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HomeMy WebLinkAboutBld-20-000383 ,Y �,m=Usev�y `� [`Penal*!Q• 44—H r Amount rD/ Y wrr' mL Y 00 E+ _ 0--3Fs3 is da expires180 days from bib EXPRESS BUILDING PERMIT APPLICATrION TOWN OFYARMOUTH RECEIVED Yarmouth Building Department = 1146 Route 28 J U L 2 3 2019 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 B U 1 =P_"""` T By _ CONSTRUCTION ADDRESS: /e y 421}(a- pasr1./1 Ti_ Jo ir, '/2- ASSESSOR'S INFORMATION: Map: Parcel: OWNER: . l�G- 14/yes' /4 /por/4- /i9 ./P/5' NAME PRESENT ADDRESS TEL # Email Address: CONTRACTOR: ,TA72i//, CO,v ®D_ �/ .</01/0(fl2. .O/9cZ-S219 ,4eG//111;g9gYi/Ala NAME MAILING ADDRESS TEL# Email AddressC°1 �Reside.ntia9 Commercial Est.Cost of Construction$ 7( d Home Improvement Contractor Lic.# /l L199-7 Construction Supervisor Lic.# (7, ?..5-24 Workman's Compensation Insurance: (check one) I am the homeowner I am the sole proprietor I ha 4orker's Compensation Insurance Insurance Company Name: //e,,V.6/ /r-,/ Worker's Comp.Policy# `1 ./l):t.775/z2i WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares (',.3 (V)Remove existing*(max.2 layers) Insulation Old Sings Highway/Historic Dist. ( )Replacing like for like *The debris will be disposed of at yfef-wy,T) 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 'on of my license and fo rosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: ,C e2,1 i 7, Date: /6//7 Owners Signature(or attachment) lilt Date: Approved By: L ` Date: -4,3'ly Building Official(or designee) Zoning District Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District Within 100 ft.of Wetlands: Yes No Yes No !LC (....ummonweazrJz of iVlasSachusettS __ ► , Department of Industrial Accidents ...z..74-Infm. y 1 Conb ess Street,Suite 100 Boston, MA 02114-2017 • ��� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): cc9K Address: jy Z,,,,, 10,)A 47„0. City/State/Zip: /, Y7,e I0 2,4ce Phone #: Are you an employer? Check the appropriate box: Type of project(required): 1.�[am a employer with 3 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 g•�Remodeling any capacity. [No workers'comp. insurance required.) 3.0 I am a homeowner doing all work myself [No workers'comp.insurance required.]t ❑ Demolition i.❑I am a homeowner and will be hiring contractors to conduct all work on my roe I will 10 Building addition ensure that all contractors either have la/ulcers'compensation insurance or are sole 11.❑ Electrical repairs or additions proprietors with no employees. i.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 12.❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.t 13-El Roof repairs i.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] .ny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information_ iomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have .ployees. If the sub-contractors have employees,they must provide their workers'comp.policy number. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. surance Company Name: 7Q/2l/r1.rS�,,s— slicy# or Self-ins_ Lic.#: j/�c���� Expiration Date: 00.6 b Site Address: 79:`/1 j/Z.0.ii(fr- 7 City/State/Zip: ,c'd 147/1_, /'..47 a each a copy of the workers' compensation policy declaration page(showing the policy number and expiration date), ilure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 d/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 y against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance verage verification. hereby certify under the pains and penalties of perjury that the information provided above is true and correct ;nature: //, Date: one#: rf'% .�J� 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): I. 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 number(s) 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, geed 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 (Le. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial.Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia (wm Rio,uinrn//Ar o/"/loainvitteJc'f1J Division of Professional Licensure Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR • Board of Building Regulations and Standards TYPE:Corporation Construction Supervisor Registration Expiration 100497 03/24/2020 CS-063537 Expires: 10115/2019 DAVID COX,INC: t 3"„ DAVID R COX 1 PO BOX 401 4 SOUTH YARMOUTH MA 02664 DAVID R.COX k- 19 LAVENDER LN W.YARMOUTH,MA 02673 Undersecretary Commissioner • 1 _----"041 DAVID-2 OP ID: LAN A►CVRo CERTIFICATE OF LIABILITY INSURANCE DA07/16/2019TE Y) �----'" o7n s�2o19 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 rights to the certificate holder in lieu of such endorsement(s). PRODUCER 508-771-1632 CONTACT NAME: SG&D Insurance Agencies,LLC ' PHONE FAX 540 Main Street,Suite 9 (A/C,No,Ext):508-771-1632 (A/c,No): Hyannis,MA 02601 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Travelers Insurance Company 723 DINSURED INSURER B:Norfolk&Dedham Mutual Ins. 23965 avid Cox Inc. P.O.Box 401 INSURER C: S Yarmouth,MA 02664 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 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP I LIMITS LTR JNSD WVD '(MM/DD/YYYY1 (MM/DD/YYYY1 A COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR 680-1481M796-19-42 03/14/2019 03/14/2020 DAMAGES( RENTED 300,000 PREMISES lEa occurrence) $ X Business Owners MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GE 'I_AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY i I PRO-T i LOC PRODUCTS-COMP/OP AGG $ 2,000,000 �J JEC OTHER: I $ B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO 91561469A 04/19/2019 04/19/2020 BODILY INJURY(Per person) $ 250,000 OWNED SCHEDULED 500,000 AUTOS ONLY X AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE 100,000 AUTOS ONLY AUTOS ONLY (Per accident) $ _._ , UMBRELLA LIAB I OCCUR EACH OCCURRENCE $ EXCESS LIAB 1 CLAIMS-MADE AGGREGATE $ _ I I I DED i RETENTION$ $ A !WORKERS COMPENSATION I X STATUTE ERPER i AND EMPLOYERS'LIABILITY Y/N 6HUB-910X742-2-19 07/16/2019 07/16/2020 100,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 'OFFICER/MEMBER EXCLUDED'? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 i If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Barnstable THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main St Hyannis, MA 02601 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD