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BLD-19-002447
y'b< r: LESS S 1 I IAN t 0 SO F I ri.''.LI. Office Use Only • OF' 4RA t-:_A F 1IN1 1 'Fd ()i: o r _Ir IPermit/ O n:, if tlr L''rLINE FG =. Sc._ 0 SR IFAf ^ ix. FT:ET rrom ,IIS!- ,; AND lAmount y • 1 ` MT ] } et..wnW]�E s:Pcmvt expires Igo days from issue date l P 4 EXPRESS SHED PERMIT APPLICA r etii C E I V E D TOWN OF YARMOUTH Yarmouth Building Department 24 2��8 1146 Route 28 OCT South Yarmouth, MA 02664 (508)398-2231 Ext. 1261 still feu I- •A• igiT `/ ay:N.-J CONSTRUCTION ADDRESS: 38 Le.wNs B41 3DvIE'cvtX t NYS{ yAYrniu1ll ASSESSOR'S INFORMATION: I Map: Parcel: OWNER: -)gitcc W TY"Act,t•f� 38 Lrws }?tl 1%LID Wyatr.y,6*%_ 978-81Y-7dr1 NAME PRESENT ADDRESS t EL. # CONTRACTOR:\Aidt SLtd( Plitt C to rs I•rt.v'k el Akrheet ma frog) 5171 -On NAME MAILING ADDRESS r t TEL.H `Rcsi� f� .0 u' dential 0 Commercial Est.Cost of Construction$ Y/ ODO. Home Improvement Contractor Lie.4_ - Construction Supervisor Lie.# Cg'd 5(aq(PS Workman's Compensation Insurance: (check one). . 0 I am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance -y c Insurance Company Name: 'r(i'1 UQ..4. 9 Worker's Comp.Policy/ LOC—LI `6 PCS3 id' SHED INFORMATION X r 1 New Size L Pr ,x W SO x H Corner Lot: Yes No X. Per Town of Yarmouth Zoning By-Law Sec 203.5 E: Side and rear setbacks for accessory buildings less than 150 square feet and single story, shall he 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 N "The debris will be disposed of at Location of Facility I declare wider 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 answers) will be just cause for denial or revocation of my license and • prosecution under M.G.L.Ch.263.Section I. Applicant's Signature: W (111 ' Date: /O//1c,9//an Owners Signature(or nttachmet,F)—yd _ n,2. IA s- Date: /O// ie Approved By: s i Date: !_4222_ " 67 in fici or designee) a' AIL ADDRESS: Zoning District: Historical District: -1 Yes Fl No Flood Plain Zone: 11 Ycs G No Water Resource Protection District: Within 100 ft.of Wetlands:•" LI Yes C No Y1 Yes 0 No • ***Note:Conservation review required if within 100 ft.of Wetlands • 9/13 A`� ® CERTIFICATE OF LIABILITY INSURANCE DA 1'B/ 1°e"' 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(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the temp 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 NAME LI Melissa Fisher Robert E South('Jr Ins Agcy PNC"Ne.EXG: 5085643560 FAx 1352 Route 28A E-MAIL IA/c,No: 508-564.5531 PO Box 400 ADDRESS: rbouchleaBouchlelnsurance.com Cataumet,MA 02534 INSURER(S)AFFORDING COVERAGE NAIC 0 INSURER A: Scottsdale Ins(Boston Ins Specialists) INSURED INSURER B: Plymouth Rock Assurance HH Structures LLC dba Hoophous INSURER C: MWCARP(Travelers) The Shed Place Attn: Ralph B INSURER D: PO Box 2430 Mashpee,MA 02649 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 POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. MSR AI*LSUUN POLICY EFF POLICY EXP LTR TYPE OF INSURANCE /NSD VMD POLICY NUMBER (MWOO/YYYY) (MM/DDO'YYY) LIMITS X COMMERCIAL GENERAL LABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MACE El OCCUR PREMISES(Es occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 A _ Y CPS3083148 08/07/18 08/07/19 PERSONAL 6ADV INJURY $ 1,000,000_ GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE _ $ 2,000,000 1POLICY EITEr" 0 LOC PRODUCTS-COMRVPAGO $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) _ ANY AUTO BODILY INJURY(Per parson) $ 100,000 — OWNED B AUTOS ONLY X SAUTHOEDULED PRC00001001722 08/07/18 08/07/19 BODILY INJURY(Pr auident) $ 300,000 HIRED NON-OWNED PROPERTY DAMAGE _ AUTOS ONLY _ AUTOS ONLY (Pr accident) $ 100,000_ $ UMBRELLA UAB OCCUR _EACH OCCURRENCE $ — EXCESS UAB I CLAIMS-MADE AGGREGATE _ $ — DED 1 RETENTION$ S WORKERS COMPENSATOR X PTATUTE I ER AND EMPLOYERS'LIABILITY Y/N C OFFICER/ME BER EXCLUDEDTECUTNE[] NIA WC-4788P02-3-18 08/26/18 08/26119 EL EACH ACCIDENT $ 100,000 (Mandatory In NH) EL DISEASE-EA EMPLOYEES 100,000 I/yes.deaalbe Under DESCRIPTION OF OPERATORS below E.L.DISEASE-POLICY LIMIT $ 600,000 DESCRIPTOR OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 1D1,Additional Remarks Schedule,may be attached V more space Is required) email:davebradburvCicomcastnet CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN David Bradbury ACCORDANCE WITH THE POLICY PROVISIONS. 38 Lewis Bay Blvd. West Yarmouth,MA 02673 AUTHORIZED REPRESENTATIVE Robert E.Bouchle Jr. 1 ®1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD • • ih . PLOT PLAN •n • FOR LOT N Indicate location of garage or accessory building Additions with dashed lines Sewerage disposal (cesspool) • Well 0 I I — — — I (lot ft. rear) I Abuttor's 440 0 — — — Name I Abutter' Lot N I Name --.)C951,.-t a i 1 I Lot N X this is a 'y • I REAR YARD �oxner l If this trite in name corner If street. to I write I name of 0. other street. .13 o 4 I • SIDE YARD HOUSE SIDE YARD Di 0 ! • : • • I • • • : SET •SACK • • ++ ft. : I u 1 C. (lot ft. frontage) / \ / (NAME OF STREET) / \ Information Supplied by • IARK NORTH POINT • • • Information and Instructions• ,. t enicksette General taws chaps 152 makes all a4loyha to yard &waken'compesadoa be their employer, Pursuant*tie ie is1utr,a.apk r is defined ei "...svay pawn it the aadks of another under any cant of bice, eapaaa at implied,and or mime." Aa calks,is defied sea individual.paimsahtq aupdatbt,amperatka or other legal entity,or say two a mots of Airs**engaged is a jolt atnpdee,and tachdhig the bpi nptawaadwa o[a dsoaaaJ a mloy%a the omelet wades oho I-Lk al,paAoaahyl asnekdaa at other kph aatltx,eatploylog amplsyee. Hawes the owls ore ending home baying not mon this tint aprfmaoat and win raider third;a the aoeopaat sf the divan how of sad wive ampioye peaces to de mrllaaoca,conned=or rep*work on sods dwelling bout at our the pomade a bdiding apptaenet thaw*shad not because of sock employment be dawned to be as sn$.,.0 MOIL chapter 152.121C(6)tee slues that"every state et Mal Uesashgnpsy aW wWkeid Ike bane tar nanrddtdame erpermit hoperate abuds Gertea.MndShip hatheaowwatlkDer a y amanita!who Nat at prated seaptaMM Sane of anplaaee with be Seas aanrsp required." AdditI aally.MOI.Ampler 152.WAy)sea'Tbelths the commonwealth oar any diet political nbdividas shell cast Is say canna lir the pet/stow otpubis wadi nod-eatable evidence ofaa ch aece with the instance esquires*of tib chap*/bade been ptaeeudGee the eaattsat6ryateherih." Appliques • Please di ed the wakes'eampemaoe amdevd completely,bycheckng the borne this apply te your aiaatioe u4 tf a nembegs)does widt their L.. Limited Liddy Coopenies(L[C7 LiLi ited Lia 4y (LLP) .aLwith om)of aapisy. hs vita titr rnsmboa tepidness.eta mt aped te any warkaa'caeyertlaa Iceman*, tae LLC at LLP doe have employee~a policy M required. Be added that this amdai any be nodded d t the Depatmeat of t 1.l Accidents lata eandistu lee of Insaace coverage. Aka lie ata to sip sad date the amdavlt. The amdavit tisk! be Sod te the sky et ten thus the eppllatM earths ponds lees is being.aquee- L ase ahs neatened of • buhattliAeeldede. Shedd youhave say goaleemanly thelawaifyeaaereglad lobtain awakaa' sampeee --pods%S please call the Departs*s abet ember Iced below 5 1Eimmed camped*should ass their s.iiiaaase Ices maim as eke wawa Ban coy s Taws Oaddale • Please be sus thin the dddnh is ample sad pointed legibly. The Depatmna has provided:apace at the bobs of the amdnd Aur you to AN out in the sad the Ohms arbiresdpdoes het contact yrs apnbng the'pliant Pias be an is ml he the paminkew wan wbeb will be and se a redeems soba: Ie oddities.as applicant this need admit maid*peaiYtlemsappiked*.lany shwa yew,need adysubmit one affidavitSkating awes p (Ify)and aim lob Slw&Meese the appli Ger dawid Wan"an londoe to tee)."AspyoftheamdmdthshassUy been at by agatonenaybepaddedte�e w applicant past tettavildamdeddleAle LrUwe poodle akat Anew edited teatbefilled owl each peat.Whets a home int actaaat abate*.a base arpomdactakled to any budsw acoma_14 venom (Ga s dog bean a pond at be.leaves es).said puma is NOT required l commit,this amdavit The oma of laveatIplIcs wood like Ms thank you it edema Aa your coop/radon and should you have say gastio % please deoat hesitate lgive use call. The QeprmsaCe address.hkphaee sad de amiss The Commoawsaith of Massachusetts Department of Industrial Aca Ment l Oars of fnndpfl.0 600 Washington Street Roston.MA 02111 Tel.1 617-727-4900 and 406 or 1-877-MA99AFE Revised i 1.aId Fax 1617.727-7749 www.mastgovidia • • • The Commonwealth of Massachusetts 2a�f11 = _ / DepartmentofIndustrial Accidents r og 534 . kz38 • e ri 1 Congress Street, Suite 100 `� _ , Boston, MA 02119-2017 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): �Qv%ex "-era /1 0Vrt ✓ Address: 3 93 1-tv.., s 4?)ai PoeCit City/State/Zip: In/eSf \lq,Imav` t Phone #: ell S -aey-'1 as 1 Are you ap employer?Check the appropriate box: Type of project(required): 1. am a employer with employees(full and/or part-time).* 7. 0 New construction • 2.0 1 ant 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[No workers'comp.insurance required.] 9. ❑Demolition 10 0 Building addition 4.❑1 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. 12.0 Plumbing repairs or additions 5.0 I am a general contactor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof 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 e. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] 'Arty 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. tContractors 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: T ra up.J€r f' Policy#or Self-ins.Lic.#: ke qi as -ba i j Expiration Date: 426 j i 9 Job Site Address: 3 3— L Jt 'S City/State/Zip: to . QOu Attach a copy of the workers' compensation poll declaration page(showing the policy number& .t'M 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 certify under the ins an penalties of perjury that the information provided above is true and correct ,Siena as L y Date: tor2`i 1\g Phone#: q76 Se' '1 ZS\ 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: oir ea<Consu�wa Aawrseyae : a.q a-maGov-nmmv Intern.' _ - O k ..o<.ew�m.mmenKee.a o.'us.. wn-iC5 a -4 C surcn._ P• n h(v�' Ta O1l..i Cnmmmn An...—.RSIr l Mass.gov '" s x .. : -* , 1'3 �-rt;,' sSrD is _ Y , ° Offs a of eons , e�r, `. -„k 7 Si�..p�� , a r x i*+:•g ” . .s „ ,�.. ..„a+ a gmG�<Y x - 1f _r< r yz 4 f .ffa_i res a' d :i� { .r ° $fay- ¢{�, a i t `? x' t s '` ; ! Y'A�+ �..F. }�}"'� � � Dat i�� '� �on...„ t„... , .ci..,,-,:tifE72..-2,,. •• a B sinesM, t z r _ ,. G.. , , r 5- sLY s a•= 4. es' �n - Re afro = t. 2 [[ Ho I 1.4 HIC Registration Complaints 1 R I Regatration# 109728 I Registrant Steven Shapiro DBA Shapiro Balding&Remodeling Name STEVEN SHAPIRO Address 4 Deer Ridge Rd. t. City,State Lp MASHPEE,MA 02649 Expiration Date 09.212020 6 ' Complaints Details k ' No complaints found for this registrant You ten also view arbitration and Guaranty Fund history Back To Search t i Site Policies Contact Us i A 2018 Commonwealth of MassachusettMassachusetts.Mass.GostB rs a registered service mark of the Coommonweatih _Massachusetts ®Q Type veto search a} fel e 0 0 ' C8 it ^ a7 W }ssPM 4 MA IDIS 4 ` Massachusetts Department of Public Safety Board of Building Regulations and Standards " .- License: CS-056965 - '_ ` ` = Construction Supervis©r, r STEVEN M SHAPRO 1 I DEER RIDGE RD x Lt :T � -e , z - MASHPEE MA 02649 ��.. La aq ` ( 8"