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Home My WebLink AboutBLD-19-000918 o�'Y 9R umce use vary .` e-4t '2.s 4o Permit# 0 It'Vg H ''Amon!. SD es "`"'n,'•"`cid 1 Permit expires 180 days from 1 (q 'k a aate[/l_ qtr f) 1 EXPRESS BUILDING PERMIT APPLICATION - --_ TOWN OF YARMOUTH _ M Yarmouth Building Department [ AUG 15 2018 1146 Route 28eu; r South Yarmouth,MA 02664 il� ti�_I 9�/ (508) 398-2231��31Ext. 126112 /Q�� CONSTRUCTION ADDRESS: Or/O �fr4 i leg ./.Z1 a f6eer'W ASSESSOR'S INFORMATION: O Map Parcel: OWNER: 49, Y `/Dar9d ew , iwf2 fdY74 -C96g - N' 0 / PRESENTADDRES / TEL # Email Address: CONTRACTOR`.41/J/ i. Lr '. 41,/, .-ii I ir . .i • / . i 547-1 lv/03d NAME / MAILING ADDRESS TEL# Email Address: Residential Commercial / Est.Cost of Construction$ ' S I /d�U �y Home Improvement Contractor Lic.# 9 Construction Supervisor Lic.# C-9 '�C/_J.7 /J Workman's Compensation Insurance: (check one) I am the homeowner I am the sole�/� proprietor CsComp.Poli:y / 44 ompensation Insurance/ Q��/ Q Insurance Company Name: I�'9 i/ed -%%iC77a wirer WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares ' Replacement windows:# Replacement doors: # aRoofing: #of Squares o75 ('v)Remov#existing*(max.2 layers)s)/� Insulation Old Kings Highway/Historic Dist. y"(t% Replacing like for like (/�..C�� • *The debris will be disposed of at ��iet el t��.G�(!�a�ele 4�a �/ Location of Facility I declare under penalties of perjury that the starPmnats 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 yvoccaattiion of myalicense fo pros= ution under M.G.L.CL 268,Section 1. "At Applicant'sSignanue' �l•r�//!/(.24 , Date:rIS9wners Signature(or attachment) �1 � Date: �� Approved By: // -A�i.tl Date: C.� —/‘—/e33 Building Official'f i..- ) . -- _ -- Zoning District. Historical District Yes No Flood Plain Zone: Yes No Water Resource Protection District Within 100 R of Wetlands: • Yes No Yes No The Commonwealth of Massachusetts It Department of Industrial Accidents to EMIL d 1 Congress Street,Suite 100 't Y Boston,MA 02114-2017 \,;�,, www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information ��,J 9� /,�}.y, Please Print Legibly Name(Business/Organ. tii000nn/IInnjdividual):0�� /IC�.(,C %rC�fi awe • Address: 1p2L,,%((��,ui 42/ (//r J/ City/State/Zip:/{C�//t��f�� i� j Phone#:,�D�aPj'% �,c9/J Are you an employer?Check the appropriate box: / Type of project(required): am a employer with employees(full and/or part-time).* ❑New construction 2❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity,[No workers'comp.insurance required.] 9. ❑Demolition 3.1:11 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. I will 10 ❑Building addition ensure that all contractors either have workers'compensation insurance or are sole I1.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5❑I ant a general contractor and I have hired the sub-contractors listed on the attached sheet. 13aof repairs These sub-contractors have employees and have workers'comp.insurance./ 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.pother 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. ?I lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors,ihat 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 - Insurance C lAL2�i Insurance Company Name: '_c/ ll'' q Xl/� Policy#or Self-ins.Lie.1#:�J149 of 1�yy��iJ�[/ Q Expiration Date: Job Site Address: deld I City/State/Zip: ,/ ///� /so 6� Attach a copy of the workers'compensation policy declaration page(showing the policy numbe . d 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. I do hereby certif nder the pains and p allies o perjury that the information provided above is true and correct. $ienature: S�r Date: er4��4" Phone#: 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 II: 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 iildMdual,partneeship}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 th o'b upant of the dwelling house of another who employs persons to do maintenance,consiructioe or'repair wo cVuc dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed Robe 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." -X)1 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-contractor(s)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 Cl. ' t- Please be sure that the affidavit is complete and printed legibly.*The Department has provided a space at the bottom 1`t of the affidavit l'or you to fill out in the event the Office of.Investigations has to contact yon regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In adiilom 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 burn leaves etc.)said person is NOT required to complete this affidavit. \ 'r \ \\‘.rNT%.. v • 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 a • • • • • Commonwealth of Massachusetts Division of Professional Licensure • Board of Building Regulations and Standards Constructit`f%t P9Srvisor CS-034718 �ires:09119f2019 • c44 _ ti THOMAS AHjLCHEYM '8 _ j'? OLD CHATHAM 02.8 ROAD , 41 HARWICH MA 07y6t. ^ `�fJic�'.Fil�a ✓ Commissioner CAt • • • • Office of Consumer Affair&Business Regulation HOME IMPROVEMENT CONTRACTOR -- n Registration valid for Individual use only ',k Type: Individual before the expiration date. If found return to; '' TRealstradoq• Expiration Office of Consumer Affairs and Business Regulation . :1-110649 11!022018 10 Park Plaza-Suite 6170 Thomas A Hi�tley Boston,MA 02116 Thomas Hilchey, :;:_; • • 114741 62 Old Chatham Road';. `p ra " �yHarwich,MA 02645C, �/�GV /�/v/� f Z/ Undersecretary Not valid without slgnatur� 04/04/2018 10:54AM 9788514848 SULLIVAN PAGE 01/01 eRD' CERTIFICATE OF LIABILITY INSURANCE I DATE aMJDDRYm 04/04/2018 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 DY 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 denlfcete holder is an ADDITIONAL INSURED, the pellcy(Ia) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and condlaons of the policy,*Mala sondes may require en endorsement AetetemeM on this oerd¶eate dao not deafer rights loth* certMeaae holder In lieu et such nderaem*M(4. PRODUCER Mons (S71)8618800 Fan (e78)e51454a ' cONNNTACT Sullivan Insurance Agency SULLIVAN INSURANCE AGENCY ,NON/ p 885 MAIN STREET edd,No Pr (978)851.8600 Wuc Not (878)881.4848 i. TEWKSBURY MA 01876 ADDRESS • . INSURER(S)AFFORDING COVERAGE NAIC N eEURERA : XS Brokers Insurance Agency,Inc ' ,N5Unt0 THOMAS AHILCHEY KAR/Re a ACE Group• DBA THOMAS A HILCHEY CONSTRUCTION ' • msuREMc 3 ✓ 92 OLD CHATHAM ROAD EMMA Et HARWICH MA 02645 ,NeuRe3i . INSURER? : • COVERAGES CERTIFICATE NUMBER: 29258 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCV 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 PAO CLAIMS. INFO ups or INSUMRRANCa ADOL R POLICY EFF Poucr EMP LTR IMER WVO POLICY NUMBER aJMNamr I—MMBanmt LIMA A IMNUML UMW./ 3E02719 09128/17 09/26118 EACH OCCURRENCE S 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGFTORFNTEO CLAIMS-MADE [] MED.D.EXP(Anyonepenan) 5 5 1,000 PERSONAL aADV INJURY $ i,000,00l • GENERAL AGGREGATE S 2,000,000 GENE AGGREGATE LIMIT APPLIES PER: PRODUCTS.COMPIOP AGB S 2,000,000 7 POLICY , 1 ' LOC — n i A YONOEaa DMILIrY • J COMYNEO MOM LIMIT N3eme ne i *5W AUTO BODILYDUURY IParmeson) i —ALL OWNED —SCHEDULED BODILY WNTN(Por*aideM) S ..HIRED AUTOS —NON-OWNED 1pnnRTN WMArC t AUTOS tor,.uor.° S UMBRELLA LM OCCUR • EACH OCCURRENCES — gnu um CLAIMS-MADE AGGREGATE t —1 J OFD IRETt:NT10Na t B RDRICRs COMPIINSENON - 0862UB•12E09540-0.18 03/18/18 03/15119 `Tn•O V USEr ' OT. -� :MAT uA91un I ORY IWTa 1 1 ER t MY PROPMefnRNARrNEe161eGRryE TM E.L.EACH ACciomn 5 100,000 EMPIMAP/mEMr amMmM ri M/A IspsaslinIN&tnIr O1.OISFASE{A EMPLOYEE t 100,000 • :MP=OF OPERATORS mea El.DISEASE-POLICY LIMIT S • 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Mach ACORD 101,MdIUenat RamaAs Schedule.V more Was Is Nuked) Tom!Blaney is excluded from the Workers Compensation policy • • CERTIFICATE HOLDER CANCELLATION • Town Of Dennis SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BO CANCELLED BEFORE • $85 Rout*134 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN South Dennis,MA 02660 ACCORDANCE WITH THE POLICY PROVISIONS_ Areaway AEPREIIMATNT n