Loading...
HomeMy WebLinkAboutBld-20-2671 •Office Use Only ,01*.'46141.4_ 0 Permit:If 4i:14t. C /4. 'Amount ''.r..5),„r....,,,;- ff Permit expires 180 days from 3(1, _2 D—aol I , issue dale .. .......... - — r••• i`.•:- `.! V: 0 EXPRESS BUILDING PERMIT APPLICATION ° , TOWN OF YARMOUTH Yarmouth Building Department NOV u 7 )°19 1146 Route 28 South Yarmouth,MA 02664 (508)398-22.31 Ext. 1261 ,i, Clc a, m ., 7-, _1 tin CONSTRUCTION ADDRESS: .ve. •-r C.-1 o K VO ASSESSOR'S INFORMATION: Map: Parcel: • (0A—d * OWNTR: 13Ctri`i 6 6 d-1 606 Vat t A i ?or ,4/0)- g.( 6 7 NAN4 PRESENT,i.DDRESS TEL # CONTRACTOR—T(4 fr rkelf 1'7-77 S Mrelsok, 51. 1:t6ou 0441(41;1° 605- 36e-1,70. MAILING ADDRESS TEL. pResidential C Commercial Est.Cost of Construction S ( Six). vid Home Improvement Contractor Lie.# 141 d 9 it t Construction Supervisor Lie.N Workman's Compensation Insurance: (check one) L 1 am the homeowner - I am the sole proprietor st()have Worker's Compensation Insurance Insurance Company Name:4itfkiE =C: -/----- _ Worker's Comp.Policy#/1/1/A.)C,10 5-7-09`00 0 i wel jR 0 t'cil..v% ...V111 A f --'41C1 - oIC TO BE PERFORMED \Q Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will bc disposed of at: PI-U.A.)iN &imp 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' Signature: ---& Date: t I--7 is Owners Signature(or attachment) I - Date: // IA Approved By: 91, 104;;510."..........• 45,..- Date: / 1 7 Building Official 4 ign EMAIL ADDR Zoning District: Historical District: 2. Yes :: No Flood Plain Zone: -..- Yes _ No Water Resource Protection District: Within 100 ft of Wetlands: Yes ' No .. Yes No The Commonwealth of Massachusetts —* !/ Department of Industrial Accidents A =- p{ 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. Anolicant Information Please Print Legibly Name (Business/Organization/Individual): 3A.ry'7 ` 6,,✓;C Address:d City/State/Zip: S. / r,MJ� /14 A 4))664/ Phone#:'o 9 V�-—6 8'0,7 Are you as employer?Check the appropriate box: Type of project(required): I.Q I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.01 am a sole proprietor or partnership and have no employees working for me in any capacity.[No 'comp.insurance required.] 8. D Remodeling 3.0 I am a homeowner doing all work myself[No workers' t 9. ©Demolition comp.insurance required.] I am a homeowner and will be hiringcontractors to conduct all work on 10 Q Building addition 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. 12.0 Plumbing repairs or additions 5.❑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,: t/ ] 5.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other /-e w n f v {1Q 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box 61 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: , h'14 -(o/cc- eii3 /J ✓iS;tv1 Policy#or Self-ins.Lic.#: 144451u.Q ill w C 3 i 9 d w Expiration Date: 3— do Job Site Address: i 7 ‘r, y/,r]( iC cL City/StatelZip:S �/ar n1,r. . iv"4 b 6 6 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). y 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 S250.00 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 hereb ' , he pains and penalties of perjury that the information provided above is true and correct Signature: Date: Phone#: 3 S-, SNd. al 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#: The Commonwealth of Massachusetts 111_ � 1, Department of Industrial Accidents �"-'01— 1 Congress Street,Suite 100 Boston,MA 02114-2017 s.-1. ), - 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):Tuff Shed Inc. Address: 1777 S. Harrison St.#600 City/State/Zip:Denver CO. 80210 Phone#:603-868-1300 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 25 employees(full and/or part-time).* 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.1=l I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 El Building addition 4.1=I 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. 12.0 Plumbing repairs or additions 5.EI 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.: p 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El Other SHEDS INSTALL 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:IMA, Inc. -Colorado Division Policy#or Self-ins.Lic.#:MWC31257200 Expiration Date:03/1/20 Job Site Address: 27 Captain York Rd City/State/Zip:Yarmouth, MA Attach a copy of the workers'compensation policy declaration page(showing the policy number 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 certify under the pains and penalties of perjury that the information provided above is true and correct o9.W.M.edb0.ya.yry Signature: M UQuigley M,. �. Date: Phone#:603-421-6755 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 defmed as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defmed 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 y° #pJ77/ Office of Consumer Affairs and Business Regulation 1000 Washington Street -Suite 710 Boston, Massachusetts 02118 Home improvement Contractor Registration Type: Corporation . Registration: 192914 TURF SHED,NC 1777 SOUTHHARRISON,SUITE 600Expiration: U8t27t2t#2D DEN ER.CO 80210 Update Address and Return Card. /Z, Z,ao�d�,Rf.#le�6l=F'r.'.✓ni !'Y _ .Y-F/<%i 'y fi.k-f Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:motion before the expiration date., if found return to: Reoistt anon Exoiration Office of Consumer Affairs and Business Regulation 192914 08112712020 1000 Washington Street-.Suite 710 TUFF SHED,INC. Boston,M 0211 TOM SAUREY 1 fi :x r t 1777 SOUTH HARRISON,SUITE 600 i _w Not without 2r#ute OEfdvER,CO 10 Undersetur D1(t) n Envelo a ID:E072963A-5E21-49AA-888B D104204E8467 Barry Lewis TUFFSHED' 27 Captain York Rd 711111.41.14.10amm . , ^ ,,,',Ii-, "•',, " '' ',',1."-1- ',' ,' •-',',' 1 Yarmouth MA 02664 01071640-1068886 x « ' a4 j. 2 °h: , i,t,,:, ,, . ..:. Wall D Wall A Wall C 31 - ‘ \ + Wall B Base Details Options Details Jobsite/Installer Details Building Size&Style Doors Do you plan to insulate this building after Tuff Shed Sundance Lean-To-6'wide by 9'long 4'x 6'2"Single Shed Door,Left Hinge installs it? Paint Selection Placement No Base:No Paint,Trim:No Paint 4'x 6'2"Single Shed Door,Right Hinge Is there a power outlet within 100 feet of installation Customer to apply 2nd coat Placement location? Roof Selection Floor and Foundation Yes Charcoal 3 Tab 54 Sq Ft 3/4"Treated Floor Decking The building location must be level to properly install the Drip Edge Upgrade building.How level is the install location? White Within 4"of level Will there be 18,,of unobstructed workspace around the perimeter of all four walls? Yes Can the installers park their pickup truck&trailer within approximately 200'of your installation site? Yes Substrate Shed will be installed on? Grass �DocuS ned by: Customer Signature: Date: 11/6/2019 —85A893D50578462... • • PLOT PLAN FOR LOT # Indicate location of garage or accessory building Additions with dashed lines Sewerage disposal (cesspool) ED Well gig I I I (lot ft. rear) I Abutter's .Ca• - --.. - _ AbuttNameI Lot # I Name I Name ' Lot # f this is a REAR YARD :orner lot, If this tribe in name ft. i of street. Darner write• name of b .p. • other b street. : SIDE YARD • I HOUSE SIDE YARD •: . • . . . I • SET BACK : • • ft . I (lot ft. frontage) °,ft 1 ---- ' (NAME OF STREET) Informatinn \ Supplied by LARK NORTH POINT