HomeMy WebLinkAboutBLD-19-001882 / dr r-.2 I F;,31 i VAN '.'-.'�:d) t'1 `cH- U 'O ce Use Only
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/ y 1.:i1t..1}.n r''O 1--.1. T FR.CA1 Fa J%-:j ANN 1 i,Amoun[ •
VI
��\�^+.m%:4 ,Permit expires ISO days from
'issue date+ C
bu,— lci . ECEIV ':: L)
EXPRESS SHED PERMIT APPLICATI •
TOWN OF YARMOUTH OCT 1 - 20181
Yarmouth Building Department
1146 Route 28 BUILD 1 Vg " "r
ny: _ . b_
South Yarmouth, MA 02664
.(5008) 398-2231 Ext. 1261
1/4.„/"CONSTRUCTION ADDRESS: ...3
✓ LC) t.% t 're Z IFI-16114141:0)
2TMA o2 CC 1
ASSESSOR'S INFORMATION:
Map: i O Co Parcel: S7
1
t�OWNER: '52_ raj •C - 19F 1.b 55t_t} m,f ?II 5cL &n4.288
ANTE" t(6G-r-
.r-r- P T ADDRtE�SSaTEL #
CONTRACTOR: AL risk- iw 4 rregiAL ONAME MAILING ADDRESS J TEL# /�/�
0 Residential 0 Commercial Est.Cost of Construction$ h-�/a C oo . (�`)
Home Improvement Contractor Lie.# 13a `13 5 Construction Supervisor Lie.# b/38.12 C
Workman's Compensation Insurance: (check one)
0 I am the homeowner 0 I rum the sole proprietor 0 I have Worker's Compensation Insurance
Insurance Company Name: Worker's Comp.Policyit
SITED INFORMATION
New V Size L ( x GY l x H c31 Corner Lot: Yes_ No V .
Per Town of Yarmouth Zoning Bp-Law 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 W / x II1
*The debris will be disposed of at t jJ0 ' i ) tS` J
Location of Facility
I declare ander penalties of perjury tha3 I entsstained are true and correct to the best of my knowledge and belief. I understand that any false auwerts)
will be just cause far deni. • o w rev! '.. prosecution under M.G.L Ch.265.Section 1. Q
Applicant's Sigmat v,P1 la.. Date: ID. j . ifl
Owners Signature(or attachme `7r i ,.• Date: (0. 1 - 11c;
Approved 8y: ��'a Date: /a---/°-/tJ
Bail ;Oa al(or d wee) EM jorisDRESS: a-»_ ,� ... .v. .---
Zoning District:
Historical District -I Yes i I No Flood Plain Zone: ; Yes G No
Water Resource Protection District: Within 100 ft.of Wetlands:saa
0 Yes C No 11 Yes C' No
• ***Note:Conservation review required if within 100 ft.of Wetlands
9/13
or/la/auto 11:u1An FAS 15034301115+ PINE HARBOR !
20001/0001
The Commonwealth of Massachusetts •
Department of Industrial Accidents .
'-:r Office of Investigations
—i ' ' 600 Washington Street
Boston,MA 02111w.
•
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L.
C wwmass.gov/dla
Workers'Compensation Insurance Affidavit: Buitdcrs/Contracto eetricians/Plumbefs
Annlicant Information Gat
r) Q���.Ii Please Print� I,eaa'biv
Name W viduap: & GI "fast 4. &anti o4ioo
Address: a,9 Quem Ann Rand A
city/Staterzip: ieb 62t9415 Phone#: B'4 o•aeco
Are you an employer?Check the appropriate box:
of proj (sc9dnd):
1.❑ I amla employer with 4 ❑ have hired the0
employees(dill and/or part-time). 6. New construction
2.❑ I ma a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These subcontractors have 8. 0 Demolition
working for me in any capacity, employees and have workers' 9.
[No workers'comp.insurance comp.Insurance.: ❑ gig addition
required.] 5. C] We area corporation and its 1 ❑Electriad repairs or additions
3.❑ lam a homeowner doing all work officers have exercised their
ow.No workers'comp, right of exemption per MOL 11i.❑Plumbing repairs or additionsm
. insurance required.]t e.152,$1(4),and we have no l*Q Roof Mein
employees.[No workers' 13.0 Other
comp.insurance required.]
'any'Mien the cheeks box 0 mod also fill out the reetiod below shewingtheir workers'memematlon polity IatWmaliie,
ltamwweas who aroma thin atndawk attics they at doing an work and then him outside convectors men submit a new ending k nett
tCeasaorota that check this bux mat attached an addilioani sheet showing the nate of the sub-uoneacems and nal whetheranotets@ entities here
nr loyees. lithe seb•a-aaaots have employee.they mat provide their wenn'comp.policy number. 4
f QM an employertltat bprovidfas workers'eonglonadlon h►smmteefortyy enplanes Below b Aepolcy endive the
Wfornmtiow. 1
Insurance Company Name: _hi'e r_njpktalI U .C r
Policy#or Self-int Lic.#:fl&(Qq,-'4m4:p1-DOISA Ent/linden&e_s`la'g B, 9.$1
lob Site Address; City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the po .amber and expiation dam)
Failure to scan coverage as required under Section 25A of MOL a.152 can lead to the gluon of criminal penalties of a
line up to 51,500.00 and/or one-year imprisonment,as well as civic penalties in the form of a;STOP WORK ORDER and a fine
of up to 5250.00 a day mai . . ...., Be advised that a copy of this statement maybe forwarded to the Office of
Investigations Of the D ., insurance coy verification.
trio herebycertifj.a da Me j 1. . r •.. , a dfPerfa,3,that the L{fonmatfow provided above b pee and cornet
jittruture: Dater
Phone#: SOB ' lw4=
Offilal use on!,. Do not write In the new,to ire completed by dry or town official
City or Town: Penuk/[leease#
Isatin Authority(circle one):
•
I.Board of Heakh 2.BuiWiag Department 3I City/Town Clerk 4.Electrical Inspect.r 5.Plumbing Inspector
tOther
Contact Persons Phone N:
,p. ' ' of 1� _ �� � � /;
/2Pi to/ • ' - �� ✓r IifaofieTa•
•
gin—
Office of Co sumer Affairs and Business Regulation
_J .` 0 Park Plaia - Suite 5170
•:.Ca' Boston, Massae. Ietts 02116 l
•Home Improvement riga' tor Registration..
p -' —_ ., : t Commonwealth of Massachusetts
e—'= Division of Professional Licensure
McGRATH POST& BEAM C . =" �= ��' Board of Building Regulations and Standards
JAMES MCGRATH = Construc to
259 QUEEN ANNE RD. r.-_-_•= �►,Sa�ef�6omc1&2 Family
HARWICH, MA 02645• a =._ _ �r' CS'A-073665 eziolin Qtplres 03/14/202
yti i # tip � ,r��~ —rte
JAMES R MCGRAT 4.1 ,
111111`��- 204CRANVIEW RD 'x•,44 r .y
BREWSTER MA.02631•-' �`• �t
r a. •nuj.••ul.•e.a.e - ' .L", iM 1r
mmissioner Cit `
•
•
.\ (fly W, 1 •0 /' meq!" / 440 -I ''',4
frrn j
a} Office of Consumer Affairs and Busine Regulation
10 Park Plaza- Suite 5170
Boston, Mahusetts 0216
Ho a improvemgr •Qantractor Registration
I. r; Registration: .132ypec 935 °n
McGRATH POST& BEA CO. = /i-j
259 Queen Anne Rd. r,r — 3 t';! Expiration: 10/30/201e
Harwich, MA 02645 I:\T - c i
• 7__.-" Update Address and return card. Mark reason for change.
SCA1 0 20N-0Yit
—
0 Address 0 Renewal 0 Employment 0 Lost Card
Iii a enmmonweir/.GC olcieaaj�•f
Office of Consumer Antra&Business Regulation
,.
r," r HOME IM'- n i ENT CONTRACTOR
• •e: Registration valid for Individual use only
Tsar
•• .•, beton the expiration date. if round return to:
�,. a'� "rttoistration Exotratlon Office of Consumer Affairs and Business Regulation
,till is f92035 to/3ourlola 10 • Plaza.Sul%5170
Bost•n,MA 02116 C
• McGRATH POST&REAM CO. /
DB/A Pine HattorWootf,.
Products `
•
Ifs
259 Queen Anne Rd.-
Harwich.MA 02645 Undersecretiy Not valid withoSt signature
•
•
• /""1 MCGRPOS-01 2HELLWIG
• A`OR�� CERTIFICATE OF LIABILITY INS I,IJRANCE °Ae
THIS CERTIFICATE IS ISSUED AS A MATTE.I 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 held ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain pellicles may require an endorsement A statement on
this certificate does not confer rights to the certificate holder In lieu of such endoreement(e).
�Paoouc9
South 1Dem�di,Gray 0266 Agency.Inc. ;1E����n 4w Pb)(877)816-2158.--
M S:... flraYe
__ _ a]APFGIa1N0CwERAq[ _ NAea
,INSURER A:Travelers Indemnity Company of America 25886
NNEMO .Prel!;Traveler!lndemn y Company . .. . ;2_'•1/0_.'//0
McGrath Post&Beam Com ,nsR n I e:few Hampshire Employers Insurance Carman ,13053
Obs Pine Harbor Wood Products
259 Queen Anne Rd :INSURER 0: . .. .. . . . _.._.... ._ .
Herwlch,MA 02645 •INSURER■:
NRREI r;
COVERAGES CERTIFICATE NUMBER: REVISION NUMBEEIt
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRA Cf'OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. TIE INSURANCE AFFORDED BY THE POLICIE� DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN.MAY HAVE BEEN REDUCED BY PAID CLAIMS.
EISRint TYPE OF RSIRANCE ANEDtiitiOL
I rD ICY MASE[ (LILP vD'rD D YY) UNITE
A X CONMEIICIAL GENERAL ISOMIY EACHocpIRgENCE 0.0
,•e, 1,0000
CLAIMS-MADE ' X OCCUR I-850-03588196.11,045 01/31/2018 0'/31/2019 =1 .. 100.000
MED mn(Pew aprem] ,I 5.000
•
PERSONAL&ADV EUURY $ 1,000,000
1)06
•GENU AGGRFSATs UNIT APPLIES PER: DETERS AGGREGATE _.$ 2' '
•X.POLICY L LOC FRO M"•COLOAPAG4:i Z000,OOo
oReR s
B AYTOMOaIE I •
.cnea.EEDGc CLEU ST . .1 1,000,000
_ ApWyyNAEIpT:17 - BA-44878885-18-SEL 01/31/2018 01/31/2019 {sEo�otynLAR ,)reema •$
•AUTOSOIYY - X AUTOS I BODILY INJURY(Pat ASSAD,1
.X: $s ONLY .X SITS IPsramma .1 .___
• I
• 1 ORELAUAS I OCCUR I • EACH 00l1RRENCE f
•
MUSLIMI CUM-MADE
OEO : :MEMOIR ' .AGGREGATE - ;I
•
_ $
C AND EMPLOY®' M LnY I . 1 X NTE _.FR _.I..
ANyppppplErowvMTNEareXEcurrvE VIN•" ECC-600-4000957-2018A 07/08/2016 •019 10 000
OFFICEwryM O EXCLUDED' N M/A .E.L EACH ACCIDENT .E 0'
(eN",aMn¢B !!"In rH"1 I I I ,EL DISEASE.EA 9a7AYEE S 06,606
yy�M, I
OFSCFUPTION OF OPERATIONS Sop • ,F, nL¢¢ee¢_pOL;CYLypT f 500,000
DESCRIPTION M OP9A710Mer LOGTIDne1VENIC.EE(*CORD I el.AA/Mal lath.-- -- M N renes Imore Y nag
CERTIFICATE HOLDER CANCELLATION
swum ANY OF TIE ABOVE DESCRIBED POLICIES BE CANCELLED BORE
Town ofYamIOuth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED SI
ACCORDANCE WITH THE POLICY PROVISIONS.
148 MaDe
n Stn,Route 28
South Yarmouth,MA 02884 AMNON=REPRESENTATIVE
ACORD 25(2016/03) 019n-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of*CORD
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: b.-AN-Ease))pe fitisztro �! ' APPROVED 1 °�' ; s,"> •
i� — ��ZtYu.tzANG�C}�... - RECE . SEP 26 2018 SEP 26 2018 j::
• YAttMOU I H
w d s'fTtttQ .TY' 6y ED
YARMOUTH OLD KING'S HIGHWAY
i:� ;A A r OLD KING'SHIGHW �� rim
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SEP 27 YJt
1 '" `Y .ISGJG(�: ARDi�lJj 7OWNCLERK
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• • RECEIVED APPROVED 'RECEIVE® .
C-3?Cf5T14E- R E •
SEP 2 7 2018 SEP 2 6 2018 SEP 2 6 2018
} ' YARMOUTH YARMOUTH
/ _ TOWN CLERK OLD KING'S HIGHWAY OLD KING'S HIGHWAY
ri iSt2o rr>aT r SOUTH YARMOUTH,MA
asalgi4_ K atIATEDLrn4e+0,4 II 2.101 glal:AelacnIlL CT At=51!11401
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','.d' I APPROVED BY: I DRAB
DATE: CI, 7j3 ), I - —REVI
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( c TOWN OF YARMOUT ��� �
,___ ,-,-4, 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451
ma' rTelephone (508)398-2231 Ext. 1292-Fax(508)398-0836
—•art , _ SEP 262018
Rt:'-'411 6 ffKING'S HIGHWAY HISTORIC DISTRICT COM ITTEHMoUTH
SEP 27 2UtU OLD KING'S HIGHWAY
APPLICATION FOR
TOWN G OUH1 CERTIFICATE OF EXEMPTION
SOUTH YARMT
Application is hereby made for the issuance of a Certificate of Exemption under Sections 6 and 7 of Chapter 470 of
Acts of 1973, as amended, for the proposed work as described below and on plans; drawings, or photographs
accompanying this application.
Type or print legibly: ^� r ..-Lw____ /
Address of proposedywork: I �(�i u IZr (J� Map/Lot# (0 fo/ S7 9
Owne s): C 1E Phone#:5ig _c_,01.2$R 2
Ail applications must be s •mitted by owner or accom•anted by letter from owner approving submittal of application.
Mailing address: , „ - I
^ s 4,4.ip .! A a ,Bearbuilt: /979'
Email: ` . a / I �i- Or . ast /,;, Preferred notification method: Phone 1 Email
Agent/Contractor: Phone#:
Mailing Address:
Email: .9 Preferred notification method: Phone Email
Description of Proposed Work(Additional pages may be attached if necessary):
i� i u- ' x$7 WocD '1 t c.4E• Prel1Zf U vn l j 0 i_t ?ea-62(e5)11
alc)
C�A -1
Oaet �C;'t[= ��5 AT �� .a F c A� �1�a.J�(
obi ViD 1Dg witacK
Signed(Owner or agenrare,
si-, Date: tic, _25. /
D Owner/contractor/agent is aware that a permit may be required from the Building Department(Check other departments,also.)
> This certificate is good for one year from approval date or upon date of expiration of Building Permit,whichever date shall be later.
For Committee use only: _ r
Date: 9-c2 tri r t Approved _Approved with changes =DeniMrl
Amount ccb
Reason for denial: APPROVED
Cash/CK#: /ay SEP 2 6 2018
Rcvd by. 4/ YARMOUTI I
OLD KING'S HIGHWAY
Date Signed: 9/z6%0 ir Signed: U-teE 1 G 0
APPLICATION
V52017