HomeMy WebLinkAboutBld-20-000144 t~ i. i .. -
_0 ,
Amount
z tPer t expires 180 days from
date
EXPRESS SHED PERMIT APPLICATION ATI4N .
TOWN OF YARMOUTH J U L ,3 2019
Yarmouth Building Department
1146 Route 28
C South Yarmouth,MA 02664
S08 2231 Ext. 1261398- ��
CONSTRUCTION ADDRESS: a 5 L n LLB(R i .
ASSESSOR'S INFORMATION:
Map: S Parcel:
OWNER: n c S I 4 1INN/ /
PRESENT ADD: s �� kS�-0o26�
CONTRACTOR. (IX( TEL. t
AME MAILING ADDRESS '���
TEL#
'if-Residential 0 Commercial
Est.Cost of Cron S �.
Home Improvement Contractor Lie.# a �S (1 cJ �
_ C
Construction Supervisor LLie.#eS*� "b7 3
Workman's Compensation Insurance: (check one)
D I am the homeowner G I am the sole proprietor pr'aP' /61,I have Worker's Compensation Insurance
Insurance Company Name: g�1(,�Q FMOIL �✓�
.1t1C Worker's Comp.Policy#t -(_Pa) ' 41600957- 20/84
1 / !� SHED LN TIO
FORMAN
`
New A_ Size L 1`-I x W I f) x H :
Corner Lot: Yes No
Per Town of Yarmouth Zomba?' -Law Sec 203.5E:
Side and rear setbacks for accessory buildings less than 150 square feet and single story, shall be 6feet in all districts but
in no case built closer than 12 feet to any other building.
Replace ezisbag* Size Lam+ x W x H
*The debris will be disposed of at 1 ayec.4l A('(��d —�- 1 ,V ( c iC`
Location of Facility
I declare under penalties of..• ?. the statements herein , are true and correct to the best of myknowledge
will be just cause for den' . «•... « of my ' and for« and belief I understand that any false answer(s)
under M.G.L.Ck 268,Section i. eAp�ieaaat's Sigonure: /�/ f. 7S.4 D UunSl 36 10011
Owners Mgnature(or Al chin
Date:
Approved By
Building designee) DRESS: Date: �'— ��
Zoning District:
Historical District: 0 Yes El No Flood Plain Zone: El Yes Li No
Water Resource Protection District: Within 100 ft.of Wetlands:***
0 Yes n No L Yes C No
***Note:Conservation review required if within 100 ft.of Wetlands
9/13
•
The Commonwealth of Massachusetts
=--_'
.f Depa nt of Industrial Accidents ide
Office of Investigations_ __ n
1-;T
600 Washington Street
Boston,MA 02111
www mas&gov/dks
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers t Information
Please Prin -b
Name(Business/Organization/Individual): V i
Address: , e a
Ci /State/Zi.: 1, !11_t 1L 0 q Phone#: 44 a • t; I I
Are you an employer?Check the a -
PProp�te box:
I.❑ I am a employer with 4. 0 I a a general contractor and I Type of project(required):m
employees(fiill and/or part-time).* have hired the sub-contractors - 6. 0 New construction
2.❑ I am a sole proprietor or partner listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have
working for me in any capacity. employees and have workers' 8. 0 Demolition
[No workers'comp.insurance camp.insurance.: 9. ❑Building addition
3.❑ required.] 5• ❑ We area corporation and its 10.0 Electrical repairs or additions
I am a homeowner doing all work officers have exercised their 11.0Plumb'
myself.[No workers'comp. right of exemption per MGL or additions
. insurance required.]t c. 152,§1(4),and we have no 12.0 Roof repairs
employees. [No workers' 13.0 Other
comp.insurance required.] r;
`Any 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.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
nuployees. If the sub-contractors have employees,they must provide their workers'gyp.policy number.
lam employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
Insurance Company Name: Hapipshire & ers Iriorary e _
Policy#or Self-ins.Lic.#: Et& •al arm,- ao18A Expiration Date:..) N 8,
tOt $9
lob Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year unprisormnent,as well as civil penalties in the form of a STOP WORK ORDER and a fine
rf up to$250.00 a day :_t: I,, I. ,.,,: Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the D . • insurance cov= .e verification.
f do hereby certify the , , .T , , , ,�,, of perjury that the information provided above is true and correct
Sr , . . Date:
Phone#: . V. , _ _ a
D flcial use only. Do not write in this area to be completed by city or town official I
City or Town: Permit/License#
lssfning 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#:
,
PLOT PLAN
•P'.. r
FOR LOT
atsZocatt°" oZdd
dF werage disposalashed lines Off'
Well (Pool) EA Y---------
I
I (lot................ft. rem)
I
. -.. .r1
. . . .
AbuAbutter's ,I I
..r
Name
abutter
IName
f this is a REAR YARD Lot I)
xprintr lot, h
'rite in name • v ........'....tt. If this
corner _
t street.
,. I writs i
.. name of
•Ci► f other
43
• SIDE YARD
.
• HOUSE• SIDE YARD •
d--— ....ma- 0 •
.
•
SET BACK .
•
.
• •
......•..ft. •
•
I
(lot ft. frontage)
/ 9\C . 1-1116alL poi cs .1
. 1 ,
` ! (NAME OF STREET)
/ ♦ Information
• Supplied by
ARK NORTH POINT
-v. �' Office of Consumer Affairs and Busin ss eg
Regulation
f y. 10 Park Plana - Suite 5170
Boston, Massac ut -efts 02116
Home ImProvement- ' ,1,
' tor Registratiorn, •-
='� L. 4* Coounon rsa�n of Massachusetts
Division of Professiwel
McGRATH POST& BEAM CO. ---. -r+ - •` Con of cti a and s
JAMES McGRATH ____ � construct;o 1 s 2 Family
259 QUEEN ANNE RD. CSFA-073 iy
- HARWICH,MA 02645 __ _ 'v,- *ti Wires:0�14I 0�
•
" y�e�� JAMES R M �� 10 c
v� 204 s tY
•
v BREWSTER
-
•
Commissioner CAL
•
•
Office of Consumer Affairs and Business Regulation
1000 Washi• n Street-Suite 710
Boston, M , husetts 02118
Home Improve x ., • tractor Registration
re
Type: Corporation
MCGRATH POST&BEAM CO. :., - Registration: 132935
D/B/A PINE HARBOR WOOD PRODUCTS .�.;i: ice. Expiration: 10/30J2020
259 QUEEN ANNE RD. =
HARWICH,MA 02645 II W .,
v .
_ _ _ _ _ „,...
o`"
, ..w., ,,
M Y
:A/ 0 2pwl pSry7 r � �Address and Return Card.
574
Mee of Csnsumsr Afra s&&a.Mess Regulmoon
HOME IM- - • ,.J ENT FOR
--. Registration va1W onlyfor individual use
4 ' " ' before the expiration date. If found return to:
— Office of Consumer Affairs Buses Regulation
MCGRATH •f = 1000 Waehtnpton Street-Stdbs 710
s , , Boston.MA 02115
DIB/A PINE r_ : -_ ODUCTS
„"
• F_f
JAMES R.MC(i-,' r_"(<;
259 QUEEN ANNE~'.P
HARWICH,MA 02645 Undersecretary Not valid without signature
•
•
•
ABC MCGRPOS.01 ,
CERTIFICATE OF LIABILITY INSURANCE
CENTIFICATE THIS CITE R9 IeaueD AS A MATTER OP INFORMATION ONLY AND02104/2019
� NOT AFFIRMATIVELY OR ISITEM VELY AMEND, EXTEND.rEE COVERAGE RENTS UPON THE FFOI7FICfiTE HOLDER.THIS
DOES NOT AfPORDEO Blf THE POLICED REPRESENTATIVE OR P BELOW. THE CERTWICATE OF INSURANCE CERTIFICATE HOLD A CONTRACT B THE ISSN 1~AUTHORIZED
IMPORTANT: N the certificate holder lean!IMMORAL ENURED the
It SUBROGATION IS WAIVED, sub/ea to the Mears and 'ns of the policy,
must haw ADDITIONALrequire
a proM�sn.or be enthused.Ede SUBROGATION
dos not confer • to the holler Pam►,certain pokies may nquis an sndemsms A stadmsrd on
Aooueet
Rte 3e�ay Insurance Agency,Inc. T
South Donnie.MA 02160 ro Nat 000)563-1801 I c icy*wpm 816 Z156
INSUMINENAFFOIRMISCOVERAGE RACE
MUM anent*:Travelers Indemnity ContIMITV 25858
McGrathrN
Post i Bean Corp MUM e:New Hampshire Employers Insurance Colman 13083
259 Queen Aisne dim PG*Ilarber Wood Productsmumsc:
Harelch,MA OMB enuestD'
COVERAGES CERTIFICATE
F:
CERTIFICATE NUMBER: REVISION
DUB 16 70 CERTIFY THAT TIE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE SMUTTED NAMED ABOVE FOR TIE POLICY PERIOD
INDICATED. NCRIETTFIBTANDING ANY REQUIREMEIR;TERM OR CONDITION OF ANY MAYISSUED OR MAY PERTAIN. TIE INSURANcE AFFORDS) BY THE CONTRACT OR OTHER DOCU NT WITH RESPECT TO WHICH THIS
CERTIEXCLUSIONS AND CONDRWNB OF SUCH POLICES.LIMITS SHONE MAY HAVE BEEN REDUCED BY (D H B SUB.ECT 70 ALL THE TERMS,LAIMS.
Nan
'- F
A RstAI(E
A X IPLa�ILLUMIU Y sa gm t)IAI.YN11a6Et; l.anB
OAaa ralpE Q OCCUR 01/31/2019 0113112020 I 3 1100,
MEO ..41,0810
000
�'Ww 5,000
anstMnan) i PERSONAL AADVINJURY s 1,000,000
X nELear or,g7 PER
MINERAL AGGREGATE i $000,000
IOTHER PRODUCTS-cdAailuPRQti : 2,000.000
A AUTOBEER E mousyi
p� WSW"'um"
s
AIKNIrp 8d� 01131/2019 8U31/2020
AAIOB may X, sooty mum(Praynon) s
x aaY x EXIST
s 1.000,000
IALIAB OCCUR3
MESS CAUSERIE USERI7E _
1 I RETENTIONS ATE/REBATE $
IN Y �10A 07J08R018 07A8l2019
pNr N' NIA E L EACH ACCIDENT s 100,000
triaRIP"741 bell OF TO)NSSnow EL.t1plTiAtE-d►6�LOR� $ 180,00.
El-DREAM•MUM(UAW $oirecernol ,0�
roFDPIWA1IOSSILACA1RA$I Sue JS(AI'pn tat,AmainiLRyrtsSdaw HAS be HHHH41 Mom Isis.,. 4
CERTIFICATE HOLDER CANCELLATION.
SHOULD ANY OF THE ABOVE DESCRIBED POLICES SE CANCELED
BEFORE
TowndYan:OilSt TIE EXPIRATION DATE THEREOF, NOTICE WILL SE DELIVERED IN
Bulking Dept
ACCORDANCE WITH THE POLICY PROAIBID118,
1146 Mibi Ronk)25
South Yartnotttll,MA 02884 MoRaiwiNTATNE
7i
ACORD 15 pins* O 1988-2015 ACORD CORPORATION. AN right:rmsNread.
The ACORD Lane and logo are registered marks of ACORD