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Home My WebLink AboutBld-20-001495 �% 'Office Use Only O Permit# _H 1 Amount S ..1 Cf " MATTACM ES 4. "�,.a,�.fb Cad Permit expires 180 days from issue date BCD-a b-c )I4 96- , EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH 12 Ei Yarmouth Building Department -_F 1146 Route 28 South Yarmouth, MA 02664 C-0 ` 1 Co53 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: .5 ,a/y ASSESSOR'S INFORMATION: dell j j Parcel:rcel �J 7��'/f OWNER: deli(/ 5 0 i00 OId'ig "9,0,114, tUg / [� rZ,V, P• SENT ADDRESS TEL. # ,[� Email�A�d/dres+s/: �r CONTRACTOR: 416/1,24 1i i, axediMed. /� /U6 027� 17gv / NAME MAILING ADDRESS TEL # ,�— Email Address: / Residential Commercial Est.Cost of Construction$ j9/5�J/oD ' `Home Improvement Contractor Lic.# /IdCG 7`9 Construction Supervisor Lic.# ( --a_. / 7) 7 Workman's Compensation Insurance: (check one) I am the homeowner I am the sole proprietor I have Worker's Compensation Insurance ,v,� Insurance Company Name: allit/P021/14Si Worker's Comp.Policy# G��' e9 0.130 19 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares c/Y (X)Remove existing*(max.2 layers) Insulation X Old Kings Highway/Historic Dist. (j Replacing like for like *The debris will be disposed of at: /1"/1449tV.4)&iir c*F�'r^h Lotration 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 lice d for osecution under M.G.L.Ch.268,Section 1. fiA Applicant's Signature:� Date: 7 wners Signature(or attachment) Date: Approved By: ✓-Grp G-�� Date: r 1 Building Official(or 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 • .1 lie c,'ommonwealth of Massachusetts f r Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 ..S . www.massgov/dia 'Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers, TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): eft,/ /a/3„..- Address: go? did aaatipyazer; City/State/Zip: 4uS' Z), hone #: 005 t; Are you an employer? Check the appropriate box: Type of project (required): 1.U [am a employer with employees(full and/or part-time).* 7. ❑ 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.n I am a homeowner doing all work myself. 9. [' Demolition y [No workers'comp. insurance required.]t 4.[7 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 sol 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 (�Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.t 13.0 Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El Other 152,§1(4),and we have no employees. [No workers'comp. insurance required.] *Any applicant that checks box iiI 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 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. �� Insurance Company Name: fr4�� /"-1 (-)ildi, Policy# or Self-ins. Lic. #:16.0 e15 ".4 /9 Expiration Date: c..�l.(./9 Job Site Address: 5, �2 City/State/Zip:,,,,..-1 G�A� Je Attach a copy of the workers' compensation policy declaration page(showing the policy mber and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable 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 ORDER and a fine of up to$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert.y under the poi s and enalties of perjury that the information provided above is true and correct. Si natur Date: J es�++-- d f, Phone#`..32V—plyg —/ii & Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: • Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards ConstuicEitirf'$iipervisor CS-034718 * %spires: THOMAS A WICK ; - • 82 OLD CHA11t)M'R9 P rr . . HARWICH MA 0 t§46 '-. • :' • "` 4 Commissioner Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 110649 11/02/2020 1000 Washington Street-Suite 710 THOMAS A.HILCHEY Boston,MA 02118 THOMAS A.HILCHEY .. 82 OLD CHATHAM-ROAD. U —— - HARW ICH,MA 02645 Undersecretary Not valid without sig re 03/07/2019 14:00 Su I I i van Insurance (FAX)978 851 4848 P,001/001 DAYS (MM,Dm'YY) RD' CERTIFICATE OF LIABILITY INSURANCE 03/07/2019 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 POUCIES 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 be endorsed. If SUBROGATION IS WAIVED, eubject 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 eertIflcate holder In lieu of such endorsement(s). PRODUCER Phonic (9781861.9e00 Fax:(978)Bri-eim8 CONTACT Kim Caron SULLIVAN INSURANCE AGENCY PHONE 978 475.04-R Fes,,,; (978)475.2171 585 MAIN STREET (p10 No,Ems,( ) E-MAIL TEWKSBURY MA 01876 ADDnEss• INSURERS)AFFORDING COVERAGE NAIL B INSURERA : XS Brokers Insurance Agency,Inc u�SJRED — INmURg19 : ACE Group THOMAS A HILCHEY — - — � DBA THOMAS A HILCHEY CONSTRUCTION INSURER C : 82 OLD CHATHAM ROAD INSURER 0; HARWICH MA 02645 INSURER E : INSURER F : —COVERAGT CERTIFICATE NUMBER; 3102A 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 CONDITION 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.__,, NA AD0'L SUER POUCYEPP POLICYSXP LIMITS LTR , TYPE OF INSURANCE I w_v0 POLICY NUMBER ,j(Ipop YTYY1 _1E1111PP17;m A DENERA1. LIABILITY 3AA302088 09/26118 09/26/19 EACH OCCURRENCE S 1,000,000 X COMMERCIAL GENERAL LIABILITY OAMA T j RENTED PRF.MISEEEaverWanuu) $ 50,000 7OLA1M3-MADa I-EOCCUR MED.EXP(Any one peroon) 5 1,000 PERSONAL&ADV INJURY S 1,000,000 GENERAL AGGREGATE $ 2,000,000 EG N'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG 5 2,000,000 POLICY"— Eck 1-1.2.0C �— — $ AUTOMOBILE LIABILITY COMOINEP BINDLE UNIT (£a aotll+ni) $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per maim) $ - HIRBDAUTOS NON-OWNED RO«dd,MI DAMAGE $ -_,AUTos S UMBRELLA um: OCCUR a EACH OCCURRENCE $ _—Ezell!! uae ~CLAIMS-MADE AGGREGATE $ DED RETENTION S • $T B WORKERS vSATIa 6B62UB2E09540.0-19 03M5119 03H5/20 �W TA r ER E Loa LIABILITY ANY PROPRIETOMPARTNERIEXECImVE YIN E,L EACH ACCIDENT S 100,000 OPPIGER IMEMBER ExOLVOE07 NIA E.L.DisEASE-EA EMPLOYEE $ 100,000 PMdtlory In NN) DESCRIPTION OFer Dhow E.L.DISEASE-POLICY LIMIT -S 000,000 DESCRIPTION OF OPERATIONS!LOCATIONS I VEHICLES(Attach ACORP 101,Additional Remarks Schsduts.If more space is required) Thomas Hllchey Is excluded from the Workers Compensation policy CERTIFICATE HOLDER CANCELLATION Town of Dennis MA ' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 685 Routh 134 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN South Dennis, MA 02060 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Attention: J 0 — • Amy R.Jose le)lo .0 .oRo c RPORATION. I rights reserved.