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Home My WebLink Aboutbld-20-004790 `.*•O�•YdlR $ iulee use um), Jr .. 0 -A Permit# //� O 'i �Amount �V A~T esF 1, I N �`°"°"'�°"�c $ v Permit expires 180 days from BLI)-- 0-s-r7q ;issue date EXPRESS BUILDING PERMIT APPLICA I! " - C E RI E D TOWN OF YARMOUTH Yarmouth Building Department MAR 02 20201 1146 Route 28 I :, yr ,�. i South Yarmouth, MA 02664 ' �'� I (508) 398-2231 Ext. 1261 / CONSTRUCTION ADDRESS: ' s. / J/',D A / /f. /Qr&/&!4 ,i//��it ASSESSOR'S INFORMATION: Map: Parcel: OWNER: A.,___,Al�t ai°42-e (/// -2 LJ .2Q /G,,P,,---, )F�'• V�i)- 75 9 P // NAME PRESENT ADDRESS TEL. # CONTRACTOR: ' G-&-22 M 5,A44tT).4'o Z' &enrc,oe1 c},udwie*/ 7tiV- S3-- ql Z.c NAME MAILING ADDRESS TEL.# residential ❑Commercial Est. Cost of Construction$lc\/110 &l e' Home Improvement Contractor Lic.# f/S Si Construction Supervisor Lic.# CAL 567 7 \. Workman's Compensation Insurance: (check one) I am the homeowner ❑ I am the sole proprietor ( have Worker's Compensation Insurance / Insurance Company Name: LA`LiT� i 4 �,n-�t/�./ Worker's Comp.Policy# wLC 500.S4/ g/yr120/,I� WORK TO BE PERFORMED 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: QU f �\ Location of Facility I declare under penalties of perjury that the statements erein contained are d correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or revocation o I e or prosecut nder M.G.L.Ch.268,Section 1. cV Applicant's Signature: Date: l' 2.-- --)Owners Signature(or attachment)M9,(4,,a Date: i 0.,24 c 7 �0 Approved By: V .;:e...` Date: 3- - - U Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No ❑ Yes 0 No '� The Commonwealth of Massachusetts or - Department of Industrial Accidents j 1 Congress Street, Suite 100 ..\, ,‘ Boston, MA 02114-2017 '��„„5�•`'� 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)` �� -e _...4( /�e/ �ddress: 7 d X e P-- City/State/Ziprid of ;}�,Q/OM Phone #: e- 759 P?/9 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. E New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. E Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner all work myself. 9. ❑ Demolition ❑ doing y [No workers'comp. insurance required.]t _ m a homeowner and will be hiring contractors to conduct all work on myproperty. I will 10 _ Building addition ..isure 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 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.❑Roof repairs These sub-contractors have employees and have workers'comp. insurance.: 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other S I DC 4,J7JC, 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. 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: Policy# or Self-ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: 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. •_nature• /. 7 Dat _�® . �U C 2&'z ,C) J Phone#: 3-1— Zv 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#: Division of Professional Licensure litit Board of Building Regulations and Standards Construction BSnpervisor CS-025077 ESpires: 04/12/2020 PETER C MEOMARTINO 29 BOARDLEYRD SANDWICH MA 02563 Commissioner s r - nrm(a ru ea/6(a/' I z Aaj ?, Offceoff Consumer Maim&Business.Regulation> HOME IMPROVEMENT �'. P,. TYPE:IndMdual 115231 04/19/2020 PETER MEOM RTINO PETER C.IEN EOMARTIN(p SANDWICH,MA 02563 Undersecretary `>' ^ Y QS DATE(MM/DD/YYYY) A Cc CERTIFICATE OF LIABILITY INSURANCE 02128120 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 CONTACT NAME: FAX United Insurance Agency,Inc. PHON u ). 508-759-6595 (A/C,No): 508-759-3822 199 Main Street ii k ' • P.O.Box 1013 ADDRESS: Buzzards Bay,MA 02532 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Atlantic Casualty INSURED INSURER B: Commerce Insurance Co Bruce E Wenzel INSURER C: AEIC Bx 187 INSURER D: Buzzards Bay,MA 02532-0187 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. INSR TYPE OF INSURANCE ADDLSUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO REN rED CLAIMS-MADE OCCUR PREMISES Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 A L307000183 07/25/19 07/25/20 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY n JJECOT ' I LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ 100,000 B OWNED Ale SCHEDULED HQT603 09/27/19 09/27/20 BODILY INJURY(Per accident) $ 300,000 AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE _ AUTOS ONLY _ AUTOS ONLY (Per accident) $ 100,000 $ UMBRELLA LIAR _ OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATIONOTH- AND EMPLOYERS'LIABILITY x STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 100,000 C OFFICER/MEMBER EXCLUDED? N/A WCC50050181442019A 11/29/19 11/29/20 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 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) Carpentry Wokers'Comp policy does not include coverage for Bruce Wenzel Email: pdmeo@comcast.net CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Northeast Services Inc ACCORDANCE WITH THE POLICY PROVISIONS. 17 Jan Sebastian Dr Unit 7 Sandwich,MA 02563 AUTHORIZED REPRESENTATIVE Kris Dexter @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD