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Home My WebLink AboutBLDX-25-319 application IF y9 , Office Use Only /� iei O, Pernutk CI (b w 4,,/e !!+ Amount •at J EXPRESS BUILDING PERMIT APPLICA IONL a a _3 I T TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 � _ _, F._ ' 1 g L' li South Yarmouth, MA 02664 t (508) 398-2231 Ext. 1261 rMAR 24 2025 1 • �/N.0 ,�,J/ NG ~� v _N CONSTRUCTION ADDRESS: __ -gUiLUitv(3 +� r;Eti� {tiT� E3y �. ...._.- OWNER. 25i17U/i0 /'4.c LSVCO IS-ca6lua2+0 X.0 Y.464.0.,W Th'Mel `1\tl PRFSI\i.1I)1)RESS TFL CONTRACTOR. ,Tj(!7l//,Q CXi4 P gal tom: /i1 /4 . Zc7 02.4.4' .,V \I V I I\t, •11)I)RPSS TEL.v EMAIL: .,/`ZG/ (..c�7 'CUP7 residential Commercial Est.Cost of-Construction S .__,2 6�r20� Homeowner is Applicant? 1'es No I Home Improvement Contractor Lic.# /00449-7 Construction Supervisor Lic.# aa3KF 4/7 - RI41OI ,9L$ -sum( Foe 5/(7 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares 20 Replacement windows: # • Replacement doors: # Roofing: #of Squares Insulation Temporary Mobile Home Temporary.Construction Trailer Demolition— Interior only Demolition Raze Structure Solar System ESS System Chimney Fence i . l'h,ase submit utility disconnect letters fur electric.@ tAs structures u%er 75 sears old require historical res jest 'The debris will be disposed of at: yAMMe rR .... /.,172,19 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 answerts) will be just cause for denial or rrrsocatio�n�ofmy!license and for prosecutionunder M.G L.('h.26S.Section I. Applicant's Signature �,�.-/G ..eAuie— le /J$1 Date e// / Owners Si;,mature lot attachment) _ Date: Approved By Date. Building Official for designee) Res b 24 s :ac - ,2 . • 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(ias)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). PRODUCER C°NTACT Paris Bourdeau , SULLIVAN GARRITY&DONNELLY INSURANCE AGENCY INC ? N : (SO8)453-2582 ,q Not, L Paris Bourdeau(c�sgdins.com l��gSES.S—____ _— _ 10 WONSTITUTE RD INSURERIS)AFFORDEVG COVERAGE ,._ RAMP CE.STER MA 01609 INSURER A: TRAVELERS INDEMNITY CO OF AMERICA 1 2566E UAv ...... .. ttt INSURED INSURERS _. D COX INC INSURER C: 4 .INSURER D PO BOX 401 INSURER E: `}-- -S YARMOUTH MA 02664 wsuRERp; COVERAGES CERTIFICATE NUMBER: 1018900 REVISION NUMBER: THIS I5 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERI00 INOICATL'-D. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO YNHICH THIS ERT?F,CATE MAY 9E ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, I_XC,'LUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ' TRW.—�• TYPE OF INSURANCE �ADOL�SiJBP! LTP NRANCfi then1 MVO POLICY NUMBER (WILCOA YL fYYYY.1 LIMITS " COMMERCIAL GENE!RAALAI L UAUTY EACH OCCURRENCE $ CLAIM$-MADE I OCCUR DAMAGE,PREMISES{Eaorx,.rcrence) !$ • --- 1 MED EXP(any one person) $ . N N/A I PERSONAL S ADV INJURYi_ r c.SM.AGGREGATE LIMIT APPLIES PER- GENERAL AGGREGATE $ . ET o POLICY: _,JE_ cr. 7 LOC PROOLCTS•COMPIOPAGG 3 I I 'OTHER. } r ) COMBINED SINGLE LACAUTOMOSILBLIABILITY I $ i ANY AUTO I I BODILY INJURY(Per person) $ ' -^°MME'0 —)SCHEDULED N/A BODILY INJURY(Per aoordant) $ i,—y AUTOS ONLY :,____I AUTOS I _ - HIRED ,NON-OWNED P a ..:,N I A $ „r,-AUTOS ONLY F,__y ALTOS ONLY • I UMBRELLA LIAR !OCCUR ! � EACH OCCURRENCE `$ • EMCEES LUL8 j�CLAIMS.MADE WA AGGREGATE $ I PFA I L RETENT!QR$ I p $ ,WORKERS COMPENSATION 'XI STATUTE 1 LE p E. AND EMPLOYERS'LIABIUTY NYPROPRIETORPARTNER/E)F.CUTIVE Y r NIT-1 E.L.EACH ACCIDENT $ 100,000 A .DFFFCEINSEMBEREXCLUDCC9 L era WA 6HL1B910X742224 i 07/1612024 07/16/2025 --- (MairrMtay in NHI E.L.DlSPAAP-EA EMPLOYEE $ 100,000 11 VHS.axalbe under 'OPSOdPTIONOFQRTIOabi I { EL.DISEASE 500,000 _ — � N;A • i ~DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES IACOPO tot,Additional Remarks Schedule.may be attached it more space Is resdirod) 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 stales 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 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 ICoverage Verificat,on Search tool at www.mass.gov/Iwdrworkersoompensation/rnvestigationsf. . CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN Town of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main St AUTHORIZED REPRESENTATIVE -ti HYannln; MA 02601 Daniel M.Croarl/ty.CPCU,Vice President--Residual Market-WCRIBMA ®1988-2015 ACORD CORPORATION, All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents =:� Office of Investigations Lafayette City Center 71,07/ 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): ;Lr ' d,x Address: /gl,,,L/. esr_ City/State/Zip: /,z/ /,i ( _ Phone#: ,'F- �:a.-'5 7,9 Are/you an employer?Check the appropriate box: Type of project(required): 1.El I am a employer with / 4. ❑ I am a general contractor and I 6. [] New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' p y t 9. ❑ Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions eq ] 3.❑ officers I am a homeowner doing all work have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other _ comp. insurance required.] *My 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: %/f./V/J7lt,/Q- Policy#or Self-ins. Lic. #: L L ' 9/CI X 9y2i. Expiration Date: F//0: Job Site Address: A�.0 City/State/Zip: y/.e/771,-'�y�:� 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of pedury that the information provided above is true and correct. Sn Si afore: D ate r / Phone#: 9 2 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): lDBoard of Health 20 Building Department 3EICity/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: THE COMMONWtJL l m yr ' Office of Consumer AffatAxl Business Regulation 1000 Washing ' rt,,Suite 710 Bosto ts :`! 118 • Home Im "`$ -' ro tra'.lon ('"/& '• 1 Type. Corporation j - *at 100497 DAVID COX,INC. Pi 4 - E stun. 03/24/2026 19 LAVENDER LN ,,j W.YARMOUTH,MA 02673 -1 p • vt Up rate Addmss and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affair.&Business Regulation Registration valid for individual;•se only oefore the • HOME IMPROVEM CONTRACTOR expiration dale H found return v Office • TYPE: a3 oa Oce of Consumer Affairs and Fuusiness Regulation 1000 Washington Street-Suite%'0 26 Boston.YA 02116 DAVID COX,INC. �� I • r ia,e f D OX �. 19DAVI LAVENRCDER LN ''` -��"�r :� .v n ltR W.YARMOUTH,MA 026'Y3 ,_ Undersecretary Not valid without.signatu tom. IFvf ',Commonwealth of Massachusetts = Division of Occupational Licensure Board of Building Regulations and Standards Cottsirtuct€on Super;,sr (CS 063537 Expires 1 011 5/20 2 5 i DAVID R COX PO BOX 401 _ SOUTH YARMOUTH MA 02664 ti Cr7Tirrlls inner Cow i;nrtsfncted-Buildings of any use group which contain €t• s: an..:15,000 cubic feet(991 cubic meters)of enclosed sgac=. j:.,ii srr to I2Cssess a current edition of Massachusetts I4,te Building Cone is cause for revocation of this license. lot information about tytis license i Cal!0517)727-3200 of visitwww.mass.govidpl •