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Home My WebLink AboutBuilding Permits (2)PERMIT 805 10/28/96 LOT F1 10/28/96 /Sr fi° 111-Ar e R � ow Rogers, Theodore 426A High Bank Road South Yarmouth, MA 02664 Changc4 windows, add 2 fireplaces with chimney $10,00 SHEET 81 mr �D9 �J Fwf mrusk hw ll�w EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUrK Yarmoafk B.Bdhg Depar�ent 1146 Route 28 Sw & Yarmouth, MA 02664 (501) 399.2231 Ext. 261 IANf)xUCnONAa0aP8a:.4c7(,O_Htg.H,BANk_EQ S•.tiArrnouTK MA. OZ(afoy esSESSMs auIaeMATM: * q a F.a+ nwuFs•:iY�ti - iFaeX<- C. C.A"SVAI-I 4R(o F!t( amok QA r wodmr'F r lo(mom) a 1=20 Wimfook, -r1 0lLowwoddi ImQaoce Mp lm fo corm wortdicamp. FMCY# .- • a Taw (Fin o.aaredeq am waw src .crs�3d)/�_ o . i�.p �'iR tvU o ayro��••,wc . N �w w o ws- 4 Q� oa•.aae#efs"W. KtA�ACLI' qs 1 — ()A+FFsow�- pa�a�_�r��a� a S+S C o S3Frt H M AFw"War WE aww" onkm (w "W w) )n"Mud aimkt 0 Yes -kNo w•aramNM Fmbcfim IMmtt a Ya )�,Wo � 7 v Fbcift•Z� g a No e a. •rwafodc Yn 0 No KS) The Commonwealth of Massachusetts Department of Indus&W Accidents Office oflnvestlgations 600 Washington Street . Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: BaUders/Contractors/Electricians/Plambera Arialicant Information Please Print Leeibly Name c19 t) e$i K A,mrems: 4,2 S. ARmnuTH ED City/State/Zio "pq IS Mn 02-(o3¢3 Phone#: 5L) 8 -385^0905 ~�So B 2gc et`l� Are you an employer? Check the appropriate boz Type of project (required): 1. ❑ I am a employer with 4. ❑ 1 am a general contractor and I ew construction �Ployees (full and/or part-time).• have hired the sub -contractor 6. ❑ 2. ga'I a n a sole proprietor or partner- listed on the attached sheet 7. [71Remodeling ship and have no employees These sub-contractars have S. ❑ Demolition to and have workers' working for me in any capacity. Y� t 9. ❑ dtrug addition [No workers' comp. insurance comp. i iuuranre req�] 5. ❑ We are a corporation and its 1 repair or additions 3. ❑ I am a homeowner doing all work officers have exercised their 10lumbbin repairs or additions right of exemption per MGL myself worker comp a 152, § 1(4), and we have no 12 ❑Roof repairs insuurrancee rreequired ] t ®ployaa. [No workers, 13.0 Other comp. insurance required.] 'Any applicant dint chicks boa A nun also fin out the action below showing aces workers' congaustim pohoY inforvuam. t Homeowner who subtdt this affidavit indicating they we doing as work and tam hive muide eoatnslas mist sub®t a our afidawt Indicating such :Contactor that check this boa mud attached an additions! sheet showing the name of the subcontractors and soft whether or not these endtia have employees. If the subemtnaan have tnyloyees, they naut provide dair. workers' comp policy number. Ian an employer that is prasddbtg worker' compensation insurance for my employees Below Is the porky and fob site Informadon, insurance Company Name Policy # or Self -ins. Lis Expiration Date Job Site Address: City/Stave 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a foe 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 I do hereby ce&& under t ke pp/aaiinss/and p�/e/•//.yWes o erjaq that the informadon provided above' Is true and correct o:--...--.K7 /1 / /A I . �V 9• Hate!' /0 -,2 0 � phone #: area, to be completed by city or town ofJkial. City or Town: PermilAUceme # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6.Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employees to provide workers' compensation for their employees. Pun%= to this statute, an employee is defined as "...every person in the service of another under any contract of litre, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having of more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the Issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the Insurance coverage required." Additionally, MGL chapter 152, 125C(7) states "Neither the commonwealth nor any of its political subdivisions &ball enter into any contract for. the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), addresses) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LL.C) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insu som coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation polity, please call the Department at the number listed below. Self -insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applimnL Please be sure to fill in the pemmittlicense number which will be used as a reference number. In addition, an applicant that nowt submit multiple permitticense applications in any given year, reed only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit The Office of Investigations would lice to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-977-M_ ASSAFE Revised 11-22-06 Fax # 617-727-7749 www.mass.gov/dia ScottsCarpentry 42 S. Yarmouth rd .� Dennis, MA 02638 CARNEVALI 426 HIGHBANK RD. S. YARMOUTH, MA. SIDING- REPLACE ALL SIDING WITH MAMM DOUBLE DIPPED SHINGES TRIM REPLACE AS MUCH TRIM AS POSSIBLE WITH AZEK PVC TRIM NEW WINDOWS- ADD 4 NEW WINDOWS ON SOUTH FACING WALL RAILINGS- REPLACE ALL DECK RAILINGS WITH A VINYL RAILING SYSTEM BATHROOM- REMOVE TUB AND MAKE O.OSET FOR STAOC M WASKER/DRYER AND SHELVES Liberty Mutual Group llbe2'iy P.O. Box 9090 Mutual. Dover, NH 03821-9090 Telephone (800)653-7893 Fax(603)-245-5330 October 29, 2008 TOWN OF YARMOUTH ATTN: BLDG DEPT 1146 MAIN STREET SOUTH YARMOUTH, MA 02664- RE: Certificate of Workers Compensation Insurance 42 SOUTH YARMOUTH ROAD DENNIS. MA 02638 Policy Number. WC2-31S-369288-018 Effective: 10/7 /2008 Expiration: 10/7 /2009 Coverage afforded under Workers Compensation Law of the following state(s): MA EElplo)xrs Liabilitsl: Sole Proprietor/Partner Coverage Election: Bodily Injury By Accident: $ 100,000 Each Accident The workers' compensation policy doe not provide Bodily Injury by Disease: $ 100,000 Each Person °overage for: BodilyIn' b Disease: = DSCOITMURDOCK Injury y 500,000 Policy Limits As of this date, the above -referenced policybolder is insured by Liberty Mutual Fire Insurance Co under the policy fisted above. The insurance afforded by the listed policy is subject to all the tears, exclusions and conditions, and is not altered by any requirement, tern or condition of any or other documents with respect to which this certificate may be issued. This certificate is issued as a matter of information only and confers no right upon you, the certificate holder. This certificate is not an insurance policy and does not amend, extend, or alter the coverage afforded by the policy listed above. If this policy is cancelled before the stated expiration date, Liberty Mutual will endeavor to notify you of such cancellation. T l— AUTHORIZED REPRESENTATIVE LIBERTY MUTUAL INSURANCE GROUP TAY Casifkw is emmd by I..BFFRRTYIdurUAL INSURANCE GROUP u aspms sub rose a is oS,NM by shm emponis cc: Insured: D SCOTT MURDOCK t 42 SOUTH YARMOUTH ROAD DENNIS, MA 02638 Producer of Retard ROGERS do GRAY INS AGCY INC 434 ROUTE 134 SOUTHDENNLS, MA 02660 10/29/2D08 ACORD. CERTIFICATE OF LIABILITY INSURANCE 101`"""°°"Y'Y' 10128108 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION - Rogers 3 Gray Ins. So. Dennis ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 434.Route 134 HOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR P. O. Box 1601 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. South Dennis, MA 02660.1601 INSURERS AFFORDING COVERAGE NAIC 0 INSURED D. Scott Murdock INSURER A National Grange Mutual INSURER a 42 South Yarmouth Road INSURER c Dennis, MA 02638 INSURER D: INSURER E.- 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 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TR HSRE TYPE OF INSURANCE POUCYRUYSER IEEE DATE IY 08102/08 POLICY EXPIRATION LIMITS A GENERAL LIABILITY MPB64999 08/02/09 EACH OCCURRENCE 51000000 X COMLERCUL GENERAL UABR1iY CLAIMS MADE FAI OCCUR DAMAGEPREIMSETO RENTED SSOO OOO MED EX►(Any IRA penwn) $10 000 PERSONAL S ADV INJURY fi 000 000 GENERAL AGGREGATE f2 OOO O00 GENL AGGREGATE LIMIT APPLIES PER POLICY PRa M Loc PRODUCTS• coMPIOP AGO s2000000 AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE UMIT (6 eeddRA) i ALL OWNED AUTOS SCHEDULED AUTOS INJURY (P-Py ) i HIRED AUTO.q NON -OWNED AUTOS (P-ILY INJURY aLadNII) f (I �SOAALA(IE f GARAGE LIABILITY AUTO ONLY. FA ACCIDENT S OTKFEA ACC THAN S ANY AUTO i AUTO tno ONLY.' AGO ESCESWYSRELLA LIABILITY EACH OCCURRENCE s AGGREGATE s OCCUR CLAIMS MADE s DEDUCTIBLE S RETENTION WORI�Rf CDYPENSATDNAND EMPLOYERS' LIABILITY WCSTATLL OTH- ANY PROPRIEIORIPARTNERIEXECUTIVE EL EACH ACCIDENT S OFyFeeIC,FRMEMBER EXCLUDED? SPECI PROVISIONS below E.L. DISEASE. EA EMPLOYEE f E.L. DISEASE. POLICY LIMIT S OTHER DESCAN TION OF OPERATIONS I LOCATIONS I VENUES I EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS "PLEASE NOTE THAT A WORKERS COMPENSATION CERTIFICATE WILL FOLLOW SHORTLY UNDER SEPARATE COVER, AS IT IS BEING ISSUED DIRECTLY BY THE INSURANCE COMPANY" FAXED TO: 508398.2365 Town of Yarmouth attn: Building Dept. 1146 Main St. South Yarmouth, MA 02664 LO ANY OF THE ADM DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION THEREOF.TNEMMOMBURERWLLENDEAVORTOWUL .U_ DAYBYRITTEN A To THE CERTIFICATE HOLDER NAMED TO THE LEFT. BUT FAILURE TD Do SO SHALL E No OBLIGATION OR LIABILITY OF ANY KIND UPON THE SNNIRM ITS AGENTS OR ACORD 25 (2001108)1 of 2 839761 MLV 0 ACORD CORPORATION tORB .��/t If.YH�IIfYAVI�� [� /�IJ.kIf�Y3r�d Board of Building Regulations and Standards .Construction Supervisor License License: CS 80395 Birthdate: 3/13/1964 Expiration: 3113/200g Tri 9751 t Restriction: 00 D SCOTT MURDOCK 42 S YARMOUTH RD �i�- �• DENNIS, MA 02638 Commissioner '✓7ia �YuesnorwYni�Gi r� ��a,tr:r/iude(�s Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR r Registration: 144829 Expiration: 11I 2008 Tr0 124376 Type: Individual D. SCOTT MURDOCK DAVID MURDOCK 42 S. YARMOUTH RD. DENNIS, MA 02638 Admlaistrator �' 2 71rl.#;P SIIpGen- Portal Hame Document Category Map -Block Number Street Number Street Name Department Parcel ID Backfile Batch Scan Document? Additional Naming Info Index Operator Date - Time Town of Yarmouth Template [Building Dept] Slipsheet Identifier [sg28156] Building Permits 092.7 EFT: RO . � Building 12793 No Operator, Yarmscan 2015-06-17 - 10:23 ttoAasedche771SIPCOY 1/1