The URL can be used to link to this page

Home My WebLink AboutBld-20-000463 0 O Fee$ • Permit expires 6 months from M V-41 � aroutoa issue date. EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 , . (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: r, 3 13 c.r r)c;c I c 1/2 c ASSESSOR'S INFORMATION: Map: Parcel: OWNER: 4% ll G "} '/' �.t.1 IJr �c -, I,.irt• . (t /2 (SCS) %7C .. j c/LC, NAME PRESENT ADDRESS TEL # •CTOR: /JJ•c4e.eI N. ft4.i»�.•� PC 15ck � 3>c� 13a(, )1r• /`//1 ( ) C $ } 22( C � y7 NAME MAILING ADDRESS 0 q TEL# O1 ' a-Residential 0 Commercial 0 Est.Cost of Construction$ k� Home Improvement Contractor Lic.# /I Y 3ieC,^ Construction Supervisor Lic.# Ci l Z r y Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor Et-rave Worker's Compensation Insurance Insurance Company Name: II,. ( Worker's Comp.Policy# v - L I c i G c'/; f.i 24! /' WORK TO BE PERFORMED ❑Tent (Fire Retardant Certificate attached) 0 Wood Stove Shed 0 Siding: #of Squares 0 Replacement windows:# 0 Replacement doors: # B1le-roof #of Squares 2 Z_. 0 Insulation (afnpping old shingles* ()going over layers of existing roof Old Kings Highway/Historic District Roofing/Siding(Like for Like) *The debris will be disposed of at: PKc. / I) c a lc / ) 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 revocation of my license and for prosecution under M.G.L Ch.268,Section 1. Applicant's Signature: �� / �. r Date: 7/Z�af-////,ti Owners Signature(or attachment) /�j 1/� �-• Date: 7 -')9 Approved By: v Date: 7" -W — Buil ' fcial(or designee) Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No ❑ Yes ❑• No 3/01 • The Commonwealth of Massachusetts , IshiiINN �� Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 ` www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): P2,c ‘-1( -/A. •, 4, Address: Z it P71 L ry City/State/Zip: i 2), z - . </(+ 6 Z C 3( Phone#:C o f( (.3 7 )- Are you an employer?Check the appropriate box: r� — 4. I am a general contractor and I Type of project(required), I.D i am a emplo with L ❑ • employees fu l,And/or part-time).* have hired the sub-contractors 6 ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. ❑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• El Building addition required] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doingall work officers have exercised their11.0Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑ Roof repairs insurance r t c. 152, §1(4),and we have no ❑ 3a.❑ I am a homeowner acting as a employees. [No workers' 13. Other general contractor(refer to#4) comp.insuranCe required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensatiodfoolicy 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. tConttactors that check this box must attached an additional sheet showing the name of the sub tractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'co policynumber. comp. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site informatlont, Insurance Company Name: Po L.,/.„ 3 / Policy#or Self-ins. Lic.#: V(Au i c L c, c )Th Y Z c, i" A Expiration Date: // 1e <; Job Site Address: G S I5 t; ie n i 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 imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: l/z3/1 5 Phone# c (s" 7 t C 3 7 ) 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#: s Information and Instructions , Inf , for their employees. f ��Laws chapter 152 requires all Y�to provide wort'compensation contract of ore, '� Massachusetts is defined as"..• person in the service of another under any ,k I Pursuant to this statute,an�� express cc implied,oral or written." or association,COrpocaa0ar other legalentity, any two the r more of se kee ►is defined as"an individual,P includingthe legal of a deceased employer, the in a joint ems! However re the foregoingassociation or other legal a y,eus loy� the occupant the receiver oa trustee of as se having than thece and who resides the cis or on such house dwelling of a dwelling another more persons to do maintenance,CO0i�ti0°of� to be an employes:" or onith haw of bolding apps thereto�not��of such eaploymeat be deemed or the rounds the Issuance or state shall withhold that"every ,wealth far say renewal al efat 152,4rp also sty tea badness or to Is the come » renewal of a eHassesorset produced a acceptable evidence of eons with he im erase*avenge required." appikaat ww has the prod�4 ates"Neither the commonwealthof its political subdivisions Ate,MC IL chapter of public work until acceptable enter into any fact hoc the performance of the contracting authority;of this chapter have been presented requirements Applicants be boxes that apply to your act and,affidavit completely,by checking with their certificate(s)tosiof Please aryl out the work supply ers'conep�0a) s),�(L ited LiabilityOtt a (LLP)with et of �°the 1 necessary,insurance. L Liability sCompa (LLC) imuaaaee. if m LLC or L1�does have member employees, per• not r ��at this affidavit may mimed to the Dew of should Acciden a policy in 1 an B Abe be sore to s�and date the affidavit. The affidavit be tern for the 0°of ��for the permit or license laming meted'net a Department of be:eternal to the city err tows that the regaeding the law or upon are required to obis should has Ind w . phoned sill have any gseaa a number listed below►.Self insured a enter c policy,please�the Dept lionselfinseams� on the PleaseCla or Taws Oat the a has provided that the affidavit is complete and printed legibly. Tim Department i space at the bottom be sure the Office of Inveatiptione has to contact you maw Pleaseof applicant the be sure for you to pll out inI the mber which will be used as a reference mother. that be sure toit filltin applications in any given year, only submit one ffidavit indics "$ or One must submit n�nM " wddrese"the applicantshould write in to the town)."patiof(if necessary)t and s beene Job Site or madded by the city or tows may be provided policy copy of the affidavit�his officially stamped or licenser. A new affidavit errant�filled out each applicant proof a is on file for Niece pansiatbusiness or eomnseled tea venture r that a validnot reined to say Who a hones ownuw or citizen is obtaining a license ar is permit equired to�P this affidavit (i.e.a dog license or p�to burn leaves )said person The Office of InresddAtiOOe would Igoe to thank you in advance for your eeoperation and should you have any questions, please do not hesitate to give us a call. l he Depasment's address'telephone and fax maser: The Cotmnoaweald>t of Massachusetts Department of Industrial Accidents Ott of Invnsdpdost 600 Washington Street Boston,MA 02111 Tel. J#617-727-4900 ext 406 or Fax#617 Revised 11-22-06 WWw.stloss.gov/din DATE(MNV A R EP CERTIFICATE OF LIABILITY INSURANCE (MMDDIYYYY) • 201s I- 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 POLICIES u BELGW. 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 policy(ies)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 endorsement(s). PRODUCER CONTACT Linda Sullivan DOWLING & O'NEIL INSURANCE AGENCY PHONE _ t,: (508)7751620 AX (; ,No): E-MAIL SS: Iullivan c@doins.com 9731YANNOUGH RD INSURER(S)AFFORDINGCOVERAGE NAIC# HYANNIS MA 02601 INSURER A: AIM MUTUAL INS CO 33758 INSURED INSURER B: MICHAEL HUTCHINSON INSURERC: HUTCHINSON ROOFING INSURERD: P O BOX 534 INSURER E: BREWSTER MA 02631 INSURER F: COVERAGES CERTIFICATE NUMBER: 402656 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. INSR ADOLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (M M!DD/YYYY) IMWDO/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PET LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident) ANY AUTO BODILY INJURY(Per person) $ _ ALL OWNED SCHEDULED AUTOS N/A BODILY INJURY(Per accident) $ AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'UABIUTY ANYPROPRIETOX STATUTE ER OTH- A OFFICERIMEMBBER XCL DE�ECUTIVE wA N/A NIA VWC10060065982019A 01/15/2019 01/15/2020 E.L.EACH ACCIDENT $ 500,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance. The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.govilwd/workers-compensalion/investigations/. MICHAEL HUTCHINSON has elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN John Anderson Go Michael Hutchinson ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 534 AUTHORIZED--� REPRESENTATIVE Brewster MA 02631 --)w�i Cv C I Daniel M.CroJey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD Te FOMr ewee<e¢`/ce Wiirisac ui:e/4 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration gxoiration 138330 ` 03/25/2021 MICHAEL HUTCHINSON D/B/A HUTCHINSON ROOFING MICHAEL R.HUTCHINSON �• 26 MAURY LANE A BREWSTER,MA 02631 Undersecretary r Commonwealth of Massachusetts 115 Division of Professional Licensure Board of Building Regulations and Standards Constr tiltai rvisor CS-099258 Aires: 12/25/2019 i r I f MICHAEL R HUTCH! 414. PO BOX 534 i r `� BREWSTER MAL2631R c))cS'Li��` • Commissioner __�