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Home My WebLink AboutBld-20-003901 Office Use Only OY.YAit 4' '� Permit# p Amount SD- Y w«.K•4tc Permit expires 180 days from 60 -2c —3(2,t) issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH 5 Yarmouth Building Department 1146 Route 28 i ( O South Yarmouth, MA 02664 � (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: I c�c a Viv . �1/i fi 5 � uw V\ M A G CGL0 ASSESSOR'S INFORMATION: Map: Parcel: OWNER: 1-ke"--Uttf-1\A.11 kti S Li I t4.-- } I LC(0 ClV1 I�VQ. ICU-01( )-%\ U W I NAME` PRESENT ADDRESS u,�;Jr TEL. # C CONTRACTOR: �(.,1 tL.QVQ GCQ.LXI kClnittkPoiik 6Z(ot(10 1 S I-(LIL,-77i ] NAME MAILING ADDRESS TEL.# [residential 0 Commercial Est.Cost of Construction$__Si CZU Home Improvement Contractor Lic.# (} Q� Construction Supervisor Lic.# C5 Oaf Z 1-L15 Workman's Compensation Insurance: (check one) I am the homeowner ❑ 1 am the sole proprietor • I have Worker's Compensation Insurance r 5T1,�} C 13 9 �t 5 9 Insurance Company Name: V v l,S�' 111�,;�2U1 Worker's Comp.Policy# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# j Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *Tile debris will be disposed of at: (46.. ni t-i'r l U J Location of acility I declare under penalties of perjury that erein contained are true and correct to the best of my knowledge and belief. 1 understand that any false answer(s) will be just cause for denial or revocaf of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: l�j 2C� Owners Signature(or attachment) / .0 111 /L l L ("(' y ' Date: — 3 2_CD Approved By: Date: /7'..2Q Bui g Off" (or des gnee) EMAIL AI]8 'SS: e h,t Bo t c0111 Zoning District: Historical District: ': Yes No Flood Plain Zone: Yes ':3 No Water Resource Protection District: Within 100 ft.of Wetlands: �:_! Yes I No i::1 Yes No The Commonwealth of Massachusetts —_ Department ofIndustrial Accidents P _e:/fl= Congress Street, Suite 100 ��_ Boston, MA 02114-2017 T,`", 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): S LA,1, q V\.k dV"P� Address: 0 Ck P'v , City/State/Zip: -1 lnx � „�— �(} 0 2.lc9(,) Phone#: 1 t -kg L -1 / 7 Are you an employer?Check the appropriate box: Type of project(required): i2jt I am a employer with Li employees(full and/or part-time).* 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. remodeling 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 0 Building addition 4.0 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 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 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.; 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 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: 'A/4 - - \q.c(irtkAi Policy#or Self-ins.Lic.#: S'(-(,L( ( 3 Gj S c% Expiration Date: / -3--Z I #'di Job Site Address: )i&( &Q,v l'&.c t j . 5 4(,1 i11 t4l U tc t-/ City/State/Zip: S <(act)) i11 F} 6 e- (c( 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 u • r .•'ns and penalties of perjury that the information provided above is true and correct Signature: Date: A- / • Phone#: ` ( , Y 72/ 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#: A Worker's Compensation and Employer's Liability Policy v�6et" h I're Hathaway NorGUARD Insurance Company - A Stock Co. ♦ Y Policy Number STWC139459 fr4�� Insurance Renewal of'STWC009749 AS GuA�D Companies NCCI No. [25844] • Policy Information Page [1]Named Insured and Mailing Address Agency Straight and Level Inc WEST'S INSURANCE AGENCY DBA/TA Mr. Handyman Capecod and Islands 1225 Tri-State Pkwy. 21 Ocean Ave Suite 500 Harwich Port, MA 02646-2130 Gurnee, IL 60031 Agency Code: ILIROQ17 Federal Employer's ID 82-3025675 , Insured is Corporation Additional Names of Insured (N2) Mr. Handyman Capecod and Islands [2] Policy Period From January 3, 2020 to January 3, 2021, 12:01 AM, standard time at the insured's mailing address. [3] Coverage A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation Law of the following states: Massachusetts B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed in item [3]A. The limits of our liability under Part Two are: Bodily Injury by Accident - each accident $500,000 Bodily Injury by Disease - each employee $500,000 Bodily Injury by Disease - policy limit $500,000 C. Other States Insurance - Part Three of this policy applies to all states, except any state listed in item [3]A. and the states of North Dakota, Ohio, Washington, and Wyoming. g D. This policy includes these endorsements and schedules: 8 See Extension of Information Page - Schedule of Forms N [4] Premium The Premium Basis and, therefore, the premium will be determined by our Manual of Rules, Classifications, Rates, and Rating Plans. All required information is subject to verification and change by audit. (Continued on another page), a 0 g 0 V Total Estimated Policy Premium $ 7,070 Total Surcharges/Assessments $ $232.00 Total Estimated Cost $ $7,302.00 INTERNAL USE XX Page - 1 - Information Page MGA : STWC139459 WC 000001A Date : 11/29/2019 MANOTE Issuing Office: P.O. Box A-H, 39 Public Square,Wilkes-Barre, PA 18703-0020 • www.guard.com Plit Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR •Individual Expiration 03/15/2021 PHILIP BOIREIj _ �_ 4 � � PHILIP BOIRE \k' 21 OCEAN AVE HARWICHPORT,MA'02646• Undersecretary! Commonwealth of Massachusetts - Division of Professional Licensure ". Board of Building Regulations and Standards 1; Constzil' '!risor CS-092745 0.,pires:05/18/2021 PHILIP BOI { 21 OCEAN A 1. HARWICH O Commissioner • • • ,�4