HomeMy WebLinkAboutBLD-23-001571 ..b.i.yak- ]Office Use Only
r i Permit#
.ON. . .3 Amount
[ V
':" MATTACI, CSC J '
- *`°"'""`°" E ; j Permit expires 180 days from
i issue date
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EXPRESS BUILDING PERMIT APPLICATI
TOWN OF YARMOUTH F C E I V E 0
Yarmouth Building Department 1
1146 Route 28i L $EP 2022
South Yarmouth, MA 02664 j _
J
(508) 398-2231 Ext. 1261 au NT
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CONSTRUCTION ADDRESS: 65 A vo4 Lb
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER:
11d1 kunfh— 65A-vok /2o 203— (io(,- 1Q?2
NAME PRESENT ADDRESS TEL. #
CONTRACTOR: NAME Lfc Go NY4 C Pam M157 AILING ADD/RE ,8 ?o t, h 5TE O A --6 3_
Residential 0 Commercial Est.Cost of Construction$ / bU
b ----
Home Improvement Contractor Lic.# Os 02 3 Z Construction Supervisor Lic.# /e, '. S-A�;
Workman's Compensation Insurance: (check one)
❑ I am the homeowner ❑ I am the sole proprietor 41 I have Worker's Compensation Insurance
Insurance Company Name: 19 e/1 l f +j 1 i ft mini f-)Z Worker's Comp.Policy# J-J(V 0 I c 3??o I
1
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares Replacement windows:# Replacement doors: #
Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation
V Old Kings Highway/Historic Dist. (I)Replacing like for like Pool fencing ,
*The debris will be disposed of at: l 4( (- ) ,041 0-4-z- o > 6 \fa,-
Location of Facility
I declare under penalties of perjury that the statements herein ntained 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 revocati-,n of my license and r prosecution under M.G.L.Ch.268,Section I. /
Applicant's Signature: ��� Date: ( 7. 6 . 2O C
Owners Signa re(or attachment)i Date: —
i
Approved By: / Date: L� ��
Building 0 • ial(. s' ee) EMAI DRESS:
Zoning District:
Historical District: 0 Yes El No Flood Plain Zone: 0 Yes 0 No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes ❑ No
_ _ '�' The Commonwealth of Massachusetts
—* 3�_ iDepartment of Industrial Accidents
,e 1 Congress Street, Suite 100
�-��\=a
Boston, MA 02114-2017
• �;s�• � 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): Li k)EL,„(( /left (-, / ri ,.t,
Address: (' O do \ 44
City/State/Zip: t I fps ,'rri- 0 L. 657 Phone #: 6/2 - q -- /f/;'p
Are you an employer?Check the appropriate box: Type of project(required):
l.❑I am a employer with employees(full and/or part-time).* 7. _ New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. E Remodeling
any capacity.[No workers'comp.insurance required.]
3. I am a homeowner doing all work myself. 9. ❑ Demolition
❑ y [No workers'comp. insurance required.]'
4.11 myProPe�y•I am a homeowner and will be hiring contractors to conduct all work on I will 10 [ Building addition
. 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.fl 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: VAV&(eh S
Policy#or Self-ins. Lic. #: 6/4 i4C; - LE ri —8-Z t Expiration Date: O LU Z.I / LtQJ
Job Site Address: C 0/i 2� City/State/Zip: I`2 V„0 t... Q E 7i
/
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 under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date: 0 q L& • Z021
/
Phone#:
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#:
1..
4 1
r q Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership, association, corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance or
renewal of a Iicense or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s)name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
r Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
•Y�R £ £ o 1 officgro t U 7O q
P. O 1 1 13' 2- Permit#
OU. x ...4 Amount
L MATTACM c
"'*p3� Permit expires 180 days from
i&P '44 — issue date
D0I�dd-- RECEIVED
EXPRESS BUILDING PERMIT APPLICATION------
TOWN OF YARMOUTH SEP 02 2022
Yarmouth Building Department
1146 Route 28 BUILDING DEPARTMENT
South Yarmouth, MA 02664 BY -- — —_
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 5 A✓v,ki / 2 J "/ Z 1hoi.,1174 f27'z /
ASSESSOR'S INFORMATION:
Map: Parcel: 'p
OWNER: I IM ( 2
CS ivy 'P ilAz 1 ,t1f1't'2r 203 66,6 eq I L
NAME %1 PRESENT I TEL. #
CONTRACTOR: E1 U O (-ON S�-kt,G��iV (I i ti gut Pr r9 5: .�. 6C) Y
N MAILING ADDRESS u_ I(1441- TEL.#
Residential 0 Commercial Est.Cost of Construction$ _)I 0
Home Improvement Contractor Lic.# 1.1- O2$Z Construction Supervisor Lic.# CS `025 c4r+
Workman's Compensation Insurance: (check one)
0 I am the homeowner 0 I am the sole proprietor VI have Worker's Compensation Insurance
TA''riiC eArizaYL
Insurance Company Name: ) Worker's Comp.Policy# 1,ILV OISO ' 01
WORK TO BE PERFORMED
Tent El Duration (Fire Retardant Certificate attached?) Wood Stove n
Siding: #of Squares Replacement windows: # •/,11) Replacement doors: # 2_t 2.
Roofing: #of Squares (❑)Remove existing* (max.2 layers) Insulation [Ti
Old Kings Highway/Historic Dist. Replacing like for like Pool fencing n
co,,,,(„z_
*The debris will be disposed of at:
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. 1 understand that any false answer(s)
will be just cause for denial or revocatio f my license and f r prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: �~ f Date: 64
. ill1,`
\�� DDD
Owners Signature ::::ial
ed By: .0
(or desig ee) AIL ADDRESS:
V cto4
Zoning District:
Historical District: El Yes :13 No Flood.Plain Zone: L Yes L No
Water Resource Protection District: Within 100 ft.of Wetlands: , 1�%i r. r �/1
Li Yes LI No ❑ Yes 0 No (i{J VX U
0/6N
.,- Commonwealth of Massachusetts
.... ••• .i:•.z•.....•:'... -"I raw.— • z .
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Division of Professional Licensure ' '.' .........--Ar. • s
,
Board of Building Regulations and Standards;,....., :, - . . 1 ,
Constr,s0- ' )•IzIk%iiiripkvisor , Registration valid for individual use only
-4.. • —before the expiration date. If found return to:
‘4). •• Office of Consumer Affairs and Business Regulation - .,
1
CS-102587 ...,,•/k" iv ' '04 tpire s: 01/29/2023 - 1000 Washington Street '.•Suite 710
.........,_ ,
BRYAN F BYE
r , ,..3 , Boston,MA 02118
POBOX461 I C ,
NORTH EASTOAM M - e2s.I .• ' 1 4.— -----..- _...___ .
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/a ff CERTIFICATE OF LIABILITY INSURANCE DATEsro D/YYYY)
22
.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(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 lieu of such endorsement(s).
MooucER • mule JIM HINDMAN
Schlegel&Schlegel Ins Brokers,Inc. PHONE
Ext); 508-7'71-8381 FAX No>: 508-77i-0663
34 Main Street ADDRESS: schlegeilnsurance@gmallcom
West Yarmouth,MA 02673 ,)AFFORDING COVERAGE MAWS
INSURER A: NGM
INSURED INSURER B: ATLANTIC CHARTER
MAZZEO CONSTRUCTION LLC INSURER C:
157 PINE BLUFF RD INSURER II:
BREWSTER,MA 02631 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!Y AID CLAIMS.
EXP
7R TYPE OF INSURANCE PMv W Y
,RDOt V0 t POLICY NUMBER (SUUDE tYYYY) (MMIDDJYYYY) UNITS
X COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE S 1,000,000 '
DAMAGE TO RI:N I ED 500,000
CLAIMS-MADE I XI OCCUR PREMISES(Ea occurrence) $
MED EXP(Anyone person) s 10,000
A MP39994A 03/19122 03/19/23 PERSONAL&ADV INJURY s 1,000,000
GENERAL AGGREGATE S 2,000,000
GEM.AGGREGATE LIMIT APPLIES PER:
PROOUCTs-COMP/OP AGG S 2,000,000
1 POLICY LOC S
OTHER: COMBINED SINGLE LIMIT s
AUTOMOBILE LIABILITY Ma eccdent)
BODILY INJURY(Per person) S
ANY AUTO
OWNED SCHEDULED BODILY INJURY(Per accident) S
AUTOS ONLY AUTOS
HIRED ON OWNED PROPERTY DAMAGE S
{Per accident}
AUTOS ONLY AUTOS ONLY S
UMBRELLA UAB OCCUR EACH OCCURRENCE S
EXCESS UAB CLAIMS-MADE AGGREGATE S
DED 1 I RETENTIONS TiJ7E ( {ER S
14-
WORKERS COMPENSATION f !
AND EMPLOYERS'LIABILITY E.L.EACH ACCIDENT S 100,000
ANY PROPRIETOR/EXCLUDED?
R/EXECUTI'I Y� N I A 03/20/22 03/20/23 100,000
B (Mandatory
in NH) EXCLUDED? N WCV01509901 E.L DISEASE-EA EMPLOYEE s
(Mandatory in NH) 500,000
II yes desrsibe under E.L.DISEASE-POLICY UNIT T S
DESCRIPTION OF OPERATIONS Belo
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES IACARO tal.Additional Runnvks SchedukLenay be attached If rave apace Is re4Wred)
CORPORATE OFFICERS HAVE ELECTED TO BE COVERED UNDER THEIR CURRENT WORKERS COMPENSATION POLICY
INSURANCE COVERAGE IS LIMITED TO THE TERMS,CONDITIONS,EXCLUSIONS AND OTHER LIMITATIONS AND ENDORSEMENTS OF THE
POLICY
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.
TOWN OF BREWSTER
BUILDING DEPARTMENT AUTHORIZED REPRESENTATIVE
BREWSTER MA
ID 1988- 1 ACORD CORPORATION. NI rights resented.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
TOWN OF YARMOUTH
�,, N ? 1146 ROUTE 28,SOUTH YARMOUTH, MA 02664-4451
RED � � ° `' Telephone(508)398-2231 Ext. 1292—Fax(508)398-0836
AUG 1 1 2022 OLD KING'S HIGHWAY HISTORIC DISTRICT COMMITTEE
YANMO 1TI o APPLICATION FOR
OLD KING'S HIGHWAY
CERTIFICATE OF EXEMPTION
Application is hereby made for the issuance of a Certificate of Exemption under Sections 6 and 7 of Chapter 470 of
Acts of 1973, as amended, for the proposed work as described below and on plans, drawings, or photographs
accompanying this application.
• Typo or print legibly; //� NN �) r
"
Address of proposed work: (i! AI(�1 K �- uo(( ( �0Z Map/Lot# !43'r7
C
Owner(s): rtt�i'l 1 — K (� 1M- pod
Phone#: 2..0 3 e-Of
All applications must be submitted by owner or accompanied by letter from owner approving submittal of application.
Mailing address:� s �0 't (Me, - icti)'�,f1 �114,C-r 0(G<( Year.built: I 0
Email: (iC.LOU (-51-tr 'AI 0 Preferred notification method. V Phone ti/ Email
/� r� yc�tn0a.MTh
A( 'Cv S ty Ct ("( Phone#: C -- 300 -- 3 835
Mailing Address: y� /
Email: !7!u� `�0 O A Y�(ftet 0)1 of„ Gj f Th iila gallon method: `' Phone Email
Description ofProposed Work(Additional pages may be attached if necessary):
9 bt;cn ld'�5 ��� boiciz clece_ Si) L (a- Gup
Signed(Owner or agent): Date. :VA
> Owner/contractorlagent is aware that a permit may be required from the Building Department.(Check other departments,also.)
Y This certificate is good for one year from approval date or upon dale of expiration of Building Permit,whichever date shall be later.
For Committee use only:
Date:._ /112•2 Approved _ Approved with d ' �'-s P reed
Amount_,JA,�at Reason for denial: AUG 1 ) NQ2 ......._..._....._.____. __
Cash/CK a:// Yf YAi-( )UU l!{
Rcvd by: Lr+5. _ t7 HIGH WA
Date Signed:'/ji/402'1 Signed. cep 6,11-ze .c I
APPLICATION#:
V5 2017