The URL can be used to link to this page

Home My WebLink AboutBld-20-001283 _ b Y Office Use Only ►f Permit# rr�� LS D O . .ftsol•'; . HI '"Amount l.J n�ri-AZn esc •r °Rondo'�6Cd,' 'Permit expires 180 days from a issue date 13U - 2,CD—COIa�3 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 f:l `'' 4)019 CONSTRUCTION ADDRESS: -30 v1 50/1 '�, �� W)U - ASSESSOR'S INFORMATION: // Map: Parcel: OWNER: 'So n /14C 1)G SGt ✓� e NAME PRESENT ADDRESS TEL. # CONTRACTOR: 1-05 Ross-el- P, 0• &i )'C VLF cog .7 0-oi(O 2- NA E LNG ADDRESS D 2_ TEL.# l l Residential 0 Commercial Est.Cost of Construction$ b UO Home Improvement Contractor Lic.# /.�!'39 r Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) • 0 I am the homeowner 0 I am the sole proprietor )I I have Worker's Compensation Insurance Insurance Company Name: Dcw'Lv3 t an 2(( Worker's Comp.Policy# i4 ODS—A')W1j 2O 15 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares t .2 ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. (,)0)Replacing like for like Pool fencing *The debris will be disposed of at: 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 revocation of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: c////1 T Owners Signa e(or attachment) Date: Approved By: / Date: 1 Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts r 1 'lit= L Department oflndustrialAccidents =z7ir- 1 Congress Street, Suite 100 _a Boston, MA 02114-2017 ;;5 www.mass.gov/dig Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Josh bc, DOSS-COL Address: P. 0, SoY / 7a City/State/Zip: i ' 87 ctn(1;s pal ITA/,d 02v)?hone #: DOE --360-01612- Are you an employer?Check the appropriate box: Type of project(required): 1: I am a employer with L1 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 8. ❑ 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.❑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 5.1=I I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.XRoof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.7 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. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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: .7)O J/j ?AO n p i/ Policy#or Self-ins. Lic. #: j,/CC3"Od-vo)Y T Expiration Date: /rV'2-61 g Job Site Address: 3 0 .1 oW nS0e1 City/State/Zip: ti, Koko uj- I 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 penalties of perjury that the information provided above is true and correct. Signature: Date: Wct115 Phone*: 6-'03'^ ?ro 0-011,Q?...- 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#: • ZL9a0 vW'10bdSINN`,11-1 \ 9Zl X09 Od 113SSv9'9 vf1HS(-Ir` '119S9v9 9 vf1HSCr OZOZ/lZ/Z.0 96C9€L Uoggiidx3 Uo}e.i3s16aa IsnPIAIPuI adA1 dO13V0.114001N3 1/43AO Id Wl 31111OH uogeinbaa sseuisng sJIeyy Jewnsuo3 to atai,P.D s,N ryprwyrvrrJl&/ V/fv,I,iruvrccruo ej4j Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constrvektri' p rvisor CS-113552 Apires: 05/25/2023 JOSHUA B BPS(ti + 1 :f PO BOX 128 f = i i W HYANNISPI • M► # `, ` / Commissioner Client#:36429 2BASSETTJO ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MMIMlDDlYYYY) 3104DD 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 NAME: The Hilb Group of N.E.dba PAVE.ExtI.508 775-1620 I rkt,No): 5087781218 Dowling&O'Neil Insurance Agy E-NWL ADDRESS: P.O. Box 1990 INSURER(S)AFFORDING COVERAGE NAIC s Hyannis,MA 02601 INSURERA:NGM Insurance Company 14788 INSURED INSURER B:Associated Employers Insurance Company 11104 Joshua13.Bassett INSURER C P.O.Box 128 INSURER D: West Hyannisport,MA 02672 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. LTR TYPE OF INSURANCE ADDLSUBR POLICY EFF POLICY EXP MI LIMITS INSR WVD POLICY NUMBER (MDD!YYYY) (MMIDDIYYYY) A X COMMERCIAL GENERAL LIABILITY MPJ2966M 0311 /2019 0311112020 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR PREMISES(Ea o r ce) $500,000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $2,000,000 PRO- v POLICY X JECT X LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) _ ANY AUTO BODILY INJURY(Per person) S OWNED OS ONLY SCHEDULED BODILY INJURY(Per occident) $ AUTOS HIRED NON-OWNED PROPERTY DAMAGE S _ AUTOS ONLY ^ AUTOS ONLY (Per accident) UMBRELLA LIAR ( OCCUR EACH OCCURRENCE $ EXCESS uAB I CLAIMS-MADE i AGGREGATE S DED RETENTIONS $ B WORKERS COMPENSATION tWCC50050078582019A 01104/2019 01/04/2020,X: srATUTE ERA AND EMPLOYERS'LIAEUUTY Y!N ANY PROPRIETOR/PARTNER/EXECUTIVE N NIA E.L.EACH ACCIDENT s500,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY UMIT $500,000 DESCRIPTION OF OPERATIONS!LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Certificate holder Is named additional insured for general liability when required by written contract. 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 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD #S231447/M231436 RPJX1 A-NC3819/T-3850-3-part carbonless contractors proposal / 'It rOPO U Page# of pages 305A(-0L4&selt— p.0, Boy /2`S wool W, J./yan�iyor4— AA-o o ) Z pe PROPOSAL SUBMITTED TO:L // JOB NAME JOB# —3Dhh A4cAotle ADDRESS JOB LOCATION 30-To hh,Son 1 DATE DATE OF PLANS bl, 6 f r rn Oa+A PHONE# 6 oa\ J /`7 S 2 5— FAX# ARCHITECT \\ J / / e hereby submit specifications and estimates for ..._..:_ ` A�1 to 4 /� A4f2 4ttew„ \ Fs- . l l'51" - S1'' a/n r -- / fa>�if' jt'ci --ff/ ybD, — J c . I'eWI:et Wood acc�Wcr/ / A13 ' At-do Al/Aciiirs_ = 6'00, !/ef Z —' 7 in i)r/1°5 57 04C73 — -—r 4 Cr 1*--J o 0, \I 2_ l�olis ZcCit 110 C✓ - i _ - - . ?_�1.-1, Pp ._.... . - -- -- — -- - co+¢ , . 1',,^�� LoL Jrftj— I Box &v,-t //a,1S — 9o4--+, r13 .4 if f-v- r , -- ---— - �te>' Pr krP_ - 2 33 5—;i // We pro ose hereby to furnish material and labor—complete in accordance with the above specifications for the sum of: _ $ 3 CiGL� . G460( o! t Ol `�f4t3, �J.n TuA O"� /JJa- 1iUi 'or %_ee Dollars with payments to be made as follows: Pai i' i 4II wg' ,l. /3 l r e, Any alteration or deviation from above specifications involving extra costs Respectfully ig.,4../: 4,"="' r•—•"`-' will be executed only upon written order,and will become an extra charge submitted over and above the estimate. All agreements contingent upon strikes, \accidents,or delays beyond our control. Note-this proposal may be withdrawn by.us if not accepted within days. acceptance of firopo5ai The above prices,specifications and conditions are satisfactory and are /' hereby accepted. You are authorized to do the work as specified. Signature �f Payments will be made as outlined above. /,