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Home My WebLink AboutBLD-19-3296 ;1 A• Office Use Only ' �SS. .01"Y,4444 Act7-/9T-ca 3Z.. I` w. . vit_y Amount SD—' ` NATTA 1, L ,fr dSSS "^•«•�•' 2 • f Permia expires 180 days from ?issue EXPRESS BUILDING PERMIT APPLICATIQJ IGE , TOWN OF YARMOUTH i C E I V E &.i t Yarmouth Building Department 1 1146 Route 28 NOV 2 9 2018 ; 1 South Yarmouth,MA 02664 J (508)/• 398-223139Ext. 1261 By t"' 1,1 CONSTRUCTION ADDRESS: GJg £/ i*.*a ill s �l ASSESSOR'S INFORMATION: EMap: Parcel: OWNER: h /fi' i / /to / manUC aZi as-4s x , ADDRESS Email Address: coNTRAcr� �Qi� -121.Uy£2 dn. �&s' 14&S b S -f -/1(.0 NAME -MAILING ADDRESS TEL-tf y�� a Email Address: 0 Commercial Est.Cost of Construction$ /�s%7'7/��i7'�//�y Home Improvement Contractor Lic.# /no 4y Construction Supervisor Lie.# � 4. yY�� Workman's Compensation Insurance: (check one) I am the homeowner I am the sole proprietor 1 have Worker's Compensation Insurance �A/ /� 93-#:,10 / Insurance Company Name6I , Worker's Comp.Policy#4541 13'JSd /t WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares __ Replacement windows:# Replacement doors: # Roofing: #of Squares /4 (pc Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. (K.2 Replacing like for like ,{//� *The debris will be disposed of at: a Vll,�z./l✓Y Ike-. 'l Yaj 4 Iodation 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 vocation of my lic and for.rosecution under M.O.L Ch.268,Section 1. p Applicant's Signalnre�a ,(� % .. Date: ��7 �er r er Owners Signature(or attachment) � � /• _„'-/�.02.1 X- 7:.� Date: I�� Approved By: / !/ Date: ��%2P Vf Buil.'. g 0/41 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_ t tie commonwealth of Massachusetts � 1= l Department ofIndustrial Accidents _' � 1= I Congress Street, Suite I00 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 /JPlease Print Legibly Name (Business/Organization/Individual)Caail /el"- Address: id d ith 8/0,y-na, ,d. City/State/Zip:,' Aid,AJ ,, Al, /, Phone #: 37-p''7lj -A._3'e Are you an employer? Check the appropriate box: - Type of project (required): ja employer with 9 employees(full and/or part-time).* 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers'comp. insurance required.) 8• ❑ Remodeling 3.0 I am a homeowner doing ell work myself[No workers'comp.insurance required.]t 9. El Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 12.r❑y Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.t 1312.0 3. IycOOf repairs 6.0 We area corporation and its officers have exercised their right of exemption per MGL c. 14.0❑�Other 152,$1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box*l 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 ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: allakadA Policy#or Self-ins. Lie.#4540,8 dt4 4—y0-0-Yt Expiration Date: S/tf 9 Job Site Address:13/ ,/,/J G 74 Attach a copy of the workers' compensation policy declaration page(showing the policy number aya expiration date). !� Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to S1,500.00 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 certif, under the pain and penalties of perjury that the information provided above is true and correct. Si•naturera't, / of i. 1 LDate: Phone#: 61—ot •' 6 i 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 gmployee 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. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia • 11/29/2018 09:22 Sullivan Insurance (FAX)976 851 4648 P.001/001 A�R CERTIFICATE OF •LIABILITY INSURANCE DATE sole 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 pollcy(les) must M endorsed. If SUBROGATION IS WAIVED, subject to the tense and conditions of the policy,certain policies Rey require en endorsement A statement on this cerJDcste does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER Peones (979)001-9000 Fat (57°)8°1-4841 CONTACT Sullivan Insurance Agency SULLIVAN INSURANCE AGENCY PHONE �Ax (978)861.4348 EBS MAIN STREET ,SNA EA. (978)851.9600 vYc Ner TEW KSBURY MA 01876 CAM INSURERS)APPORDINC COVEMOE —, NAICI INSURERS : ACE Group THOMAS A HILCHEY INSURERS : XS Brokers Insurance Agency,Inc PEA THOMAS A HlLCHEY CONSTRUCTION — ReuRERe : 82 OLD CHATHAM ROAD INSURPAD HARWICH MA 02845 INSURERS L INSURERP COVERAGES CERTIFICATE NUMBER: 30596 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 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 ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, MDR ADPL SUER POLICY IFP POLICYWI urns LTR OR TYPE OF INSURANCE Jr, we POLICY NUMBER ,u;_nYWI __r_npnnnYl— B DINOAL uaaIuw . 3AA302088 09126118 09126)19 EACH OCCURRENCE ^1 1,000,000 Tames Er commutCUL GENERAL LIABILITY mono TD res us ul S 60.000 N, 14TE0 -- jCAIMLMADE Q OCCUR MED.EXP(Any one Patton) I 1,000 PERSONAL&ADEINJURY $ 1,000.000 GENERAL AGGREGATE 1 2,000,000 oast AGGREGATE'LIMIT APPLIES PERI PRODUCTS-COMP/OP AGO a 2,000,000 — 7 POLICYr-i 74 n UAC _ $ Alm/MOSESMILT' Wee.d,j,COmiiINCIE NaIE UMR S +ANY AUTO BODILY INAIRY(Per person) S '--ALL OWNED —SCHEDULED BODILY INJURY(Per eceidenl) S I �'NONAUT.OWNFD PAOPEATY DAMAGE II HIRED AUTOS ,_AUTOS O.rrwm.N $ —WMRBLA Use OCCUR EACH OCCURRENCE I DC155 LIN ` CLAIMS-MADE AGGREGATE S DEO I 'RETENTION I S :pm COMPSNSATIN 6662UB-2E09540.0.15 03,16/18 0315!19 I ORYLTM� En $ A ANT EM PRISTI9• UAauJYY ANT MOPRflOWPAarNeeaXEcunw VIM E.L.EACH ACCIDENT S 100,000 OPPICEMR1 EMEND? ❑Y NIA EL DISEASE-EA EMPLOYEE S 100,000 Ia1�endwery In/BE IEitlddsipevnd'I TIONS edea E.L,DIBEASE-POLICY LIMB - 5 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Mach ACORD 101,Ado111enal Remarks Schedule,If men apses Is required) Thomas Ritchey Is excluded from the Workers Compensation policy • CERTIFICATE HOLDER CANCELLATION • Town of Dennis SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 686 Route 134 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN South Dennis, MA 02E60 ACCORDANCE WITH THE POLICY PROVISIONS. - AUTHORZED RE)'AEUENTATrvt Attention: IJP ♦ J my R.Jose • -ACORD 25(2010105) ®1988 110 A ORD CORPORATION. MI rights reserved. The ACORD name and logo are registered marks of ACOR' • Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only - 9 TYPE,Individual before the expiration date. If found return to: JteaistratIott gxoiratio4 Office of Consumer Affairs and Business Regulation [110649-n111/02/2020 - 1000 Washington Street•Suite 710 ��cc � Boston,MA 02118 THOMAS A.HICICHEY` tri C 4* , THOMAS A.HILCHEY -9 J ' t /.1 82 OLD CHATHAM ROAD,/ Not valid without sig 11,1re , HARWICH,MA 02645 Undersecretary f • Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constroatessf Upervisor CCS-034718 . Etc ares:09119/2019 THOMAS AHILCHEYY1 • : 82 OLD CHATRAM ROAD HARWICH MA 09j§4Sr.`.tt.,2tb• � Commissioner `�