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Bld-20-000968 0f.Yi Office Use Only ws0 Permit# O - •l%y H P.,Amount HD sc7.2 <Permit expires 180 days from 8 CO'2.1)A ta r i ,I. EXPRESS BUILDING PERMIT APPLICATION'T 6 1201 ; I --T— r.14C7� TOWN OF YARMOUTH I Yarmouth Building Department ,3i.: L2' , PA T 1146 Route 28 Lh''- .--_ South Yannouth, MA 02664 7 �LI, (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: C.� cS �A/tA 4?' eL\ li( <0M4fiG97-1/ '& 7 1 ASSESSOR'S INFORMATION: 6G Map: Parcel: OWNER: 6e6O --7-;e 1.5/ as fit I�� ix.et 7 4 . 7S/33/ 3 7 2 NAME PRESENT ADDRESS TEL. # CONTRACTOR: M/r�'' / 2/17 7 / Zd <— 5 ' ' NAME .ING ADDRESS . TEL.# .esidential ❑Commercial Est.Cost of Construction$ /S 6 ' Home Improvement Contractor Lic.# `�.5 D C 7 Construction Supervisor Lic.# GS -161/709 Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor J/I have Worker's Compensation Insurance Insurance Company Name: 4/44 wei72'/4�. Worker's Comp.Policy# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove ..'tiding: #of Squares 3 Replac ' ent windows:# Replacement doors: # 47 'Roofing: #of Squares a ( Remove existing* (max.2 layers) Insulation ZOO ,_-- Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: 1441/p4,0/A4 t 4 7.Pee-/2G/0m�f5 7 'i 7i3 2�' / t Z,#Vj LJV/4 71-- atio of Facili_ #edzet �t4� eese,,C...5/ 41 .44/40,tosley I declare under penalties of perjury at the i': erne .he,- in . ed are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for den.- or re ration,. y ' ens- .t•a . osecution under M.G.L.Ch.268,Section 1. .>�i; g/ Z / // Applicant's Sign...-: Date: ::: : ig. ture(or attar 1 i ent) 1 ;0, '��I� 4 i • C Date: AVid 2 j '2O / q// �� i d., • Date: 9-` 2t ' I Qj Building 0. ci 1' EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No The Commonwealth of Massachusetts l Department oflndustrialAccidents WOW' 1 Congress Street, Suite 100 _0= Boston, MA 02114-2017 NMI .• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/Individual): ��,j',.c Address: /?4 .533( City/State/Zip: `!IJX,�,$, �•0 ,/- 6hone #: 7fS/'7S`J' — 5-Z26 Are you an employer?Check the appropriate box: Type of project(required): 1. ./1 am a employer with ® employees(full and/or part-time).* 7. ❑New construction 21/`-'�'"' am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all work myself. 9. ❑ Demolition ❑ y [No workers'comp.insurance required.]` 10 ❑ Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insura ce.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other $7Z, .41 �� 152,§1(4),and we have no employees. [No workers'comp. insurance required.] *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 sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 4/4/5 iriliA,2441Z Policy#or Self-ins. Lic.#: Expiration Date: 7,// 0'6/ Job Site Address: z .40/2/� /�L1Dl/Jl7/ City/State/Zip: ��/Y A 9& ?/d Z‘?3 Attach a copy of the workers' comp nsation policydeclaration page(showing the policynumb>3r and expiration date). P ) 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. I do hereby certi der e ms aides of perjury that the information provided above is true nd correct. Signature: Date: 1? Phone#: 20/-7...J S LSO 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 Phone#: Contact Person: M t Commonwealth of Massachusetts Board �' Division of Professio of Building Regulationsnal Licensure and Standards Constrictibn'8OPervisor CS-011729 a Lr>pires: 11/12/2019 MICHAEL G LILLYa - Ain PO BOX 558 % -� .• , MARSHFIELD NILLS MA 02051 " , k Commissioner !`/11- l�oC I4rJJaCki.feh Gcinu�mewl//( &Business RegulationA - fof Consumer Affairs •A- I(IOME IMPROVEMENT CONTRACTOR it �l�tegistration: 115087 Type: �� =Expiration: . 1�2017�� Individual • +,.HAEL LILLY • I MICHAEL LILLY - 1717 MAIN ST N.MAF. ELD,MA 02059 Undetsecretkry , • l ACC O CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYV) 08/21/2019 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 lieu of such endorsement(s). PRODUCER CONTACT NAME: Gregory Coutts DON BUNKER INS AGENCY (A/C.No.Est): (781)312-7206 FAX No): E-MAIL ADDRESS: Iauren@donbunkerinsurance.com P 0 BOX 221 INSURER(S)AFFORDING COVERAGE NAIC# HANOVER MA 02339 INSURER A: AIM MUTUAL INS CO 33758 INSURED INSURER B: LILLY ROOFING INC INSURERC: INSURER D PO BOX 558 INSURER E: MARSHFIELD MA 02051 INSURER F: COVERAGES CERTIFICATE NUMBER: 440000 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 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP W LIMITS LTR INSD VD POLICY NUMBER (MM/DD/YYYY) IMM/DD/YYYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- CT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ _ _ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS $(Per accident) UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH X PEATUTE ER AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBEREXCLUDED? P N/A N/A AWC40070328592019A 07/08/2019 07/08/2020 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensationfinvestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Rte 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 Daniel M.Cro,9ey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD