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Home My WebLink AboutBld-20-001494 / Office Use Only 1 ,ag.Y`9R ` -Permit# 0 . -y Amount 50 ta MATTACM ES -c - V, �+.wne09 Lid Permit expires 180 days from j )..2O-Obi Li 9 4 issue date gu EXPRESS BUILDING PERMIT APPLICATION_: TOWN OF YARMOUTH Yarmouth Building Department SEP 1 ,7 21ii 1146 Route 28 South Yarmouth, MA 02664 C 4 H "7(e%-3 (308) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: c. ( 011,,),JAVet 0,0 , ASSESSOR'S INFORMATION: 01 Cl' Map: Parcel: OWNER: fa ` ,—CD — ''/GVIJ N PRES ADDRESS TEL # Email Address: CONTRALTO less: NAME MAILING ADDRESS TEL• ®(/A Email Address: Residenti. Commercial Est.Cost of Construction$ 4;r9A Home Improvement Contractor Lic.# //o2 519 Construction Supervisor Lic.# '.Z.9 - y , Workman's Compensation Insurance: (check one) I am the homeowner I am the s proprietor I have Worker's Compensation Insurance t Insurance Company Name: () Worker's Comp.Policy#6_962/O6'gEdff 5/0% 9 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares r, (D)Remove existing*(max.2 layers) Insulation K Old Kings Highway/Historic Dist. ( )Replacing like for like *The debris will be disposed of at: eitioad N Location 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 for osecution under M.G.L.Ch.268,Section 1. Applicant's Signature: d9 Date: /�� Owners Signature(or attachment) Cmyt / Date: 9 7/1' c Approved By: _'G,., Date: 1— 0 —)c1 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 lice L'o mmon wealth of Massachusetts ,_ , 1 Department oflndustrialAccidents y� 1 Congress Street, Suite 100 e ,1r. Boston, MA 02114-2017 ..vis www.mass.crov/dig Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Aki",.- Name (Business/Organization/Individual): '14thZe....,91:- Address:gar 4.(1) eh2 7; 4 j dee. City/State/Zip: > 2 Phone #: 2. ' /5 ' -/Y, l Are you an employer? Check the appropriate box: /— Type of project (required): I. I.am a employer with .7 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. El Remodeling 3.0 I am a homeowner doing all work myself. t 9. ❑ Demolition y [No workers'comp. insurance required.] 4.❑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 sole 11.❑ Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance.t 13. oOf repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees. [No workers'comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I. 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. ili/LIC)e4P Insurance Company Name: Policy#or Self-ins. Lic. #: StiocaU/9 o7 5 fw J/7 Expiration Date: 1�e Job Site Address: 5le /� City/State/Zip: Attach a copy of the worke compensation policy declaration page(showing the polic umber 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 certi y under the pain and penalties of perjury that the information provided above is true and correct. Si natur • _ Date: c/17 Phone#• �a" */ --/y 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7)states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and,if necessary, supply sub-contractor(s)name(s), address(es) and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the.applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia Commonwealth of Massachusetts tilt/ Division of Professional Licensure Board of Building Regulations and Standards Constr ct r iipervisor CS-034718 * .t : Epires:09/19/2019 s. • THOMAS A HILL • - • 82 OLD CHATR#1M° o "` ► . ti HARWICH MA O46$5. `- • d" Commissioner .77e 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 ----- 612C6(2?--- 74mpte/ielia4,e4 82 OLD CHATHAM ROAD.:` Not HARWICH,MA 02645 valid without sig re Undersecretary 03/07/2019 14:00 Su I I Ivan Insurance (FAX)978 851 4848 P,001/001 ---"—mi f ��)' CERTIFICATE QF LIA61LITY INSURANCE . Dare (MWDOYY) 03/07/2019 THIS CERTIFICATE IS ISSUED AS AMATTER 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 POLICIES 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(tes) must 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 endorsemem(s). PR.00UCER Phones (978)861.9600 Fax:(976)e61-4848 NONeACT Kim Caron _ SULLIVAN INSURANCE AGENCY _No EML• (978)475.0400 PAx m, (978)4T5.21:1 885 MAIN STREET E-MA'L TEWKSBURY MA 01876 Aoogfss INSURERS)AFFORDING COVERADE NAIC# INSURER A : XS Brokers Insurance Agency,Inc ousunel5 THOMAS A HILCHEY meuREA a : ACE GroupADBA THOMAS A HILCHEY CONSTRUCTION INauRERC : _ 82 OLD CHATHAM ROAD INSURER D; HARW►CH MA 02645 INSURERS INSURER F : -- COVERAGES CERTIFICATE NUMBER; 31024 _ 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, I_EXCLU81ONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. AMYL Buell POLICY EPP POLICY E7IP LIMITS L R TYPE OF INSURANCE _NEL wig) POUCY NUMBER _ ( DlYri l e.mIIRCO rn A QENERAI. uaelurr 3AA302088 09/26/18 09/26119 EACH OCCURRENCE S 1,000,000 DAMAB m RENTCD $ 00,90g X COMMERCIAL GENERAL LIABILITY PRP.M,sesib xwrenwn `CLAIMS MADE [E( OCCUR MED.EXP(My one pereon) S 1,000 PERSONAL 8 ADV INJURY S 1,000,000 GENERAL AGGREGATE $ 2,000,000 EG Nt AGGREGATE LIMIT APPLIES PER; PRODUCTS-COMP/OP AOG $ 2,000,000 PRo I— $ 1 POLICY n JET El LOC AUTOMOBLE LIABILITY CO OII ED INGLE OMIT $ ANY AUTO BODILY INJURY(Pet parser') V $ ALL OWNED SCHEDULED— BODILY INJURY(Per accident) 8 HIREDN AUTOS HIRED AUTOS J NON OWNEO I °oor II�4A°E S ,---,AUTOSS UMBRELLA LIAR OCCUR �� — EACH OCCURRENCE 5 EXCESS ,UAB CLAIMS-MADE AGGREGATE $ DEG (RETENTION E $ B % � SATIDN 6862UB-2E09540.0-19a 03/15119 03115/20 lTOv ATU-e I waking ANY PROPRIeTORIPARTNERiEXECURVE YIN E,LEACHACCIDENT S 10D,DDD OFFICER/MEMBER ESOLUEE07 n NIA E.L.DISEASE-EA EMPLOYEE $ 100,000 IIIye3 doryln NH) E.L.DISEASE-POLICY LIMIT S 500,000 OYam.dIPTIoNeiNNON undo DESCRIPTION OF OPERATIONS wow DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES(Attach ACORD 101,Addlnanat Remarks Schedule,It mere awe Is required) Thomas Hllchey Is excluded from the Workers Compensation policy CERTIFICATE HOLDER CANCELLA ION 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 02660 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHOwzEO REPRESENTATIVE Attention: Z— .—f—. ‘aL-1.e. 0%-Q—• Amy R.Jose In 10 .oRn CORPORATION. All rights reserved.