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HomeMy WebLinkAboutBLD-19-003673 sit•Y.q� �r 4 ` Office Use Only : :. 4 (Permit# C 5t O --"Ova —yH t Amount u t MlT I, ccEZ s r„l li "°"��,�••+c� Permit expires 180 days from issue date • Bib-1q-MK EXPRESS BUILDING PERMIT APPLICATI N E C C I V E U TOWN OF YARMOUTH Yarmouth Building DepartmentGEC 18 2018 1146 Route 28 L, South Yarmouth,MA 02664 [ u r • g ,� �T (508) 398-2231 Ext. 1261 k l6 fde CONSTRUCTION ADDRESS: 4 4.,24S 1 .....i7TlJ�/./ �i.�. �� � ASSESSOR'S INFORMATION: Map: P�arrcel: OWNER* T- J4� /,d 1 ,' Y9/-7f aalai/PR4, Email Address: coNTRAcroee+ paled ,,b,aaleN ME ADDRESS �Jn Email Address: Commercial J L,�'� Est.Cost of Construction$ (X 7��,Q�/�/� Q Home Improvement Contractor Lie.# //QU#5 Construction Supervisor Lie.# C.—6/S9Ver e Workman's Compensation Insurance: (check one) I am the homeowner Iam a syeprro�prietor '_rave Worker's Compensation Insuraance,A' Insurance Company Name:homeowners c�iL�Y Worker's Comp.Policy#(9m/U.�—271/ WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares ' Replacement windows:# Replacement doors: # Roofing: #of Squares (/c)Remove existing*(max.2 layers) Insulation • Old Kings Highway/Historic Dist. ((J )Replacing like for like The debris will be disposed of at �� (.��/,��� afr • 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 . ation of my license/. fo pros.utioa under MG.L Ch.268,Section 1. Applicant's Signature:e.O�.Z1 J 4 A ✓ Date: — / /i Owners Signatn (or atta eat) • ate: i i Approved By:- Oin Date: / Building.. .if.1 :re ;.ice) Zoning District Historical District Yes No Flood Plain Zone: Yes No Water Resource Protection District Within 100 ft.of Wetlands: Yes NO Yes No �dCee� -.•-' —�•.•••w•.rr wain vJ a rA wo'ucs uoetts s � �1 Department ofindustrialAccidents int= 1 Congress Street, Suite 100 eit-'~rf- � 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 2! �y}�� 1���cl� 1Zadiji �✓�'1 ���%4 Please Print Legibly Name (Business/Organzation/Individual): ;1 ( lf�/�r94/ Address: pi,died,,aa�tiA/ City/State/Zip: I ,/, ,,4144G, */ phone#: Are you an employer? Check the appropriate box: �/ ,,A Type of project(required): 1. I am a employer with— �J employees(full and/or part-time).* 2.0 wt am a sole proprietor or or partnership and have no employees working for me in 7. 0 New construction any capacity. [No workers'comp. insurance required.] 8• 0 Remodeling 3.0I am a homeowner doing all work myself [No workers'comp.insurance required); 9. El Demolition 40I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contactors either have workers'compensation insurance or are sole proprietors with no employees. 11.0 Electrical repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 12.❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.; 13oof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§I(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. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :ontracmrs that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have nployees. If the sub-contractors have employees,they must provide their workers'comp,policy number. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site !formation. isurance Company Name: eitelikirik44e, olicy#or Self-ins.Lic. #�C.Aj 7,19,491-30--0 'eV- Expiration Date: 3//1 eidaza lb Site Address: / e a� r City/State2ip:el .ttach a copy of the workers' coir enation policy declaration page(showing the policy number a expiration date). allure to secure coverage as required under MOL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 id/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 iy against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance average verification. do hereby cerci y under the pain and penalties of perjury that the information provided above is true and correct i•natur- /,///Lii/ .e___�,/%r Date: j zone#:67,1- e ,� 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): I6.. Boarrd of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector Contact Person: Phone It: • • iniormatlon and instructions y , k. 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 ortrustee 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, §250(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,MOL 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 contacting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply sub-contractors)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 burn 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. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.rnass.gov/dia V • • reeneneneefeadeligaakZeZideak Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE;Individual before the expiration date. If found return to: Realstratiof pxniratiob Office of Consumer Affairs and Business Regulation F110649 —' 11/02/2020 1000 Washington Street-Suite 710 THOMAS A.HI ! : Boston,MA 02118 �HEY !- - �i., THOMAS A.HILCHEY r '� �`(`^ccp-R a<u .1. , i d 82 OLD CHATHAM ROAD ` u - Not valid without sig tri re HARWICH,MA 02645` Undersecretary • • o Commonwealth Professional s Massachusettss Licensur Division of Professional Licensure i Board of Building Regulations and Standards COnstruttiOn4S UPgrvisor CS-034718 rV r Wires:09/19/2019 ti THOMAS A H)LCHEYS . a 82 OLD CHATHAM ROADY =� „x i HARWICH MA 07t§46 .� �.� 4;i% Commissioner 11/2'3/2018 09:22 Sullivan Insurance (FAX)978 851 4846 Pool/001 o' CERTIFICATE OF •LIABILITY INSURANCE DATE OAe 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 en ADDITIONAL INSURED, the softiies) must be endorsed. H SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require en endorsement.A statement on this certiscets does not canter rights to the tattling'holder In Iteu of such endorsemsngs). _ IMODUCe1 Pnone: (079)651.9600 FEE Is78)661.4641 =TACT Sullivan Insurance Agency SULLIVAN INSURANCE AGENCY PRIORI, wCNa 6,n: (978)8514800 Lit NoI. (978)851.4948 885 MAIN SWEET ,nun TEWKSBURY MA 01878 AOOSLU: INSUREN(S)AFFORDING COVERAGE - NAICII INIURERA : ACE Group 'TOWS THOMAS A HILCHEY INSURER II : XS Brokers Insurance Agency,Inc DEA THOMAS A HILCHEY CONSTRUCTION WSURERC I 82 OLD CHATHAM ROADINSURER R — HARWICH MA 02845 NaMERe I _ IMAM COVERAGES CERTIFICATE NUMBER: 30598 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED MOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDMON 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 ALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID_CLAIMS. men Mot ELISA POMO OE POLICY EV LIMITS TYPE OF INSURANCE JSyympn aR WED POLICY NUMBER . Wyl aimEEMYTB g DEONAL unsung 3M302088 09/26118- 09/28/19 EACH OCCURRENCE a 1,000,000 X COMMERCIAL GENERAL LUBWTY 'Daman to nwitto PR EO EECenml _S 50,000 CLAIMSMADE OCCUR MED.EXP(My one Person) 1 1,000 PERSONALS AOM INJURY $ 1,000,000 GENERAL AGGREGATE s 2,000,000 • GPMAGGREGAATE MIT APPLIES PER PRODUCTS-COMP/OP AGO $ 2,000.000 PpolicyI 7 I E n LoC _ f AUmMOSRe LIMIUT• coo/MCPb ooMEN ya T E �ANY AUTO DOPEY INJURY(Par moo) S —ALLOWNED r—SCHEDULEDPODILY INJURY(Per accident) S HIRED FNOrN:RTY DAMAGE HIRED AUTOS AUN•OWNED UN aroewll $ AUTOS S VMe*4LA LIMP OCCUR EACH OCCURRENCE $ •—Y1U15 URA ' CLAIM8d1ADE - AGGREGATE $ OED IRaTENYION iS WORAERe coMre6$MION 65g1UB4EOS540-0-18 03/15/18 03/15/19 I TORYIIMTura ER $ A :rine uMWn TIN • E.L EACH ACCIDENT a 100,000 ANT MopMINIR ERMIMED1 LUT1Ua OP?ICENMEM$SR UCLUOIDt El NIA ILL DISEASE•EA EMPLOYEE S 100,000 IiMrrre ACIIIPabeunlN EL,DISEASB.rOLICY LIMIT 1 500,000 oESCBIPTIONOr OPFMTIONS Sq., - DESCRIPTION or OPERATIONS I LOCATIONS I VEHICLES(Attach*CORP TOL AbNlanal RAMarM ScIMule,a Mtn yen Is required) Thomas Molloy Is excluded from the Workers Compensation policy CERTIFICATE HOLDER CANCELLATION Town of Dennis SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 685 Route 134 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN South Dennis,MA 02660 ACCORDANCE WITH THE POLICY PROVISIONS. — AUMORlEO REPAESENTATMir • Attention: • • 0 IP 'ilia 0 ' y R.Jose ACORD 25(2010105) ©1288 '10 • ORD CORPORATION. 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