The URL can be used to link to this page

Home My WebLink Aboutbld-20-002669 Office Use Only • Permit# 0 Amount MA `M S.t c-F, Permit expires 180 days from :: .: :... 13L,t -QV- IIJt9 issue date EXPRESS BUILDING PERMIT APPLICATI Y b► � u 4 ' p TOWN OF YARMOUTH Yarmouth Building Department UV 0 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 1#3 61J1Sf 1i1t:;t,rjy0--t4.4% ia-at j 1U . 111 Oat(o 1 3 ASSESSOR'S INFORMATION: t/ �i Map: Parcel: +-� OWNER: 5k Eipt ArV .)D� 155 ,0 auayx;ts (z-at S b(S- 30. - a l dc7 1 NAMEPRESENTADDRESS/eat/pits' itthze,/ra_ bal03ti CONTRACTOR: at to e'C* CO y1$eKfi7l-i ISY\. IS RG2+'t L U e&,evyt^ �A __. NAME r MAILING ADDRESS TEL.# 7/Residential 0 Commercial Est.Cost of Construction$ O 6 U C) Home Improvement Contractor Lic.# /7 $ 8IO O Construction Supervisor Lic.# Workman's CompensationInsurance: (check one) ✓I am the homeowner E I am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: 3)u i4K C G iN()Ark (i(15.() C'R. Worker's Comp.Policy (/JC ( S cso/'7 7 56 /al 6 . - A-iv6 "nt�-� � -e wC e.. 5a-b 9,5 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 5 Replacement windows:# 6 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: U CVYY)1,l11/ p 14-/ 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 revocatio y license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signatur - Date: v ! i l mi Owners Sign ur r a h Date: j C} Approved By: Date: // 7// Building Official esi e) EMAI RESS: Zoning District: Historical District: 1_! Yes No Flood Plain Zone: Yes G No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No 1 Yes I No The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectriciPleasans/Plumbers Leeiblv Applicant Information _ f Name(Business/Organization/Individual):_ 6 mil Address: Le4� St t'Z' Se-tPl,cf i c.k �u& 0., $ 3 Phone#:. ,moo g 3 4 0,2 I3 a City/State/Zip:Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 4. I ant a general contractor and I 6. New construction employees(full and/or part-time).*C) have sub-contractorsRemodeling listed on the attached sheet. I am a sole proprietor er- These sub-contractors have 7.8. Demolition ship and have no employees ogees and have workers' working for me in any capacity. employees9. Building addition [No required.]workers'comp. insurance comp.insurance.t We are a corporation and its 10. Electrical repairs or additions 5. 3. I am a homeowner doing all work officers have exercised their 11. Plumbing repairs or additions right of exemption per MGL myself. [No workers'comp. 12. Roof repairs c. 152,§1(4),and we have no Other insurance required.]t employees. [No workers' 13 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. "LW)Insurance Company Name: /&�(� f1'7/ A 6 a Policy#or Self-ins.Lic.#: /il/C e SO 5-4) !g-.2 9-5 Expiration Date: /AQ.,& /o2 6 d City/State/Zip: tnr Wr U aG 7 3 Job Site Address: 1/3 GJI� ��'o�^s'�` � 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the ' and penalties of perjury that the information provided above is true and correct. Signature: ,�'%�� Date: I ry / / 02,61 i Phone#: Sad .340ai? o . , +:' t. 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#: AFRO' CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 6/3/2019 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 rights to the certificate holder in lieu of such endorsement(s). PRODUCER C4NTACT Larry Cowan Cowan Insurance Agency,Inc. �"N F,,,).978-372-1451 w FAXNo):978-521-4669 359 Main Street E-MA :MAIL tarry@cowaninsurance.com INSURER(S)AFFORDING COVERAGE NAIC t Haverhill MA 01830 INSURER A:Associated Employers Insurance Company INSURED INSURER B Stephen Duff INSURER C: 1586 Hyannis Road INSURER D: INSURER E: Barnstable MA 02630 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. IEXP TR TYPE OF INSURANCE WWI POLICY NUMBER (iMOMIDOIYEYYYi 1 (MMID POLICY YYY) UNITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO RENTD $ CLAIMS-MADE OCCUR PRFMISFS(Fa occur nre) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY jECT LOC PRODUCTS-COMP/OP AGG $ OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Fa acridnM) ANY AUTO BODILY INJURY(Per person) $ —OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY — AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY — AUTOS ONLY (Per arxident) UMBRELLA UAB OCCUR EACH OCCURRENCE _ $ EXCESS UAB CLAIMS-MADE AGGREGATE $ QED RETENTION$ $ WORKERS COMPENSATION X PER O Tt1TF FR AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y E.L.EACH ACCIDENT $100,000 A OFFICER/MEMBER EXCLUDED? N N/A WCC5009775012018 02/10/2019 02/10/2020 (Mandatory in NH) EL DISEASE-EA EMPLOYEE $100,000 I7 s describe under 9CRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Biuiiding Dept. Carpentry contractor. CERTIFICATE HOLDER CANCELLATION Town of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE • <SC> I Fax:(508)790-6230 IW b , 0 1 988-201 5 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD - :�- Vc`+Swf`" t'h r A# ",.- -_ .- $a aE a .�- .a . br 'axr R �r� 3 , p,}- ..-"ca Y y £ sua !nn :i t .fig,; *� :� i"` ^¢! .. cnj , _ F4 l ^ 4-,," i? s� 4 ,` ^ t � !M1 " l o- .}fi �3 4 v,r `4; h cmom- ' h E i • % !£)+ fir x v F { r s��: L {.. -' t ,s � ' .,�ya. - -�� l.a a�,r, f em n'Y i..y4 • �,�y n .k^rou ,t x ' +µ��R FE(W- �a �� 4} 4 s,aP iatX*:�. ' ' ''." " ,+ >a� u f c .77-w yam; E'k s - wit firs & �� 'y 4 ' (� ((�%ildill()11/fief/// (/fl /(aJJieAuj(IJ Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation Registration: 188860 STEPHEN DUFF CONSTRUCTION,LLC Expiration: 09/11/2021 1586 HYANNIS RD BARNSTABLE,MA 02630 Update Address and Return Card. Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 188860 09/11/2021 1000 Washington Street -Suite 710 STEPHEN DUFF CONSTRUCTION,LLC Boston,MA 02118 STEPHEN DUFF 1586 HYANNIS RD �(,�.er l , sk ( r BARNSTABLE,MA 02630 Undersecretaryt valid without signature