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Bld-20-004311 Office Use Only 4 .c... O Permit# N -r,�r �Amount / �V / « n �,ATT �' cc47. ,Permit expires 180 days from IJ-p�tp cam/' issue date RECEIVED ! EXPRESS BUILDING PERMIT APPLICAT N I TOWN OF YARMOUTH 1 EB 5 21]2:_^c= � 3 Yarmouth Building Department 0. .__.,..__._ .. ...w.....I ' 1146 Route 28 BUILDING DEPARTMENT 1 South Yarmouth, MA 02664 ©yC1--64 j 2� p �/J (508) 398-2231 Ext. 1261 I�l� 9 CONSTRUCTION ADDRESS: J r �•'' C X`P /✓r 5 A iv-its--1 la/ 74✓f �' ` - ASSESSOR'S INFORMATION: Map: /l.� // Parcel:/ , / (/ l / c OWNER: /QQSOled/(W J9/)7,d'J//'�' - Arh LJ 7Ct/eavA �UO -d % -Q 649 NAME // /PRESENT ADDRESS / _, CONTRACTORJCt /Mc 6vaii, N d3 LUfJj /S �Af"/ jJ Oa, 6744 3ff-tl-, ) NAME MAILING ADDRESS TEL.# / Residential 0 Commercial / 7 Est.Cost of Construction$Home Improvement Contractor Lie.# /93f6 Construction Supervisor Lic.# CS^ d /Q /&S? Workman's Compensation Insurance: (check one) Li I am the homeowner Cl I am the sole proprietor [YI have Worker's Compensation Insurance 1 J, Q Insurance Company Name: /I.,.rd7 Worker's Comp.Policy# LA (C S-6lTS Q /2 . Jd�I/ WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 'V Replacement windows: # ✓ 6 Replacement doors: # Roofing: #of Squares / ( 14temove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: r&✓/14//t.>-s I ,li /—r 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 rrto�catiioon of�py,�icense for -under M.G.L.Ch.268,Section 1. Applicant's Signature: — l� Date: a1 /2-6 Owners Signature(or attachment) rJin „ C� Date: C� Sid-O Approved By: Lj Date: ��ss�% • m kill(or designee) L ADDRESS: Zoning District: Historical District: _, Yes r No Flood Plain Zone: C Yes No Water Resource Protection District: Within 100 ft.of Wetlands: 17 Yes 11 No Li Yes r No The Commonwealth of Massachusetts ; ,� Department of Industrial Accidents • N.: ?/IPin l= 1 Congress Street, Suite 100 _ = Boston, MA 02114-2017 = www.mass.gov/dia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): mac,(n/-c,e Pc / s Address: 23 rat//, Jis P4 1 CT� City/State/Zip:S0 -'lit"VA/1'(/i 1V?G - Phone#: .S2't=• .3G 2 5-a-76 Are you an employer?Check the appropriate box: Type of project(required): I.�am a employer with / 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 8. modeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall work myself. t 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.❑EIectrical 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. 13.❑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 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: 4---,1'/vr Policy#or Self-ins.Lic.#: 6-) C( S02).S 6 / 9 7). /J c f / Expiration Date: /71-/'t4 o Job Site Address: . 711 /r`i c N c //ti' S /u fl4 w Y ivi City/State/ZipA4 Oa-4 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 c fy under the ains and penalties of perjury that the information provided above is ue and correct. Si ature: Date: Phone#: - 6 7 S7) 7O 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#: Client# 765382 2SANDDOI ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 12/04/2019 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(les)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 PHONE 508 775-1620 FAX 5087781218 (A/C,No,Ext): (A/C,No): Dowling&O'Neil Insurance Agy E-NAIL ADDRESS: P.O.Box 1990 INSURER(S)AFFORDING COVERAGE NAIC# Hyannis,MA 02601 INSURER A:A.I.M.Mutual Insurance Company 33758 INSURED INSURER B: Sand Dollar Customs, LLC INSURER C 23 Whites Path, Unit G,Suite 1 South Yarmouth,MA 02664 INsuRERo: 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. INS TYPE OF INSURANCE ADM SUER POLICY EFF POLICY EXP LTR INSR 4WD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYW) LIMITS COMMERCIAL GENERAL LIABILITY EACH ggSS(OCCURRENCE $ CLAIMS-MADE OCCUR PREMISEEe oar°nce) $ MED EXP(My one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO- POLICY JECT LOC PRODUCTS-COMP/OPAGG $ OTHER: $ AUTOMOBILE LIABILITY Ea as de0 SINGLE LIMIT ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY _ AUTOS ONLY (Per accident) UMBRELLA UAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION WCC50050197212019 12/04/2019 12/04/2020 X PER OTH- AND EMPLOYERS'LIABILITY Y!N RTATt ITF FR ANY EXCLUDED?ECUTIVE Y NIA E.L.EACH ACCIDENT $500,000 (Mandatory In NH) E L.DISEASE-EA EMPLOYEE $500,000 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) 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.The workers compensation policy does not provide coverage for individuals,partners,or members unless otherwise stated. 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 REPRESENTATI VET+ lI 1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD #S248633/M248632 TB1 Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, M.-�-'`: husetts 02118 Home Improve tractor Registration , r . -•- Type: Corporation SAND DOLLAR CUSTOMS LLC z j -�_ 1r Registration: 193567 1851 FALMOUTH ROAD M ;''!l Yi Expiration: 10/29/2020 CENTERVILLE,MA 02632 (c ? - _1 y Update Address and Return Card. SCA 1 0 20M-05/17 Office of Consumer Affairs a Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TY Qoraoratlon before the expiration date. If found return to: EXoiratlon Office of Consumer Affairs and Business Regulation �_ =_- 10/29/2020 1000 Washington Street-Suite 710 r Boston,MA 02118 SAND DOLLAf�?;_ - '7- w -i ' I ' , J , 1 , f, W. WALTER R.WA 1851 FALMOUTH =, l �� CENTERVILLE,MA 02832 Undersecretary Not v..' • •out ignature V m Comonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constrlitcebrt supervisor CS-091653 Ei_pires:09/30/2020 i 1 '1116C,, r WALTER R r, - 40 AL.EXAN DR YARMOUTH MW. MA .•6 N)• Commissioner CAL