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Home My WebLink AboutBLDX-26-435 application 611-4*. RECEIVED Use Only o _ y, MAY 12 2026 Amount - -,- ,\`er. MATTACMEELL /4 { ��CORP0 RAtS�A BUILDING DEPARTMENT EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 IVv (508) 398-2231 Ext. 1261 /� CONSTRUCTION ADDRESS: '( 5 iP br -= OWNER: ft-414.1a / 3 kAlle ii socf 3l0+ > NAME PRES NT ADDRESS TEL. # CONTRACTOR: /7 d.l." ' if Si<<sJ e� it/ S j�Pd,3e-B o? Y6 NAME MAILIN0`A[DDRESS i TEL.# EMAIL: Aoto&(Ae a; ieLen . eG "# ' .may► Vesidential LI Commercial Est.Cost of Construction$ 1 I,'St)V Homeowner is Applicant? Yes No Home Improvement Contractor Lic.# /I OZ 3 2 a Construction Supervisor Lic.# 6 Y a / a y WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares Replacement windows: # Replacement doors: # Roofing: #of Squares 0 Insulation Temporary Mobile Home Temporary Construction Trailer Demolition—Interior only *Demolition Raze Structure Solar System ESS System Chimney Fence *Please submit utility disconnect letters for electric& gas—structures over 75 years old require historical review *The debris will be disposed of at: i A Ni/4t,e V.6' Wiett.A. 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 denia or rev a n of my license and for prosecution under M.G.L.Ch.268,Section I. Applicant's Signature: / 41-1-4.4.- Date: 6-4)/p_a Owners Signature(or attachment) Date: Approved By: Date: Building Official(or designee) Rev 6/24 k The Commonwealth of Massachusetts , Department of Industrial Accidents Office of Investigations -am - Lafayette City Center WM OW _...sue' 2 Avenue de Lafayette, Boston, MA 02111-1750 wwn.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): • Address: //_ ( Z City/State/Zip: �� S Phone #: Gj a/ 2 C o' D ? V5 Are you an employer? Check the appropriate box: Type of project (required): 1. EI am a employer with 4. ❑ I 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. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. emplo:yees and have workers' [No workers' comp. insurance comp. insurance. 9. ❑ Building addition ] re uired. 5. 0 We are a corporation and its 10.❑ Electrical repairs or additions required.] 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 12.42of repairs insurance required.] t c. 152, §1(4), and we have no 13.❑ Other employees. [No workers' 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, surance for my employees. Below is the policy and job site information. - / Insurance Company Name: �� /rv) � U uG�G / Policy# or Self-ins. Lic. #: W C gl e d G j / 3 �/. � � p a S�J Expiration Date: � �. Job Site Address: q 3 1,4,- 06.6, City/State/Zip: 1,t. (. ST � n0zd4`4 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi ,finder the pains and enalties of perjury that the information provided above is true and correct. / 7 Si ature: Q-✓ Date: / 09! Phone #: 57, J / 6 `7 Y Official use only. Do not write in this area, to be completed by city or town official. City or Town: _ _Permit/License # Issuing Authority (check one): 10Board of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector 5E1Plumbing Inspector 6.0Other Contact Person: Phone #: r- • • • I i , • Commonwealth of Massachusetts C' DIVISION of Occupational Llcensure : V • I oar: of Building Re uiatlons and Standards1,: Cons ,�?'41 ��rvisor CS-040124 � `� ` >3,,; it• � ° { ;Aspires03/29/2027 LIBEROJM I i �,, 0- ,/, .,2;11SHEEPP T `'• ,:, � � ° '� " '.EAST SAND I 4 , 1. '1:' .+ . , ' O ,,1,3. i,';< �(, �f• ; g 7 Commissioner ,...E.,..44 I zvd.4.,, _ _ __ _ 7:- - f ;! Unregtric - 35,000d ' Flub ti ".k�t`uttion Sucublo , , onuP Vvts,t _ _10 Aiceg 'nety 'itch h contain 1 enclosed spacQs than Failure to Posse euildin Contact ppg Code asc��renf edition o SI. (6171 ;273200 o r ca iooM.:s tts _ for se S r Visit �yw - :Nu n$e late •.. ., lice THE COI iviONwhALTK OF: MASSACHUSETTS 8g'�1O`'ki Office of Consumer Affaas. & Business Regulation pllopsi g HOME IMPROV N _ ONTRACTOR TYP i nv! al, Re, ist t_L s' •-. elation 7-1)5. . e44547 JBERO J. MOLINARI r'4=-- 1 '' ` r - :: `ff 11 . -: y , ,----_ ir ..._. _, . . i „.44. 41 cl 0 f tAndi& Registration valid for individual use only before the _IBERO J. MOLINARI .{�;- a "� ' �; `ifound return to: i ! < •• � :t� � '' expiration date. If I 1 SHEEP PASTURE Vie Y - • Office GC Consumer Affairs and Business Regulation '{T�----z •� ems= =AST SANDWICH, MA 02�7_�,��,- r � , .. 1 Federal Street • Suite 720 -. %0-4\-.61'., .�" r ' Undersecretary Boston, MA 02110 rY i1r. -- - - ..,-'may r-Tir-7 r -gyp ,-.,~-^ .,i '' " - Tom•- .aLtr:=• .—._=T 4/2/ ' t. /7.. • �'t...�_s/__ .. GJ�_ ....• --....•,......—.. t... Not rralfd i ut signature J o< Co L ( , c • ACC o e CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDO/YYYY) 04/07/2026 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 REPF�_.SIENTATIVE 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 Ileu of such endorseLment(s).PRODUCER CONTACT SMITH BROTHERS INSURANCE LLC NAME: Lori Wong PHONE we Na FxiL (660)652-3235 1 FAX EJNAIL UI/C.Not. 68 NATIONAL DRIVE ADDREss: Iwong@smithbrothersusa.com GLASTONBURYINSURER(S)AFFORDING COVERAGE NA/CS INSURED —- CT 06033 INSDRER A:AIM MUTUAL INS CO 33758 LIBERO MOUARI INSURER B: MOLINARI HOME IMPROVEMENT INSURER D: 11 SHEEP PASTURE WAY INSURER D: EAST SANDWICH INSURER E: MA 02537 INSURER F: COVERAGES CERTIFICATE NUMBER:1209313 THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUREDEVISION NAMED ABOVEB 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. WSR LTR TYPE OF INSURANCE t POLICY NUMBER COMAERCIAL GENERAL LIABILITY aaaUDOrVYVVt IMaPNDDA'YYYI DMITB CLAIMS-MADE Li OCCUREACH OCCURRENCE S i MED EXP(My one person) S N/A GENE AGGREGATE LIMIT APPLIES PER' PERSONAL d ADV INJURY $ —POLICY❑2a �LOC GENERA.AGGREGATE S OTHER PRODUCTS-COMP/OP AGG S AUTOMOBILE LIABRJTY S COMBINED SINGLE LIMIT S ANY AUTO 2 1,111E tl /AU SCHEDULED BODILY INJURY(Per person) S __AUTOS ONLY -_AUTO$ N/A BODILY INJURY P ) HIRED NON-0NNED (Per accident/ I _�AUTOS ONLY _AUTOS ONLY PROPERT D (Per:aTeYnttAMAGE S UMBRELLA LUB __OCCUR S EXCESS LOU CLAIMS.AAOE N/A EACH OCCURRENCE $ DED I 1 RETENTIONS AGGREGATE $ WORKERS COMPENSATION S ANDEMPLOYERS'IJABIUTYSTATUTE I IEER ANYPROPRIETOWPARTNER/EXECUTNE Y/X A OFFICERAUEMBEREXCLUDED? MI NIA NIA AWC40070061132025A 05/21/2025 05/21/2026 E.L.EACH ACCIDENT $ 100,000 (Mendeory in NH) nESCy�es des`roe urMer E.L.DIAFASF-EA EMPLOYE S 100,000 DRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS r LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be 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 authoriration 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 policy precedes the issue date of this certificate of insurance I. The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Iwd/wUrkers- compensatioMnvestigations/. Sole proprietor has not elected coverage. 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 AUTHOR RED REPRESENTATIVE Bamslable MA 02630 --\I'4"("'C Daniel M.Cm Iy,CPCU,Vice President-Residual Market-VVCRIBMA ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD CORPORATION. All rights reserved.