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Bld-20-000658
wI•YAR Office Use Only ' ' ' • 0 Permit# 4" ! /.y-� 0 -#011I•/,w . H Amount/CO ICA MATTACFI IiHe x 4O*/waco^p c� 'Permit expires 180 days from I' 80�20- ,t r i issue date EXPRESS BUILDING PERMIT APPLICATI C E f V E D TOWN OF YARMOUTH eYarmouth Building Department 1146 Route 28 ! �� '' 2019 South Yarmouth, MA 02664 DUI IyYYy�- --- . .,. (508) 398-2231 Ext. 1261 1 ,.._ � CONSTRUCTION ADDRESS: / 7 / w E iR._ Rot9-0 ASSESSOR'S INFORMATION: Map: Parcel: OWNER: CL4r � 1-U pU)( g /7( W k0 Ygotocfari SOi•-So4-,807‘ NAMES,,n PRESENT ADDRESS `�' tel TEL. # l CONTRACTOR: ( ews,-`� t. ( S/ % MA470r( Po /nR9 c.2?4.5" "'7- 77Y off(a"I / /( NAME MAILING ADDRESS TEL.# Q Residential ❑Commercial Q Est.Cost of Construction$ /O( 00 0. CO Home Improvement Contractor Lic.# / 13 6 / / Construction Supervisor Lic.# C_8- 0 g 8 V02/ Workman's Compensation Insuranceck one) ❑ I am the homeowner I am the sole proprietor ❑ 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 Cj Replacement windows:# 8 Replacement doors: # Roofs #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: v 4- -' e/Cwbetittts S-s Location of Facility I declare under penalties of perjury that the statements herein cont . d 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 o evocation of m ligen d for p ution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: 33 Owners Signature(or attachme � Date: Aar s Approved By: ` Date: g - --i Building Officiakfor sib ee) E 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 Cl No 0 Yes ❑ No The Commonwealth of Massachusetts tit" . c Department oflndustrialAccidents 1 Congress Street, Suite 100 k:,..:_ I. Boston, 1114 02114-2017 °,M M,5••`'� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information /j Please Print Legibly Name (Business/Organization/Individual): Efit� 77 /'CEbPe Address: 44, /not�1..-f /206 0 City/State/Zip: 50 . COrq n i'16 DZ6 S 9 Phone #: 77 c/ -,Q IQ — it/ / j Are you an employer?Check the appropriate box: Type of project(required): l.E I a 8employer with employees(full and/or part-time).* 7. E New construction 2. am a sole proprietor or partnership and have no employees working for me in g . ❑ 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.]` 10 ❑ Building addition 4.E 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.❑Plumbing repairs or additions 5.E 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.' 14.E Other kJ t 1�(n a W S 6.E We are a corporation and its officers have exercised their right of exemption per MGL c. _$l O iNGG 152,§1(4),and we have no employees. [No workers'comp. insurance required.] V *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: Policy#or Self-ins.Lic. #: 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 certi/,,under the i/ i and tides of perjury that the information provided above is true and correct. Signature: '='< ' Date: 7/ 0// 5 Phone#: 779 -.1.1 , - /y 1 I 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#: Commonwealth of Massachusetts kV' 0iviti;o tof Professional Licen4re <p' Board of Building Regliitati6OS.And Standards' -4.11 Constractitin SUperVISOr CS-068429 Ocpires 08/1 4120 1 9 i Y BARRY T FtEOPELL,`SR 98 MORTON Wow y MA"0266i9 SOtliTH CHATHAM ;. Commissioner %�rF nirtinoiarc rn�l if. 1/4rr.-Jsarhii e,44 ; 'Office of Consume'Affairs&BuC �Regulation HOME UIkPROVEMENT CT TYPE:Individual Bitilianten '193619 1110412020 RRY T EO'3,,,SR. ;it • • . BARRY T.RED PELL SR 96 MORTON ROAD 02659 SOUTH CHATHAM,MAUnde . /'^1) REOPELL OP ID: '4RO" CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 08/01/2019 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 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 pollcy(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 508-398-6060eCT Bryden&Sullivan Insurance Bryden&Sullivan Ins Agency PHONE 508-398-6060 I FAX 508-394-2267 of Dennis Inc. (NC,No,Est): (NC,No): 485 Route 134,PO Box 1497 Mass: So.Dennis,MA 02660 Bryden&Sullivan Insurance INSURERISI AFFORDING COVERAGE NAIC# INSURER A:NGM Insurance Company 14788 ggINSURED INSURER B:Associated Employers Insurance Road SOUtth Chatham,MA 02659 INSURER C: INSURER D: 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 LTR TYPE OF INSURANCE ANgDL SUBR POLICY NUMBER POLICY EFF POLICY EXP /MM/DD LIMITS A COMMERCIAL GENERAL LUIBIUTY EACH OCCURRENCE $ 1,000,0 CLAIMS-MADE n OCCUR MPP3180F 01/05/2019 01/05/2020 DR E3 RENTED cal $ 500,0 X Business Owners MED EXP(Any one person) $ 10,0 PERSONAL&ADV INJURY $ 1,000,0 GEN'L AGGREGATELIMIT Ar.LES PER: GENERAL AGGREGATE $ 2,000,0 POLICY I jlt8f LOC PRODUCTS-COMP/OP AGG $ 2,000,0 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT(Ea accident) $ — ANY AUTO BODILY INJURY(Per person) $ — OWNED $CHEDSULED AUTOS�E AUTOWNEp p ONLY AALO BODILY INJURY(Per accident), $ — AUTOS ONLY _ pNLY r�tg:galDAMAGE $ $ UMBRELLA LIAR _ OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ B ANRKEres� B�N RTMDEMPLOYERS*LIABILITYILITY X TTT E A�NYFI�PROPRIETORIPARTNE CUTIVE Y/N WCC50050182702019A 01/08/2019 01/08/2020 100,0 Q�FIC MEMB �EXCLUDED? N N I A E.L.EACH ACCIDENT $ 100,0' Ifund E.L DISEASE-FA EMPLOYEE $ yes. OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,0 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE HOLDER CANCELLATION TOWN-02 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 POLICY PROVISIONS. 1146 ROUTE 28 S.YARMOUTH,MA 02664 AUTHORIZED REPRESENTATIVE Bryden&Sullivan Insurance 1 ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reservec The ACORD name and logo are registered marks of ACORD ® TOWN OF YARMOUTH 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451 E E l vE D Telephone(508) 398-2231 Ext. 1292-Fax(508)398-0836 !� to .QLD KING'S HIGHWAY HISTORIC DISTRICT COMMITTED: -- `� 2019 OVF rr-,rviviuu 1 N AUG 0 _ ® APPLICATION FOR OLD KING'S HIGHWAY 20, CERTIFICATE OF EXEMPTION SOU T UWN C Application t� Hfe'f e - for the issuance of a Certificate of Exemption under Sections 6 and 7 of Chapter 470 of Acts of 1973, as ame •t itt4the proposed work as described below and on plans, drawings, or photographs accompanying this application. Type or print legibly: r t /� Q Address of proposed work: I /j''7 1 W E I i` _ ► r16 Map/Lot# Owner(s): CLJ t/ L() 't) L3 t ES Phone#: 50f`5O 7- O O74 AU applications must be submitted by owner accompanied by letter from owner approving submittal of application. Mailing address: - 1 7 ' W E(� '� l� er ki I Year built: Email: C a 1-O b w (C 13 & YA k Ce vpreferred notification method: V Phone Email Agent/Contractor: BAke—N., /Q IL J Phone#: 77 ` -c(a.-/W/ Mailing Address: 'i4, ►'t'oe--lok 0 St, COA-4 qwl_ AA. baes2 Email: R 12-& AD l_t f�0,'\- Preferred notification method: r' Phone Email Description of Proposed W k(Additional pages may be attached if necessary: .4.j ,) I�Ng oQ� 'To 2€RACE-'- E IS"1't ire fJ l b$C 't r4 a.)Lr( is T`7 �S ,8C�(�ca� �� Tr 1 trifk l. L,1 Kt- s, ANCl`RSOill €5 6'4'13 Wtatej f W *®�c ! +s , e e tJg 0 �,F. w. j �St ,,F 0P�� 4 -SQ` _ c+� � Ec4tf€AL ai 11 ( s )lip+ Co obte. tt y tAt.litrg-s f Signed(Owner or agent): Date: .6_3 - l > Owner/contractor/agent is aware that a permit may be required from the Building Department.(Check other departments,also.) This certificate is good for one year from approval date or upon date of expiration of Building Permit,whichever date shall be later. For Committee use only: Date: S-S—t 9 Approved Approved with changes Denied Amount as Reason for denial: z Cash/CK#: 1- 3'.- / Rcvd by: D'%/ +f !..ij ( , ','J t {' >l,`l,1�, l s Date Signed: 86 Z.OI 4 Signed: !/`� (� i Q / APPLICATION#: //rE-0 2a V5.2017