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Home My WebLink AboutBLD-23-02996 Y - i lIzji Office Use Only •;'� `T',• M%��✓"_ I 'S-q/ 'IPermit# 1 0 O _ , y 'Amount coo o { .��nn��rrxcn ut l ,A 4%9oo..TL cad,. IPermit expires 180 days from ;,..;...' l issue date 131 1)-013 -j0�g4, EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 DEC 01 2022 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT CONSTRUCTION ADDRESS: -//vCti LA' sc) )4,4 /7•70//7 By- ASSESSOR'S INFORMATION: Map: Parcel: OWNER: A ,C'/(3,C Pa/70Z F FM'61✓ LA SOP-4'Od- ' NAME PRESENT ADDRESSTEL. # CONTRACTOR: �,Oi/�D e.O.k' 1Pd VO/ <So Kit, el-- qe z—5"z99 {{ NAME MAILING ADDRESS TEL.# Residential ❑Commercial Est.Cost of Construction$ji-&'i.O LyU Home Improvement Contractor Lic.# / J4/9: Construction Supervisor Lie.# 06 gs39. Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor VI have Worker's Compensation Insurance Insurance Company Name: 7/e,X4/4"L!170 Worker's Comp.Policy# 9/40)('7C/Z Z 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 Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: }/,t7 '.J 2l>r_'.)77✓ 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 revoc 'on of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: ac `„ip 4/ - Date: f/ �:��Z Owners Signat (or atta ent) / Date: q Approved By: . �.,� Date: C e Building(4 u. .45 ignee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes '❑ No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 • Boston, MA 02114-2017 r'V, www.mass.gov/dig \Y orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): „ff,w >/;) Address: rk^U, City/State/Zip: � 4):', v' 6 = Phone #: 3 f.e,7 -.5-2,F.,(-7 Are you an employer?Check the appropriate box: Type of project(required): 1.12. I am a employer with employees(full and/or part-time).* 7. New construction 2.D I 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 E 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.E1 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.1 6.1:1 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El 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: 7l'.,pt'i.1'iL Policy#or Self-ins.Lic. #: 57/Crk-? 77 Expiration Date: C/f 2 3 Job Site Address: j i/..A(vr/ ,!, City/State/Zip: Ye/L. ./"4(7-a,b 5/� 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 ,,der the pains and penalties of perjury that the information provided above is true and correct. Signature: ,1z/�?/F'.> `t- '� Date: J/ ;' ' Phone#: �� G� 2 - 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 Phone#: Contact Person: 7 DATf tMMlDD1YVYY} ACORD CERTIFICATE OF LIABILITY INSURANCE ��, 06/29i2022 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 pollcy(ies)must have ADDITIONAL INSURED provisions or be endorsed. I If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on i this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). t PRODUCER CT Karen Gedenberg ..i SULLIVAN GARRITY & DONNELLY INSURANCE AGENCY INC PNONN.Ertl: (508)453-2529 FAX Nor �__ __� AADOREss; Karen.Gedenberg(�ssgdins.com r 10 INSTITUTE RD INSURER(S)AFFORDING COVERAGE I NAIL E ___i WORCESTER MA 01609 INSURER A: TRAVELERS INDEMNITY CO OF AMERICA INSURER B: 25666 INSURED —, —_ DAVID COX INC :.1 INSURERC: __ •-_ ._i_ { INSURER D: I PC)BOX 401 INSURER E: t — — —._.._.._..._._4 S YARMOUTH MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: 789581 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 I EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY NAVE BEEN REDUCED BY PAID CLAIMS, ___ INSR r_-...__.___�_ iADDLISU6R POLICY NUMBER POLICY EFT I POLICY EXP LIMITS LTR TYPE OF INSURANCE ,LNSD i WVD 1 tmM1DONYYy (MMIDD,'YYYY1 I T — COMMERUAL GENERAL LIABILITY EACH OCCURRENCE !$ _,_, _I DAMAGE TO RENTED CLAIMS•MA(,E 'I OCCUR PREMISES(Ea QCCLt nceI '$t __. _._ —__.-1 ilME:D EXP IAny one person) f S __� PERSONAL&ADV INJURY $ -,—__ GFN'L AGGREGATE LIMIT APPUES PER. I GENERAL AGGREGATE $7 L I 1 LOC _� — PRO. i i '— ! PRODUCTS-COMP/OP AGG F$—________ —_.__.4 � I POLICY JECT I I I I OTHER $ AUTOMOBILE LABILITY COMBI d IT 1$ idini; } _...-_._____..—. I BODILY INJURY(oqr person) 1 S _) ANY AUTO OYJNED T SCHEDULED N/A BODILY INJURY leer accidert)I$ __ _ _— H ONLY AuTOS PROPERTY DAMAGE I HIRED i AUTOS NEY j ;Per accident) $ �_,_ AUTOS ONLY �� I AUTOS ONLY !i � �— 'i EACH OCCURRENCE $ UMBRELLA1.1AB OCCUR AGGREGATE ,$ EXCESS LIAO r��CLA:MS-MAD N/A MD I RETENTIONS t I I i t WORKERS COMPENSATION �X I STATUTE 1 I ERH I _--._. i AND EMPLOYERS'LIABILITY Y 1 N I E L.EACH ACCIDENT b100,000 — A,, IpNFICFRM MBF.RF..X ILDErIk')XECUT1yF (I� WA NIA 6HUB910X742222 1 07/16/2022 07/16/2023 t (Mandatory in NH) I 1 E.L.DISEASE-EA EMPLOYEE II S 100,000 —) !II yes.describe ardor E.L.DISEASE-POLICY LINT S 500.000 OESCRiPTICJN OP OPERATIONS below ,-� i• i r N/A l i I 1 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it more space is required) t to orsement C 20 03 clams for benefitss otlon emp employees in s Ill stbe es ofd heor thansachusetts Massachusetts employees the insured hires,nor has nh hired those employeesOouttside of Massachusetts.on is to pay This certificate of Insurance shows the policy In force on the date that this certificate was issued(unless the expiration date on the above policy precedes the Issue date of this certificate of insurance) The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass-govilwd/workers-oempensationllnvestigations/. CERTIFICATE HOLDER CANCELLATION I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 4 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Sandwich --I 30 Main Street AUTHORIZED REPRESENTATIVE -_", r: 4 (.f } �..• I I MA 02563 Daniel Sandwich Daniel tit.Cro4y,CPCU,Vice President—Residual Market—WCRIBMA ( 0 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 26(2016/03) The ACORD name and logo are registered marks of ACORD , • • Office of Consumer Affair.s and Business Regulation 1000 Washington.Street- Suite 710 Boston,tvlassactiusetts 02118 Home Improvement C,ontractor Registration • I'VP0t • COPOIrMion rtigistration, 100491 DAVE) COX, NC. ation". 03,24/2024 19 LAVENDER Lik4 w•VARMOLF04,MA 02678 Update Are**sad 911101um Card. oNs CansainierAJ &Swinge*Pirouln HOME10VMNT COMMACIVR ketoistristion vaiki or inahrinwid un.ir tray rYPE:ententiotton bPe* tt.exvitationtm faM/*Writ in: ltivitlitimetts 011icept Comicality Attaiitt and usahltips nagulaiinn Klogtire fratZet4Z4 1 netWiniiiastittei Stine -Sun*716 0A410 COX ItiC }kola&MA Win DAM la LAVENDER Liv ViiiIMOUrn.AM 026n Not valid without signatu e Unoeesecretary Commonwealth of Massachusetts Division of Professional Licensure II Board of Building Repulations and Standards C 0 ns isor CS-063537 155pires; 10/15/2023 DAM ROO*" PO sox 401. SOUTH YARRIARU.86,,, Commissioner i)a..efifa K. • • ' •••••r- • • •