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Home My WebLink AboutBLD-20-3030 O�,.Y�� cii VLUCC USC .J1U �r0 Permit# D 1 C O . - • . H 1 Amount ve ."'"+ro,,,,00:63? i Permit expires 180 days from / TT i issue date &b�20 V EXPRESS BUILDING PERMIT APPLICAPIO.,NEWED TOWN OF YARMOUTH Yarmouth Building Department NOV 25 2019 1146 Route 28 South Yarmouth, MA 02664 Bu ,, / ',, (508) 398-2231 Ext. 1261 f>Y � _ T CONSTRUCTION ADDRESS: `eci , -t. ‘. ,10 1 1' ►'".i O ZIo6� ASSESSOR'S INFORMATION: Map: Parcel: OWNER f�C� 1 V - 3r \ r - ( `�fr MA'3ii v15; J RS.J6A 8'LOW NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# 0 Residential ommercial Est.Cost of Construction$ • Home Improvement Contractor Lie.# Construction Supervisor Lic.# C5 - 10 S 323 Workman's Compensation Insurance: (check one) D I am the homeowner 0 I am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: W.,.._, M M Worker's Comp.Policy# `i g35r WORK TO BE PERFORMED �-%yv rC1f ,4J'"� `'� 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 l,*...) V . ocahon 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 des'- 'r revocation of lice and for secution under M.G.L.Ch.268,Section 1. ` ` t ) r I 9 Applicant's Sib atur-��` .. ' Date: ` Owners Signature(or attachment S,�t rcvk ,(91 a. Date: ` ~' 5- 11 Approved By: _....Gr• e- Date: 1\ r a-S `11 Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No The Commonwealth of Massachusetts _g = Department of Industrial Accidents __Lf�- 1 Congress Street, Suite 100 _ `= Boston, MA 02114-2017 m. :. 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): 1j 'V‘ )--, {t' '\--Q, Address: ` 5C1 ' toy :,-1--- City/State/Zip: )4024111Thone 4: 57)c5 .308 28so . e you an employer?Check the appropriate box: I t am a employer with employees(full and/or part-time).* Type of project(required): 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity. [No workers'comp.insurance required.] 9. ❑ Demolition 3.❑I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 10 Building addition 4. 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.E Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 6.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E Roof 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.El 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. 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: t J Of `' , 1ft," Policy 4 or Self-ins. Lic. #: �1 \ \ 0 A Expiration Date: �j 1E\-zo 1 Job Site Address: 1 ct $ ,5 % City/State/Zip: -O'? ' 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby un er the ain and pre [ties of erjury that the information provided above is true and correct. Signature. �'1 Date: Ll —'2.0')1 Phone#: 'Sete `� I ` - -77 I L4)F)702 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License 4 Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone 4: Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construction Supervisor CS-105323 E4pires:03/14/2020 WILLIAM M FEDER 24 PARRISH WAY WEST BARNStABLE MA 0266$ Commissioner l Construction Supervisor Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet psi cubic meters)of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Call(617)727-3200 or visit www.mass.gov/dpl WORKERS COMPENSATION AND EMPLOYERS'LIABILTY INSURANCE POLICY--INFORMATION PAGE INSURER: POLICY NO: NE114835A NORFOLK & DEDHAM MUTUAL FIRE INSURANCE COMPANY 222 AMES STREET RENEWAL DEDHAM, MA 02026 NCCI Company No: 21059 "�E Account No: FEIN: 26-1913272 Lit ITEM 1. NAMED INSURED AND MAILING ADDRESS: PARKERS RIVER RESORT' LLC AGENT 759 MAIN STREET ROGERRS & GRAY INS. AND ADDRESS: SOUTH YARMOUTH,` MA 02664 OFFICY, INC SOUTH DENNIS OFFICE 434 ROUTE 134. SOUTH DENNIS, MA 02660 AGENT NO.: 20577 LEGAL ENTITY: LIMITED LIABILITY COMPANY (LLC) OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Classification Schedule) ITEM 2. POLICY PERIOD: From: 05/18/2019 To: 05/18/2020 Effective 12:01 A.M.Standard Time at the Insured's mailing address. ITEM 3. COVERAGE: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B.Employers'liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease: $ 500,000 policy limit Bodily Injury by Disease: $ 500,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any,listed here: SEE ENDORSEMENT WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: See Schedule of Forms and Endorsements. ITEM 4. PREMIUM:The premium for this Policy will be determined by our Manuals of Rules,Classifications, Rates and Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to verification and change by audit. Total Estimated Minimum Premium $ 231 Annual Premium: $ 549 Audit Period:ANNUAL Additional I Return Premium: Comments: Issued At Date:04/08/2019 Countersigned by WC 00 00 01 A Copyright 1987 National Council on Compensation insurance INSURED COPY 1 R VERMONT MUTUAL GROUP BUSINESSOWNERS 89 State Street,PO Box 188 POLICY DECLARATION Montpelier,VT 05601-0188 To report a claim call your Agent or the Company at 800-435-0397 Policy Number: BP21042734 - RENEWAL POLICY Type of Biiiing:DIRECT BILL TO INSURED Named Insured/Address Agency/Address PARKERS RIVER RESORT LLC DOWLING & O'NEIL INS. AGENCY LEWIS BAY PROPERTIES INC 973 IYANNOUGH ROAD PO BOX 753 WEST YARMOUTH, MA 02673-0753 HYANNIS, MA 02601 -1869 POLICY PERIOD From 07/21/2018 (508) 775-1620 `Standard Time at your mailing address shown above. TO 07/21/2019 at 12:01 A.M. INSURANCE PROVIDED BY: NORTHERN SECURITY INS CO. TOTAL POLICY PREMIUM at inception is: $7,197 and at each anniversary. IN RETURN FOR THE PAYMENT OF THE PREMIUM,AND SUBJECT TO ALL THE TERMS OF THIS POLICY,WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. BUSINESS DESCRIPTION Form of Business: LIMITED LIABILITY COMPANY DESCRIBED PREMISES Prem. No. Blda. No. Location/Occupancy 001 001 24 UNIT MOTEL / MANAGER APT Mortgageholder Name and Address 753 MAI T (See Schedule of Mortgageholder(s) - WEST YARMOUTH, MA 02673 BPDEC5- If Applicable) PROPERTY-Limits of Insurance for BUILDINGS $ 1 ,275,228 • Actual Cash Value- Buildings Option (Y/N) N • Automatic Increase- Building Limit(pct.) 4% BUSINESS PERSONAL PROPERTY $ 85,000 EARTHQUAKE DEDUCTIBLE(pct) % DEDUCTIBLE$ 2,500 OPTIONAL COVERAGE/EXTERIOR BUILDING GLASS DEDUCTIBLE$ 250 OPTIONAL COVERAGES-Applicable only if an "X"is shown in the boxes below: Limits of Insurance 1• ❑Outdoor Signs 2. 0 Tenant's Exterior Building Glass $ per occurrence 3.Interior Glass ❑Basement/ground floor level $ 4. 0 Employee Dishonesty ❑All Floors included 5 0 Money&Securities(Special Form Only) $ per occurrence $ Inside the Premises COVERAGE EXTENSIONS $ Outside the Premises 1. Optional Higher Limits-Accounts Receivable 2. Optional Higher Limits-Valuable Papers $ ADDITIONAL COVERAGES Optional Higher Limits-Forgery and Alteration $ $ LIABILITY AND MEDICAL PAYMENTS Except for Fire Legal Liability, each paid claim for the following coverages reduces the amount of insurance we provide duringthe applicable annual period. Please refer to Paragraph D.4. of the Businessowners Liability Coverage Form. PP Liability and Medical Expenses Limits of Insurance $ 1,000,000 Medical Expenses $ 5,000 Per person Fire Legal Liability $ 50,000 Any one fire or explosion FORMS/ENDORSEMENTS ATTACHED TO THIS POLICY:(See Schedule o Fop, . a ,-- ndors COUNTERSIGNED 7 1 �, liter BPDEC4) (DATE) , BY REPRESENTATIVE) THESE DECLARATIONS TOGETHER WITH THE COVERAGE FORM(S), COMMON POL CY CONDITIONS, FORMS AND ENDORSEMENTS, IF ANY, ISSUED TO FORMA PART THEREFORE,COMPLETE THE ABOVE NUMBERED POLICY. Includes copyrighted material of the Insurance Services Office, Inc. Copyright, Insurance Services Office, Inc., 1997 BPDECI 01/10 INSURED COPY 06/26/2018 (JSMI)