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Home My WebLink Aboutbld-20-3031 Office Use Only Y.. SHEDS LESS THAN 150 SQ. FT. SHALL d BE PLACED A MINIMUM OF 30 FEET Permit# �v a A[t1,g c' FROM THE FRONT LOT LINE AND A Fees p - „et.,,,.'- hiMINIMUM OF 6 FEET FROM SIDES AND Permitz�ires6monthsfrom `F` µ��s J WI s REAR LOT LIN issue date. 13W— au--3a3/ EXPRESS BUILDING PERMIT APPLICA' 'h01 TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 . L-t1 C .5 V (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 3 2 0/K C4 " " S 4 34 fie,.i ASSESSOR'S INFORMATION: F'incis CO I -q) VC,Map: /3 3 Parcel: yt, / OWNER: rs'l akl 4.c.I5 At as, 4..A. Si firs.a 440w7s/ r r-r-f 4 l-/ A.. G?O ri NAME l PRESENT ADDRESS` SY #2 2,i CONTRACTOR:g`,C..:�w S i u i& 44r 1.3 c- 113'�tNN�/i, a 2c r-" 5�c l`'�'1' /f,e f' NAME MAILING ADDRESS TEL.# @Residential ❑Commercial Est.Cost of Construction$ ?Ott `� -r n` 044,1i) Home Improvement Contractor Lic.# / 'ek L 3 Construction Supervisor Lic.# 0/9Ca 2- Workman's Compensation Insurance: (check one) �� 0 I am the homeowner❑ I am the sole proprietor trl Have Worker's Compensation Insurance Insurance Company Name: r r. it, I-1 G'Ll:,fn-f/ Worker's Comp.Policy# 11f COO S r& c�/ /3/t 24414 WORK TO BE PERFORMED ❑ Tent (Fire Retardant Certificate attached) n Duran n ,Y/ ` 'j r �/ 14 1 od Stove Shed ❑Siding: #of Squares 0 Replacement windows:# ❑Replacement doors: # ❑Re-roof #of Squares ()Shipping old shingles* ()going over layers of existing roof ❑ Old Kings Highway/Historic District / �► / Roofmg/Siding(Like for Like) y 'The debris will be disposed of at: tie/'t s'4 L_Gib s"'/f 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 of my license prosecution under M.G.L.Ch.268,Section 1. A Date ��2�j1�// Applicant's S. Owners Si a(or attachment) Date: Approved By: �� //2 Date: /, - l., -7- Building cial designee) Zoning District: Historical District: ❑ Yes 0 No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No 0 Yes 0 No 3/01 The Commonwealth of Massachusetts Department of Industrial Accidents —=k_ Office of Investigations " _- " 600 Washington Street -- "` = Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information �J /1 /� /_ Please Print Legibly Name(Business/Organization/Individual): /Jt ii L�iifrJ /rZ `i1 6.4 I Address: / '4 : 11°.y i 3 fi- City/State/Zip:4)SIIA4'`/L `'"" oZcr"Phone#: Ps= 72/ 3 `I/ Are you an employer?Check the appropriate box: • Type of project(required): • 1.[ am a employer with. ,/ 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. 0 New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. gefemolition workingfor me in anyemployees and have workers' capacity. 9. 0 Building addition [No workers'comp.insurance comp.insurance.: required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself[No workers'comp. right of exemption per MGL 12.0 Roof repairs insurance ]t c. 152,§1(4),and we have no 13.❑Other 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: A. X, /14. ri-ft/te."4 ,4c,5 W,a", Policy#or Self-ins.Lic.#: u- 0'4'`S'7tf 13/ 1 2e/9 A Expiration Date: gf .//9. Job Site Address: 3L O1 / J a 6 G City/State/Zip: Lj�n.".40 1.-`* 4. Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u the pains and of perjury that the information provided above is true and correct. Signature: r, Date: I//71/f • Phone#: 'St--' 7 7/ gf-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#: 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,§25C(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),address(es)and phone numbers)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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.govfdia Client#: 13680 2CROSTONWI ACORD,. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)10/22/2019 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 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 any rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT The Hilb Group of N.E.dba r,1 etto,Exy:508 775.1620 FAx No): 5087781218 Dowling&O'Neil Insurance Agy -MAIL AMIN; P.O.Box 1990 INSURERS)AFFORDING COVERAGE NAIC# _ Hyannis,MA 02601 INSURER A:NOM Insurance Company 14788 INSURED INSURER B:Associated Employers Insurance Company 11104 William W.Croston D/B/A INSURER C William W.Croston Building Contractor INSURER D: P.O. Box 138 INSURER E: Osterville,MA 02655 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 REDUCEDOLCy� BYp PAID ECLAIMS. tilir TYPE OF INSURANCE INSR Sy yQ POLICY NUMBER (MMIDDIYYYY) (MMIDDIYYV� LIMITS A X COMMERCIAL GENERAL LIABILITY MP039676 10/13/2019 10/13/2020 EACH $1,000,000 ' CLAIMS-MADE I_ X]OCCUR PREMEa occurrence) $500,000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY X JE PRO-CT I X I LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY M9039676 10/13/2019 10/13/2020 iEa acci4 JINGLE LIMIT $1,000,000 ANY AUTO BODILY INJURY(Per person) $ AUTOS ONLY X AUTOSULED BODILY INJURY(Per accident) $ HIRED NON•OWNED PROPERTY DAMAGE $ X AUTOS ONLY X AUTOS ONLY (Per accident) $ - A X UMBRELLA LIAB X OCCUR CU039676 ' 10/13/2019 10/13/2020 EACH OCCURRENCE $5,000,000 EXCESS LIAB _ CLAIMS-MADE AGGREGATE $5,000,000 __ DED X RETENTION$10000 _ —_ $ B WORKERS COMPENSATION `WCC50050193162019A 09/08/2019 09/08/2020 X STATUTE ERH AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE rY/N E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? I V N I A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If ysa,describe under E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) **Workers Comp Information** Proprietors/Partners/Executive Officers/Members Excluded: William W.Croston,Sole Proprietor Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION R Mullen and Associates Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 190 Old Derby Street Suite 207 ACCORDANCE WITH THE POLICY PROVISIONS. Hingham,MA 02043 AUTHORIZEDTHg REPRESENTATIVE ^! ! c. I 01988.2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD 08245728/M245726 RPCH1 Uinice 01 l.UiisUii1CI t111t1irs OL DUsu iess A.CgUiaiioi1 - iVlass.IJUV rage i Ul L Mass:gov Office of Consumer Affairs and Business Regulation (OCABR HIC Registration Con " CommomveaithofMassachusetts l)ivisron of Professional Licensure Board of Buildiny Regulations and Standards Construction Supervisor Registration # 100023 CS-014112 Expires: 04/25/2020 Registrant WILLIAM W. CROSTON WILLIAM W CROSTON JR Name WILLIAM CROSTON 66 SUOMI RD HYANNIS MA 02601 Address 55 SUOMI RD City, State Zip HYANNIS, MA 02601 commissioner C-1-- _-- Expiration Date 06/07/2020 Complaints Details No complaints found for this registrant. You can also view arbitration and Guaranty Fund history. Back To Search Site Policies Contact Us https://services.oca.state.ma.us/hic/licdetails.aspx?txtSearchLN=100023 7/9/2018 BILL CROSTON BUILDING CONTRACTOR BOX 138—OSTERVILLE, MA 02655—(508) 428-8657 1-800-924-1073 MA LIC. #014112 MA REG. #100023 October 20, 2019 Town Of Yarmouth Building Department 1146Rt28 South Yarmouth, Ma 02664 Re:32 Old Church St To whom it my concern, I Francisco Dafonte as owner of the property at 32 Old Church St Yarmouth Port, Ma here by authorize Bill Croston Of Bill Croston Building Contractor Inc to act in my behalf in all maters relative to the work authorized by the building permit application for 32 Old Church St. rancisco DaFonte Dated FRIA&i(S (61 fi e Print name