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Home My WebLink AboutExpress Permit applicationPermit# -,Amount MATT^C" s d - Permit expires 180 days from issue date R E C E I 72021 RESS BUILDING PERMIT APPLICATION __. _.._..�TOWN OF YARMOUTH armoutn .Buiieiing Department AU 22 -3 1146 Route 28 _ South Yarmouth, MA 02664 BUILDING DEPARTMENT (508) 398-2231 Ext. 1261 By CONSTRUCTION ADDRESS: f T so v 'n � —rl ' oc I c� ASSESSOR'S INFORMATION: r OWNER: tI� nos NAIL CONTRACTOR: ll P v,-YV Map: Parcel: V551 S 121 U PRESENT ADDRESS TEL. MAILING TEL. s-;:-, R <//I 2 Residential ❑ Commercial Est. Cost of Construction $ Z V d Home Improvement Contractor Lic. # /,3z" Construction Supervisor Lic. 9�3 Workman's Compensation Insurance: k one) ❑ I am the homeowner l am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: �J'riJ� J Lam( /� Worker's Comp. Policy# / ' A Z WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Siding: # of Squares a,_ Replacement windows: # Roofing: # of Squares ( ) Remove existing* (max. 2 layers) Old Kings Highway/Historic Dist. ( -I'Replacing like for like tT�� ✓r► Wood Stove Replacement doors: # I Pool fencin6 Insulation *The debris will be disposed of at: j� 0 Se, ;/ l ��G-ss4- L 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 revocati my 1' d for prose ion under ivI.G.L. Ch. 268, Section 1. l Applicant's Signature: Date: Q l Owners Signature (or attachm t) Date: D 2 Approved By: Building SETtal (or ADDRESS: Date: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft. of Wetlands: 0 Yes 0 No 0 Yes 1:3 No The Comtnonwealth of Massachusetts Department oflndustrialAccidents a I Congress Street, Suite 100 Boston, MA 02114-2017 °�M s�•�` www.mass.gov/dia 11"orkers' Compensation Insurance Affidavit: Builders/Contractors/ElectricianslP lumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly AI? ne (Rncingcc//h , ,:__/1-�:_.:�.,_l);_, Cc�CidT%S ....... a�'lri..:au. Address: ly City/State/Zip: vi , -e r%® S �c Phone 4 .Are you an employer? Check the appropriate box: s6�� y1 �9 7 1. ❑ I am a employer with employees (full and/or part-time).* 2.F1 I am a sole proprietor or partnership and have no employees working for me in any capacity. Pqo workers' comp. insurance required.] 3.❑ I am a homeowner doing all work myself. [No workers' comp, insurance required.] t 4.❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all con'ttractors either have workers' compensation insurance or are sole pro�ag rs whit no employees. 5. aneral contractor and I have hired the sub -contractors listed on the attached sheet. 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. 152, § 1(4), and we have no employees. [No workers' camp insurance required.] Type of project (required): 7. ❑ New construction 8. ❑ Remodeling 9. ❑ Demolition 10 ❑ Building addition 11. ❑ Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13. Fw-il�o`of repairs IA. Q10ther Xrz� -xny appiicanL LUa[ enecrs oox a I .must also till out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new afidavit 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. Ifthe 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: Policy _ or Self -ins. Lie. / % 5 Expiration Date: Job Site Address: y'c�-T�l��'-'��✓�� City/State/Zip: 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 t gay be forwarded to the Office of Investigations of the DI.A for insurance coverage verification. I do hereby certify cinder the pains and penalties of perjury that the information provided above is true and correct. Sis:nature: y''i 1455 -:: Date: tg 22 Phone Of iciai 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): I. Board of Health 2. Building Department 3. City/Town Clerk EIectrical Inspector 5. Plumbing Inspector o. Other Contact Person: Phone =. commonwealth Of pjassacnusetl-, Division of Professional Licensure Board of Building Regulations and Standards CS-035693 DAVID A. WOODS 43 MA1THEW WAY MARSTONS MILLS MA 02648 E-:xpires: 0111812022 Commissioner Office of Consumer Affairs & Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE. Individual E190YAW! 1papiuffim 132361 11/18/2022 DAVID WOODS, DAVID A. WOODS 43 MATTHEW WAY MARSTONS MILLS, MA 02648 Undersecretary r 0 CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIMY) F08l23121 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). I PRODUCER CONTACT NAME: JIM HINDMAN Schlegel &Schlegel Ins Broker AIc°NN Ext : 508-771-8381 AIc No): 508-771-0663 34 Main Street West Yarmouth, MA 02673 E-MAIL ADDRESS: schlegelinsurance@gmail.com INSURER($) AFFORDING COVERAGE NAIC # INSURERA: NGM INSURANCE COMPANY 14788 INSURED INSURER B : TRAVELERS INSURER C : MARCOS SILVA DBA EMERSON CONSTRUCTION 67 SEA ST APT 11 INSURER D : HYANNIS, MA 02601 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 i 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 LTR TYPE OF INSURANCE AUUL INSD hUHKPOLICY WVD POLICY NUMBER EFF MMI00 POLICY EXP MMIDD LIMITS x COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR EACH OCCURRENCE $_ 1,000,0ow PREMISES Ea occurrence $ 500>0001 _ MED EXP (Any oneperson) S 10,000 PERSONAL BADVINJURY $ 1,000,000 A MPT9375T 11/09/20 11/09/21 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY 0 PRO- JECT LOC GENERAL AGGREGATE $ 2,000,000. PRODUCTS • COMPlOP AGG $ 2,000,0001 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident S BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident $ UMBRELLA LIAB HCLAIMS-MADE OCCUR EACH OCCURRENCE S AGGREGATE _ S EXCESS LIAR DED I I RETENTION$ $ I _ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIV£ OFFICERIMEMBER EXCLUDED? NIA 6HUB1 K96638A20 04117/21 04117/22 PERTOTH- STAUTE ER -3 I E.L. EACH ACCIDENT _ $ 100,0001 E.L. DISEASE . EA EMPLOYEE S 100,0017' (Mandatory In NH) If yes, describe under E.L. DISEASE - POLICY LIMIT —) 1 $ 500,000 DESCRIPTION OF OPERATIONS below 0 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) MARCOS SILVA HAS ELECTED TO BE COVERED UNDER HIS CURRENT WORKERS COMPENSATION POLICY INSURANCE COVERAGE IS LIMITED TO THE TERMS, CONDITIONS, EXCLUSIONS, OTHER LIMITATIONS AND ENDORSEMENTS OF THE POLICY I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE j THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN DAVID WOODS ACCORDANCE WITH THE POLICY PROVISIONS. 43 MATTHEW WAY IS MARSTONS MILLS MA 02648 AUTHORIZED REPRESENTATIVE - WILLIANA CASTRO IYANOUGH43@YAHOO.COM I @ 1988-2015 ACORD CORPORATION. All rights reservod. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD