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Home My WebLink AboutBld-20-003628 N,,,r0 ;YA Office Use Only i; R O 340 (O� 1+' . ,] !Amount G CSE I 0.0...,. rya,% ;Permit expires 180 days from '- * • 'issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department • 1146 Route 28 South Yarmouth, MA 02664 .7a ._ (508) 398-2231 Ext. 1261 / CONSTRUCTION ADDRESS: I�r�� '1ver�i� i �' 1 aYI4 j r G . . .,,,, ASSESSOR'S INFORMATION: �' f Map: 70 Parcel:cp OWNER: Lauor& T 1lfki ag ENT ADDRESS `� ,. . # t, 5z2 CONTRACTOR: �tr) ING 6ADt al (Vic. sceSSL.# / MI/1 AMEesidential ❑Commercial Est. Cost of Construction$ 47ca2 4.'.0 Home Improvement Contractor Lic.# I q�J,` Construction Supervisor Lic.#CI, 2.ge, Workman's Compensation Insurance: (check one) ` � I 1� � ❑ I am the homeowner.+0 I am the sole proprietor y have Worker's Compensation Insurance Insurance Company Name: ` 1 I �j�� Worker's Comp.Policy# .? ,icy WORK TO BE PERFORMED eCjii Tent Duration e etardant kiertificate attached?) Wood Stove Z'Siding: #of Squares 7 3 Replacement windows:# ` 1 , (z) 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: SY1440tith lagn oc 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: Date: Owners Signature(or attachment) eve..60. &l ✓ Date: Approved By: ,,...,—. Date: O. 3O— )41 Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No ❑ Yes C No ,n�f _ The Commonwealth of Massachusetts +W, = Department oflndustrialAccidents • _z p= 1 Congress Street, Suite 100 Boston, MA 02114-2017 °�M„q•''y 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):) Address: 10-14City/State/Zip: Vy, 10,V 4 jtib Phone #: Z , eery , 77/4" Are you an employer?Check the appropriate box: Type of project(required): I. I am a employer with 2J 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. ❑ Remodeling any capacity. [No workers'comp. insurance required.] . 3.❑I am a homeowner doing all work myself.[No workers'comp. insurance required.]t 9. ❑ Demolition 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.❑ 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. 13.E Roof repairs These sub-contractors have employees and have workers'comp. insurance.: "Acitino 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 R1 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: V- 1T' Policy#or Self-ins. Lic. #: j' •)1 • zeZ'4 1 • f 1 r7 Expiration Date: 5''16-es.c? Job Site Address: tio ,e t\ � City/State/Zip: ( � Attach a copy of the workers' compensapolicy 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 a penalties of perjury that the information provided above is true and correct. Signature: 7 Date: 10. 9 /7 Phone#: �-• $07 4.7 7 7/. 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#: Y December 5, 2019 To: Town of Yarmouth Building Dept. Please accept this letter as my authorization to allow Mr. Gary Ellis to apply for a building permit for my home at 8 Bass River Rd. and to act in my behalf on this project. Sincer Lawrence P. Sullivan Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construct'ran'Supervisor CS-066290 Expires:07/12/2021 GEORGE MOUDOURIS 12 ATHENS WAY WEST YARMOUTH MA 02673 Commissioner 7t/ Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE;won R before the valid for individual use only Registration Expiration Office of won date. tf found returnes e 139811 O8/24f2021 Affairs and Business Regulation MOUDOURIS CONSTRUCTION INC Boston,1000Washington MA 0 11 Street -Suite 710 MA 02118 GEORGE M.MOUDOURIS 12 ATHENS WAY ✓✓ ittuy.t.„L W.YARMOUTH,MA 02673a` Undersecretary W valid without signature TRAVELERS Jft, WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6HUB-2E21 1 00-9-1 9) RENEWAL OF (6HUB-2E21 1 00-9-1 8) INSURER: THE TRAVELERS INDEMNITY COMPANY OF AMERICA 1. NCCI CO CODE: 13439 INSURED: PRODUCER: MOUDOURIS CONSTRUCTION INC SULLIVAN GARRITY & 10-12 ATHENS WAY 10 INSTITUTE RD WEST YARMOUTH MA 02673 WORCESTER MA 01609 Insured is A CORPORATION Other work places and identification numbers are shown In the schedule(s) attached. 2. The policy period is from 05-15-19 t0 05-15-20 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policyapplies to work in each state listed In dam, Ppl item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: t o0000 Each Accident Bodily Injury by Disease: $ 500000 Policy Limit Bodily Injury by Disease: $ 100000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B ammum D. This policy includes these endorsements and schedules: ___ SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 05-10-19 WC ST ASSIGN: MA OFFICE: ORLANDO INDUS AFF 161 PRODUCER: SULLIVAN GARRITY & 77X6T 0004N pamndl@comcast.net From: Moudouris Construction <moudourisconstruction@gmail.com> Sent: Friday, December 6, 2019 3:41 PM To: Gary Ellis Subject: License& Insurance Attachments: G Moudouris License &WC Insurance.pdf Hello Gary - Please see attachment with George's license(s), our WC coverage coverage page. Let me know if you need anything else or a certificate of insurance & who to make it to. Diane www.MoudourisConstruction.corn MoudourisConstruction(c�gmail.corn Office: (508) 778-4586 1