Loading...
HomeMy WebLinkAboutBLD-23-006031 /,m 5 13)?3 Office Use Only > C�.y Permit# j0 [� A.k r S `" o © Ci A .I1(' C Amount „ `y,� Permit expires 180 days from issue date 8Uf 023 --406903i EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department HAY 1146 Route 28 0 2 2023 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 BUILDING N G DEPARTMENT B Y CONSTRUCTION ADDRESS: P 39 Captain Crocker Rd - -- ASSESSOR'S INFORMATION: Map: Parcel: OWNER: Demetrios 39 Captain Rd South Yarrnc 6174172747 NAME PRESENT ADDRESS TEL, # CONTRACTOR: David Sawyer C( 318 Meiggs Backus Rd San 5085391992 NAME MAILING ADDRESS TEL,# 0 Residential i Commercial Est.Cost of Construction$12200.00 Home improvement Contractor Lic.# 134313 Construction Supervisor Lic.N 098859 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 0 1 have Worker's Compensation Insurance Insurance Company Name: Farm Family Worker's Comp.Policy#20001 w6406 WORK TO BE PERFORMED Tent n Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 20 (0)Remove existing*(max.2 layers) Insulation El ri Old Kings Highway/Historic Dist. 0,1 Replacing like for like Pool fencing El *The debris will be disposed of at: y armouth landfill Location of Facility I declare under penalties of perju the statemen 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 ation of m li and for prosecut( Ch. ,Section I. CC Date: 5-2-23 Applicant's Signature: 6.r.t 1 „6" � Owners Signature(o ttachment) Date: Approved By, Date: 57-'2--Z 3 Building Official(or desi e) EMAIL ADD Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetland§®u>ianoD'I' 'Nod'3 uAn'1! Yes No Yes No The Commonwealth of Massachusetts ►h 4, Department of Industrial Accidents tM >a 1 Congress Street,Suite 100 Vit—EBoston,.IVIA02114-2017 _ ,�' www mass gov/dour Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. ,Ataolicent Info melon — —Vette rrint .- tbiv Name(Business/Organization/Individual): David Sawyer Construction Address:318 Meiggs Backus Rd City/State/Zip:Sandwich Ma 02563 Phone#: 5085391992 Are you an employer?Check the appropriate box: Type of project(required): t.Ot tan a employer with _ _employes(felt and/or part-time).* 7, Q New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8, a Remodeling any capacity,(No workers'camp.insurance required.) 3.01 a a doing all work mutt[No workers°gip,inerrant required.]a 9, Demolition 10 0 Building addition 401 am a homeowner and will be hiring contractors to conduct all work on my property, 1 will ensure that all either have workers'compensation insurance or are sole 11. Electrical repairs or additions proprietors with no employees, 124:Plumbing repairs or additions 5.01 Imo a contractor and 1 have hired the listed an the sheet 13,El f repairs These sub.contractors have employees and have workers'comp,iru ,t 6,0We are a and its officers have exercised their right of par MG,c. 14. Other 152,11(4),and we have no employees.[No workers'comp.insurance required.) *Any applicant that checks be x 41 must also fill out the section below showing theirs/otters'compensation policy information- Homeowners who submit this affidavit indicating they are doing all work and then hire outside contramots must submit a new affidavit indicating such. *Contmal ors that check this box must attached an additional sheet showing the naflm of the an and state whether or not those entities have eta ogees. If the sir have employees,they must provide their workers'come.policy number, I Wit an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site inforrnatlon. Insurance Company Name: Farm Family IN Policy#or Self-ins,Leo.#: 20001 W6405 Expiration Date: 3/5/24 39 Captain Crocker Rd__ City/State/Zip: South Yarmouth Ma 02664 Job Site Address: - ___ Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MOL e. 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 =sy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby crab,wider e pans - d perjury ,, the ilafot Lion provided above is true and correct. .1 14 , . / r •,., . 5085 :1992 Official us 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 insps®to of, 1porAloltlu r 6.Other Contact Person: 4/22/23,8:20 AM Scan_20220318(3).jpg '7/(aA, 60,4f/ii. .. Q./Zefit44-L- Property Owner to complete and sign if using a builder/contractor P. }. J M 1"i"z ID Av�.T1 h t5 ,as owner of this property ereby authorize .�(,�i d 4 fa,&i,r- '.0,0t),7'(i7e'�=7 To act on my behalf, in all matters relative to work authorized by the building permit for address: __.: 3°r CrfL.&vL— p CZ ear Yokot,Xte+pwr 1 (Address of work) Cad.. ,Gi \\)%, Si nature of Owner ate t ...81,11„‘..) 1/ %,n► toS 192TiAloS Pint Name Co) 1 �z44 n o f:i :3 tnX. �v `, C 3 p 2,?, n m to o *,m th o c ii' n 6)0 to o n =� <, o -1 tiD WN 3 ; 9 'r � �D„_d .. i f.?,._::'°-':-lt,..H.', i= 5. E .:. 7 A N 41 N G N O N Mass.gov 4111,- • • IP (OCABR) HIC Registration Complaints Registration # 134313 Registrant DAVID SAWYER Name DAVID SAWYER Address 318 MEIGGS BACKUS RD. City, State Zip SANDWICH, MA 02563 Expiration Date 10/23/2023 Complaints Details No complaints found for this registrant. You can also view arbitration and Guaranty Fund history. Back To Search -s Woad-d6a3 From: ddsawyerl@comcast.net Subject: 2023 license Date: Mar 21, 2023 at 6:23:38 AM To: Home Sawyer ddsawyerl@comcast.net ScL cc C...)(10)ke47 ! Fjam sr t-m!2 , �l�j b ✓_ tt t - 33 3 j h 3 +C t /D ?3 Sent from my iPhone JOWOAOD '04flOd. uAny Farm Family Casualty AIR y l insurance Company rim AntelkdaliationalConttany Nitalatek 344 ROUTE 9W I GLENMONT,NY 12077 2910 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE �'•' NCCI COMPANY NO. 16721 MARK SYLVIA INSURANCE AGENCY U.0 POLICY NO. 2001W6406 404 MAIN ST EFFECTIVE 03/05/2023 CENTERVILLE MA,02632-2916 TRANSACTION TYPE Renew FEIN It 5084428-0440 _.` INSURED AND MAILING ADDRESS: DAVID SAWYER SEE EXTENSION SCHEDULE SAWYER CONSTRUCTION 318 MEIGGS BACKUS RD SANDWICH.MA 02563-3131 THE INSURED IS INDIVIDUAL Workplaces covered by this policy: ST WP NO. . ADDRESS OF WORKPLACE RTG.BUR NO. INTRASTATE NO. MA 1 318 MEIGGS BACKUS RD 210677 SANDWICH MA 02563-3131 er .r. 8 The policy per'period is from 03-05-2023 to 03-05-202412 01 A.M.Standard Time at the insured%mailing address. :aT ea1� �.S`.;. ✓ .;,.�:. _:. r -, ..«.= .....^. .:.-, ,n ..�.. .w_c_,s- cs. .a_ - ,,"•.o",. ....m`'. .2 _ ",+.._ .>>..r _ r. s.."„ ..-.e. A. Workers Compensation Insurance:Part One of the policy applies to the Workers Compensation Law of the state fisted here: MA B. Employers Liability Insurance:Part Two of the policy applies to work in each state listed in item 3.A.The limits of our liability under Part Two are: Bodily Injury By Acckdent Bodily Injury By Disease Bodily Injury By Disease $1,000,000 each accident $1,000,000 policy limit S1,000,000 each employee C. Other States Insurance:Part Three of the policy applies to the states,if any,listed here: All states except the states designated in item 3.A.of the information page and ND,OH,WA,and WY D. This policy includes these endorsements and schedules: WC000001A0319 WC00000000115 WC0003150985 WC0004140790 WC000422C0121 WC2003010484 WC200302A0908 WC200303D0810 WC2004030191 WC2004060601 WC200601A0708 W(2006041102 pRocEssED 2on3.o1:30 covright1 "caw.° tcwnPeasalia61161112122