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Home My WebLink AboutBLD-20-2804 in , - 1 r-k_., - ►` ,t i4 _2" F.�y .�. ��'"�>>. 3=,'a,. _..`€�:�e .ur-i.,=±rt.+ �t�:. ;�. .�:.,;';*��:;Lxc�ti�S:y:,t.x"i�i` -' - - - - - Y '.-,y . - _ --sue:.=, "- - - - _ " - - - - - - .ter "- S- -yx�Y„A'_� p� �ty' + ciF �} �y C1: fl >M7 �!�FI - _ --. _ . ,.**--..'r i "may., - • - - - "- - - _ - -- Ham s".L�.,,, - - _ - -- r, a`4i�` h r�3 T. - - lt, t� �^ em i s.> - - - ti t r k-- a w,- J- 3 + 5�.. :ems v r • _ x, t.: 1',„ , Ai'' ?m�,�,} } _ � t� r•i• -1 k a, n. }I' try>`'" yY ' - - - - s. �,. `?fit: !(^ ..�tit PIM f�i.,"., '"-"'-- 'y,•� >--Isr �\ _ a <:3t"', Y4� -. zC47""A*4 ,„y4il G:' i�iitI fir. - _ r x .. > " 414r ' - - 'rya,. y.. - __ - - - - -�"£„ jam"; ,�(�_ - IIRM�� -, K 1�R�JR julkiFl ux S x�¢ 1- r/ r�h ,.5�- P "L4AT ,...�,-, ., .. t.-,i ice, - _ r> s 5->x`a f: # 'kY`t - �'9+ ) _, v Qi Y� v `wa ".y r - 4 .2_a 3µS, : sw N��y_z., / R - J' d - _ ] ' - --- - „- aim - 'fi.r < --= - - _ "`,e � "= - - - -- -ir - - - - - - " -- • -. s_ + r � " osad W 4i , # OR. CI7Ib fylt `.: ' ' 1,-W3 -• , - : ��aSotip!tiort-=fly-P r 7 - - - __ . r -E- EDP a. 0. _r - ' - - - - - .A - _ - - _ _ - - _ may - _ '_�3'`>� - .- - - _ " Q .�. :.� ,, \ :yam,, -.:. _ - - - - - � - fir .� - c :Yid`."'�° - _ 'v�: ' r. toMil Pro ,n�.+ =w,,_. = _ !'C�' =rL}Hf. :.Kt,. :a. w.irsi-'-n..'', f ,x - - .. - - - - - _ • biWtsi:t�fklts Dt'�yi�. _': - SMG _ - - - - 7 + . f ---SeCtiptill 'MU--011-MLPIEEPCMOVffiOCIAR-Mt 411:-.-::,---,-...2--._,.-_;,---_-,r-,- ---,-,---- --------,--,------, - ',---,',--,-- -------- ----;-_---%,----._..-,--:-_,--- - • aw ! -, s " - - � %n We -, . �' � � - • -- - %'L1 „1::� " + . ti� � �/ _ _ _ _ . , _ ,_. SE 14Oet-e�'ERA1#r _ _ _ - " -°inn ;ot 4 ntt a , ri+ `.k 'fN•. .N -22 aR t V r, xx, 1 k. `ry� ^e - 4: Eiroata0Post At _sfs: ^il a r may', - :M-` r-.�.IYN - ' ,-'tom•...-=.-'r _� '�`:,i 'fat.^•- =p" ,max ,- — - -` c: c } w:x< a , { _ - _- - :,•='sue"^ - - - _ , tip:',- >'r_ - The Co• mmonwealth of Massachusetts 49, Department of Industrial Accidents 1 Congress Street, Suite 100 47 • Boston, MA 02114-2017 .77 ,...,�Y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information AA Please Print Legibly Name (Business/Organization/Individual): jA�� j`6�/aytv 7-7"..,G Address: 29 D 9( /2 p City/State/Zip: �j��yyp�,„�,r /�� Phone #: 72/9S Are you an employer?Check the appropriate box: Type of project(required): 1.❑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 any capacity.[No workers'comp. insurance required.] 8. ❑ Remodeling 3.0 I am a homeowner doing all work myself [No workers'comp.insurance required.)t 9. Demolition 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 11.0 Electrical repairs or additions proprietors with no employees. am a general contractor and I have hired the sub-contractors listed on the attached sheet 12'❑Plumbing repairs or additions �/�T'These sub-contractors have employees and have workers'comp.insurance.: 13. Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that check box#1 must also fill out the section below showing their workers'compensation policy ii,fut u►ation 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: Policy#or Self-ins.Lie.#: 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 pen • of perjury that the information provided above is true and correct. Signature: 7**#' Date: `P-340 /9 Phone#: 26'7 9c3- Q/ Official use only. Do not write in this area, to be completed by city or town offccial. 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#: 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 legal 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, §25 C(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), addresses)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 Please be sure that the affidavit is complete and printed legibly. The Department has provided a space 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, MA02114-2017 • Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia <d , Y ^r TOWN OF YARMOUTH -yg c BUILDING DEPARTMENT • o 'a, " 4. '3 1146 Route 28, South Yarmouth,MA 02664 v3`*...... s�� 508-398-2231 ext. 1261 Fax 508-398-0836 • BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G.L. Chapter 40,Section 54 and 780 CMR, Chapter I, Section 111.5, I hereby certify that the debris resulting from the proposed work/demolition to be conducted at Work Address r 7 vG h/es ..L. Is to be disposed of at the following location: h 4t 7 • /1,,Pu icri.,— Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 1S0A. ignature of Application Date Permit No. s • 0 l.Hi., )mncanu w maaaauruxu� Division ofProfessional Licensure . Board of Building Regulations and Standards Construcmiun'S pervisor CS-025077 Expires:04/12/2020 PETER C MEOMARTI NO` ' 20 BOARDLEYRD SANDWICH MA.02563 CCommissioner l Trommoorordd "/ Ifama AUW" Business Office of 'disks 0elitaRaulOR �T. sofa titilTYP I nammoil Bialatlea 11 0411912020 pEIER NEONARTR-4° PETER C•meokiAmiNo 29 BOARDRD Uttderseery SANDWICH.hik 02563 PEIR 7 CONDOMINIUMS i WIN O B5�15 PR OKBSd'15 f ; , ; BT-1 BT-1 io `J 83 5/18" °° V !: II m Room Nano Room Name . TYP: For Units 9, 10, 11, 12, 14, 30,31,32,33, 34 All dimensions and size designations f�. Design drawings are provided Designed:09.29.19 must be verified on the site to fit job conditions f4p for the fair use by the client or Printed:09.29.19 Client accepts these drawings as is and ,4 his agent in completing the can use them on its own risk. project as listed within this contract Design:moto Drawing#:1 Display settings 3/8"=1' • • Ago CERTIFICATE OF LIABILITY INSURANCE DATE`M"WDDImY) `.----- 05117/19 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. a. 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 E, T JIM HINDMAN Schlegel&Schlegel Ins Broker Ever 508-771-8381 ( ,No: 508-771-0663 34 Main Street FL . West Yarmouth,MA 02673 ADDRESS: sCi..j.nsurance@gmail.com INSURERIS)AFFORDING COVERAGE NAIC if INSURER A: NGM INSURANCE COMPANY 14788 INSURED INSURER B: AIM MUTUAL Adilson Segolini INSURER C; DBA SEGOLINI CONSTRUCTION INSURER D 117 Minton Lane W Bamstable,MA 02668-1818 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. IN R TYPE OF INSURANCE RODE SUER POLICY EFF POLICY EXP RiSD WVD POLICY NUMBER (MMIDOIWW) (MMDElYYYY) UMITS X COMMERCIAL GENERAL UAB1UTY EACH OCCURRENCE $ 1,000,000 DGE CLAIMS-MADE n n OCCUR PREMISES(EaE NTED - - occurrence) $ 500,000 MED EXP(Any one person) $ 10,000 A MPT8486U 05/07/19 05/07/20 PERSONAL 8.ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 ri PRODUCTS-COMP/OP AGG S 2,000,000 POLICYri pi LOC S OTHER: AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) S — — OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS ONLY ^ AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ _ AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAR — OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE S DED RETENTION$ _ $ WORKERS COMPENSATION STATUTE ERH AND EMPLOYERS LIABILITY B OFFICERIMEMBER EXCLUDED?ECUTIVE Y� N IA AWC-400-7026025-2015 05/23/19 05/23/20 E L EACHACCIDENT $ 100,000 (Mandatory in NH) E.L DISEASE-EA EMPLOYEE S 10,000 ye DESCRIPTION OF OPERATIONS below E.I. DISEASE-POLICY LIMIT 5 500,000 • DESCRIPTION OF OPERATIONS!LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) ADILSON SEGOUNI HAS ELECTED TO BE COVERED UNDER HIS CURRENT WORKERS COMPENSATION POUCY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN CUSTOMER COPY ACCORDANCE WITH THE POLICY PROVISIONS. • AUTHORIZED REPRES TAT,VE I 2015 ACORD CORPORATION.•All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD '" N A CO -& CO Z rn CO oCO -i CAA Cal CDCD W CQ w ...... co co 03 CO CO 1113 _s. Co CID V V .11 CA g INNI W as CAf _ ww Om 0 (a) N W 3 -a. CO 17s II N O Z p CA, O C o g s o 2 CO o 0 03 N XI CD V N CO• 3 Ca N V s CU A Paa W N A • N N CAA N 0 r A N