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Home My WebLink AboutBLD-19-001718 A Office Use Only a i' Y qR R S." k/ l E D - nl %poi ° ti 4 SCP 212018 ,Amount ,+ k^w..u• c,e/,, r.Permit expires 180 days from r✓ " . issue date -, El ILf"lNC, E rrME T EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 9/ � �� J/ �',y+, CONSTRUCTION ADDRESS: .(IQi /' ��/I5L' !/I/�� ' ASSESSOR'S INFORMATION: /-7iyr'/euG�; % Map: 72 Parcel: a360 OWNER: /% � � 7 9.z mfai'f N,LN /rE�Ii�VG(J/1 at- - NAME �/1��/9'- �PRES ADDRESS �y/y� �j� /yam TEL # ,cam Email Address: CGNTRACTORC? I///.or�2i�' , g �61 ,had/��j/.c{�• '(ic i c^6 ✓a7'Aa?!p�1 NAME vv MAILING ADDRESS TEL# �r Email Address: Residential Commercial/ Est.Cost of Construction SY-Cot Q//.00 Home Improvement Contractor Lie.# //d�y9 Construction Supervisor Lie.# (: —a-91,4r Workman's Compensation Insurance: (check one) I am the homeowner /�//,I aamm/the solep,(moprietor I have Worker's Compensation Insurance �f�/ Insurance Company Name:-cite iV" O`er-/ '4/' Worker's Comp.Policy#,KW124-#0107590 WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Coofrng: #of Squares `4 ( Cc Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. (( ))Replacing like for like // �/y��/�J/) *The debris will be disposed of at: leki"��/eat CJO//4 /J�.iC//v//if.N/ Locatiaffir of Facility I declare under penalties of perjury that the statements here 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 vocation of my lit fo .ros>• tion under M.G.L Ch.268,Section 1.Applicant's Signature. ;tC�l�!'[^�i / Date: Wirt♦Owner Signature(or attachment) /fit...-� . / Dete: (� Approved By: y, - , s ate: 9/2 it//d 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 a The Commonwealth of Massachusetts Department of Industrial Accidents C eEMll I 1 Congress Street, Suite 100 st"cc �_ �' Boston, MA 02114-2017 t .� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): I'/ frj7l.�/2 7.1 • Address: Ygitil �(. p 2. City/State/Zip: 4,7/1 %//dam Phone #: cti�li'�� 0 Are you an employer?Check the appropri box: Type of project(required): I. I am a employer with employees(full and/or part-time).' 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 3.0 l am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑ Demolition 10 0 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 11.0 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 ]3ZRoof repairs These sub-contractors have employees and have workers'comp.insurance.; 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 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 providin workers'compensation insurance for my employees. Below is the policy and job site information. (/ ,`►�fA/U_C � Insurance Company Name: L, Policy#or Self-ins.Lic.#�!2 14f9 Ta Expiration Date: �� c...9„4.179Job Site Address: 5//i! �T City/State/Zip:GU„P/ ' Attach a copy of the workers' compensation policy declaration page(showing the policy number a 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 certify der the painsi� // an na 'es of perjury that the information provided aabovv is true and correct Sienatur�..�:2 Date: ..�fdAe Phone#t 3-d// oey/� -71. 2/3 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#: 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 ajoint 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-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 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. # 617-7274900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia • • • • ' cr7,'Ttbutmoneen((A o/C`sl unr4uJe,,. �� Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Type: Individual beoretheexpfrgistration ldforlI dual only return tz before the expiration date. If found to; cam„ -_-. 110849 Expiration Office parkf Consumern-sAffairs and Suelne88 Regulation 11/02/1018 Suite 6170 Thomas A.Hildhey: Boston MA 02116 Thomas Hffchey- ' ::'?- - : . 82 Old Chatham Road_:�= '- `p �-� Harwich,MA 02845 ,/}1rv, ,�y'� ge, � Undersecretary ��/// �'1/NNott validlalwithout signatur— • • Commonwealth of Massachusetts Division of Professional Lkensure Board of Building Regulations and Standards Construflf rft ipervisor CS-034718 .5 5plres:09/19/2019 094 THOMAS AHILCHE 1- - Y� .a:.;,. 82 OLD CHATHAM ROAD '•. ` - HARWICH MAO 45. ' b."-sr Commissioner C>1- `� • • 04/04/2018 10:54AM 9788514848 SULLIVAN PAGE 01/01 .••••^l 4Ro' CERTIFICATE OF LIABILITY INSURANCE Il I DATE itemonYrn 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 BT 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: M the certificate holder is an ADDITIONAL INSURED, the poilcy(lea) must be andone0, If SUBROGATION IS WAIVED.subject to the teems end condleons cc the policy,cattaln donde, may metre en endorsement.Aetdemee/ent is corneal*On not dancer rights to the certificate holder In lieu or suet.endmmmentjs). PROOVcSR Poona: ($70)051.0600 Fan (078)O51.4646 wMLADI Sullivan Insurance Agency SULLVAN INSURANCE AGENCY °14"1BBS MAIN STREET tar No PO (879)851.8800 �` 1b4 (978)891.4848 TEWNSBURY MA 01878 A ADORERS • .INSURER(S)AFFORDING COVERAGE NAIL a INSURED SIMMER : XS Brokers Insurance Agency,In; THOMAS A HILCHEY INoUREaa : ACE Group' DBA THOMAS A HILCHEY CONSTRUCTION ' INSURER e . 82 OLD CHATHAM ROAD HARWICH MA 02645 `'"°"nO1p' INEURa,5 : NOURESF : • COVERAGES CERTIFICATE NUMBER: 29258 REVISION NUMBER: THI3 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 AU.THE TERMS, EXOLVSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE MLR ReTUCED BY PA CLAIMS. ITR NER TYPE OF emu/twice '� SSA MM�CYlFF ►U Eim Lena - WM PDLICYNUMe6R A GINNRN. uLMIurY 3E02719 08)25117 09/26115 EACH OCCURRENCE S 1,000,000 X COsimenc .oensRALUABiurr DAMAGE TO RENTED PREMCUIM!-MAGE ElOCCUR MED.ES(E,ay nnm) $ 80,000 MED. XP(MY me dome, 5 1,006 • Pertsoi La ADV INJURY $ 1,000,006 • GENERAL AGGREGATE $ 2,000,000 OEENIL AGGREGATE LIMIT APPLIES PER: PRODUCTS.COMPJOP AGO s 2,000,000 i poucy1^I:Egg; El toe a uJTOMCela LIABILITY �M mom UNIT $ AM AUTO �BONEPULFD BODLY IINJURY per person) I —ALL OWNED AUTOS AUTOS • BODILY INJURY(PeremduN) S _HIREDAUTDS __AUTOS ee....MYMMAGc 5 I._s_ I maRSUA Uu _OCCUR • EACH000URRENCE S MIFeMS Iles CIAIMSMADE AGGREGATE -J $ OED IRETENTIONI S • B womalte comPINsATIONrY •/r• SS82UB,2E09540-0.15 0311W10 03)19119 TORY UMBO I .I En S ANYOff PIWvai% CDTN. ELL EACH ACCIDENT $ 100,000 IMmCAyhNN1 Lu N/A • EL DISEASEEA EMPLOYEE 3 100,000 Irmrqa aewlMw , • et SCPIPnoN OP OPERATION'Mow EL.DISEAaE•PauCY LIMIT $ • 500,000 DtOCRIPTION OF OPERATIONS(LOCATIONS/VEHICLES(Attach ACORD 101,AddWOMM RamaMe Schedule,N mere some Is meulred) Tom Michel/In excluded from the Workers Compensation policy • CERTIFICATE HOLDER CANCELLATION