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HomeMy WebLinkAboutBld-20-000167 , !, h 3 i .�. r e-' (�i(J^ v� i •t# 00 0/6 S7 H b t_ Amount Permit expires 180 days from issue date EXPRESS SHED PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department I` 1146 Route 28 South Yarmouth,MA 02664 p (508)398-2231 Ext. 12661 �^ /CONSTRUCTION ADDRESS: `N( \6l r"i � • h 141/ c�W\O(, (M ik 0 9-()6 4 ASSESSOR'S INFORMATION: > IMap: I Parcel: OWNER: \-k-O.ce ` -R\\A O.' 4(2\Q SO NAME i PRESENT ADDRESS TEL # CONTRACTOR. rn u4s o� n Kd q 3C) ` 60 NAME MAILING ADDRESS TEL# idential G Commercial Est.Cost of Construction S qUertgto, IW./ Home Improvement Contractor Lie.# Construction Supervisor Lie.# C Jt A` 4,38,ps Workman's Compensation Insurance: (check one) G I am the homeowner G I am the sole proprietor 1( I have Worker's Compensation Insurance Insurance Company Name: �ii-k ET1913tiewS :En( Worker's Comp.Policy#? CC-tpa) 4ocaq7- SHED INFORMATION New 9c Size LID x W x H 9 1 O r Corner Lot: Yes No Per Town of Yarmouth Zombis, 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* Xt. Size L t7 x W ') x H `p *The debris will be disposed of at c)3 1 0.3u1\ . 4ir1 t - T Location of Facility I declare under penalties of per • i 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 i vocation ,f my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: / '• Date: 1 ( 1 I t 9 Owners Signature(or a /haunt) Date: ^� Approved By: Date: / - l / Building Official(or designee) EMAIL ADDRESS: Zoning District: 1 Historical District: 0 Yes El No Flood Plain Zone: 0 Yes Li No Water Resource Protection District: Within 100 ft.of Wetlands:*** 0 Yes 0 No D Yes 0 No ***Note:Conservation review required if within 100 ft.of Wetlands 9/13 07/09/2019 12:40PM FAX 15084301115+ PINE HARBOR fs310001/0001 1 The Commonwealth ofMassachusetts `, _"A f',`. `� Department of Industrial Accidents , =_�+= 1 Congress Streit,Sam 100 -,.4- Boston,164.E 02114-2017 Y -:�: www.mas�gow Workers'Canpeasadoa Insurance Affidavit:Baikkra/Coatrscto„efEkttri ,as/plae„ TO BE FILED WITH THE PERMITTING AUTHORITY. &Aug!stoma dolt se Print Legibly r Name(Business/Or imtionandividual): = t ky Address: City/StateIZip:_Nh rw i tJ .m A ()(141 Phone#: , +0 2 Are as ample r's'?Cheek the appropriate bon: I. t am a employer with employees(full and/or pad tinny" . [am a sole proprietor or partnership and have no • Type of project(required): 7. • New construction mnployeea working For aee4p -,,. ■ Remodeling any capacity.(No workers'comp.insurance required,) S..'r 3.0I am a homeowner doing all work myself(No workers'comp•instoauree ]r it r ,,. CO I am a homeowner and will be hiring caauaetora to conduct all work on • ensure than all contractors either have workers'compensation insurance at am '� I wi11 Electrical . r additions proprietors with no employees. Plumbing repairs or additions sr'tam a salmi contractor and I have hired the listed on the attached sheet, ■ These,ulwomractora have employees and have workers'comp.insurance.: I 3.0 Roof repairs 6.0We am a corporation and is officers have exercised their right of meemption per MGR.c. Other 152.11(4),and no have no employees.(No weans'comp.insurance required.] 'Any applicant that cheeks boa M l must also till out the section below showing their workers'tampo mean policy infornmtion. Honeownets who submit this affidavit indicating they are doing all work and then hire outside contragt=R net submit a new affidavit lodieating such. taw:tractors that check this book must cached an additional sheet showing the name of the and state whether or not dose entities have imp .. If the have ",.:r • mot. their writers'-, policy number. t wit an employer th k pr 's'workers'coaipensaron insurance ferirgn employee. Below is the potty and job site Insurance Company Name: ilI1R g Icjiz ' _Inc"an tr efvrflpir Policy#or Self--ins.Lie.5:�-y i ff 1- Qii 3 A Expiration Date: \Ti li' 8, 004.0 Job Site Address: _ Cityy/StstetZip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MM.,c. 152.§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,es well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day or i nca the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. .......e I do hereby cent& , Z.. p , 0;,, - o �j t e Won:radon providedabove fs acre and cocorrectSiQnaUn : _ j_ ?tonal,: r — ille: use o* De not writs in this Irma,to be completed 4y dip or town Wad City or Towel: Permlt/Licease# Inning Authority(check one): L Board of Health 2.Bnilding Department 3.Citytfowe Clerk 4.Electrical Inspector 5.Plumbing Inspector 4.Other Contact Person: Phone#: •, " PLOT PLAN 0 Pe-- 11 FOR LOT Indicate Addit3o with dh es °1' acuy-b Se dispose/ (cesspool) m ---- I IClot................ft. I Abutboc's .p. 1 ` Lot 6 Abhst tor Mese Name f this is a REAR YARDi j — Lot =nor lot, • +rite in name , ft. tip If this �EstreetI er writes I name of '�' other ,o suet, 4 SIDE YARD . SIDE YARD HOUSE • . • • t . • i � SET BACK • • .........ft. • ' t I 40. uot..................ft. frontage) ♦ // (NAME OF STREET) ÷.—.r / ♦ Information Supplied by ARK NORTH POINT -.�n' �1 Office of Consumer Affairs and Busi s .�Z�G�P. . 2 Regulation 10 Park Plaza - Suite 5170 -''3 Boston, Massa,,, setts 02116 Home Improvement 1 .9 tor Registration, • Commonwealth of Massachusetts Division of Professional Licensure 1�Ic?RATH POST & BEAM CO. j1- . 1) Board or Building S a Standards JAMES McGRATH -__ .1 construction &2 Family 259 QUEEN ANNE RD. -�-- 't CSFA-073865 HARWICH. MA 02645 Q =' _ * i' prres:0�14/�02p � JAMES R M• ',1 x!< O CRAW 0 sv i �Q • aru%i)4_1.•n»•R ��1 3 � •___ Commissionerl/'i'- _, _., • _ . • • ty,4- w .6)4A.,,,,..-„,,,,,,,,,‘4. Office of Consumer Affairs and Business Regulation 1000 Washing n Street-Suite 710 Boston, M; husetts 02118 iii Home Improve j -_ e tractor Registration K =�k=: Type: peon MCGRATH POST&BEAM CO. u -_S: Registration. 132935 D/B/A PINE HARBOR WOOD PRODUCTS ., �- i 10J30J2020 • 259 QUEEN ANNE RD. HARWICH,MA 02t345 ='iik _ -i=te.f.____=------ ity i N. CA 1a 2oraasm Updaa Address and Return Card. "A Wonteiscvaraarire/ramistares&aiift onoo or Consumer Mars&Swims,Regulation HOME NWPR• , ENT CONTRACTOR Registration valid for Individual use only -'' before the expiration dabs. N found return to: 10I302020 Office of Consumer Affairs and Business Regulation MCGRATH P � -� • 1000 in Street-Srdb 710 DOA PINE r- Boston,MA 02118 JAMES R.MC 7;= - �j� --""f^ 259 QUEEN ANNE •• -r.` HARWICH,MA 02645 - Undersecretary Not valid without signature AC . MCGRPOS-01 THORNE `.,..--- CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 7/8/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOL CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THEDER THIS POLICIES BELOW. THIS CERTIFICATE OF INeURANCE 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 polkyges)must have ADDITIONAL INSURED provisions or be endorsed. if SUBROGATION IS WAIVED, subject to the terms 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 galeCT We &Gray insurance Rrit South Den FAX nis,is,MA 0 Agency, . Ettk(�)553-1801 I(A e.,No1:(877)816-2156 USH68:mail@rogersgray.com INSURER(S)AFFORDMG COVERAGE NAIL* MSURER A:Travelers Indemnity Company 25658 IMMURED McGrath Post INSURER B:New Hampshire Employers insurance Colman 13083 ;limn CorSt t <4 dba Pine Harbbr1111ood P ' INSURER c '5.19� p s`< INSURER D: IIMIWiCht*CO2646 a NSURERE: INSURER F: COVERAGES C��UMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 117E P�� U BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTVYfTHSTANDINC ENT ( ,CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR �' AIN, THE 1 SURA�AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCHLICIES.LIMITS,SHOWNMAY HAVE BEEN REDUCED BY PAID CLAIMS. iNSR LTR TYPE OF INSURANCE .'s R ,t p POUCV NUMBER I NYP/WI fW 1 LINTSA X COMMERCIAL. W IB .UAMjrY 4 c { EACH OCCURRENCE 1; 1,000,000 1.660-20 6-1 49ND.1 hr 1/31,2019 1/31,2020 7o( ) 1$ 100,000 CLAIMS-MADE X j OCCUR MED EXP(Any are Person) $ 5,0 0 PERSONAL&ADV INJURY $ 1,000,000 GBIL AGGREGATE L/ I (aENevAL AGGREGATE ; 2,000,000 X POLlCY�; r I Ok PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: AUTOMOBILE L (JTY , e LIMIT $ h O ANY f' }_� BA-4487B686-11 11T019 '� BODY INJURY(Par person) 3 AmosoNL1t {`.te 5 GE X �; • + pB�QtpDIpLY INJURY(PaodderY)•S 1,�,000 AUTOS ONLY _ +r` s• • (Peraerrt IS I• OA J.ALYIB OCCUR . Y. F1 ar k x OCCURRENCE ; EXCESS LJAB CLAIMS-MADE f DED RETENTIONS :N AGGAE�" $ B MIORIO OOilEMIA�q�N z y; i F p $ AIM EMPLOYERS' LIABLlIY Y/UHF , SSTTATUTr{ 1 ER ANY s ERS. ors xEdr -ECC�00095`7 6A 7/8r2019 . 71 2020 x 500,000 EXCLUDED? N/A E3yySCHACCIDENT $ I deeaibe under EL DISEASE- ; 500,000 DESCRIPTION OF OPERATIONS below :'; ;;-£` EL D Z` Y ,�� ISI IC LIMA( , x DESCRt 11Otl OF OPERATIONS/LOCATIONS/VEIICLES(ACORD let,Addfloml Ramsiks S k 1X IIR if mOr.specs I$raqu*edj 3 l CERTIFICATE HOLDER CANCELLATION SHOULD ANY CFO*ABOVE DESCRIBED POLICES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Dept ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Main St,Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATTIWEE ° J;--44/.41 ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD