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Home My WebLink AboutBld-20-004151 01..1r gR ,-1(Mice Use Onlyi. k l- . Permit !'! /, QU H Amount U ._� Il � L MA'fTACM eSE �,�`° °E°"Q�yd Permit expires 180 days from Z ( j I Si ;issue date EXPRESS BUILDING PERMIT APPLICAT CEIVED1 TOWN OF YARMOUTH ll 1 Yarmouth Building Department .1AN ! 2021' 1 1 1146 Route 28 p U South Yarmouth, MA 02664 \ nDOA (lL I� (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 'S k (rY071.,.,.e. -c «T rN( 1,- 2. , lipee.irlr,0) \),n, t i ku A. ASSESSOR'S INFORMATION: Map: j LtO Parcel: s ._ (2:i tc,Z. OWNER:*li7O.v"l n 1.'\r-. `i T :aril C'nc st,Ntn lq&) L i-kN:- 0Cti2lnlc':Yrbkst t N A.csLLbi: So?) '533 - i i NAME PRESENT ADDRESS TEL. # ASGa e.�r2v ,>'v,_ CONTRACTOR: i'At C:51 K.ksi,\ �cc:.ati d'(CANT vii'y Qcf A Q4d l'c,�2'�'. CA ri-Sln�ttti°I A. L 7 b 4`i 509-Z'a.1-S c13?> NAME MAILING TEL.# .XResidential ❑Commercial Est. Cost of Construction$ Home Improvement Contractor Lic.# \7.)4S65 3 Construction Supervisor Lic.# C. -O b r', Q c t Workman's Compensation Insurance: (check one) D I am the homeowner D. I am the sole proprietor VI have Worker's Compensation Insurance Insurance Company Name:S',..,T.N,K.T34 L l`s„,Sc,,,,,k v y C,i) Worker's Comp.Policy# 12,S'} k;)43‘K Catsk l q 1( ti WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows: # Replacement doors: # Roofing: #of Squares c,-'..5 ( )Remove e ' ting* (max.2 layers) Insulation ( '1 Old Kings Highway/Historic Dist. ( Replacing like for like Pool fencing *The debris will be disposed of at: Cl'-.1,)t_V , ..0i arfAcGTo a.- {`,s_w'.J.c.- 01.&\4N'41-\S 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: • Xc.:� Date: � al`)C 3. //2.�/ 7�/ Owners Signature(or attachment) Date: 2S c. Approved By: Date: /- di- api 0 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 A No 0 Yes % No • The Commonwealth of Massachusetts / Department oflndustrialAccidents =1 = 1 Congress Street, Suite 100 I Boston, MA 02114-2017 www.mass oov/dia .. Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lezibly Name (Business/Organization/Individual): Co vsc hA Address: 9f _b ?-�ry City/State/Zip: tivtv, l Vt. ail:.4 Phone #: (01.- Are you an employer?Check the appropriate box: Type of project(required): I.E.I am a employer with b employees(full and/or part-time).* 7. ❑New construction ?.❑I am a sole proprietor or partnership and have no employees working for me in 8. [] Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑ Demolition 3.❑I am a homeowner doing all work myself. [No workers'comp.insurance required.]t 10 El Building addition 41-.0 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. 12.0 Plumbing repairs or additions 6.0 I am a general contractor and I have hired the sub-contractors listed on the artarhed sheet 13.El Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.�C Other ;�.71 v J C)U rer i? 152,§1(4),and we have no employees. [No workers'comp.insurance required.] iN= *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-contactors 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: C c i , N m-L. C.,y,..+e.4 u Co Policy Al or Self-ins.Lic.#: 061 K.00Lt Cal Expiration Date: \30 1 o 2c Job Site Address: kS ( N7VT. cTs % Ic\ City/State/Zip: V I tti1r ,Y;,Z� Attach a copy of the workers' compensation policy declaration page(showing the policy number and expira on 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 and ains and penalties of perjury that the information provided above is true and correct Signature:—I(,'\". Date: 3.\L7.1 V2(-)14..) Phone#: ",I\—coc 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 Phone#: Contact Person: ' COMPASS REALTY DEVELOPMENT CORPORATION. 25 Carleton Drive Mashpee, MA 02649 January 27,2020. To: David Holt 207 Coachman Lane West Barnstable,MA 02668 Property Address: 154 Center Street,unit 1-2 Yarmouthport, MA To: The Building Inspector, Compass Realty Development Corp/Michael Dedecko a license Massachusetts Construction Supervisor and Massachusetts home improvement contractor will be assisting David Holt with filing the proper application for the require permit at the address above.The owner hired a contractor to repair the roof.The owner supervised the repair.The owner will take full responsibility for the work completed.Compass realty development did not do the work.We do not take any responsibility for the work completed.We did go to the premise and look at the work completed. It appears to be done satisfactory. If you have any question regarding this application,feel free to contact me At 508 221-5003 or email me at: compassrealtydevelopment@gmail.com. Sincerely. - SD k,-C2ac, Michael Dedecko Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation Registration: 138653 COMPASS REALTY DEVELOPMENT CORP. Expiration: 06/21/2021 P.O.BOX 2384 MASHPEE,MA 02649 Update Address and Return Card. SCA 1 0 20M-05/17 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: Racistratiorl Expiration Office of Consumer Affairs and Business Regulation 138663 06/21/2021 1000 Washington Street -Suite 710 COMPASS REAL1YDE tw?PMENT CORP. Boston,MA 02118 MICHAEL A.DEDEGK4 •Ita-e..9 a.0 2 9te- 25 CARLETON DR 1' ,lwtia• ri ` MASHPEE,MA 02649 Undersecretary Not valid without signature ®r Commonwealth of Massachusetts Division of Professional Licensure P Board of Building Regulations and Standards Constr tiOnIStlpervisor CS-065891 Expires: 11/09/2021 MICHAEL A DEDECKO, is 25 CARLETON DRIVE MASHPEE MA 02649 -f. Commissioner f.) - AW D CERTIFICATE OF LIABILITY INSURANCE DATE ( ) o8/06/2019 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 POUCIES 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 ADDmONAL INSURED,the pollcy(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 Neu of such endorsement(s). PRODUCER CONTACTNAME! Germani Insurance Agency FIAjly - (508)428-9194 j FAXNe1: (508)428-3068 IL 908 Main Street e : certs@germaniinsurance.com INSURER(S)AFFORDING COVERAGE NAM* Osterville MA 02655 INSURER A: Penn America Insurance Co INSURED INSURER B: CONTINENTAL CASUALTY CO 20443 Compass Realty Development INSURER C: Po Box 2384 INSURER D: INSURER E: Mashpee MA 02649 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY 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. POUCY ESP LTRR TYPE OF INSURANCE wan. POUCY NUMBER IrM IrYYYYY1 lMWOD/YYYY1 UNITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 DAMAGE ENT CLAIMS-MADE X OCCUR PREMISES Ea oc ssrrence) $ 100,000 MED EXP(Any one person) S 5,000 — A N N PAV0202857 03292019 03292020 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLES PER: GENERAL AGGREGATE $ 2,000,000 PRO PRODUCTS-COMP/OP AGG S 2,000,000 POLICY I I ►ECT LOC $ OTHER: COMBINED SINGLE UNIT $ AUTOMOBILE UABIUTY (Ea accident) ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS ONLY _ AUTOS PROPERTY—aAMAGE HIRED NON-OWNED (Per accident) AUTOS ONLY — AUTOS ONLY S UMBRELLA LUU) OCCUR EACH OCCURRENCE S EXCESS UAB CLAIMS-MADE AGGREGATE S DED RETENTION S S WORKERS COMPENSATION X SSTATUTEI ER AND EMPLOYERS'LABILITY / ANY PROPRIETORIPARTNEWEXECUTIVE N!A N 6S59U61 K80119119 03/302019 03/30/2020 E.L EACH ACCIDENT S 500,000 B OFFICE(Mandatory In ER EXCLUDED? y in NH) E.L DISEASE-EA EMPLOYEE S S00,000 If under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY UNIT S 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Sebedias,may be attached It more space Is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay daims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance).The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Barnstable ACCORDANCE WITH THE POUCY PROVISIONS. 367 Main Street AUTHOR®REPRESENTATIVE 1 I Hyannis MA 02601 -- `. Ftabt:_ Email: a 1888-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2015/03) The ACORD name and logo are registered marks of ACORD