The URL can be used to link to this page

Home My WebLink AboutBLDX-25-438 4 1( 41 Office Use Only �� 0, Permit 0' Amount 5 /1 EXPRESS BUILDING PERMIT APPLICATI n., i TOWN OF YARMOUTH y L. `.. t '' '"" Yarmouth Building Department rt_ — 1 1 146 Route 28 i APR 10 2025 1 r South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 ' 3y CONSTRUCTION ADDRESS: 93 LII(4/,47/0 ,Lg ,50,._ Y I& oWNER c2z/vx isvix SQL�J_ _9,34izzyicC,c/8 J� \\\ll I'RI SI \I \I)l)RI 5s Tl'l CONTRACTOR: 7"170/ eae. ./°l1 re,/ So ?iC/L Lo -=_f6Z-cam \\II \I All I\(�ADM! s FL c EMAIL: 2,�LJ4/G ? y, w lr_ Vesidential :Commercial Est.Cost of Construction S" Homeowner is Applicant? Yes No [/ Home Improvement Contractor Lic.# 4/9=-7- Construction Supenisor Lic.# Q6 `?-. WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares Replacement windows: # Replacement doors: # Roofing: #of Squares dd Insulation Temporary Mobile Home Temporary.Construction Trailer Demolition- Interior only Demolition Raze Structure Solar System ESS System Chimney Fence Pic.t.e .Omni utilits tijticonnect letters tot cls,iris \ t4s. sit uelures,,scr 75 scat,. 4111.1 teyujrc hi.lorical resiess *The debris will he disposed of at: Yj4i2,7 2eJe/TT/ „„Dy 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 he just cause for denial or res()cation of my license and for prosecution under\l(i I Ch.268.Section I Applicants Signature Date Owners Signature for attachment) Date: Approsed By: Date: Building Official for designee' Res 6 24 • 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 endorsementts). PRODUCER CONTACT. pails olourdeau SUt.1.IVAN GARRITY&DONNELLY INSURANCE AGENCY INC rxN^G,dy. (508)453-2582 Riejt "Agoura: Parie.Bourdeau@sgclins.com INSTITUTE RD INSYRERs)AFPQRDMG COVERAGE i 14A1C S WORCESTER MA 01609 _. —,usURERA, TRAVELERS INDEMNITY CO OF AMERICA 25666 INSURED _..... INSURER a: DAVID COX INC INSURERC: .---,___._ ----... ._..----. .. ... -- INSURER O: 111 PO BOX 401 INSURER E: I. S YARMOUTH MA 02664 INSURER p: COVERAGES CERTIFICATE NUMBER: 1018930 REVISION NUMBER: THIS IS TO CERTIFY THAI 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 WTH RESPECT TO WHICH THIS CERTIFICATE MAY SE 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. Loa I TYPE Of INSURANCE1enrQ POLICY NVMESR oIMIODfYwYI!flRfd vi UNITS � r COMMERCIAL GENERAL LIABILITY ( EACH OCCURRENCE .s 1 CLAIMS.MADE OCCUR ! I DAMAGE rOEn poc>r' �i PREMISES(Ea oxyr!ence! $ ----+ MED EXP tAnn one person) S I N/A , PERSONAL S ADV INJURY S G R AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ • r— '-1 PRO. � i--�PORGY JECT L--�)LOC PRODUCTS-COMP/OP AGG $ — :OTHER: I $ AUTOMOBILE uAeLu Y 1 1 COMSI DSINGLE Leaf y III ( I @ eCLldeMl I •ANY AUTO ( BODILY INJURY(Per person) $ -- omen •'-SCHEDULED I N/A BODILY INJURY(Pal Nolan() S -- T •AUTOS ONLY F,_-AUTOS II I HIRED I NONAWNED I.: .... ERTY DAMAGE E Lrr,AUTOS ONLY AUTOS ONLY ,Par aoddeni! H _ I S yI I UMBRELLA LIAR •11-- OCet'R yl EACH OCCURRENCE $ H�i EXCESS LIDS (~CLAIMS-MADE N/A AGGREGATE $ �� . I nE0 I i RETENTIONS r S H lAIICa wYER9IJASILITY X I iVTUTE I I gd" Y/N E.L.EACH ACCIDENT $ 100,000 A '' PIOEFAGMg RE EXcuiDECIS C7T"� Le WA NM 6HUB810X742224 07/16/2024 07/16/2025 . :,jMendaW ly In eis EL.DISEASE•EA EMPLOYEE$ 100;000 1I,ynqE dewm4e under _ r5 iBPTIQtI OF OPERATI NS Below t EL DISEASE.POLICY UNIT $ 500,000 N/A 1 ~DESCRIPTION OF OPERATIONS I LOCATIONS I VBNICLEB(ACOR)1D1,Additional Remarks Schedule,may de attached((more.ce a is leeuired) 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. phis 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 toe issue date of this oertifioate of insurance). The status of this coverage can be monitored daily by amassing the Proof of Coverage- Coverage Verification Search loot et www rnass.govllwd/workers-compensatiorVinvestigations/. • . CERTIFICATE HOLDER CANCELLATION • SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Herrhsteble ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main St AUTNORIZEO REPRESENTATIVE I-Iyannla MA12601 Daniel M.ICrey,CPCU,Vice President-Residual Market-WCRIBMA sl 1988-2015 ACORES CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts n Department of Industrial Accidents _AD Office of Investigations 'air,- 1— Lafayette City Center Q'' .7 2 Avenue de Lafayette, Boston,MA 02111-1750 - www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): �.if;//!`e 6;%X� % Address: /9/p1./zt ,?/S ' liC City/State/Zip:/v)' '7 ,/%C r 4",r7. Phone#: se/57--96 2_., - 29:2 Are you an employer? Check the appropriate box: Type of project(required): 1.0 I am a employer with / 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. n Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.Lei Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other 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: 71.C/��','c? Policy#or Self-ins. Lic. #: C4e fr 2A- yC: Expiration Date: 7/G/ - Job Site Address: Jl'3 G/L-C Y /G' .M ' City/State/Zip: , sr�`- ,!','2(,: g Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify uler the painsand penalties of perjury that the information provided above is true and correct. SiQrtature: ,& 'O_�-fib , 'fUC/ Date: y'` ',//� Phone#: L-67 r--.-e776' -.s229 ' Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): 10Board of Health 20 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 5E1'lumbing Inspector 6.0Other Contact Person: Phone#: • THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affai} t Business Regulation 1000 WashirrgtOrt,-Suite 710 Bnsto 118 Home imgro Atration t w ; Type: corporation 't`'c 1t"xL 141, > :anon: 100497 DAVID COT,INC. "" - atbn; 0312 4/20 2a 19 LAVENDER LN W YARMOUTH,MA 02ti73 r �hf'�,..,Ay sMh j�..r• Update Address and Return Card, THE COMMONWEALTH Or MASSACHUSETTS Ofheo of Conformer Anatt1,&Sustains Appleton Regietradon valid for individual uaa only before The HONE IMPROVUFPItcONTRACTOR expiration dale if bound return to: raWrefiteRrO4R Office of Consumer Affairs and Burliness Reputation Eattt1441,*,:4ilividiftar. 1000 Washington Street-Sure 710 1.05ki9Vintr Boston,MA 021111 DAVID COX,INC :1„41214 77. 1 r r r h DAVID COX 'k1r1� r f. i/E �� ' T L IS LAVENDER. OXtN c�pi na'._ W.YARMOUTH,MA O'L67Di,;;.,x Undersecretary.,,-.: Not valid without signature o,nih,.r nweaiU' Mass.trht,r.etts Giv,sion of Occupational Liconsure [Board of Building Regulations and Standards ,.,,St tkC trbr,t itf:.iu,` is,'r�r CS-063537 Expires:10115!2025 DAVID R COX i ,i i45 PO BOX 401 4 SOUTH YARMOUTh MA 02604 Commissioner Con`_...."4"4^t?1v 6L�. Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(gal cubic meters)of enclosed space.. L ca•ture to possess a current edition of the Massachusetts State Building Coda is cause for revocation of this license. For Information about this license daelfaale twCal l t017)727-3200 or visitwww,mass.govldpl••••• '4510