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Home My WebLink AboutBld-20-003158 O ;.Y Office Use Only •Z � Permit# O �+ - hi 'Amount 9 0-- MATT 1M 4. u'� :Permit expires 180 days from °''issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH ii % ,, ! 'tj�' Yarmouth Building Department 1146 Route 280" South Yarmouth, MA 02664 t �1 (508W ) 398-2y231 Ext. 126�11� "] CONSTRUCTION ADDRESS: 31 S ftj( 2 g 94L1 Ain 026 I �j ( aO— 3 k r' ASSESSOR'S INFORMATION: q I,�� i��-�,� Map: ( �i t� Parcel: p ��r OWNER: 11� 4Mt24 04!,M 0"K1I /NLMbt ►1 I\Q/S t rv,,t cog 131 9 6`(4 . N PRESENT DRESS TEL.L # CONTRACTOR: I S Coxi9 ul'Jx ts 1 S tirr V� 1J vl,W`1 �t/D et 1o6fl NAME MAILING ADDRESS TESL./# ❑Residential Commercial Est.Cost of Construction$ 30✓ 0O 0 Home Improvement Contractor Lic.# Construction Supervisor Lic.# CS—S—Min 1 `.- Workman's Compensation Insurance: (check one) ❑ I am the homeowner{' ❑ I am the sole proprietor I have Worker's Compensation Insurance � �+�`{p r Insurance Company Name: ''`' C C��Q & I WIrt��(j lecorker's Comp.Policy# (j C VC 14 00 00 0 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 11.0 ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: (I)NOS n \ 141V1Location Facility I declare under penalties . . rjury at 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 ford I . . ation of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: '.!—ailk Date: Ck ' TO'1 Owners Signsiiir,t,-hme �'�' Date: Approved By: s�r'� l A N O(.I35 Date: (JC.e, I 20 iCk Building Offici:1 o ) EMAIL AD s-. SS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: u Yes ❑ No Li Yes 0 No The Commonwealth ofMassachusetts *_= Department of Industrial Accidents 1= 1 Congress Street, Suite 100 1,0- Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information t Please Print Leeibly Name (Business/Organization/Individual): 1ket CpiQ. Address: 1 L? ,'; Gtimptodin oeliA L(' City/State/Zip: G ktfb(M( & MA (Titbit Phone#: 5Cf6 851 0637 Are you an employer?Check the appropriate box: Type of project(required): 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 doingall workmyself. t 9. ❑Demolition ❑ [No workers'comp.insurance required.) 4.❑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.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.01 am a general contractor and I have hired the sub-contractors listed on the attached sheet. i' Roof repairs These sub-contractors have employees and have workers'comp.insuranc,e.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El Other 152,§I(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.suancC 1WIATC Otitotiik \ few. t o Insurance Company Name: `//� pr M� ,L Policy#or Self-ins.Lic.#: K/C1 V O 1 `k OCODO Expiration Date: O'f J V U)20 Job Site Address: I) ki U/ 4 PaitIVI4M\ City/State/Zip: 641t V GD13 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$250.00 a day against the viol. _ .A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verific• 4 o I do hereby c:a ' • . e pains and penalties of perjury that the information provided above is true and correct Signature: it) Date: 4�;L I U)(9 •` • Phone#: 1 c� ati' 6651 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: �`pF'�'RR's Office Use Only A'' • `tr s. �! O\ Permit# i •d: W jCi i l+ ,;:r Amount lN\.un;., Sr/_ ,9 Permit expires 180 days from issue date EXPRES . BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: .P.9+?) ftj( 28' ( '� -1rm 4j MA 02(,7 ASSESSOR'S INFORMATION: ��y� � 1 ,Map,:: 1,,,� r� Parcel: �-�i /� OWNER: Ati �6� ' L-41At 1k s c l c & f1 C16` 4 , N PRESENT TEL. # CONTRACTOR: 1CY(l/p) "+)( to' r 5 t .1 NAME MAILING ADDRESS TEL.# J Residential Commercial Est.Costof Construction$ 50. 00 C Home Improvement Contractor Lic.# Construction Supervisor Lic.# CS-CT9 16. Workman's Compensation Insurance: (check one) I am the homeowner - I am th sole proprietor have Worker's Compensation Insurance Insurance Company Name: t"f1��Iri�t tC• 4, •,p... `i �y� p y# (�,i` t!(�4 �q ,>€ o orker's Com .folic WORK TO BE PERFORMED Tent Duration Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares eplacement windows:# Replacement doors: # Roofing: #of Squares f'W ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic D t. ( )Replacing like for like Pool fencing *The debris will be disposed of at: (1)61,SI AA kocr . Location of Facility 1 declare under penalties • • 'ury , the statem herein contained are true and correct to the best of my knowledge and belief. 1 understand that any false answers) will be just cause for•-.I •• .. • : ion of my lice and for prosecution under M.G.L.Ch.268,Section 1. �/ r` Applicant's Signature: ►. Date: NC ( L- ' 161 Owners Signature(orb if�ent) Date: Approved By: e N n41 )(. tia Date: () I 20`41 Building Official(or designee) EMAIL AD SS: Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No • commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards • Constrf{%tlpgrvisor .CS-084916 = E,pires: 04/02/2021 . MALL J HOPXINS y + BOX 231 f S.YARMOUTFIMA 4 Commissioner it,/,:.;?I/,+ A CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/13/2019 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: :f the certificate holder is an ADDITIONAL INSURED,the policy(ies)must 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 00906-001 ACT McShea Insurance Agency NW Ex): (508)420-9011 rn.No.: 1645 Falmouth Road,Fit 28-Suite 2 . Centerville,MA 02632 , INSURER/SI AFFORDING COVERAGE NAM* INSURER A: Atlantic Charter Insurance Company VDAC 44326 INSURED HOPKINS COR? INSURERS: INSURER C: 311 Paddocks Path Dennis,MA 02638 INSURER D INSURER E: R1JRFR F: COVERAGES CERTIFIC 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. TYPE OF INSURANCE ri t POLICY NUMBER ( g ( Sr LIMITSGENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABIUTY DAMAGE TO RENTED $ PREMISES(Ea occurrence) CLAIMS-MADE I OCCUR IMED EXP(Any one person) $ PERSONAL&ADV INJURY $ I I GENERAL AGGREGATE $ IGEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ I1 POUCY t !JECTLOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO I (Ea accideml $ BODILY INJURY(Per person) $ I ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS i (Per accident) $ I i UMBRELLA LIAB OCCUR j EACH OCCURRENCE $ - ,EXCESS LIAB CLAIMS MADE AGGREGATE $ DED I RETENTION $ i $ Epp��q� s I�N ( VV�/Nt� ! I X l 1'ORY LIMITS I IR- A OFFICER/MEMBER EXCLUDED9 ECUTIVEf 1 N/A WCVO1450000 4/23/2019 04/23/2020 E.L EACH ACCIDENT $ 500,000.00 (Mandatory in NH) I E.L DISEASE-EA EMPLOYEE $ I�{{ aeS desSc�nnbb and Policy Coverage State:MA 500,000.00 D SC`RIPTION OF gPERATIONS below E.L DISEASE-POLICY LIMIT $ 500,000.00 I i i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) CERTIFICATE HOLDER CANCELLATION Town of Dennis SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 685 Route 134 BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY South Dennis,MA 02660 WILL ENDEAVOR TO MAIL NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE fivrwital& ACORD 25(2014/01) 01988-2014 ACORD CORPORATION.All rights reserved. The ACORD name and logo are registered marks of ACORD CERTIFICATE HOLDER COPY ACO CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY)• `.."--. 11/12/2019 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 T-IE CERTIFICATE HOLDER. IMPORTANT. !f the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBRGtai,T1ON 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 CONTACT NAME: Sharon COVIno MCSnea Insurance Agency,Inc PHONE (A/C.No,Ex0, (508)420-9011 i Fax (508)420-9010 1545 Falmouth Road, Rt 28 BLDG D E-MAIL er e!ville, MA 02632 ADDRESS: sharon@mcsheainsurance.com INSURER(S)AFFORDING COVERAGE NAIC i INSURER A: EVANSTON INSURED ,INSURER 8: Hopkins Corp i INSURERC: al•'. rac dOckS Path I INSURER D: Dennis,MA 02638 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 00000000-0 REVISION NUMBER: 3 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 VNTH 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 ADDL(((BBBUUUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD LWVD POLICY NUMBER (MMIDD/YYYY) (MMIDD/YYYY) OMITS A X COMMERCIAL GENERAL LIABILITY r 3EV2552 04/25/2019 04/25/2020 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 1 CLAIMS-MADE n OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: ! GENERAL AGGREGATE $ 2,000,000 X POLICY! i JPRo- ECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILEUABILITY I - COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ — OWNED SCHEDULED BODILYINJURY(Per $ AUTOS ONLY AUTOS ( ) HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY L_ AUTOS ONLY (Per accident) $ 1 _ _ $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ 1 1EXCESS UAB CLAIMS-MADE; AGGREGATE $ DED RETENTION$ I $ !WORKERS COMPENSATION I AND EMPLOYERS'UABIUTY Y/N I PER ERY MANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ i OFFICER/MEMBER EXCLUDED? N/A 1(Mandatory In NH) 1Ifyes despiteunder E.L.DISEASE-EA EMPLOYEE$ I DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(AcORD 101,Additional Remarks Schedule,may be attached it more space Is required) Workers Comp Certificate to come directly from the carrier Certificate Holder is an Additional Insured for duration of the contract CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN TOWN OF DENNIS ACCORDANCE�E WITH THE POLICY PROVISIONS. AUTHOR/ amD RESENTATIVE 2 )74Th (SSC) ®1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2C,G/03) The ACORD name and logo are registered marks of ACORD Printed by SSC on November 12,2019 at 12:19PM