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HomeMy WebLinkAboutBLD-23-003369 O .yRR �°E� f{'i� � 'Office Use Only ` $ O 1 1 jjZ- Ia Pa Permit#1`'r,"°i 32 Ve MATTACt� LSE 1 Y Z:I i� /O _'Amount // J 1 = 5= '' I Pennit expires 180 days from ;issue date 6L-0-01.3 EXPRESS BUILDING PERMIT APPLICA IPX C E I V E D TOWN OF YARMOUTH ._._. &• ...,..•.--. Yarmouth Building Department DEC 16 2022 1146 Route 28 ° L South Yarmouth, MA 02664 BUILDING DEPARTMENT (508) 398-2231 Ext. 1261 By. CONSTRUCTION ADDRESS: 36 e,/(to. .7rtte a, S•/ Gt 7t4(rM / e& y4 ASSESSOR'S INFORMATION: '�, //�� Map: Parcel: OWNER: U (J Ji 1,4 J `I h .S QYve z y_ V/3-o CO NAME _ PRESENT ADDRESS TEL. # CONTRACTOR: NAME *1 5ory!7GCl—�j# I 5-etyv-4:ry /zi-/3a/fieSv/ 5 t1-4 Iei/aiS i 257,- O0•72c MAILING ADDRESS `1 TEL.# ( Residential ❑ 4/�0i/ c� Commercial Est.Cost of Construction$ ✓S —0'7'3 / D/ Home Improvement Contractor Lie.# y / 1 2)3 s it Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: Jp Jj / �/�,,„n� ,I uyc/iI +� Worker's Comp.Policy# jf �Jit.64•444S6,a7//�� WORK TO BE PERFORMED `7 Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows: # 1 02,02— Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation l"1---- Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing 1 WO 19419-L—d-- *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. I understand that any false answer(s) will be just cause for denial or revocatio is and rosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: /2//�j/2 a 2 2 Owners Signature(or attachment) �? Approved By: 7 Date: / Date: y/9-22- Building Official(or sign EMAIL ADD Zoning District: Historical District: 0 Yes 0 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 11, Department of Industrial Accidents + ' 1 Congress Street, Suite 100 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 PIease Print Legibly Name (Business/Organization/Individual)://(sa`0k ---kr ,L f n ' tr�v//D h Address: J 2 - /J /vg v- ) I s©ac t Din I'5 41, 6 2 G6(2:) City/State/Zip: Phone #: , —2>/ •— o 0 2 E) Are you an employer?Check the appropriate box: Type of project(required): i. 1 I am a employer with employees(full and/or part-time).* 7. _ 2. I am a sole proprietor or partnership and have no employees working for me in RNemw construction tlon any capacity. [No workers'comp.insurance required.] 8. Remodeling — ' 3.❑I am a homeowner doing all work myself. [No workers'comp.insurance required.]; 9 Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sol property. proprietors with no employees. 11.Q Electrical repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.El Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance.: 13.❑Roof repairs 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: Y�,t.v L-L . v,... Policy#or Self-ins. Lic. #: •2-51 g,6-4 Expiration Date: /2/.5 l�4"-23 Job Site Address: .�‘ ,/ e_ /(•� 0/ p/Ac �E 5 /6, 1 J Attach a copy of the workers' compensation policydeclaration page `����t'�/Zip��l��- �2�'�'� tion (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: 7 Date: / 2_I /-E(} 2 0 2, Phone#: 7. Z cl 2 S 1 ` v 0 -v 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#: • 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 Iicensing 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, necessary, supply by checking the boxes that apply to your situation and,if su 1 sub-cont 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 town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the or 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 bum 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 .... ...... ,,, TOWN OF YARMOUTH 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451 - " Telephone(508)398-2231 Ext. 1292-Fax(508)398-0836 OLD KING'S HIGHWAY HISTORIC DISTRICT COMMITTEE APPLICATION FOR CERTIFICATE OF APPROPRIATENESS Application is hereby made for issuance of a Certificate of Appropriateness under Section 6 of Chapter 470, Acts of 1973 as amended, for proposed work as described below&on plans, drawings, photographs,&other supplemental info accompanying this application. PLEASE SUBMIT 4 copies OF SPEC SHEET(S),ELEVATIONS,PHOTOS,&SUPPLEMENTAL INFORMATION. Check All Categories That Apply: Indicate type of Building: Commercial ti/ Residential 1) Exterior Building Construction: New Building Addition Alterations Reroof Garage Shed Solar Panels Other: ILI i:vl 41 ow rer( o-to)I- 2) Exterior Painting: Siding Shutters Doors Trim Other: 3)Signs/Billboards: New Sign Change to Existing Sign 4) Miscellaneous Structures: Fence Wall Flagpole Pool Other: Please type or print legibly: Address of proposed work: 3 C.. t; /le 1 ihe 14)e '1 12 d. 1 qv'VY tiiittp eq-t MapotOt# I ? ",..9,_ 6 1 Owner(s): TO I')VI g,-. Pei ft'i?c 7 et )e vi 0,etiq Phone#: 7 )- i 3 6-0-7L/ All applications must be submitted by owner or accompanied by letter from owner approving submittal of application. Mailing address: ,-;4,, 11 c ir-C 'ate IV e 5 t- /GI) 'et NI co_fh ifo oie 1-- Year built: /q 7 e) Email: .N) De 11 Vi f i I 1 2 (4,) (:),yeti f, coisLe Preferred notification method Phone i,„," Email Agent/contractor- Phone if: Mailing Address: Email: Preferred notification method: Phone Email Description of Proposed Work: We /boot iz-, ref,'ig(e a 4 61..,ryie(‘-tk.“ a),71-1. 4 it d e f cell 4'/eZ ,Cer i d 04 b(e /I Li4 ii el I-,iit,Ai ryl 5 f a 1( 111 re e_ 60:‘-ri deo J5., or's lead /6 7 ttic i ,-). te C ‹ce a-H-4664 p 1 Ile rn ) Signed(Owner or agent): --- I Z64,4,, 6f ,C. - - ct, Date: /7/ib il:/ •2, > Owner/contractor/agent is aware that a permit is required from the Building Ipartnient.(Check other departments,also.) > If application is approved,approval is subject to a 10-day appeal period required by the Act. > This certificate is good for one year from approval date or upon date of expiration of Building Permit,whichever date shall be later. > All new construction will be subject to inspection by OKH.OKH-approved plans MUST be available on-site for framing&final inspections. For Committee use only,: .}„." Approved Approved with Modifications Denied Rcvd Date: I ii2:qz?,0.2 Reason for Denial: Amount '1(1.I/0 Cash/CK It: -23,5t-i i ,-----,/- • ,/ 7 Ci (, Signed: Rcvd by: Li 5% , i N 46 Days: Date Signed: / 21/Z,/ 2-e 2 1- i -1..„ 1 ' APPLICATION#: 22 Al 747 Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Const,r41b't _ prvisor CS-073981 pires: 11/11/2022 MICHAEL F DAIS •11:4304e4.14 ' • hz,1 2 CHRISTOPWR YARMOUTH RpRY y t. • Commissioner dc164 • • c t • • • • • • • • • • 12/9/22,'10:25 AM Details Licensee Details ._....................._.......................... Demographic Information Full Name: Michael F Driscoll Owner Name: License Address Information City: Yarmouth Port State: MA Zipcode: 02675 Country: United States License Information License No: CS-073981 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 12/5/2022 Issue Date: 11/11/2010 Expiration Date: 11/11/2024 License Status: Active Today's Date: 12/9/2022 Secondary License Type: Doing Business As: Driscoll Building !Status Change Reason: License Renewal P.rere uisite Information No Or-ere ufsite Information No Available Documents https://madpl.mylicense.comNerification/Details.aspx?result=456c4c76-a231-42a5-a941-40ffea691025 1/1 c � C _ o p CV C ++ re fOd N e-. _ 0 O CO` H W N h. O)�f .Q ?� N .F. UrO Q O C O i 0 47 C C a7 y • 7 tto , 0 _O C _3.pmh �N o c Q t mi.— ., -0 ,a)., u)2,',,,a „..„.,,,,,,, „,.. .. .az i .c ,•••• C ,CO, g . ,... „,:4,! „,.. 'a 0< 11 3 1.1 c V I— �Fl} sae••« zIii a"` Jihi to Q ;a ra O U r a a o A m Z N 0 o a � o Its �yZc p gmtoymK= a z ,...... ,.., o O U Z � 0 a W(-• o —I m to U J co OI-U < OW ° O of two Q o • Z O N 2 2 Z p Qm W a o Lu Q N ��fA 015 2 0� b W u 0 Yco 0I . F 0 > LL.I uxj O CrQ Q z Q ZmW u) <ti0 7 rn N rn 4 D CERTIFICATE OF LIABILITY INSURANCE D4ITE(MMIDD/YYYY) 12/05/2022 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 poiicy(ies)must have ADDITIONAL INSURED provisions ol•be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement 4 statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT MORSE INSURANCE AGENCY INC NAME: Sandy Merchant FAx PHONE (AIC.No.Exfl: (508)238-0056 (A/C,No): MAILS: sandymarchant@morseins.com 285 WASHINGTON ST INSURER(S)AFFORDING COVERAGE NAIC# NORTH EASTON MA 02356 INSURER A: TRAVELERS INDEMNITY CO OF AMERICA 1 25666 INSURED INSURER B: USAROV HOME RENOVATIONS CORP INSURER C: INSURER D: 127 BAXTER ST INSURER E: S DENNIS MA 02660 INSURER F: COVERAGES CERTIFICATE NUMBER: 840690 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 BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDD(YYYY) (MM/DD(YYYY) LIMIT COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS N/A BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE I AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION _ AND EMPLOYERS'LIABILITY YIN X PER ERH ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100 A OFFICERIMEMBEREXCLUDED? N/A NIA N/A 6HUB6R08627422 09/23/2022 09/23/2023 000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE ;$ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may he attached if more space Is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above po icy 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.gov/Iwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouthport ACCORDANCE WITH THE POLICY PROVISIONS. 1146 MA-28 AUTH ORIZED REPRESENTATIVE South Yarmouth MA 02664 Delani .CroFoey,CPCU,Vice President—Residual Market—WCRIBMA I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD