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HomeMy WebLinkAboutBuilding Permits (4)MATTI� L[it- EXPRESSBUILDING PERMIT APPLICA TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: ASSESSOR'S INFORMATION: • .CK 7`vt l "Mis1l; NAME Map: S / I Parcel: yq aRMIJI—EIMPIUM, .. TEL n Email `— tV►Jrrr'rI u"-tJ v /� j Residential Commercial Est. Cost of Construction $ I11`/� 24 • 01) Home Improvement Contractor Lie. #. t mq(; o Construction Supervisor Lie. #as — 6951a0 Workman's Compensation Insurance: (check one) I am the homeowner I am the sole proprietor I have Worker's Compensation Insurance) ' , 2�j� Insurance Company Name: �81 j0, I1 aIMM Worker's Comp. Poticy#0W C,' ram; Tent Duration Siding: # of Squares WORK TO BE PERFORMED (Fire Retardant Certificate attached?) Replacement windows: # Roofing: # of Squares ( ) Remove existing* (max. 2 layers) Old Kings Mghwayl istoric Dist. ( ) Replacing like for like 'The debris will be disposed of at: Wood Stove Replacement doors: # Insulation ij 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 answers) will be just cause for denial or revocation of my licensee and for prosecution under nG.L Ch. 268, Section 1. Applicant's Signamre: : !� _ 1 /� Date: Owners Signature (or Approved B): Date: Building Official (or designee) Zoning District: I `' L Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft. of Wetlands: Yes No Yes No The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Annticant Information Please Print Legibly Name (Business/Organindon/Indivi&W): `'r`yrotatrdGlP: w/ t� 1h1'� �'7)Y(J /M QJ IUh Phone M �� Are you an employer? Check the appropriate box: M. � 1. (A I am a employer with '2 4. ❑ I am a general contractor and I employees (full and/or part-time).' have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. (No workers' comp. insurance 3. ❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 3a.0 I am a homeowner acting as a general contractor (refer to 94) listed on the attached sheet. These sub -contractors have employees and have workers, comp. insurance.= S. ❑ We are a corporation and its Officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance reouired.l- Type of project (required): 6. ❑ New construction 7. Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions l 1.❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other 1 •Any applicant that cheeks box #1 must also fill out the section below showing their workers' compeasatiod oliey information t Homeowners who submit this aEidavit indicating they are doing all work and then him outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional shed showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they mast provide their wodmrs' comp. policy number. ! ant an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information Insurance Company Policy # or Self -ins. Lic. #: i{ ��,(��Tj / (/�j Expiration Date: 91cq1 / Job Site Address;I 9 City/State/Zip: ' XAL Attach a copy of the workers' compe tion policy declaration page (showing the policy number and expiration date). Failure -to secure coverage as required under Section 25A of MGL e. 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 cernfy `nder the pains and penalties of perjury that the information provided above is true and correct Official use only. Do not write in this area, to be completed by city or fawn official City or Town: Permit/LIcense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone 9: Information and Instructions all la to vide worlcera' wmpenaation for their employes. Massachusetts General Laws chapter 152 requires -MP Y� m the service a another under n f cont�ad of hire, pursuavi to this statute, an emplgw is defined as %.every Person express or implied, oral or written" An raep&)w is defined as "era iodividusb PartnershiP, association' corporation or other legal entity, or any two or more m s oiat sod including the legal representatives of a chased employs+ o: the of the foreping eased J am ' a other lcpl entity' employing t�PbYns' However the meiva ox trustee of as individual, apartments and who resides therein, or the occuPsnt of the owner ota dwelling hove having mot nose than three dwelling house of anther who employs persons to do maintenance, construction or repair work an such dwelling house or oa the gmuoa or buil&g spptuteasat thereto shall not because of such employment be deemed to be as employer." MGL chapter 152, 425C(6) alw states that "every state or local 11esasiag sgMY shall ����ithhold the 45f "W renewal sti a He=" or permit to operate a busiaew or to eonstrud baildlip appLkIM who has trot produced acceptable evidence of compliance with the inscasece coverage requireL" Additiaaally. MOL chapter 152, 12SC(7) states "Neither the commonwealth not any of its political subdivisions Shan eats into may contact for. the performance of lie wok until acceptable evidence of compliance with the insursxe 1 to the contracting sutbocity." requiremcntt of this chapter have been presented Applicants plena ® out the workers' coanpcosaSon affidavit completely, by checking the box" that apply to yam situatwa and, if aeeeassry, suppty sub-coatractods) aame(s), addtas(") and phone mmbm(s) along with their cerdSeste(s)ootha than the innaaaoe. Limited Csblity Coate (LLQ a Lusted Liability Partnerships (L.LP) with no �Pby ccs mambas or partners, are not required to carry workers' compensation insurance. if an LLC or LLP does have =Vloyeea, a policy is required, Be advised that this affidavit may be subaatted to the Department of Indnshial Acddents fat oronfinustion of kwxw oe coverage, Abe be aura to sip and date the'aldaviL •Ibe affidavit should be maned to the city or town that the spplicatioa for the permit cc U=w pa being requested, not the Department of indnsirial AoxideatL gild you have any goestiow rrprdmg the law Or if you are required to obtain a work= compensation policy, plum call the Depsat the as mba listed below. Self -poured companies should eater their -_ir :r.--...,.. Rr... & mrmber on the samo0ri1ie line. City or Tawa Omciais Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the both= of the affidavit for you to fill out in the went the Office of Investig dew has to contact you reprding the aPPficauL Please be stae to fill in the peamWcco" mtmber which will be used as a refer -ace munber. In addition, as applicant that mast submit multiple pamiviiecme applies tiont in any given year, need only submit am affidavit indicating cusont PO information (if neeeassry) and under "lob Sila Address" the applicant should write "all locations pa (city of town)." A copy of the affidavit that has been of trimly stamped or marked by the city or town may be provided to the applicant ere proof that a valid affidavit is on fie foe fittsae pesmib tic licenses. Anew affidavit most be filled out each year. Where a home owns or citizen is obtaining a license at permit not related to any business or commercial venture (i.e. a dog license or Pertain to burn !car" etc.) said person is NOT required to complete this affidsvit The Oaks of Iavesdpdow would lam to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. rite Department's addresik. tcicphow and fax munbet: 'Tile Commonwealth of Massachusetts Depatment of Industrial Accidents Otfles of Invesdpdons 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-877-NIASSAFE Fax 1#617-727-7749 Revised 11-224)6 wwwanass,govhlia L.M. • r . Jr..V \. �Lr HE- 75329 BENTO D COSTA 2-15 AQUIDENEECK ST New Bedford MA 03740 ii(02f20i4 1IM Massachusetts - Department o' Public Safety Board of Building Regulations and Standard.; Construction Supervisor License: CS-095606 TM�! BENTO DACOST k a' 20 QUERY ST New Bedford MA--02745`i r •f Commissioner 11/22/2016 Mass-Renwa"Jon, Repair, and Fe"n; tnitial—Ergnshin a=rdance whh 45a aaR 22.os Certificate Number H4-IM42-10-CnW , Date blued 3/26/2010 o Eep'rs3/MIWIS !�d-Sa-�`=Rztovz±DrS.raendsor,oidsR9odaa'!<RIskDJead'm; Options h Accordance u+idt 454 OM 22.08(4)(d) and (a) C-rencate: LIVH-D=004o11-01E3 David 2DaCbsta aNew n�a�ti)afford rtsn��� nn Armando M. Pereira, 3.►zIner `. -0. ^- Ni, ' - i'7,,.'dr:.ru,r pgryrr%I•i r/ • �nRelntioo �A Ofliec of CowumerAfwrs & Business ' 1.�=,:,•y'-HOME IMPOVEMENT CONTRACTOR RType. m, agjsMtlon: 172986 8l2112016 Corporation +,. •YEzpitation: -y DO C CONSTRUCTION INC. DAVID DACOSTA 20 QUERY STREET NEWBEOFORD, MA 02745 Undersecretary ems, z-O �p vv o cr LFJQ."s^I�m�f �C?w3993�r 21zis Cat eta Awa7•!s ,;$ f� e7s7r r :z r�cognitior_ jo; tlza szccessfi_ pertici��or1 and COMPIafio:z 01th m,ef SL. j, eft zj Tnz n:ng Sanir r ar A`oito® CERTIFICATE OF LIABILITY INSURANCE 122n9 014 Y' 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(les) must 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 Beu of such endorsement s PRODUCER VIVEIROS INSURANCE AGENCY 140 Plymouth Avenue Fall River, MA 02721 CONTACT NAME, PHONEAX UQ N°' .MAIL ADORES$: MSURER S AFFORDING COVERAGE NAIL a INSURER A: MAD DOC CONSTRUCTION INC INSURER a: AmGUARD Insurance Company 42390 INSURER C : INSURER D: 20 QUERY ST INSURER E: NEW BEDFORD, MA 02740 R15URER F COVERAGES CFRTIFICATF Nl1MRFR- RFMI;ION NIIMRFR- THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR 7q TYPE OF INSURANCE INSR POLICY NUMBER MWDDIY MM/DOdY LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMSAUDE OCCUR EACH OCCURRENCE $ 0 LNILU R IS •omU.nee S 0 MEO EXP one n $ 0 PERSONAL B AOV INJURY 1 0 GENERAL AGGREGATE $ 0 GEN'L AGGREGATE UMITAPPUES PER POLICY I I PRO• LOG PRODUCTS.COMPIOPAGG $ 0 $ . AUTOMOBILE LIABILITY ANY AUTO ALLOWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NOMIOWNED AUTOS COMBINED SINGLEI • ece,da BODILY INJURY(Perpenon) $ er BODILY INJURY (PeeeMent) S G a eeNdeM $ $ UMBRELLA LIAS EXCESS UAS OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ B WORKERS COMPENSATION AND EMPLOYER) LIABILITYANY PROPRIETORIPARTNEWEXECUTIVE YIN OFRCERNEMBEREXCLUDED? OY (Mannddory In NH) IF ym, undw DESCRIPTION OF OPERAPONS below NIA R2WC512962 OB/31/2014 08/31/2015 I WC STATU- X OT I ER E.L EACH ACCIDENT $ 500,000 E.L DISEASE - EA EMPLOYEE $500000 E L DISEASE. POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES (AIbdIACOROIOI,AddRbna[Re rks$eNWule,tm mpeeelerepulrW) Exclusions: DAVID DACOSTA; Yarmouth Housing Authority 534 Winslow Gray Road S South Yarmouth, MA 02664 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE, DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. i/��� m 1988.2010 ACORD CORPORATION. All rlahts ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD 1P YARMOUTH HOUSING AUTHORITY 534 Winslow Gray Road LONG POND PLAZA SOUTH YARMOUTH, MA 02664 Bambi Rosario -Wyatt Chairperson Edward A. Roderick Executive Director January 5, 2015 DDC Construction 20 Query Street New Bedford, MA 02745 Attn: Mr. David DaCosta Telephone 508-398-2920 FAX 508-398-1930 TRS 800439-2370 Re: Low -bid Approval —Yarmouth Housing Authority Work Plan 351025001; DHCD FISH 351027 Designer: Clearwater Architects Scope of Work: DHCD CR FF: Kitchen update Phase 3-1 (2017)-c.667-1 Dear David DaCosta, The Yarmouth Housing Authority and its Board of Commissioners voted on December 9, 2014 to award the -above captioned construction contract to DDC of New Bedford, MA, the lowest eligible and responsible bidder in the amount of $84,770.00. We look forward to working with you on this project. Please contact me at 508-398-2920 or e-mail varhousinencomcast.net at your earliest convenience to schedule a meeting. Sincerely, /J Edward A. Roderick Executive Director Cc; Linda Katsudas DHCD Clearwater Architects Candy Tempesta DHCD Sean Keating DHCD EXPRESS BUILDING PERMIT APPLI TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: ASSESSOR'S INFORMATION: tA "AHAF71170"A WAVIN ~ fice Use Only 'LLD /S-0D�V- Sol Permit expires 180 days from issue date gEcz 13 i�ny Email CUNTIMUIURT,C NAME N�03MMAnJNG DMS5 Tn-# Email fYl • Residential Commercial Est. Cost of Conswction S�i• Home Improvement Contractor Lia # I M q4?& Construction Supervisor Lic. # Workman's Compensation Insurance: (check one) I am the homeowner /'I am the sole proprietor /I�have Worker's Compensation Insurance 1 /I Insurance Company Name: 61(y . I f L��.Y n a - Worker's Comp. Policy#���A/f -� I �� Tent _ Duration Siding: # of Squares WORK TO BE PERFORMED (Fire Retardant Certificate attached?) Replacement windows: # Roofing: # of Squares ( ) Remove existing* (max. 2 layers) Old Kings Mghway/Historic Dist. ( ) Replacing like for like *ne debris will be disposed of at: of Facility Wood Stove Replacement doors: # Insulation I declare under penalties of perjury that the statements herein contained are tine and coned to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or revocation of my H and for prosecution under M.G.L Cut. 268, SaUon 1. Applicant's Signatue. Date: Owners Signature (or attachment) Approved Br.- .,.s vm.,_, tar designee) Date: Zoning District: 7 o Historical District: Yes No Flood Plain Zone: Yes Water Resource Protection District: Within 100 ft. of Wetlands: Yes No Yes No No ., The Commonwealth of Massachusetts Department of Industrial Accidents OJ) ce of Investigations 600 Washington Street Boston, MA 02111 • www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aanlicant Information Please Print Legibly .Name/� EP(Businessiftanizationandividual): D, l � Address: City/State/Zip: 1;MK Phone #' Are you an employer? Check the appropriate bore 1.0 I am a employer with ) _ 4. I am a general contractor and I employees (full and/or part-time).; have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. (No workers' comp, insurance required:] 3. ❑ I am a homeowner doing all work myself [No workers' comp. insurance required] t 3a. ❑ I am a homeowner acting as a general contractor (refer to #4) listed on the attached sheet. These subcontractors have employees and have workers' comp. insurance.: S. We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp, insurance recuired.l• Type of project (required): 6. ❑ New construction 7. Remodeling 8. Demolition 9. Building addition 10. ❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other t ;Any applicant that checks box #1 must also ftll out the section below showing their workers' compmaatiod-poliey information. Homeowners who submit this affidavit indicating they ate doing all work and then hire outside contractors mtut 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-coatractan have employees, they must provide their workers' comp. policy number. lam an employer that is providing workers' compensation insurance for my employees Below is the policy and Job site information. Insurance Company Policy # or Self -ins. Lic. #:� 01"1 �U Expiration Date: I ) Job Site Address: City/State/Zip: Dft&JOLI Attach a copy of the workers' compenskion policy declaration page (showing the policy n tuber and erpiration date). Failurd 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 fine of up to S250.00 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 cer* under the pains an^penalties of perjury that the informations provided above is true and correct Official use only. Do not write in this area, to be completed by city or town officia[ City or Town: Permit/License # Issuing Authority (circle one): L Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person• Phone #• Information and Instructions ' Massachusem oy2rs to provide workers' compeaaatian for their emp{oyese.. General Laws chapter 152 requites all empl pursuant to this statute, as uerplerte is dcfined as "-.every Person is the service of 2mther under any contract of hire, express or implied, oral or writtrn." " corporation or other legal eatity, or any two or Moro An exygeyw is defined as an individual, parmaship, suociatiot4 tP° of a dressed emPbytx, a the of the foregoing eapged in a joint caWrpdse, and including the legal representatives Fioweva the receiver or trustee of in individuA psrtaas�+ associzdm ere other Ina entity, cmpbyiag emPby owner of a dwelling horse laving not more than three sum and wbo resides tb=iN or tb° occupant of the dwelling hoof another who cmPbys Pem to do ...,..�.y'^ lucr uses construction or repair work on such dwelling house ' or on the gtoun& or building spptrtu:asnt tbaew shall not because of such emPloytaeat be deemed to be sa emPbytx." MGL chapter 152, ¢25C(6) also statu that "emery stay or loaf llceasi� ageneyshan withhow �at� or renewal of a Beeau or permit to operate a budam or to construct buBdlap " applicant who bus not produced saeptable eridemm of commmpltance with the lasursaca covasp rti4� Additionally. MGL chapter 152,125g7) states "Neitba the commonwealth nor any of its political subdivisions shall ' of lie work until acceptable evidence of coroPlianw with the insurance enter rate any f this the haperve been pre o the contracting uuhocity." requirements o[ this chapter have been presented Applicants , if Please fill out the workers' compcnsstuan affidavit completely, by checking the boxes that aPPty to your situation and, neoasary, supply sub-coan'acttu f s) nmw(s), addtsss(es) and pbow number(s) 910eL with Heir certiScatr(2). of thin the insumuc I i�ted Liability ComPsnies (uL7 or f 64teed Liability Psrtacrships (UP) with no emPIoY� members or P� are not required to wry workers' ia:nrance. If as LLC a LLP does have esnQbyees, a policy is required. Ek advised that this affidavit may be submitted to the Department of Indust;W Accidents for cOafunallon Of inarance coverage. Also be sera to sip and date the &M& tL 'Ilse nffidsrit should be returned to the city or town that the sppticatioet for the Peru Of lk=w is being tequeshA not the Department of Induusuial AaideatL Sold you have any goatiow regarding the law at if you ate rsgmrsd to obtain a worker ' compensation policy, p lease cs11 the Department at the rum listed below. Self -insured companies should enter their .elf-hMnZ ee scan" number on the soprovdaft HOL- City or Town 0 mclara 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 retarding the ugupiics� Please be sure to fill in the pan WVicense number which will be used as a Rfereaea number. In addition, an applicant that must submit multiple pazaitllicease applications in any given year, need only submit one affidavit indicating cuaeat polby tnfermatuoa (if necessary) and tinder "Job She Addresa" the applicsat shotuld write "all locations in (city or town)_" A copy of the affidavit that has been officially stamped oe marked by the city a town may be provided to the applicant a proof that a valid affidavit is on file foe fature 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 comaettial venture (i.e. a dot Ucem or pesuit to boast lerns etc.) said person is NOT required to complete this affidavit Tho Office of Investigations would Un to thank you is advance for your cooperation and should you have any questions, Pleases do not hesitate to give us a all. Ilse Dcpartmeat's addresstelephone and has murnben. The Commonwealth of Massachusetts Department of Industrial Accidents OMes of Investipdons 600 Washington Street Boston, MA 02111 Tel. 9 617-7274900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 11-22416 WW%v.m3ss.gov/dia _._3 -sa: HE-075329 BENTO D COSTA 245 AQUIDLNEICICST � ?yi :•�� New Bedford MA 02740 1110212014 tft Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-095606 BENTODACOSfh` 20 QUERY ST < 7 r ^= New Bedford MA02745'j ,j Expiration Commissioner 11/2212016 Mass -Renovation, Repair, and Pzfiting tnWat-Engushla .cccn ancewIth4S4CF.qRZ2JM Certi em Number. R+1=2-10.01W Date Issued 3/26/2010 o EMIreir3/26/2015 le2d-Sah ftmm aIDr Supervtorvntr R4odambs4 tsh Deteadhn Options to Accordance %kft 4S4 CMti 22118(4)(d) and (e) CertM ate: tMR-DTOD004.3-111-01 David DaCasta 245 Atiuidnetit Street rem AT, nando M. Pereira, Trainer i •-'f '-y;,•1dr:.uNr,r/r7H, .r r nlatioo r _ OBite of Consumer Affairs & Business R e �t-HOME IMPROVEMENT CONTRAC�R Type: •";�teglstmtlon: 172986 r. *=- ', Corporation {Ezpira8on: 821f2016 DOC CONSTRUCTION INC. s DAVID OACOSTA — 20 QUERY STREET NeMEDFORO- MA 02745 11.1odersevtt2r7 o 9 i \I,/• �-L.' � Y � t iT,� ,�� tit lt. R rL°�� d� 1u ri32ri7v` �tis %yerfi 'a_fsliwar•�.s Ir_ rtiIWgnition for d2a snccessf d perficipafion and compleixon of the araf IrzfettL 'raining Semi r A`� v" CERTIFICATE OF LIABILITY INSURANCE 12/29/220114 �' 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 polley(les) must be endorsed. N 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 endorsements PRODUCER VIVEIROS INSURANCE AGENCY 140 Plymouth Avenue CONTACT NAME: WPHONE FAX A c NO Eau Fall River, MA 02721 ADDRESS• INSURE ! AFFORDINO COVERAGE NAICF MSURERA• INSURED DDC CONSTRUCTION INC MSURl AmGUARD Insurance Company 42390 MSURERC• INSURERD: 20 QUERY ST INSURER E: NEW BEDFORD, MA 02740 MSURERF• COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. M!RPOLICYEFF LTR TYPE OF INSURANCE POLICY NUMBER WDDfY POLICY MWOp^/YXP UWTS GENERAL LIABILrfY EACH OCCURRENCE S 0 COMMERCIAL GENERAL LIABILITY CWMSJ,/ADE ❑ OCCUR MAGETOR PREMISES (17• occurrence f 0 Mm EXP An on•perse s 0 PERSONAL A ADJ INJURY S 0 S 0 GENERAL AGGREGATE GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OPAGG S 0 POLICY PM LOG S AUTOMOBILE LIABILITY COMBINED SINGLE Umi I • eMem BODILY INJURY (P« PMce) s ANY AUTO ALLOWNED SCHEDULED AUTOS AUTOS BODILY INJURY (P«•ald.m) s D HIRED AUTOS NON-OWNED PROPERTY DAMAGE eraccidem a $ UMBRELLA LIAS OCCUR EACH OCCURRENCE S AGGREGATE S EXCESS LIAS CIAIMS.MAGE DED RETENTION S IS WORKERS COMPENSATION w'STATU- X OTH- B AND EMPLOYERS LIABILITY ANY PROPRIETORLPARTNER/EXECUTNE YIN OFFICERIMEMBEREXCLUDED? ❑Y (MsndAwV In NH) NIA R2WC512962 08Id12014 00137R015 E.L EACH ACCIDENT f SOO,000 E.L. DISEASE - EA EMPLOYEE $500,000 X y d•scrbe under DE SCR IP TION OF OPERATIONS MIon E.L dSEASE-POLICYUMIT s500000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ABech ACORD 101, Additional RMnerte Schedule, M more space Is required) Exclusions: DAVID DACOSTA; Yarmouth Housing Authority 534 Winslow Gray Road S South Yarmouth, MA 02664 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE - DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED O 1988-2010 ACORD CORPORATION_ All rinhta reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD YARMOUTH HOUSING AUTHORITY 534 Winslow Gray Road LONG POND PLAZA SOUTH YARMOUTH, MA 02664 Bambi Rosario -Wyatt Telephone 508-398-2920 Chairperson FAX 508-398-1930 TRS 800-439-2370 Edward A. Roderick Executive Director January 5, 2015 DDC Construction 20 Query Street New Bedford, MA 02745 Attn: Mr. David DaCosta Re: Low -bid Approval —Yarmouth Housing Authority Work Plan 351025001; DHCD FISH 351027 Designer: Clearwater Architects Scope of Work: DHCD CR FF: Kitchen update Phase 3-1(2017)-c.667-1 Dear David DaCosta, The Yarmouth Housing Authority and its Board of Commissioners voted on December 9, 2014 to award the above captioned construction contract to DDC of New Bedford, MA, the lowest eligible and responsible bidder in the amount of $84,770.00. We look forward to working with you on this project. Please contact me at 508-398-2920 or e-mail yarhousin.Q@comcast.net at your earliest convenience to schedule a meeting. Sincerely, 41K'11�lale' Edward A. Roderick Executive Director Cc; Linda Katsudas DHCD Clearwater Architects Candy Tempesta DHCD Sean Keating DHCD EXPRESS BUILDING PERMIT APPLICA TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: ASSESSOR'S INFORMATION: Map: sy Parcel: L/ i Office Use Only � Amount Permit expires 180 days from issue date MA/R 10 2015 v�Z LIENT l �NAAM�E /�J} � yRPSF.rfrADDRESS J TEL n ' Email Ads CONTRACTOR:11! 1�Cfl (n,l�'. 1J) Aijm4 j j - -M-02a-Ma �� Qutd�1�LY'coY)S NAME MAILINGc,�RESS TEL# Email Np�, mr� II'' I1g5y.ny Residential Commercial �US ttvn Est. Cost of Consction SJS.� , n Home Improvement Contractor Lie. Construction Supervisor Lie. #C.� �1%UlY Workman's Compensation Insurance: (check one) I am the homeowner v� I am the sole proprietor �/1II have Worker's Compensation Insurance n /� /� Insurance Company Name: T I 1 I IGI�t r l Jf iMWorker's Comp. Policy# V 2wUJ I Z"I l/ WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Siding: # of Squares Replacement windows: # Roofing: # of Squares ( ) Remove existing* (max. 2 layers) Wood Stove Replacement doors: # Insulation Old Kings Mghway/Histooric Dist. () Replacing like forklike 'The debris will be disposed of = A 9 0 D s l^ � 1 ono IS C (n` 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 denial o1,Levocadon of my license and for prosecution under M.G.L Ch. 268, Section 1. Applicant's Signature: I�2-3 bq Owners Signature (or attachment) Date: Approved Date: Building Official (or designee) Zoning District: f2(1 o Historical District: • Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft. of Wetlands: Yes No Yes No r^ The Commonwealth ofMassaehusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 • www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aanlicant Information Please Print Legibly Name (Business/Orgmizatiou4ndividual): Address: City/State/ZiEUU 1 F)OC 1'bf?Z, MA Da1g Phone #• Are you an employer? Check the appropriate box: 1. ®I am a employer with 4_ 4. I am a general contractor and I employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required:] 3. ❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 3a. ❑ I am a homeowner acting as a general contractor (refer to #4) have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.: 5. We are a corporation and its officers have exercised their . right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance reouired.l- Type of project (required): 6. ❑ New construction 7. ® Remodeling 8. Demolition 9. Building addition 10.0 Electrical repairs or additions l 1.0 Plumbing repairs or additions 12.❑ Roof repairs 13.0 Other ;Any applicant that checks box #1 must also fill out the section below showing their workers' eompensatiod'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. tContrsctors that check this box must attached an additional sheet showing the name orthe sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they mast provide their workers' comp. policy number. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and Job site information: Insurance Company Policy # or Self -ins. Lic. #: _K1�Uy C �q Z Expiration Date: Job Site Address City/State/Zip: ill�O.M a9ulaq Attach a copy of the workers' rompers tion policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requited 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 perjury that the information provided above is true and correct -^ Of jicial use only: Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone #• Information and Instructions . Massachusetts General Laws chapter 152 requite all eaipbye'rs to provide wacitr rs' coinpenaltiaa for their a i:>plbir ea ' n defined as »-.every person in the service of another under any contract of hiie, Pursuant to rhea statute, m ewpUpcs • express a implied, oral or written." associ&tioa, corporation of other legal entity, or nay two a more An nrepleyst• is defined m individt=p partnerships i iP. of a deceased emPioycr' or the of the foregoing engaged is a joist enterprise' aad'mchhdm; the legal repeesetiva receiva or trustee of an individual, partoc ship' association a other legal entity' employing empbycs. Howeva the owns of a dwelling bouae having not matte dam three &Pttmenta a� who resides theteai, or then such d el the dwelling house of anther who employ& persona to do "";'.*r, urA construction err � work on such dwelling house or on the grounds a building apPurtcasat dhaebo shall °0t because of such empbymeat be deemed to be an employes:" MGL chapter 152,125C(6) also state that "every &Ut& or local Licensing sgeaey sha11 withhold the lsatssnee or renewal of a Mena at permit to operate a buslnew or to COastrtsct baildtaga In the caariaaawasitis foe ny le entente of eo with the liisuaaee ea vaage �l�" appikas►t whe hoe not produced saeptsb �°a Additiorsally, MGL chapter 152, 125C(7) states "Neither the commonwealth aoc any of its political subdivisiom'hall P� cats into say contract for the pa£orazsaca of lie worst until acceptable evidence of compliance with the insurance , requirements of this chapter have been presented to the coatsacting VAbOritY Applicants , Please ® out the workers' comPcn"doa affidavit comPkt9lY, by checking the baxa that apply to Your situstion ate' if necessary' supply sub• coan'actods) name(s), ad&c=Kes) and phone numbes(s) along with their certi&atc(a )aria than the innaaace. Limited Liability Campsaia (LLQ a Lim Liability Partaerahipe (LLP) with employees don hes hembers cc Ponca , are not required to carry work=' comPeasation instir=aee. if an LLC a LLP ave members employees, a policy is require& Be advised that this affidavit may bs submitted to the Department of In&Kt W Aceideati for confirmation of iashaance covcm1X- Alm he sun to sip and date the affdavit. The affidarit should be returned to the city ar town that tbs application fat the permit ur license is being regaatcd. not the Degarttacat Of Industrial Accidents. Should you have any quations regarding the law cc if you are regoired to obtain a wcxk= ' lease call the Department at the number listed below. Self-is:toed companies should eater their compeautioa Policy, p teir-in , lieea&e number on the liar. City or Taws Omdak Please be sure that the &®davit is complete and printed legibly. The DgMtmeat has provided i space at the bottom of the affidavit for you to fill out in the event the Office of invcsdpdom has to contact you regarding the 1PPk4UL Please be sure to fill in the patmtlli=wc mamba which will be used &a a refacace camber. In addition, an apptiaat that moist submit multiple pesariNiccoae application in any given yew, need only submit toe affidavit indicating cuacat policy Epp (if necessary) and undo "lob Site Address" the applicant should write "all locations in (city of tows)." A copy of the &®davit that bus been Officially stamped eye marked by the city of town may be provided to the applicant w proof that a valid affidavit is as file for future perarita oc licenses. A new affidavit rent be filkd out each year. Where a home owner at citizen is obtaining a license of permit not related to, any business at commcrcW venture (i.e. a dog liceme or permt to burn !ears etc.) said person is NOT required to complete this affidavit The Onus of lavestigstiaas would like to thank you in advaace foe your cooperation and should you have any gnatioM please do not hesitate to give to a call. the Department'& address, telephone and fir munbw. The Commonwealth of Massachusetts Department of Industrial Accidents ofila of Iaresdpttlons 600 Washington Street Boston, MA 02111 Tel. $ 617-7274900 ext 406 or 1-877-hIASSAFE Fax # 617-727-7749 Revised 11-22416 Www.mass.gov/die e -5SACHr151P_TTS ORM LICU SE rarSO _11.25.2013,eo "S0283056 lIONE • a ova 11-02-2018 11.0?-7955 �. 3�•,,...`-A cusses LCRW :ssa: f' t==++y:5•it � s'0" NONE �24SAOU10NECi(StREET � _ NE'N BmFORO, L1A 021da-141f1 UP _ _s .�Za: HE-075329 i V>• BENTO D COSTA ' •-T 245AQUDENE'CKST New Bedford Wa 027 e0 iil02f20i4 11 I Massachusetts -Department of Public Safety Board of Building Raoulations and Standards Construction Supenisnr License: CS-095606 BENTO DACOSTk 20 QUERY ST ,.. New Bedford MA702745nk i, Commissioner 11lMO16 Mass-RenovaHon,Repair, andPefiOag - tnitial-Engffsh' n accordance evith 4S4 OAR 22.03 C-rtl9cme Numbs R+I&342-20-0I337 Data Issued 3/26/2010 o 13:ptr;ei 3/ru/20t5 L—d.Sa;eY°novatnr5upervLart 7utR9oda-atdRislcDeteading Options in Acmrdanm ikAth 4S4 eM% 22.08(4)(d) and (e) ceraffmte: 11MR-13TWO043-L02E3 Dauld DaCcst a 249 AgWdnadt Strest ;Vcst SEz}fDrd, yrn Arrnar.3a M. Pereira, Trainer ` - w _ i7,,. 7 e t.N/rr nirv.r./.i r jnas ReanUtiou }'- Omct orConsamerAffairs S Bnsi �,HOME IMPROVEMENT CONTRA�R Type: ^.� feglstmtlon: 172986 Corpo[atlon iration: 812112016 P DOC CONSTRUCTION INC. DA= DACOSfA 20 QUERY STREET NEINBEDFORD, MA 02745 UnderseeretzrY Cora rzwm jr �12ga�� ibis L'erEifScat°e Awards rr=agniiion fivr fl2a szccessfzsl pa.-iic;Paf;0 ± and comple6ca of the ^Q aref ' S+feiz� rairz:n3 s¢rnir A`oizo� CERTIFICATE OF LIABILITY INSURANCE 12/29� o 4 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(les) must 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 VIVEIROS INSURANCE AGENCY 140 Plymouth Avenue Fall River, MA 02721 NTAC NAME• PHONE IAJC. Ne, /RAIL ADORES], INSURER(S) AFFORDING COVERAGE NAICs INSURER A : INSURED DDC CONSTRUCTION INC INSURERB: AmGUARD Insurance Company 42390 INSURER C: JNSURERD: 20 QUERY ST INSURER E: NEW BEDFORD, MA 02740 INSURER F COVERAGES CFRTIFTCATP NIIMRFR• RFVIAIr1N rd11MRFR- THIS IS TO CERTIFY THAT 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 LS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE POLICYNUMBER MAliIJIL WODfYYYYI (MWDDfYYYYI UNITS GENERAL LIABILITY COMMERCULL GENERAL LIABILITY CLAIMS -MACE O OCCUR EACH OCCURRENCE S 0 PREMISES seeewrtnee S 0 MED EXP we f 0 PERSONAL a ADV INJURY s 0 GENERAL AGGREGATE s 0 GENT AGGREGATE LIMIT APPLIES PER: palCr PMrT RO- F ioc PRODUCTS•COMPIOPAGG S 0 s AUTOMOBILE LIABILITY ANYAUTO. ALLOWNED SCHEDULED AUTOS AUTOS NON-OWNEDDAMAGE HIRED AUTOS AUTOS(Per COMBINED SINGLELIMIT s a snt BODILY INJURY(Pxpenon) $ BODILY INJURY (Par soddsM) S stclde,n1 f f UMBRELLA LIAR EXCESS LNB OCCUR CWMS-MADE EACH OCCURRENCE f AGGREGATE s DED I I RETENTION! f B WORKER! COMPENSATION AND EMPLOYERS LIAaILJTY ANY PROPRIETORMARTNERVEXECUTNE YIN OFFICEWFMBEREXCLUDEDT (Mandstery In NH) ud DESCRIPdr ON OF OPERATIONS below NIA R2WC512962 08l31/2014 08/d12015 WC STATLL X 0T/4 TSI E.L.EACH ACCIDENT 11500,000 EX. DISEASE - FA EMPLOYEE f 50D 000 E.L DISEASE• POLICY LIMIT $500000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORO 101, Add3bnsl Remarks Sehoduls, a moms spa" is rsqulred) Exclusions: DAVID DACOSTA; Yarmouth Housing Authority 534 Winslow Gray Road S South Yarmouth, MA 02664 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE - DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED RREEPR�ESENTATIVVEE O 1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD YARMOUT I HOUSING AUTHORITY 534 Winslow Gray Road LONG POND PLAZA SOUTH YARMOUTH, MA 02664 Bambi Rosario -Wyatt Chairperson Edward A. Roderick Executive Director January 5, 2015 DDC Construction 20 Query Street New Bedford, MA 02745 Attn: Mr. David DaCosta Telephone 508-398-2920 FAX 508-398-1930 TRS 800439-2370 Re: Low -bid Approval —Yarmouth Housing Authority Work Plan 351025001; DHCD FISH 351027 Designer: Clearwater Architects Scope of Work: DHCD CR FF: Kitchen update Phase 3-1 (2017)-c.667-1 Dear David DaCosta, The Yarmouth Housing Authority and its Board of Commissioners voted on December 9, 2014 to award the above captioned construction contract to DDC of New Bedford, MA, the lowest eligible and responsible bidder in the amount of $84,770.00. We look forward to working with you on this project. Please contact me at 508-398-2920 or e-mail varhousinsrcomcast.net at your earliest convenience to schedule a meeting. Sincerely, Edward A. Roderick Executive Director Cc; Linda Katsudas DHCD Clearwater Architects Candy Tempesta DHCD Sean Keating DHCD aficeses y W mil %% It�oi ovf • " ' �y amrnmt c' ` Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: ASSESSOR'S INFORMATION: OWNER: NAME Map: Sf I Parcel: (-% Y— yaXiYlt..5111� (�.C� # Email Address: x'MEE JNG AID tveW Turd, MA bl"ly5� #/1� Email Residential Commerciale Est. Cost of Construction $ l try fyl 0 Home Improvement Contractor Lie. #—al- p p / l�,, Constntction Supervisor Lic. # [ 1, Workman's Compensation Insurance: (check one) I am the homeowner n I am the sole proprietor I have Worker's Compensation Insurance / Insurance Company Name: A 1 si1 & 1.rd MJWICL Worker's Comp. Policy# K laIVC "I�� Tent _ Duration Siding: # of Squares WORK TO BE PERFORMED (Fire Retardant Certificate attached?) Replacement windows: # Roofing: # of Squares ( ) Remove existing* (max. 2 layers) Old Kings Highway/Historic Dist. ( ) Replacing like for like *Tile debris will be disposed of at: of Wood Stove Replacement doors: # Insulation — 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 denial or revocation of my license and forprosecutionunder M.G.L Ch. 268, Section 1. j Applicant's Signature: ' , Y ` Date: Owners Signature (or attachment) Date: Approved By Date: Building Offlcial (or designee) Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District Within 100 ft. of Wetlands: Yes No Yes No The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 • www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): p rt muahm I Y r Address: ...syiotatcrc.rp: r,lt/l l 1r)[rrt-nail .11 II-t Q; lu n Phone #• 1�4 Are you an employer? Check the appropriate box: 1. I am a employer with $ 4. ❑ I am a general contractor and I MPloyees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance 3. ❑ 1 am a homeowner doing all work myself [No workers' comp. insurance required.] t 3a. ❑ I am a homeowner acting as a general contractor (refer to 44) have hired the sub -contractors listed on the attached sheet These sub -contractors have employees and have workers' comp. insurance.: 5. ❑ We are a corporation and its officers have exercised their . right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance reauired_l- Type of project (required): 6. ❑ New construction 7. ® Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other Any applicant that checks box #1 must also fill out the section below showing their work=' compensatic polity information t Homeowners who submit this affidavit indicating they ate doing all work and then hire outside contractors must submit a new affidavit indicating such. tContnsctors that check this box must attached an additional sheet showing the name of the sub -contractors and sate whether or not those entities have employees. If the sub-eontractms have employees, they mast provide then workers' comp. policy number. lam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information Insurance Company Name Policy # or Self -ins. Lic. #:_ �2�11� �� >7 q (p Expiration Date: Job Site Address: City/Statc/Zip: t t vl�t / Attach a copy of the workers' campers Hon policy declaration page (showing the policy number and expiration date). `1 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 DU for insurance coverage verification. I do hereby cert�� under the path and penalties of perjury that the Information provided above is true and correct QQ`icial use only. Do not write in this area; to be completed by city or loin ojjiciaL City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone #• Information and Instructions Massachusetts General Laws chapter 152 requires all employs to provide workcra' compensation for their empioyEea. ' Pursuant to this statute, as caplges • defined as "...every person in the service of another under any contnd of hire, a express or implied, oral of written." An isupleyss' is defined as "era individual, Partnership, su9crstinA corparaGon or other legal entity, or any two Or more m a joint and including the legal repraeatanives of a decessed empl�• a the rt the foregoing ea�aan • i auociatino a otha legal entity, employbg =Ploys ifowtsva the receiver oc trustee of m iadiai having of more the and who resides thersirr, or the omrpant of the owner of a dwelling IF= having not nonce thin torso apartmeabt work on such dwelling horse dwelling house of another who employs persons m do n of becamencr, construction y venue or on the grounds a building appurtenant d0mto shall not because of such employment be deemed m be sa earpbyes" or MGL chapter 152,125C(6) also states till! "every state of local Ikendag sgestey�s �tk for y renewal of a license or permit to operate a business of to consumer buildings " a ant who hm not produced acceptable crldence of compliance wits, the [aserasce csTwip rM� PPS states "Neither the commonwealth nor nay of its political subdivisions shall Additionally, MOL chapter l52, orma) le evidence of compliance with the insurance cater lam any contract fa, the performance of public work until acceptsb meats of this chapter have beca presented to the contrartmg uuhority." Applicants � . Plesse fill out the workers' compensation a@idavit eompletehy, by checking the boxy that apply to yea situatiw asY1, if necasuy, mph, sub-contractor(s) name(s), address(a) and phone number(:) along with their certiscate(s) of hnsrmance. Limited );lability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or per+ are not required to carry workers' compensation iatusaaoe. If an LLC or LLP does have is requirc& He advised that is affidavit may be submitted to the Department of Industrial employees, s policythAloe be sure to si and data the atlidartt The affidavit should Accidents for confirmation of is at the a application a license is being mpested, not the Department of be returned m the city ere town that the application fa the permit s' . Industrial Accidents Should you have any questions rrgudmg the law at if you are required to obtain a worker compensation policy. p lesser call the Department � number listed below. Self-h wired companies should enter their "iGi2E=znoe Bean" cumber on the City of Town Offidsls 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 lavestigations has to contact you regarding the aPPliclut. Plesm be sera to fill is tbo pesmit/licease number which will be used u a reference number. Ice addition, as applied that must submit multiple permit Uccnaa appGcatiom in any given, year, need only submit sae at$davit indicating risen! polky, iafacMAtion (if °marl') and under "lob Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped oc marked by the city or town may be provided to the applicant a proof that a valid affidavit is on file for fatum permits or licenses. A new affidavit met be filled out each year. Where a home owner or citizen is obtaining a license at permit not related to, any business at commercial venture (Le. a dog lieema or pettait to burn lea res etc.) said person is NOT required to complete this affidavit The Office of lnvesdgations would like to !hunk you in advance The your cooperation and should you bave any questions, please do not hesitate to give us a call. the Dcpartmeat's add=& telephone and fax numbs: The Commonwealth of MasMachtuetts Department of Industrial Accidents otllles of Invesdpdons 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-877-MASSAFE_ Fax # 617-727-7749 Revised 11-22416 ww%v.mass.gov/dia )jSSAC;JW9ETTS OMERUMSE •_11.25.2013 NONE S02$3056 L y:: t.r .,.,TmOV 1 003 ��-02-2o�a 11•02-1965 f": t+r .. , 2 asr L nn Sr is s=t D its 51t r.. ,..,> r s:STRM - _a -s=: HE-075329 245 AQUIDEEMiCK ST P-esr I?edford Mir, 02740 TTl02l20TS 11 InMassachusetts - Department of Public Safety Board of Building . g R:=gulatior•.> and .,tancnrd., C+mstruction Supenisor p� License: CS-095606 BENTO DACOST t jj 20 QUERY ST New Bedford M ,M745'; ,-- • t. Hxnlatlon Commissioner 11/2=016 Mass -Renovation, Repair, and ?atittlne Initial—EngQshTn accordance eutth r!S4 OAR 22.08 Cerb1cte Number: R4-1M42-2GQ1"3 pate issued 3/2612010 o E::Pirz; 3/26/2015 LdSafeftiovator51-Terdsor`--"W1Mods RW;Detmdmg Options in Accordance wM" 454 CtIIF.t 72 08(C)(d) and (e) Cermwte: iPAR-DT0000Ca-12-016a David DmCcsta 24S Aaeldnaek stree" vcalsSi:c�fOrd, M'ar�2��'�I •.•;- Amanda M. Pereira, Trainer ' " ^Y—%,.M ��fit:Srlr lllir /�3 -tr;,ru,.,q;•rrr�/.irf Re.' ._- 01iite of Consumer Affairs 3 Business Re IMPROVEMENT COMRACTOR Type. .ateglstration: 172986 iration: W112016 Corporation DOC CONSTRUCTION INC. DAVID DACOSTA 20 QUERY STREET NEWBEDFORD,MA02745 Uuderseeretarp (Cormiyr ic�irm qy a if 1" nmv Vzis ('c3ta l�zrer�s T')-. 10 t�5i fi r I m.9nifioreTor ilea =cCassfi.l perEici a iolz . e7cd complctio:a of the ;7: _ P%t3ret uCi?jatij T!?1N_i Z3 i17' - ��7 ar ! s �`1 �® CERTIFICATE OF LIABILITY INSURANCE 1�iZ9 Z' 4"'"Y' 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(les) must 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 Neu of such endorse narR a . PRODUCER VIVEIROS INSURANCE AGENCY 140 Plymouth Avenue Fail River, MA 02721 CONTACT NAME' PHONE N. Pet e Not _,AIL ADDRESS, INSURERS AFFORDING COVERAGE NAIL e INSURER A : INSURED DOC CONSTRUCTION INC INSURER 8: AmGUARD Insurance Company 42390 C: _INSURER INSURER 0: 20 QUERY ST INSURER E: NEW BEDFORD, MA 02740 INSURER F a COVERAGES CFRTIFICATF NIIMRFR' RFV@InN NIIMRFR- THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE POLICYNUMSER MIDDIY MWDDIYY LIMITS GENERALLIABILITY COMMERCIAL GENERAL LIABILITY CLAIMSJ.IADE ❑ OCCUR EACH OCCURRENCE f 0 DAMAGE TO RENTED PREMISESe accu"w9l f 0 MED EXP one s O PERSONAL a ADV INJURY f O GENERAL AGGREGATE S 0 GEN'L AGGREGATE POUCY UMIT APPLIES PER: PRO. LOC PRODUCTS -COMPIOP AGG S 0 It ' AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON47WNM HIREDAUTOS AUTOS COMBINED E■ Keld"t BODILY IMAM (Per penan) f BODILY INJURY accident) f PROPERTY DAMAGE Me, aecMer,1 f s UMBRELLA LIAS EXCESS LIAS OCCUR CWMSMADE EACH OCCURRENCE s AGGREGATE f DED I I RETENTIONS f B WORKERS COMPENSATION AND EMPLOYERS LIABRJTYIT ANY PROPFSETORIPARTNERIE%ECUTNE YIN OFFICERIMEMBEREXCLUDED7 �Y (Mandatml, In NH) der DESCRIPTION OF OPERATIONS below NIA - R2WC512962 08131/2014 OBI31f2015 I WE STATLL X OTI+ YIIMITSIER E.L EACH ACCIDENT S 500,000 E.L DISEASE -EA EMPLOYEE f 500,000 E1. DISEASE -POLICY LIMIT f 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, AddRbnal Remarks Schedule, S more spa" to required) Exclusions: DAVID DACOSTA; Yarmouth Housing Authority 534 Winslow Gray Road S South Yarmouth, MA 02664 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE - DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED O 1988.2010 ACORD CORPORATION. All Rahts ACORD 2S (2010105) The ACORD name and logo are registered marks of ACORD YARMOUTH HOUSING AUTHORITY 534 Winslow Gray Road LONG POND PLAZA SOUTH YARMOUTH, MA 02664 Bambi Rosario -Wyatt Chairperson Edward A. Roderick Executive Director January 5, 2015 DDC Construction 20 Query Street New Bedford, MA 02745 Attn: Mr. David DaCosta Telephone 508-398-2920 FAX 508-398-1930 TRS 800-439-2370 Re: Low -bid Approval — Yarmouth Housing Authority Work Plan 351025001; DHCD FISH 351027 Designer: Clearwater Architects Scope of Work: DHCD CR FF: Kitchen update Phase 3-1 (2017)-c.667-1 Dear David DaCosta, The Yarmouth Housing Authority and its Board of Commissioners voted on December 9, 2014 to award the above captioned construction contract to DDC of New Bedford, MA, the lowest eligible and responsible bidder in the amount of $84,770.00. We look forward to working with you on this project. Please contact meat 508-398-2920 or e-mail varhousinoncomcast.net at your earliest convenience to schedule a meeting. Sincerely, Edward A. Roderick Executive Director Cc; Linda Katsudas DHCD Clearwater Architects Candy Tempesta DHCD Sean Keating DHCD EXPRESS BUILDING PERMIT API TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: ASSESSOR'S INFORMATION: OWNER: Map: '-fj- I Parcel: L// Office use Only Amours, Permit expires 180 days from issue date QED 102015 DEPARTMENT Fril WE��.,..-9 r as a AddressErna I Residential Commercial n p/Est. Cost of Construction $�%cQ' q/�� U Home Improvement Contractor Lie. # / / a `%M' Nv, iron uv-Construction Supervisor Lie. #a) -69,51 JG.� Workman's Compensation Insurance: (check one) I am the homeowner]] I am the sole proprietor I have Worker's Compensation Insurance �/► Insurance Company Name: 71 %(A�/'X'� Worker's Comp. Policy# PU WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Siding: # of Squares Replacement windows: # Roofing: # of Squares ( ) Remove existing* (max. 2 layers) Old Kings Highway/Historic Dist. ( ) Replacing like for like *The debris will be disposed of Location Wood Stove Replacement doors: # Insulation 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 denial or revocation of my license and for prosecution under NMI- Ch. 268. Section 1. % Applicant's Signature: 11 Date: Owners Signature (or attachment) Date: Approved By: Date: Building Official (or designee) Zoning District: No Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 it. of Wetlands: Yes No Yes No - The Commonwealth of Massachusetts Department of Industrial Accidents OJjtce of Investigations 600 Washington Street Boston, MA 02111 • www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Analicant Information Please Print Legibly Name (Business/Organizadon/Individual):_p P. (Ion xr, On . I hC Address: p1 City/State/Zi : Phone #: - Are you an employer? Check the appropriate box: l . ®_ I am a employer y with a 4. I am a general contractor and I Type of project (required): 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 mein any capacity. [No workers' comp. insurance employees and have workers' comp. insurance.: 9. ❑ Building addition required:] 3. ❑ I am a homeowner doing all work 5. We are a corporation and its officers have exercised their . 10.❑ Electrical repairs or additions I I.[I Plumbing repairs myself [No workers' comp. insurance right of exemption per MGL or additions 12.❑ Roof repairs required.] t 3a. ❑ I am a homeowner acting as a c. 152, § 1(4), and we have no employees. [No workers' 13.❑ Other general contractor (refer to M4) comp. insurance reouired.i- I 'Any applicant that checks box #1 mast also fill out the section below showing [heir workers' rnrrrpensatio3po t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors mast submit a new elEdavit indicating such liry information. tContractors that check this box mast attached as 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. ! am an employer that is providing workers' compensation insurance for information my employees. Below is the polity and Job site Insurance Company Name: -Aim ai n ,i' Ins 01 rQn u. Policy # or Self -ins. Lic. #: .l (Irj i� p Expiration Date: f Job Site Address: UIIn(mit, --im 2ri i i nl-%-A- I c 1/1 171 TI.. — % Iw.__.. �-� . _ _ Attach a copy of the workers' compensa4n 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 S1,500.00 and/or one-year imprisonment', as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 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 cer�tify�under thepains and penalties of perjury that the information provided above is true and correct OfflCial use only: Do not write in this area, to be completed by city or town of iciaL City or Town: Issuing Authority (circle one): Permit/I.Icense # 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone #• Information and Instructions lo to vide workers' compensation for their employees. ' Musachusetti General Laws chapter 132 requite all emp ydrs pro centred of hire, pursuant to tltis statute, an gmpliyee is defined as "...every person in the service of another under any express a implied, oral or written." An sarplgar is defined as "tea itdividusl, partaaship, assocubn4 corporation a other legal entity, or any two a more to a oint enterprise, and including the Legal representatives of a deceased employs+ a the of the farrgoiag errgsged j ::sociatioa a other legal entity, empbyiag �4� However the receiver a dwells of as is having of in sht a and who resides thcrei4 a the occupwX of the owner of t dwelling home hiving not nsxa rhea three apa:ttacnt dwelling house of another who employs persons to do maintenance, canatructim Or dwelling repair work on such house � shall not hearse of such empbymeat be deemed to be so employer." or on the grounds a building apprutcasA MGL chapter IA 125C(6) also stairs that "etrerr state of local pressing ageae s h �adstwealtlt or renewal of a license or pertalt to operate a business or to eanstrud boildlap " appueaat whe hoe not produced acceptable erkleoes of compti nee with the trios race caverag+ rWr� Addidoaalty, MGL chapter 152, ✓;25C(T)states "Neither the commonwealth oar say of its politics! n diviuoas slap • enter into any contract for. the perkmmtnce of puublic work until scceptabla evkkn= of compliance with the insuranca requirement otthin Chapter have been prssenftd to the contacting authority." , Applicant , Please tin out the wod=- comp=tatiaa of ff avkt completely, by checking the bares that apply to Your situatim sad, if necessary, supply sub_contract*s) mamo(s), addresses) and phone number(:) along with their cerr18cateia) ther rhos the innu=L Limited Liability C (LLC) a Limited Lwoty Partnerships (T-� with no emploYKs members a pumas, an not required to curly work=' compensation iasu ianm If an LLC a LLP does have employees, a policy is required. Ek advised that chit affidavit may be submitted to the Department of Industrial Am liz confismatioa of tnsttrance coverage. Abe be sure to sio and date the aifidavtL The affidavit should be returned to the city or town that the 9pplkcat3oa for the permit oe lica<se is being requested. not rho Departmerit of Industrial Aecideat>. Should you have say quesdoos for 1i the law oc if you aka requited to obtains eotkas' rtmcat at the nr>mber listed below. Self -insured companies should eater thew compensation policy, please call the Dep: .etG-iaeo Hessen number on the snproodais lins. City of Tows Omeiab Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit fa you to fill out in the event the Office of Investigations has to contad you regarding the applicud- Please be sure to till in the Mmit/license number which will be used as a rsfererra number. In addition, an WSW* that must submmt multiple pamiV11 eats spplicadons in any given year, need only submit one ailldavit imdiC'M a C=cnt poky hLEMMONtqp (if necessary) and under "Job Site Address" the applicant should writ "all locations to (city or town)." A copy of the aifldavid that has been officially stamped or muted by the city a two may be provided to the applicant as proof that s valid affidavit is on file for Rttuto permits or keens. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license a permit not related to any business at comsaaCW venture (Le. a dog lieeaso or permit to burn Ica-M etc.) said person is NOT required to complete this sffidsvit. The Onks of Investigations would like to thank you in advance The your cooperation and should you have any quatioma, please do not hesitate to give m a all. tine Deputmeat's addresstelcphmoe and fax number: 'Tile Commonwealth of Massachusetts Department of Industrial Accidents Ot1lee of Investigations 600 Washington street Boston, MA 02111 Tel. 9 617-7274900 ext 406 or 1-877-MASSAFE Fax 9 617-727-7749 Revised 11-224U6 wvvw.m=•gov/dia HE-075329�`'' BENTO D COSTA 245 AQUrDEniCK S;' P=eir Bedford NA (2740 _a-•as::-n 1tr0212014 1•71R Massachusetts - Department of Public Se'ety �Vf Board of Building Regulations and Standards Construction Supenisor MET%-'�' License: CS-095606 BENTO DACOST;k g 20 QUERY ST S ' ;' l _ New Bedford MA-02745 i -..' Commissioner 11/22/2016 pAassRenov-Von, Repair, and PeVrine finial-"Hshtn accordance u tth 4A OAR 22.03 Cardiff number. R+IM42-10-WIM Date issued 3/26/2010 o rti 3JZ'a/20s3 Ld-Sa;e F.�rnn_ior SYpenrLor i�lt Moda-at°-Rlslt petead'u+; Opttans hi Accordanea vJtth 454 OM. 22.OS(4)(d) and (e) Cer•.armte: tvrR-prc000c � a±ea Dairrd DaCOsta 11E`sJSEL'i07-Ir.,M�2�,4 F` �' Annardo M. Pereira, Tral,ler OMCC of Consumer Affairs a.. isusmms R entaHsa f-HOME IMPROVEit4E14T COIF MCTOR Type; m>. s Registration* 172966 Corporation r. S1212016 ODC CONSTRUCTION INC. DAVID DACOSTA 20 QUERY STREET NEWBEOfrORD. MA 02745 Underseerztary C�yWor oy -flo 21zis CarAOcaia Awards -T1�i I D l cS i I--- . , ,y.; onn for Aa szccessfzel panccipoon and comvlatioz± of i z 4"-11YE If ¢izVO L'mani zc, ,�erzir r �-�--�— -7 r. L L D A� �® CERTIFICATE OF LIABILITY INSURANCE 12/29/2014""" 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: It the certificate holder Is an ADDITIONAL INSURED, the polley(les) must 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 certlflcate does not confer rights to the certificate holder In 0eu of such endorsement a PRODUCER VIVEIROS INSURANCE AGENCY 140 Plymouth Avenue Fall River, MA 02721 CONTACT NAME - PHONE A/C E-MAIL ADDRESS, INSURERS AFFORDING COVERAGE NAIC a INSURER A:_ INSURED CDC CONSTRUCTION INC INSURER a- AmGUARD Insurance Company 42390 INSURER C: INSURERD: 20 QUERY ST INSURERE: NEW BEDFORD, MA 02740 INSURER F: COVERAGES CERTIFICATE NUMRFR- RFMglnN NIIMRFR- THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INEXP TR TYPE OF INSURANCE UN POLICY NUMBER MAUU EFF WODfY MWDLICY M LIMITS GENERAL LIABILITY EACH OCCURRENCE S 0 DAMAGE RLNJtU PREMISES eoaunanee S 0 COMMERCIAL GENERAL LIABILITY CWM944ADE F1 OCCUR MED EXP arse n S 0 PERSONAL A AOV INJURY f 0 GENERAL AGGREGATE f 0 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS•COMPIOP AGO S 0 POLICY PRO• LOG S AUTOMOBILE LIABILITY COMBINrO •wa BODILY INJURY(Per person) S ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY er ecckern) S NONOWNED HIRED AUTOS AUTOS - PROPERTY er ec0&nn S f UMBRELLA LIPA OCCUR EACH OCCURRENCE S EXCESS LULB CLAJMS4UOE AGGREGATE f CEO I I RETENTION! $ WORKERS COMPENSATION I WC STATLL X OTH- B AND EMPLOYERS' LIABILITY ANY PROPRETORJPARTNEWEJIECUTNE YIN OFFlCER(MEMBEREXCLUDED? ❑Y NIA R2WC512962 08/312014 08131/2015 EL EACHACCIDENT f 500,000 E.L DISEASE• EA EMPLOYE $500,000 (IMyannd�slw7 In NH) OESCRP ONundw OFOPERATIONS halaw EL DISEASE • POLICY LIMIT fSOOOOO DESCRIPTION OF OPERATIONS ILOCATIONSIVEHICLES (AMeh ACGRO101,AddhbnJR.mdrs Behedule.Nm spe lsnquired) Exclusions: DAVID DACOSTA; Yarmouth Housing Authority 534 Winslow Gray Road S South Yarmouth, MA 02664 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE - DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED O 1988-2010 ACORD CORPORATION. All ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD YARMOUTH HOUSING AUTHORITY 534 Winslow Gray Road LONG POND PLAZA SOUTH YARMOUTH, MA 02664 Bambi Rosario -Wyatt -- - --- . _ Chairperson Edward A. Roderick Executive Director January 5, 2015 DDC Construction 20 Query Street New Bedford, MA 02745 Attn: Mr. David DaCosta Telephone 508-398-2920 -- FAX 508-398-1930 - TRS 800-439-2370 Re: Low -bid Approval — Yarmouth Housing Authority Work Plan 351025001; DHCD FISH 351027 Designer: Clearwater Architects Scope of Work: DHCD CR FF: Kitchen update Phase 3-1 (2017)-c.667-1 Dear David DaCosta, The Yarmouth Housing Authority and its Board of Commissioners voted on December 9, 2014 to award the above captioned construction contract to DDC of New Bedford, MA, the lowest eligible and responsible bidder in the amount of $84,770.00. We look forward to working with you on this project. Please contact me at 508-398-2920 or e-mail varhousinsra?comcast.net at your earliest convenience to schedule a meeting. Sincerely, / Edward A. Roderick Executive Director Cc; Linda Katsudas DHCD Clearwater Architects Candy Tempesta DHCD Sean Keating DHCD Offlce Use Only °, � y Amm mt / `a ,y Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 -- - - -- - (508) 398-2231 Ext.-1261- - - CONSTRUCTION ADDRESS: ASSESSOR'S INFORMATION: yr /n/ u Map: )(Y I Parcel: V / OWNER: ti ke Y dv-e- —791 // kla/S l✓ // o-sfS / 813 7y6 asl5 NNcItc PRESENT ADDRESS TEE..# Email Address: CONTRACToR: s R(/ue- o1 -J-GSl�te- N0 04a6i /)I///1 .Sad 36y..,2(/S6 NAME MAIIJNG ADDItESS TII-# Email Address: esidenti Commercial Est. Cost of Construction $ (0,.SO 0 . Oa Home Improvement Contractor Lie. # 170576 Construction Supervisor Lic. # C5 - O 9 a 9S6 Workman's Compensation Insurance: (check one) I am the homeowner am the sole ropneto Insurance Company Name: I have Worker's Compensation Insurance Worker's Comp. Policy# WORK TO BE PERFORMED Tent _ Duration . / (Fire Retardant Certificate attached?) Wood Stove Siding: # of Squares `7 Replacement windows: # .3 Replacement doors: # Roofing: # of Squares 70 ( t/ Remove existing* (max. 2 layers) Insulation Old Kings Ilighway/IIistoric Dist. ( ) Replacing like for like *Tbe debris will be disposed of at: Ad // OTic PaeYl -k� 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 denial or revocasjpn of my lice and for prosecution under MG.L Ch. 268, Section 1. Applicant's Signature: -Shi,liCke�4 9 Dale:/S Owners Signature (or attachment) Date: Approved Dr. Date: Building Official (or designee) Zoning District: Historical District Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft. of Wetlands: Yes No Yes No The Commonwealth of Massachusetts Department oflndustrialAccidents I Congress Street, Sttite 100 Boston, MA 02114-2017 www mass.gov/dia Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. IMIT= Address: 91 7Z5 City/State/Zip: V44641r5 f1J 4 Phone #: Are you an employer? Cheek the appropriate box: 1.❑ I am a employer with employees (full and/or part-time).• 2.®I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. Q I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.[] I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.: 6.Q we are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] sC. - - - -- Type of project (required): 7. ❑ New construction 8. Remodeling 9. ❑ Demolition 10 Building addition 1 I. Electrical repairs or additions 12. Plumbing repairs or additions 13. [1rRoof repairs 14.[B"Other ,S,c�in5 *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 subcontractors 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: Policy # or Self -ins. Lie. it: Expiration Date: Job Site Address: City/State/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 MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify u er the pa' annd penalties of perjury that the information provided above7u*ue and correct.Si nature: V 'Zk Cte_`u�Date: Phone #: IGct .,2gSG Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone #: .a Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, 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 not 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, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall 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 -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) 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 insurance 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 policy, 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 applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia ® Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supeni%or License: CS-092958 SHAKE PACHEC9 81 Jasper Road �-y% j L Marstons bulls bfA 0 ,t J�„� �� "'" • � Expiration Commissioner 10/17/2015 1 a rJ/IP n/b/Ka.Lk1r/1rfJr//J Office of Consumer Affairs & Business Regulation rME IMPROVEMENT CONTRACTOR egistration: 176570 Type: plration: 9/3/2015 Individual SHANE PACHECO SHANE PACHECO 81 JASPER RD MARSTONS MILLS, MA 02648 1lndenerret ry GVM15 SlIpGen- Portal Hone Town of Yarmouth .,Y Template [Building Dept] Y Slipsheet Identifier [sg26803] Document Category Building Permits Map -Block Number 059.44 Street Number 0534 Street Name WINSLOW GRAY RD Department Building Parcel ID 8351 Backfile Batch Scan Document? Additional Naming Info Index Operator Date - Time 1`n Operator, Yarmscan 2015-06-09 - 09:22 httpJnasedchel?/Sl]pGed 1�1