HomeMy WebLinkAboutBld-19-007262 ax'"IR 1 " i,, 1
C'r . " .,'r 1 Hz, ,•.• i 3 1 i..1 Permit#
Amount
'_ t MATT 11 f .. k+, i,
r�3 / Permit expires 180 days from
1�'" "1 C/ issue date
EXPRESS SHED PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28 •
l )61111 (1 , 4 oJU V South Yarmouth,MA 02664 /112S
(508)398-2231 Ext. 1261
CONSTRUCTION ADDRESS: Z /'7-. r Cl- ç -e-e/ c, yC4/Y24-e_eru I/-I, .
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: [, ;1..../A...e fi/ ✓ a2 70 0. 3
c-IAME PRESENT ADDRESS
CONTRACTOR:` SL4{C C;a/ 4, 31 YID-( 1( TS,--2 I[ (xcr)))00( 1Sd Jc- 11 ,L8C‘)
NAME MAILING ADDRESS TEL.#
FlResidential 0 Commercial 2 Est.Cost of Construction$ 3400• (As)Home Improvement Contractor Lic.#1 P6 a 9 S Construction Supervisor Lic.# C S CA -0 es S
Workman's Compensation Insurance: (check one)
0 1 am the homeowner GI �I am the sole proprietor AI have Worker's Compensation Insurance
Insurance Company Name i�.X,�i- Cc1P Y-A ErThi,e v s751-- Worker's Comp.Policy#EC C - 60 ,l`l co(315 7cD.D)�j4'
SHED INFORMATION J`1
New (A-- Size L) 6. x w 8\ x H JO'ci“ Corner Lot Yes No'
Per Town of Yarmouth Zoniast 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(] /'�z�W x H
disposed ofa 99 l `�L Lyce.- Q�� \`U IT.11� s•. -4A-(-
Z�
*The debris will be s
Location of Facility
I declare under penalties of, jury that , 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 den'.! , ,f ... of my license and for prosecution under M.G.L.Ch.268,Section I.
Applicant's Signature: {1�/1�f%�� Dace: 300i2-(50 Q3\c5
Owners Signature(or a IIchment) Date:Approved By: K.
c Date: l� "4 V `) I
Building affivial(or designee) EMAIL ADDRESS:
Zoning District:
Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes Li No
Water Resource Protection District: Within 100 ft.of Wetlands:"""
Yes O No G Yes 0 No
***Note:Conservation review required if within 100 ft.of Wetlands
9/13
.
" Jt.,'` ✓/ie t/'1 a ac/z, uae> .
- ' r' Office of Consumer Affairs and Business Regulation
10 Park Plaia- Suite 5170
-_..r' Boston, Mass•a, , etts 02116
Home Improvement odh- tor Registration, .
=7k Commonwealth of Massachusetts
7: LI Division of Professional Licensure
= = i W Board of Building and Standards
McGRATH POST & BEAM CO. =:_ 17 Constructio �- 1 &2 Family
JAMES MCGRATH .•.- ..
ri_ CSFA-073sss r
259 QUEEN ANNE RD. _ ,�, krires:igf1UOZ0
- HARWICH, MA 02645
•_ — �` JAMS JA S R • ',i
BREWSTER
• r. anu�uru.i:•n•va - ..•,'
'�J/55�3�5
Commissioner CL
. ei W 6)4AaJ .
Office of Consumer Affairs and Business Regulation
1000 Washi •n Street-Suite 710
Boston, � - usetts 02118
Home Improve = - • tractor Registration
_v,
14 t ,1
Types Corporation
K _......_._. �'
32935
MCGRATH POST 8 BEAM CO. M -==:v i- 1
D/B/A PINE HARBOR WOOD PRODUCTS """-'- _ y�� Expiration: 1 W30/2020
• 259 QUEEN ANNE RD. = = k
HARWICH,MA 02645 �t
jfff M`
"6- Y�V
� v 6
GA 1 a Ta r aenp�7 � p o '' Modals Address and Ran Card
gZ
OlOce of ConstaserAffairs&Business Regulation
HOME IPA • ,= ENT CONTRACTOR Registration valid for individual use only
4 before the expiration dab. If found return to:
_—_ OHke of Consumer Affairs and Business Regulation
10130/2020 1000 Washington Street-Bulb 710
MCGRATH • 7_ 1 z Boston,MA 02110
DIB/A PINE - :•,, S
JAMES R.MCG-�.
259 QUEEN ANNE =Y`
HARWICH,MA 02645 Underescretary Not valid without signature
' 4
M INNIOINYVYY)
.4kom....o- CERTIFICATE OF LIABILITY INSURANCE °"
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND COII 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 N EMER THE ISSUING DISURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTFCATE HOLDER.
IMPORTANT: If the L.aUReats holder I.an ADDITIONAL INSURED,the polcy(Ms)must have ADDITIONAL INSURED provisions or be enclosed.
ff SUBROGATION IS WAIVE, subject to the terms and conditions of the policy,certain policies may requite an endorsement A statement on
this osrWIcats doer net confer,Nelda to the certificate holder In lieu of such enclorsemenits).
PRODUCER Ma
MIIC s rsV Insurance ce Agency.Inc. PHONE e�(600)565-1801 1 t R•�{ 1 MNi,�156
South Dennis,MA 02660 •malierDgersgray.com
INSUIR eA:Travele s indeen llbr Commons 25658
MUM memo s:New Hmmps!Ys Employers Insurance Commas 13083
McGrath Post&Bean Corp s IKINGC
cabs Pine Harbor Wood Products
250 Queen Anne Rd esurtato:
Hamrirb,IAA02615 INSURER E:
eeriwL F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF URANCE LISTED BELOW HAVE BEEN TO THE INSURED NAMED ABOVE FORME POLICY PERIOD
INDICATED. NOiWITHSTA DWG ANY�T,TERM OR CONDITION OF ANY CONTRACTOROTHERDOCUMENTWITHRESPECTTOWHICHTHIS
CENTIRCATE MAY BE ISSUED OR MAY PE1TAK THE INSURANCE AFFORDED BY THE POLICES DESCRY HTREINISSUBJECTTOALLTHE1ERMS,
EXCLUSIONS AND CONDITIONS OF SUCH u WAITS SHOWN MAY HAVE BEEN REDUCED BY PAD CLAWS.
ERR LIR iWEOFaSImANLE ann VIA) POLICYNIaI�t �0„ UNITS
A X caumeR:ML esamAL LIAaenY EACH OCCURRENCE s 1,000A00
I CIAaas MADE ❑X OCCUR 14104016N41141D 18 01I3112019 0121112020 AVOCU s 100.000
NEQFWUIMaeeuRNN $ 5'�
PERSONAL&ADV INJURY 1 1,000,000
MT PER cES EO ALABORATE s VOWS
2.000,000
X l I�r ( I B wRooucs-COMPIOraes s
IOTIEN s
A AuTOIIOE.E LIAaLnY 1:4=SINOLE LOST S
ANY�AUTO gLOBAE° BA..44075616-10-SEL 01AI1 010 OVS112020 OoLYv Us(mwome) $
ZISIoNLY X AUI Sp�OOpLgY�ruupRy/i000ddrt �0 $ 1 '
X OrLY X HMVlRirexidrYMAOE s
s
UNEREU A U CH OCCUR EA OCCURRENCE $
EXCESS L a.sus. E AGGREGATE $
CEO 1 I RETENTIONS $
(
B �W AV YIN X J rrP.
ANY LMrW7Y ii NIA ; -201SA 07A1BI2018 0710a12019 $ 190,009
If 77� �6b�� ELDLEA$E-EAEMPn.0I $ 108,t115
os c ddnoeOFFOOPERATIONSblow EL.DISEASE-POUCYUNE s 500,009
OECI PnONOFOPERATIOlS/LOCATIONS/YBaCIffi WOOD IOC AiRrLRMeadoSeYB/a.may M aibehed Name space la a.*bM
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DEOCRMED POLICES BE CANCELLED BEFORE
Taws of Yarmouth THE EIWI A11ON DATE THEREOF, NOTICE YOU BE DELNEIED N
ACCORDANCE WITH TIE POLICY PROVISIONS.
Building Dept
1146 Main St,Route 28
South Yarmouth,MA 02664 AUTHORIZED I RA11VE
I 41:0LS./ Ziefdtb"...****--..-•-..... .
ACORD 25(2016103) O 1988 2015 ACORD CORPORATION. AN eights reserved
The ACORD name and logo are registered marks of ACORD
e
The Commonwealth of Massachusetts
—— Department of Industrial Accidents
`'� _= : Office of Investigations
:7:7:- _� 600 Washington Street
Boston,MA 02111
'` www.mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Cpøirithø
Please Print Legibly
Name(Bncineworganizatiau/Ind v dual): MC G4Th IOSt ft3&irn n___
Address: am amen Anne JOdLI
City/State/Zip: HQrwsch.17 1 craws Phone#:�508 430.28O
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. DI am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors - 6. ❑New construction
2.0i am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. employees and have workers'
[No workers'comp.insurance comp.insurance.: 9. Building addition
required.] 5. D We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑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 13.0 Other
employees. [No workers'
comp.insurance required.]
'Any applicant that checks box ill must also fill out the section below showing their workers'compensation policy information.
r 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
anployees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
f am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
Information. j t_
Insurance Company Name: 1 hi f e �pji us lfl3'(Jr (t • 1 k i
Policy#or Self-ins.Lie.#: Etc:.j •lic n- aoiaA Expiration Date: jOki gt a•iq
rob Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiation 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
)f up to$250.00 a day against • r:,._ 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 athe I' of perjury that the information provided above is true and correct:
>rgnatrne. 01 , Date:
Phone#: . , _ ,
Official use only. Do not write in this area,to be completed by city or town ofclat
City or Town: Pormit/Liicense a
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical insportor 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
.07-- PLOT PLAN
v
e r
FOR LOT #
Indicate 10cation of garage or accessccy
Additions; with dashed lines
building
Sewerage disposal (cesspool)
Nell d3
I
...,_ _.... _
! (lot R. rear)
Abutb,r's I 4 �-- —
Na,me i� a ( i A
buttor
Lot r ________.
' e
l0 ` -� � *may
}( r. ..K
f this a I REAR YARD
Xarner lot, ( If this
...
corner
.rite in name
..a .•
.i.. rt.
stir, I
write i;
.. name of
f 14
I street.
I
other
: SIDE YARD
SIDE YARD •
4'
Q�� HOUSE•
•
• 0_��._ no •
illa•
•
•
•
• ' •
•
• •
• '• •
•
•
•
SET BACK :
iM 1 •
i .V
I
8
(lot ft. Frontage)
// -P .
(NAME OF STREET)
(------
Information
/ \\ Supplied by
ARK NORTH POINT