSURANCE INSDD WD POLICY NUMBER (r YYY) (rM IY YY) LIMITS X COMMERCIAL.GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE 10 RENTtD CLAIMS-MADE ri OCCUR PREMISES(Ea oxuraMae) $ 500,000 — MED EXP(My one person) $ 10,000 A — MPT9375T 11/09/18 11/09/19 PERSONAL AADVWORT $ 1,000,000 R G LSdTTAPPLIES PER GEIERALAGGREGATE $ 2,000,000 POLICY D,1 Q n LOC PRODUCTS-COWAN,'AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILJTY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ — OWED SCHEDULED HAS ONLY _ AUTO SD BODILY INJURY(Per accident) $ PROPERTY DAMAGE _AUTOS ONLY AUTOS ONLY (Per accident) $ $ UMBRELLA UAB _ OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ WORKERS-COMPENSATION PER I AND EMPLOYERS'LIABILITY Y!N STATUTE t ER B OFFICERJMEMBER t XANY CDED4 CAE n N!A EL EACH ACCIDENT $ 100,000 Mandatory NH) WC-1073205 04/17/19 04M7/20 yyeess'' EL DISEASE-EA EMPLOYEE t 100,000 DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LMrr $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more apace is required) MARCOS SILVA HAS ELECTED TO BE COVERED UNDER HIS CURRENT WORKERS COMPENSATION POLICY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF TIE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN DAVID WOOD ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE DAIANE BENFICA Ilia I II ACORD 25(2016/03) The ACORD name and ®1988-2015 A«•,i, CORPORATION. All rights reserved. Togo are registered marks of ACORD • • Commonwealth of Massachusetts il '�I Division of Professional Licensure tie}eioeslepun Board of Building Regulations and Standards t3b9Z0 bW'SIIIW SNO1StjdW constrocttoriltit rvisor t/M MOM v a W£b . � may = OOOM'b dlAda t t d CS-035693 ires: 01/18/2020 1 r Ti1 i*AOOM 41AVCI DAVID A.WOODS 11 o ` I` 030Z/OE/LL30 ,r c .,ice �l-� 43 MATTHEW frJAY ,jR Uo nee d MARSTONS MILL MA 02648�'� ��« Isnpinpul 1 : If>f'1cl10' 1•JOi3VIa1NO3iN3111 'OUd1N13WOH 4..--- ,11 uol;elnfiey sseulsne ig s.ge /Jawnsuo3 ao aal�o ,''I �lranv 'vr�''v,/4'v3,odinu�uia+u s Commissioner ......11.1111111111111111 41111.111111.r AV IIMIN. - - I I .-1,,i.,.., • 1-'' rg . Nr\------. ...,,.p,7„ EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARM(.)1;TH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: ___1:..:1t) 1,14//ey Pc/ a)td Y41,-„iibdiz, //17, 4c,-7- , , ASSESS(IR'S INFORMATION- I Map: Parcel: OIVNER / - 4/ — —384Y3 ..1.4.b.IE PRESENT ADD TEL 4 / CONTRACTOR NAME MAILING ADDRESS TEL 4 0 Residential 0 Commercial Est.Cost of Construction S Home Improvement Contractor Lie.# Construction Supervisor Lie.# Worlunan's Compensation Insurance: (check one) n I am the homeowner D I am the sole proprietor 0 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 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 . Facility Location of at knowledge and bead 1 nadetstand that any raise unvouto I declare under penalties of perjury that the statements herein contained are. tme.aaM.G.L.d correct. "theb,est_ _°f alyi. will be just cause for denial or revocation of my license and for under MLi I. Ch.2b5 beettall Date. Applicant's Sipahne: - Owners Siviature(or attachment) X ) ..../ Date' ' fl Approved BY: Building Official(or designee) EMAIL ADDRESS: Date: - - ---------------- Zoning District: . . Historical District 0 Yes 0 No Flood Plain Zone: 0 Yes 0 N Protection District Within 100 ft.of Wetlands Water Resource ritiv...,•.on - - 0 Yes 0 No -0 Yes 0 No , .. . .,. _ _. , . ... • , ,..., . .