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Home My WebLink AboutBld-20-003218 •O1—YRR . voice use um), - Or ! ," O . . •'� . H Amount u ATTACMCUd' 0.... .-- a ,..Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATI : ', ,, 'a TOWN OF YARMOUTH I 9 I D N �Yarmouth Building Department 1146 Route 28 ��r, 5 2Q19 m �i South Yarmouth, MA 02664 i L_ A (508) 398-2231 Ext. 1261 ;YJ' ' ' ' ' 'F= CONSTRUCTION ADDRESS: /I aii 6 W\' ASSESSOR'S NFORiMATION: Map: Parcel: OWNER:,,41 / 6 444./ �l -� J N PPES ADDRE S / . TE/L. #��2r / �/Q 7�r CONTRACT d� ,i' #:," 3/4 -l9d e NAME , • ING ADDRESS TEL.# &Residential ❑Commercial Est.Cost of Construction$ /I/ oc Home Improvement Contractor Lic.# /J /t 7/ Construction Supervisor Lic.# "a 6<PI� Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the soleoprietor f I have Worker's Compensation Insurance ( /J4j Insurance Company Name: c L 4j Worker's Comp.Policy# 4 46—'0,18®2 0-)9 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares // (A)Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: a'aei / 0��/K/. wr�� /� ohation 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 licens nd or pro cution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: 416' i Owners Signature(or attachment Date: Approved By: " Date: - Building 0 al(o signee) EMAIL ADD Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No The Commonwealth of Massachusetts Department oflndustrialAccidents ' ;( 1 Congress Street, Suite 100 Boston, MA 02114-2017 • .• www.mass.gov/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) Address: 901 eiddziov,49/4 City/State/Zip: jj,OZNj 0/1 Phone #: ,5"d�,13/ i1-3(1U Are you an employer?Check the appropriate box: Type of project(required): Lk, I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or artnership and have no employees working for me in 8. ❑ Remodeling any capacity. [No workers'comp.insurance required.] 3. I am a homeowner all work myself. 9. E Demolition ❑ doing y [No workers'comp. insurance required.]` 10 ❑ Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 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 6.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp. insurance.$ 6.❑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. T 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 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: Policy#or Self-ins. Lic. ,Q 75d'700--/,9 Expiration Date: //5`�. e, Job Site Address:// � City/State/Zip:€/ Attach a copy of the workers' mpensation policy declaration page(showing the policy number 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 certify der the pains and enaltie of perjury that the information provided above is true and correct. Signature: Date: /c /09 Phone#:efQf'.p4G 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#: 03/07/2019 14:00 Sul I i van Insurance (FAX)978 851 4848 P,001/001 —•-i—•4 , mot' CERTIFICATE OF LIABILITY INSURANCE OATS (MMIOOhYW) . 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. J IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the polley(tes) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain po1101es may require an endorsement. A statement on this certificate doss not confer rights to the certificate holder In lieu of such endorsemem(s). PRODUCER Phone: (978)a61.98OO Fax:(976)861'464e CONTACT Kim Caron SULLIVAN INSURANCE AGENCY PNON V)475.0400 Fyal; (978)475_2171 0 Na.Eats 685 MAIN STREET 9-MAIL TEWKSBURY MA 01876 'AorIKE>;.e• INSURER(S)APPORDINO COVERAGE NAIC# INsuRERA : XS Brokers Insurance Agency,Inc INSURED mum6 : ACE Group THOMAS A HILCHEY DBA THOMAS A HILCHEY CONSTRUCTION INBUAER C : 82 OLD CHATHAM ROAD INSURER 0; _ HARWICH MA 02645 INSURER S : 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, EXCLUSIONS AND CONDIT ONS OF SUCH P LICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INA ADM Mk POLICY EFP POLICYE`a, LIMITS TYPE OF INSURANCE INeR wve, POLICY NUMBER MIDDIV YYYI . ••,,•..• A OENERAi. tiamory 3AA302088 09/26/18 09126119 EACH OCCURRENCE S 1,000,000 '137;trAilt TO RENTED X COmMERCIAL GENERAL LAsiurfPRFM15E)Ea ao) $ 50,000 cLAims-imog IT OCCUR MED,EXP(My one careen) 5 1,000 PERSONAL&ADV INJURY $ 1,000,f100 .—/— -- ... GENERAL AGGREGATE $ 2,000,000 GENt AGGREGATE LimiT APPLIES PER; PRODUCTS•COMP/OP AGG $ 2,000,000 • $ AUTOMOBILE LIABILITY C£o( ICED INGLEUMR $ ��. ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS BODILY INJURY(per acc dent) $ AUTOS 'NON-OWNED I�OPERTY➢AMAGE g ' HIRED AUTOS ^-AUTOS (a•cddo"II $ UMBRELLA LIAR OCCUR i EACM OCCURRENCE S Excess uA$ __ CLAIMS-MADE AGGREGATE $ DED f (RETENTIONS _ $ woRKERO COMPENSATION 6862UB-2E09540.0-19 03/15/19 03115/20 row warsI I EAR, $ 8 MO EMPLOYERS' LIABILITY YIN EL EACH ACCIDENT $ 100,000 ANT PRDPRIETOMPARTNE1bEXEctmVE oencERNeSMSER EXOLUDEO7 n NIA EL.DISEASE-EA EMPLOYEE $ 100,000 IM$sduory In NN) DE DESCRIPTION DPERATYDN$pWow J under EL DISEASE•POLICY LIMIT $ $00,000 DESCRIPTION of OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarhe Schedule,If more apace Ic required) Thomas Hlichey 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 02860 ACCORDANCE WITH THE POLICY PROVISIONS. AVTHOPo2EO REPRESENTATVE • Attention: Z-0Amy R. Jose RI 4o .9 .0RO CORPORATION. All rights reserved. .�--- 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: Reaistratiori . Expiration Office of Consumer Affairs and Business Regulation 11 Of 49 11/02/2020 1000 Washington Street-Suite 710 THOMAS A.HILCHEY Boston,MA 02118 THOMAS A.HILCHEY_ 82 OLD CHATHAM ROAD HARW ICH,MA 02845 Undersecretary Not valid Without sig re • r " Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards C o n watt%A iSQAry i s o r CS-034718 r icpires:09/19/2021 THOMAS A F#ILCHEY f 82 OLD CHATHAM R HARWICH MIV�02646 _° 1 ,- fb. , Commissioner s a a L c