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EXPRESS SHED PERMIT APPLICAT• t ' C E I V E D
• TOWN OF YARMOUTH $ . - 6 2018
Yarmouth Building Department
1146 Route 23 rf.
South Yarmouth, MA 02664
(503)398-2231 Ext. 1261
/CONSTRUCTION ADDRESS: kelL�ftALe4Gtti _S/ dtoEy
ASSESSOR'S INFORMATION:
Map: y n Parcel: / y/3 --23-2 _s e iy,f'
OWNER /^ 'f3 / Ave-loth t e a-- 14-12a 07D7J'-
NAME PRESENT 9DD3,ESS KEL #
CONTRACTOR: 'act-- ova/ n.__
V So-1 iez,
NAME MAILNG ADDRESS fJL pX.0 TEL.#
I� r vo0��
esidential 0 Commercial Est.Cost of Construction$
• Home Improvement Contractor Lie.# 1 '59.193-s )(Construction Supervisor Lie.# Vz-q - 01 3F CS
W2rkman's Compensation Insurance: (check one)
0 I am the homeowner 0 I am the soleeproprietor 0 I have Worker's Compensation Insurance r e p
Insurance Company Name: fl b 0 ct-' (cis.)5 C41,40 I rr Worker's Comp.Policy# ter 10°`etiOb 2s
o a Ati Q&t`o
' SHED INFORMATION
L
New _ Size L 7�1 x x H 46 Corner Lot: Yes No
Per Town of Yarmouth Zonin'By-Low Sec 203.5 E:
Side and rear setbacks for accessory buildings less than 150 square feet and single story, shall be 6 feet in all districts, but
in no case built closer than 12 feet to any other building.
Replace existing* _ Size L x H" x
'The debris will be disposed of at
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 revocation of my license and for prosecution under M.G.L.Ch.263.Section I.
Applicant's Signature: Date:
Owners Signature(or attachment) Date: R
Approved By: 111.x. Date: 1 -0- 1pC
Building Official(or designee) EMAIL ADDRESS:
• «—
Zoning District:
Historical District: '1 Yes fl No Flood Plain Zone: '1 Yes No
Water Resource Protection District: Within 100 ft.of Wetlands:'*"
I) Yes C No 11 Yes 0 No
***Note:Conservation review required if within 100 ft.of Wetlands
9/13
ems.•. .rrre�_.
•
The Commonwealth of Massachusetts
• : r Department of IndustrialAccidenis
"rats t Office of Investigations
600 Washington Street
t ''t+ ' Boston,MA 02111
www.mars.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organirationtlndividual): Mc 6r0„411 Tort * B etas,?
Address: aSq (!i uccn 'Road
City/State/Zip: FLir,jirh J MA 02915 Phone#: i: •330• g(}00
Are you an employer?Check the appropriate hot Type of project(required):
I. 1 tan a employer with 4. 1 am a general contractor and I
employees(full and/or part-time).* have hired the sub contractors 6. New construction
2. 1 am a sole proprietor or partner- listed on the attached sheet 7. Remodeling
ship and have no employees These sub-contractors have 8. Demolition
working for me in any capacity. employees and have workers'
[No workers'concon insurance., 9. Building addition
required.)
p insurance 5. We are a corporation and its 10. Electrical repairs or additions
3. I am a homeowner doing all work officers have exercised their 11. Plumbing repairs or additions
myself.[No workers'comp. right of exemption per MGL 12. Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees.{No workers' - 13. Other
comp.insurance required.)
'Any applicant that checks ban 01 must also fill oat the section below showing their worker/compensation policy information.
t Homeowner who submit this affidavit indicating they are doing all work and Mtn hire outside contractors must submit a new affidavit Indicating such.
tContraetors that check this box must attached an additional sheet showing the name of the sub-contractor and stale whether or not those entities have
employees. If the suboomractan have employees,they must provide their workers'cop,policy number.
e
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I am an employer that is providing workers'compensation insurance for my employees. Below it the policy and job site
information. A
Insurance Company Name:Amrr1can 711r) f t1
A ♦ s Qa _ -�•
Policy#or Self-ins.Lie.4:Aaiun q flq B'f1 S 7 -11 Expiration Date: •.,J ti Iy 8 an 1e j
. Job Site Address: City/State/Zip: J
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MOL 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 viol.,or. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA • , urance covert-verification.
I do hereby certify 'der th: • an 3 Ir.)i fperjary that the information provided above is true and correct
Si_ atm ft a.t :
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 it:
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A ' • PLOT PLAN
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FOR LOT N
Indicate location of garage or accessory building
Additions with dashed lines
Sewerage disposal (cesspool)
Well ig
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Abuttor's Cr
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Name �� ) Aber'
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f this is a REAR YARD
:orner lot, I�kF1 If this
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Ff Office of Consumer Affairs and business Regulation
ye 9 10 Park P1l7a - Suite 5170
iiBoston, Massae. .efts 02116 I
Home Improvement _ ctor Registration.. •
I =e Commonwealth of Massachusetts
_y_)r�� F! �f Division of Professional Licensure
McGRATH POST & BEAM .CO. � Board of Budding Regulations and Standards
• JAMES McGRATH —: io�,9u lett4 or.1 8 2 Family
259 QUEEN ANNE RD. a-= - •
HARWICH, MA 02645. wiz — d CSFA-073885 • Erlpires:03/14/2020
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'o = %` ' • 'ESRMCGRATH
1'tr `sd : 1 204CRANVIEW RDR. ' ».;r:
BREWSTER MA 42031 t({ yya ;`9
Commissioner V'"`"
•
•
i C7 c �j042Mwneoec1. a/QI4 aacAuoeln
�, Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Marss• husetts 02116
Home Improveme .P4ntractor Registration
J = � Type: Corporation
ITS - - - r?%.Th Registration: 132935
MCGRATH POST& BEAM C0. 1,1,1,11 -1)*,
i ..- y4� __1 f,.i Expiration: 10/30/2018
259 Queen Anne Rd. + 7 =t '
� � " _:`_7 ,c4
Harwich, MA 02645 ,�, ., .. _re /
i Update Address and return card. Mark reason for change.
SCA 1 0 :0M-05111
[� 0 Address 0 Renewal 0 Employment 0 Lost Card
—
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C , rGorroriu r oeall4 ediaav c/iuer,di
.`h� Office of Consumer Affairs Business Regulation
.,-_
II�+' �6,2 HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
AP
Type: Corporation before the expiration date. M found return to:
Y -y Office of Consumer Affairs end Business Regulation
N : _�� `.�rpaiStration Exdiratioq 10 Park Pieza-Suite 5170
'k*..:.' z',l•f,3?e35 10l30f2076 Boston,MA 02115
McGRATH POST&REAM CO.
0/13/A Pine Harbor`Woo(f:.
Products C
James McGRATH '•
'
259 Queen Anne Rd.• •' Undersecretary Not valid without signature
Harwich,MA 02645
.--;-'11 MCGRPOS•01 KDOYLE
A`�R0' CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDOYYTY)
08/06/2018
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 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 poliey(ies)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder In lieu of such endorsement(s).
CONTACT
PRODUCER ,_NAME: —
Rogers&Gray Insurance Agency,Inc. PHO No,Ext): I FAX xeti77)816-2156
434 Rte 134 L 1
South Dennis,MA 02660 -MD RIESS'mail@rogersgray.eom
INSURER(S)AFFORDING COVERAGE NAILS
INSURER A:Travelers Indemnity Company of America k..25666
INSURED INSURER B:Travelers Indemnity Company '25658
McGrath Post&Beam Corp INSURER C:New Hampshire Employers Insurance Compan 13083
dba Pine Harbor Wood Products
259 Queen Anne Rd INSURER D:
Harwich,MA 02645 INSURER E:
INSURER F:
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 POLICES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE ADM.SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS
ITR /NCD MD IMOLIC/YEFF fPOLIC EXP
A X COMMERCIAL GENERALLIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE X OCCUR I.660-03688196-TIA-18 01131/2018 01/31/2019 DAMAGE TORENTEDRr'P1 1 100,000
PREMIBES jE10 W YIR
MED EXP(Any one person) $ 5'909
PERSONAL 8 ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2'000'000
X I POLICY` 1 Sri 1 I LOC PRODUCTS•COMP/OP AGO $ 2,000,000
OTHER: $
COMBINED SINGLE LIMIT 1,000,000
B AUTOMOBILE LIABILITY (Fe accideD) $
ANY AUTO BA-44878686-18-SEL 01/31/2018 01(31(2019 ewer INJURY(Perpersen) S
• OWNED
MS
ONLY X AUTOpSSULEOp BODILYBgINJURY(Per twoldent) $
X AUTOS ONLY X AUTNOS ONLY (PerOe¢Ment)AMAGE $
$
'UMBRELLA LIAB OCCUR EACH OCCURRENCE $_
IEXCESS UAB CLAIMS-MADE AGGREGATE $ ____
Deo RETEN11ONS PER GTN• 1-$C WORKERS COMPENSATION X STATUTE ER
AND EMPLOYERS'LV.BIDTY ECC-600.4000957.2018A 07/08/2018 07/08/2019 100,000
ANY PROPRIETOR/PARTNER/EXECUTIVE R/EXECUTIVE YIN E.L.EACH ACCIDENT $
(Mandatory In
OFFICER/MEMBER N xIA 100,000
If yes.descdbe under E.L.DISEASE•EA EMPLOYEES 50Q000
DESCRIPTION OF OPERATIONS below E L.DISEASE•POLICY LIMIT S
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Ramada Schedule,may be attached If mon space Is required)
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.
Building Dept
1146 Main St,Route 28
South Yarmouth,MA 02664 AUTHORMED REPRESENTATIVE7
I �jryt!/SEC -
ACORD 25(2016/03) ®1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD