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Home My WebLink AboutBLD-23-02869 cad I l JZ 'JZ 1 Office Use Only ; °® .Y,� ®`• Permit# of -3i ® H !�. O Id Amount c!e NAl"T- M n S "` Eo Gad Permit expires 180 days from "-• issue date 64, - 2 -5 4oe EXPRESS BUILDING PERMIT APPLICATIN TOWN OF YARMOUTH R Yarmouth Building Department ECEIVED 1146 Route 28 South Yarmouth, MA 02664 NOV 23 2022 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT CONSTRUCTION ADDRESS: 40 Circuit Road BY _ T____ ASSESSOR'S INFORMATION: Map:48 Parcel:80 OWNER: Kevin McHale 4 Browning Rd, Natick, MA 774.286.0087 NAME PRESENT ADDRESS TEL. # CONTRACTOR: Notev Building PO Box 690, S Dennis, MA 774.212.2368 NAME MAILING ADDRESS TEL.# Residential 0 Commercial Est.Cost of Construction$1 1,600'00 Home Improvement Contractor Lic.#173596 Construction Supervisor Lic.#csfa 106016 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: A.I.M. Mutual Insurance Company Worker's Comp.Policy# VWC-10060161872022A WORK TO BE PERFORMED Tent LI Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:#1 0 Replacement doors: # Roofing: #of Squares (El)Remove existing*(max.2 layers) Insulation El Old Kings Highway/Historic Dist. Replacing like for like Pool fencing I I *The debris will be disposed of at: Yarmouth Dump 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 revocation of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: "lJ Date: � Z k/Vila. �� ate: 11/22/22 Owners Signature(o t z,,. D Approved By: - Date: // 3° Building cial esi ee) EMAIL AD SS: Zoning District: Historical District: L, Yes No Flood Plain Zone: L Yes E No Water Resource Protection District: Within 100 ft.of Wetlands: L Yes ❑ No L Yes J No The Commonwealth of Massachusetts /, Department of Industrial Accidents =nm�l 1 Congress Street, Suite 100 e. ZI 1-_ Boston, MA 02114-2017 Sv, www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information 1 Please Print Legibly Q Name (Business/Organization/Individual): Dream Construction, Inc. C ' `V 2kl X lku cS Address: P.O. Box 690 City/State/Zip:S. Dennis, MA Phone#: 508-258-8385 Are you an employer?Check the appropriate box: Type of project(required): I.❑✓ I am a employer with 3 employees(full and/or part-time).* 7. ❑New construction 2.0I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑Building addition 4.0I 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 5.0I 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.: Window Replacement 6.12:IWe are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q✓ Other 152,§I(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.I.M. Mutual Insurance Company Policy#or Self-ins.Lic.#: VWC-10060161872022A Expiration Date: 10/05/2023 Job Site Address;40 Circuit Street City/State/Zip: West Yarmouth 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: 11/22/2022 Phone#: 508-258-8385 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#: THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE:Corporation Office of Consumer Affairs and Business Regulation Registration c Expiration 1000 Washington Street -Suite 710 173596 10/17/2024 Boston,MA 02118 DREAM CONSTRUCTION,INC. D/B/A NOTEV BUILDING&REMODELING DIMITAR NOTEV 10 ROUTE 28 WEST HARWICH,MA 02671 Undersecretary Not valid without signature Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards ConstructionS'tIpeiili t:.1 &2 Family - CS FA-106016 01/13/2023 DIMITAR NOTEV :r. P.O.BOX 690' SOUTH DENNIS MA 02660 %t Commissioner dic i,'. `t 5,nLu.- Construction Supervisor 1&2 Family Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Call(617)727-3200 or visit www.mass.govldpl WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE A.I.M. Mutual Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 (800) 876-2765 NCCI NO 26158 POLICY NO. VWC-100-6016187-2022A PRIOR NO. VWC-100-6016187-2021A ITEM 1. The Insured: Dream Construction Inc DBA: Notev Building &Remodeling Mailing address: P 0 Box 690 FEIN:"-"'5011 South Dennis, MA 02660-0000 Legal Entity Type: Corporation Other workplaces not shown above: See Location 2. The policy period is from 10/05/2022 to 10/05/2023 12:01 a.m.standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed 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 liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates Code Estimated Per$100 Estimated No. Total Annual Of Annual Remuneration Remuneration Premium INTRA 000558671 INTER SEE CLASS CODE SCHEDU_E Minimum Premium $500 Total Estimated Annual Premium $11,261 Deposit Premium $5,858 GOV GOV STATE CLASS State Assessments/Surcharges MA 5645 $10,848.00 x 4.1800% $453 09/28/2022 This policy,including all endorsements, is hereby countersigned by Authorized ignature Date Service Office: Bearingstar Insurance 54 Third Avenue 375 Airport Road Burlington MA 01803 Fall River, MA 02720 WC 00 00 01 A(7-11) Includes copyrighted material of the National Council on Compensation Insurance, used with its permission. �....., = ,k. . M . \ , , , ' .„7„, „ , „„,„ „ ., •';> •' , F`\r Et, . : e. --..., -...e 1.... \A CI. :> 44444. ''''-' 7. `...-:, ,7—" c.) , \ , .....„.,.•,..::,, /44,,,,,,..4.,... ;:.....m..""""".",,,,:."-,,"?""."":"".v . ,,; ;. s. 1... 0 >',, ,A . mow,:. w) ,ter.. L, ty . ^ r ' rr ✓ :J! s �'` � .: