HomeMy WebLinkAboutBld-19-007261 �� 3
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F. Nwt' �r'
�" Permit expires 180 days from
issue date
EXPRESS SHED PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department U '0
1146 Route 28
South Yarmouth,MA 02664 C -' f t
(508)398-2231 Ext. 1261
CONSTRUCTION ADDRESS: C `7 1/ii j- e 5 , Ka4/ ( .,c,
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: I��-sl�f e� / 6-1/ Ai/1C ✓ /<,, J;1 fU OS 73 7
l�NAME P,,RESEN, ei T ADDRESS TEa.. # �/ ��
coNTRACTOVi i( I�l_lJ id 2 ���ir3 60 !n-,-''.I(lf1� Y lc 7'j .j ""
NAME MAILING ADDRESS TEL#
Bt.Costof Construction$ _J 4 60 .
Residential 0 Commercial s2 ,+,,,�
Home Improvement Contractor Lic.# 1 5a 5 Construction Supervisor Lie.#CS cA - 0? J816
Workman's Compensation Insurance: (check one)
C I am the homeowner 0 I am the sole proprietori0 I h�avee,Worker's Compensation Insurance�
Insurance Company Namel,>L w '_ ,p S h;lR C (S�,t�] Worker's Comp.Policy#E C C' 06—gut)of 5—icz its^A
QSHED INFORMATION
New Size L 1 O x W E) x H � C) t 4 Corner Lot:Yes No
Per Town of Yarmouth Zonura By-.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* Size L KW x H
*The debris will be disposed of at > � WNO \'ta LAN, M 1 1
Location of Facility
I declare under penalties of, ' • herein contained are true and correct to the best of my knowledge and belief. I understand that
will be just cause for den'. o .•my license and for prosecution under M.G.L.Cb.268,Section I. any false answer(s)
1
Applicant's Signature: Dame: —.c94 t ao 19
Owners Signature(or attar meet) Date: 6 1" Z 4- ` V
Approved By / "v Date: -d�c i 5
Building OfficiAl(or designee) EMAIL ADDRESS:
Zoning District:
Historical District: r Yes 0 No Flood Plain Zone: U Yes Li No
Water Resource Protection District: Within 100 ft.of Wetlands:***
U Yes _ No Li Yes No
***Nate:Conservation review required if within 100 fk of Wetlands
9/13
The Co mmonwealth of Massachusetts
i" t Department oflndustriablccidents
r j 1 Congress Street,Suite 100
Boston,MA 02114-2017
www.tnass.govidia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
AoDlicant Information
Please Print Leeibly
Name(Btainesstorganizationikdiv duet):
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box:
1. I am a employer withType of project(required):
�oy employees(full andtor part-time).* • 7. 0 New construction
2.0 I am a sole proprietor or partnership and have no employees any capacity.[No workers'comp.insu an ured.] working for me in 8. Remodeling
3.0 I am a homeowner doing all work myself[No 'comp.insurance requited.]t 9. Demolition
ILO I am a homeowner and will be hiring connectors .. conduct all work on my property. I will 10 El Building addition
ensure that all conkactors either have waxicers'.. , 4.0n insurance o are sole
proprietors with no employees 11.Q Electrical repairs or additions
s. I am a 12.0Plumbing repairs or additions
,a sub ore have I have hired the listed on the attached sheet
employees and have workers ...,p. t 13.Q Roof repairs
6.❑We are a corporation and its officers have exercised their ri of exemption per MGL c. 14.0 Other
152,§1(4),and we have no employees.[No workers'comp. ' ,,... required,]
`Any applicant that checks box#1 must also fill out the section below .• • _their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work: d then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing,: of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their
--_- - _ 'comp.policy number.
I am an employer that is providing workers'compensation inns a for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy ft or Self-ins.Lic.#: Expiration Date:
Job Site Address: C /State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation •unishable 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 • • N ER 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 Inves 4 ons of the DIA for insurance
coverage verification.
I do hereby certil fy under the pains and penalties of perjury that the information provided, ,,# is true and correct.
Date:
Pho,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):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: __ Phone#:
•
PLOT PLAN
FOR LOT I
Indicate location of garage
A�dditf+ans a dashed or building
�S age disposal (cesspool) ED
ea D3
I
(Jot ft. sear)
Abuttor's 'O• ..... ...... ....... -
Name 1
Lot j ! NaiiieAbutt ac
D ! Name
Lot 1
;f this is a REAR YARD• 7
.rye in namewrite 1.•..tt• t
t street. �—�a Iname of
4 # other
met.
4
• SIDB7 ARD :
SIDE YARD•
HOUSE •
•
p--ems _�0
•
• •
• •
• 5
I .
SET BACK
.
. ... 5..ft. .
!
8
(Jot
ft. frontage)
/ er cl-T-E,,e_4.-
(NAME OF STREET)
/ ` atf a
/ `\ Supplied by
ARK NORTH POINT
..4 r ' Office of Consumer Affairs and Business Regulation .
10 Park Plaza- Suite 5170
,.: '� Boston, Massac•,; efts 02116 _
Home Improvement � f., = for Registration.
_- Goan onweaith of Massachusetts
`�.. Division of Professional Licensure
Board of Builrfng R Mons and Standards
•McGRATH POST& BEAM CO. —:`-_' =
JAMES McGRATH == 1 Constructio�,� i1 &2 Family
cr-
_ 259 QUEEN ANNE RD. CSFA-073865 * Wires:03/14 02o
- HARWICH, MA 02645 _ ._ �� f
`�a.4 JAMES R M, - '+@,
• 204 CRANVE*
' top v .. BREWSTER ,• 0*),
.s..,,.�, r s: ,� ,R OISS33�
Commissioner a
Office of Consumer Affairs and Business Regulation
1000 Washi •n Street-Suite 710
Boston, .t -- husetts 02118 •
41"- tractor Registration
Home Improve ;�,,;;,-=
# e.___.•__ . Type: Corporation
P W i k Registration: 132935
MCGRATH POST&BEAM CO. —•"v - Expiration: 1�
D/B/A PINE HARBOR WOOD PRODUCTS ., i�: },
259 QUEEN ANNE RD. .
HARWICH,MA 02645 ''i4t: i I t
bb.
4.
. .
Update Address and Return Card
;A 1 O 20M-05h7
. a�ovHvsoyarV. ao�aweta
Office of Consumer Atfaks&swress Regulation
HOYE IM - 9 = ENT CONTRACTOR Registration valid for Individual use only
before the expiration date. If found return to:
• . � Office of Consumer Affairs and Business Regnl tlon
100012020 1000 Washington Street-Suite 710
MCGRATH •tom _- Boston,MA 02116
DIB/A PINE ,.(- _ ., •• TS
r
JAMES R. e, ! ,F
259 QUEEN ANNE.' _ ` •
HARWICH,MA 02645 Undersecretary Not valid without signature
•
•
• -
The Commonwealth of Massachusetts
Department of Industrial Accidents
{ M :. Office of Investigations
_ _ "� 600 Washington Street
_ Boston,MA 02111
www.mass.gov/dta
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annlicant Information Please Print Legibly
Name(Business/Organizatiannndividual): Mc. GiaTh TO`,' 'f rn /` Qtj�
Address: a (Aileen Ana RÔ04
0 /State/Zi.: I! 1 ,, hi 0- (psi Phone#: '•1 1 ' t i l e
Are you an employer?Cheek the appropriate box: Type of project(required):
in❑ I am a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-time).
have hired the sub-contractors - 6. Q New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. Q Remodeling
ship and have no employees Thy sub-contractors have 8. ❑Demolition
working for me in any capacity. employees and have workers'
[No workers'comp.insurance comp.insurance.: 9. 0 Building addition
required.] 5. Q We are a corporation and its 10.0 Electrical repairs or additions
3.El officers have exercised their I am a homeowner doing all work 11.Q Plumbing repairs or additions
myself [No workers'comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees. [No workers' 13.0 Other
comp.insurance required.] J'
*Any applicant that checks box HI 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.
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
mployees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
l am an employer that is provid ng workers'compensation insurance for my employees. Below is the pone),and fob site
information.
insurance Company Name: 1 shire Enpla iers lflSQrj1J%t a •,
Policy#or Self-ins.Lic.#: ram'WO• fan 171.- 42o18A Expiration Date:.Jokj $t ;a a lei
lob Site Address: City/State/Zip: J
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 imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
3f up to$250.00 a day against " I r...- Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the D • . insurance coy •e verification.
f do hereby certify u der the , , ?a ' , , — of perjury that the information provided above is true and correct
Signature: 4 • Date:
Phone#: .• . 4' . = ' i
Official use only. Do not write in this area,to be completed by city or town official
1
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#: 1
TE 11111111NRYVV)
• ' ,i�Rcr CERTIFICATE OF LIABILITY INSURANCE °" 11
THIS CERTIRCATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND COIF NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR N®PATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BB.OW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING NHS),AUTHORED
REPRESENTATWE OR PRODUCER,AND THE CERTIRCATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL.INSURED,the policy(es)must have ADDITIONAL INSURED provision or be endorsed.
IT SUBROGATION IS WANED„ subject to the tens and conditions of the policy,certain policies may require an endorsement. A statement on
Ws oertiRpie doss not confer rights to the certificate holder in lieu of such.ndoramerd(s).
MIODUCER gaIPCT
WC
.ORB Insurance AWN",tree. R"c E n ($09)553-1801 I a N. 77)816�I'.DB
South Dennis,MA 02660 �- ogersgnY.COm
INKMORMIA HNC r
wwensa:Trahleiess rrdan Comm,y Co 2565E
NeAe® SEWERS AWN Hampshire Employers Insurance Compere 130113
McGrath Post&Beam Corp INSURER C
des Pine Harbor Wood Products
259 Queen Anne Rd MINERD: , ._
11srsIid%MA M2646 MOWERS:
mums F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OFINSURANCE LISTED BELOW HAVE BEEN ISSUEDTO THE INSURED NAMED ABOVE FOR TIE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY�T•TERM OR cONDMON OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIHCATE MAY BE ISSUED OR MAY PERIAEL TIE INSURANCE AFFORDED BY THE POUCHES DESCRIBED Hsi M SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH LMAITS SHOWN MAY HAVE BEEN REDUCC�Eyy)BY PAD CLAIMS.
VLIR IM TYPEORueImANce Y � POLICY RUINER ILW UNIT*
A X Coreeerc m.eermlAL.useenY EACH OCCURRENCE $ 1,000,000
I Ch.ABNi.rIADE I X Dcc*R IaS0-201 MI84o-1a 01/31/2019 01I31l 9 $a $ 100,000
NED EXP Pav one ewwo) $ 5,000
PERSONAL AADVINJURY $ 1,000,000
.AOSUNT PER GENERAL AGGREGATE $ 2,000,000
2.1100,00111
Illiet
pea:to s-Carapace s
II s
A AUTOMOBILE uAee-nn I)SSIG E win' s
NW AUTO _ BA-4487110664643EL 01I3112019 011 112020 'coax euURY Myr moon) s
/WfOB ONLY X AIlIDB ® BODILY INJURY(Par eeddad $ 1,000,000
X RR OILY XMSS ,SgRge"E s
s
U ORELL A LIAR OCCUR EACH O $
^' MOM Ws C7Ae1848I0E AGGunAlE s
ow 1 I REran uNs _ _ s
El �L ' " Y -2011A 0710612016 07100/2019 �` $ 100,000
AilTagRECUIWE 1 1 NIA EL EACH ACCIIMT 180,11110
ice__ E.L DISEASE-EAEMPLOYEE $
O ONZarrOPERATIONS below EL INSEAM POLICY LAST I 00
DESCRIPTION CIF OPERATIONS/LOCATIONS lVENOUS SICCED lef.AddlddRMArl.SOWER,way leatlried Noon Awe Yw4id)
CERII ICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DE9CIIISEQ POLICES BE CANCELLED BEFORE
Tom ofYarmoulh THE EXPIRATION DATE THEREOF, NOTICE WILL BE OEJVBMD IN
g ACCORDANCE WITH TIE POUCY PROM IUON&
RuNdIn Dept
1146 Main St,Route 26
South Yarmouth,MA 02664 REPREMBrrA1 E
ACORD 25(>01 ) 019884015 ACORD CORPORATION. AN sights reserved.
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