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Home My WebLink AboutBLDX-25-824- Office Use Only Permit, fOyl Amount 4{ EXPRESS BUILDING PERMIT APPLICAINViCEIVED TOWN OF YARMOUTH Yarmouth Building Department L.JilJN 24 2025` 1146 Route 28 $, South Yarmouth,MA 02664 Cg- S� (508)398-222311 Extt.. 1261 a DING DEPARTMENT CONSTRUCTION ADDRESS: Z,3p L�/�J/ �[._., ST xp___ OWNER: ZAZ eY.iA/2(r5cl/tl Z36 ee itozz5; yeze, all izex \:\\IE PRLSL\t\UDRI.SS TEL. CO\TRAC'TOR,42(1/O dQX p// .t.�10!..._S!/ XOIZ i'7.40 .S'Gc-942:i-2 9 NAME \I\ILI\G.ADDRESS TEL.e EMAIL:_ /lC/,Je�' �!/yiDil'/�i'J.•-G(IJyJ Residential J Commercial Est.Cost of Construction S/2„aeri, ._. Homeowner is Applicant" Yes No/7_ Home Improvement Contractor Lic.# /00419F Construction Supervisor Lic.# p(Z.S3-7 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Store Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares Insulation Temporary Mobile Home Temporary Construction Trailer Demolition—Interior only *Demolition Raze Structure Solar Si stem ESS Si•stem Chimney Fence Please submit utility disconnect letters for electric&gas-structures over 75 years old require historical rev iew 'The debris will he disposed of at: ) . 17/V J./S5OS.QL 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 answen s) will be just cause fir denial or reweation my license and for prosecution under NIA.L_Ch.268.Section I. Applicant's Signature. _ Date:_ / Owners Signature for attachment) Date: Appms ed H7 Date: Building Official for designee) Res 6 24 • .� ~ I THE COMMONWEALTH OF MASSACHUSETTS A 9 '« Office of Consumer Affair"dam Business Regulation 1000 Washingta ,r�- Suite 710 Bostor .p ,ta -; 118 Home tmAro R epstration — 1 -.4 =t . :;.,,-°s 0 - Type! Corporation OAV!E) COX, !NC '-t ': t-:� a: 1r anon: 03l24l2Q2b 19 LAVENDER LN ".. V.,..—.F.".»'"` . «;n:«.wi W YARMOUTH, MA 02673 "`�.° 'E-3 4,. ,: "i }4,, \.lit°! Z .,«. A. ` Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer AffeJrs&Bucinass Regulation Registration valid for Individual use only before the NOME 1MPROVEb41tcONYRACTOR expiration date. If found return to: TI( 1X1:00t► Office of Consumer umer Affairs and Business Regulation ,.. 1000 Washington Street ••Sulu 710 r -i.' ` '`a"" '>i Boston.MA 02118 �mt� DAVti) COX.INC. • „• a:.'' 1:,• � "E. er19, t • y` .. 4, E DAVID n.COX . s" p 7 ' . � i :� '� : �: 19 LAVENDER LN � , rv, . . /11!"114#I # '''''''.'("84/f:2a . W YAIaMOi)TH,AAA 02c73 [ , T Undcarsocretary Not valid without signature C:onrnonwo of Mas9aGnUstttS _ prvisVon of Occuuattonai Llcensurr Board of Building Regulations and Standards ruac �� xer ,_. I - CS-063537 Expires;10115/2025 DAVID R COX ' PO BOX 401 4 . SOUTH YARMOUTH MA 02064i Y ' Commissioner r' Con! - •,L..l'.�/LL r. Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991 cubic meters)of enclosed space. Failure to possess a current edition of the Massachusetts Srate Building Code is cause for revocation of this license. For information about this license Call(617)727.3200 or visit www.mess.govidpl i r The Commonwealth of Massachusetts Department of industrial Accidents _ 1i Office of Investigations 'a Lafayette City Center 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): 2547,zL,,) G,p/c. Address: /9c',e7/ 7t/fzn( Z/t; City/State/Zip: /-)4/, /%/p c'2,/!,-,_? Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with / 4. 0 I am a general contractor and i employees(full and/or part-time).* have hired the subcontractors 6. ❑New construction 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 working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.insurance.[ 9. ❑Building addition 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.❑Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL Ys 12.E Roof repairs insurance required.]t c.152,§1(4),and we have no employees.[No workers' 13.❑Other comp.insurance required.] •Any applicant that checks box#1 must also fill 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 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: 72,GU'Y(j 5 Policy#or Self-ins.Lic.#: (/,C 9/O.t 7Y"2 Expiration Date: // Job Site Address: 226 CLOr,'ar S7 City/State/Zip: 1/.e,f4.,V 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 petjury that the information provided above is true and correct Signature: A ��1.� 7 Date: O_f/``5 Phone#: c2J 7 �cS� Official use only. Do not write in this area,to be completed by city or town offcial. City or Town: Permit/License# Issuing Authority(check one): 1❑Board of Health 20 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: 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. i IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,D, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. It 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 ri hts to the certificate holder in lieu of such endorsement s . PRODUCER •• ' Pans l�(}LiriieBJ Nei -- — ...— - .-...�iiik . .... SLI_LiVA.N GARRITY & DONNELLY INSURANCE AGENCY INC PHONEFAiI�. Arc,No,Ext); (508) 453-2582 _ _WCA1rlo1_..._. _ AMA US; Parls.Bourdeaugsgdins.com 10 1NS TI Iit11 L RD _._. --- --INSIJRERIN AFFORDING COVERAGE NAIC e lNORC;LS T F2 MA 01609 INSURER A: TRAVELERS INDEMNITY GOOF AMERiCA •j 25666 INSURED INSURERS: DAVI;)COX INC INSURER C:._.._ , .._...... .... _.-......._. .__. - INSURER 0 r f'C) BOX 401 INSURERS: S YAIRMO!1T i•t MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER? 1018800 REVISION NUMBER: 't•ti5 IS TO CERTIFY "HAT THE POLICIES OF INSURANCE e_S',ED BELOW .-LAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POI.iCY pER U7 INL)ICATEL) NO ATHS ANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT To 'WHICH THIS CI::RTIFI(:ATL MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS EX(.:{US IONS ANC CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSf1?'_._.—_ .. IAbDLISUH' I P'OL.10EFF POUCYEXP ! LIP TYPE OF INSURANCE i INSD 1 WVI]I POLICY NUMBER IMNIMOIYY YYL,p1IIIMIDONYY111 LIMITS COMMERCIAL GENERAL LIABILITY �-7 EACH OCCURRENCE S i CLAIMS-MAUL i OCCUR I DAMA S jEk rsTED • PRFNII�SE5 jEgonr4nCe) y $ r _ _ ! ^MED EXP(Any erre�rerson} ...S ._._— J�~ �� N/A PERSONAL&ADY INJURY S I :N*1 AGGREGATE LIMIT APPLIES PER 1 GENERAL AGGREGATE S ______ POLICY I R� Ti LOC I PRODUCTS-CONK*AGO $ _ _. . OTHER: {I I $ AUTOMOBILEL?ABILITY I (Ea COMBINED SII L UM T $ W 4WW^ (Ea accident) ^- ANY AUTO I BODILY INJURY(For parson; S -"- OVYNEV 1 SCHEDULED i N/A E3OO L Y INJURY;Per acoident) $ .-.._.- _; A;ITO.,ONl_. ;.-......4 Amos i I Hi fi o Noty-OWNED i I PROPERTY DAMOE y AUTOS ONLY I AUTOS ONLY y Pfr accident) _ _,_ _„„I $ ! UMBRELLA ..IAB t--- ' OCCUR ' i EACH OCCURRENCE S I CxCESSLIAR : [ CLAIMS-MADE i N/A AGGREGATE $ DiW RETENTIONS ----11I 1 1 I S `WORKERS COMPENSATION r �� PER O,� AND EMPLOYERS'LABILITY I c STATUTE L _ g.R _ ANvaRovRIE r4R1PARTNEr.IEXECU1'IVE IY N I E.L.EACH ACCIDENT $ 100,000 A. r: IC,RVMENABERvixCLUDEDI IN1A1 Nra I NIA 6HU8910X742224 i 07/16/2024 07/16/2025 ; l ---- ,Wand:tmy in NH) ; 1 E.I.DISEASE-EAEMPLOYF.Ei $ 100,000 f ,•s.derscribe vnr_ler 1 _� ;;If HIP Of-QPERATIONS below , i 1 ! _ 1 E-L.DISEASE- POLICY LIMIT $ 500.000 N/A• i ~DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES I,ACORD 10i.Additional Remarks Scneaule,rosy be attached it more spaces requhed) 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 nired 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 - Coveraye Verification Search tool at www mass.govtlwd!workers-compensation/investigations/. . _ i CERTIFICATE HOLDER - CANCELLATION -- . SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, 1 own of Barnstablo :?00 Maui St - AUTHORIZED REPRESENTATIVE Y 'l-lyanrm., `VIA 02601 , � Daniel M. Crowley, CPCU, Vice President-Residual Market -WCRIBIv!A 61988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD