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Home My WebLink Aboutbld-20-3504 ,oF,Y`qR vurce use uwy Permit# =r c Ou. - • .�H+ :Amount CiL.' — eA C •'TTA Mµs j4 °"°°• o c1, Permit expires 180 days from ^- 0"3J Tissue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department n j� (��l�Z 1146 Route 28 lam` South Yarmouth, MA 02664 (508) 398-2231 Ext. 12 1 CONSTRUCTION ADDRESS: ?9,' ,ei-Ty- .. ASSESSOR'S INFORMATION: D �: //` Map: Parcel: `J � �- OWNER: AV41141td/h ' • RE�SjENT A�jD/],�R/E}S�S� .�j TEL. �j �29 CONTRALTO 0�4�<iLir4/Ci��iGCr�'/U .8.",1,4 i471 , "/�e NAME MAILING ADDRESS L.# AA l/ ❑Residential "Commercial Est.Cost of Construction$ �UD1 4 Home Improvement Contractor Lic.# n0d97 Construction Supervisor Lic.# r7y�j, Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole`proprietor d I have Worker's Compensation Insurance Insurance Company Name: ,0�Cy`�%� V Worker's Comp.Policy#Lra 6.26,�(/,/19-- 3"€ WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 4 (X)Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: iett,fe, adlid.) ..../e/dX#12edori 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 licen an for p secution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: ,40,47 Alas Signature(or attachment) Date: / /iy 1P Approved By: _„,�,°/ Date: IV-1'I-)5 Building Official(or designee) EivIAIL ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts �2 I Department of Industrial Accidents r MG 1 Congress Street, Suite 100 W, Boston, MA 02114-2017 \t„,, 5�•`''� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. nfo Applicant Irmation , Plea Print Legibly Name (Bus Applicant Information mati Individual): �.703/.7(eG,// Address: ,(21 " City/State/Zip: i%/ Phone #: ��07 `/ , Are you an employer?Check the appropriie box: Type of project(required): 1. 11 I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity. [No workers'comp.insurance required.] 3._I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. ❑ Demolition 10 Ei 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.Q Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 6.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. I3 of 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 providi a workers'compensation insurance for my employees. Below is the policy and job site information.suancC ��f,) / c,„ Insurance Company Name:/ G J fred) Policy#or Self-ins.Lic. 4%90 01gDR '`-1,7 Expiration Date: „SI/1d Job Site Address: City/State/Zip...' / J� Attach a copy of the workers' compensation policy declaration page(showing the policy number an./ xpiration 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 under the pains d enalties of perjury that the information provided above is true and correct. Sisnatur Ad/P /9 �/ ,(� 5� Date: Phone#:LW"�% �l( .1(! 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 retumed 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 03/07/2019 14:00 Su I I i van Insurance (FAX)978 851 4848 P,001/001 '.".4 WI (Mew0 WYV) A= CERTIFICATE OF LIABILITY INSURANCE . 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 polloy(tes) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain polities may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). �. PRODUCER Phone: (978)861.98009900 Fax:(978)861-464e —�— NONEACT Kim Caron SULLIVAN INSURANCE AGENCY PHONE WO No,ErtC (978)475.0400 fac_Ne): (978)475•T1y1 885 MAIN STREET €4M11. TEWKSBURY MA 01676 AOn 5S• INSYRER(S)AFFORDING COVERAGE NAM 0 INSURER A : XS Brokers Insurance Agency,Inc INSURED THOMAS A HILCHEY ACE B : ACE Group , DBA THOMAS A HILCHEY CONSTRUCTION INSURER C : 82 OLD CHATHAM ROAD INSURER D: HARWICH MA 02645 INS 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 AU.THE TERMS, _EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, , INSR ADMMAR POLICY EFP POUCYE*F LIMITS LTR TYPE OF INSURANCE — INse wvo POUCY NUMBER Imo.-. , ,DI> 'n A OENERAL ueaILRY 3AA302058 09/26118 09126/19 EACH OCCURRENCE y$ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMA TO RENTED PR $ 50,000 F•MIeE�Es varyren� MED.EXP(Any one peroon) S 1,000 CLAIMS MADE `�OCCUR PERSONAL 8 ADV INJURY $ 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 —I POLICY I:GT 7 LOC $ AUTOMOBa-E LIABILITY (CEO BIN 091NGLEUMR $ MANY AUTO BODILY INJURY(Per semen) $ ALL OWNED —SCHEDULED BODILY INJURY(Per eccldenq $ — AUTOS H AUTORED8AV703 --AUTOSWNEO (pa.Ii P „I I I UMBRELLA LJAB OCCUR EACH OCCURRENCE S _!-Excess use CLAIMS-MADE AGGREGATE S Deo f RETENTIONS _ $ woRKERE COMPENSATION 6662UB-2E09540-0-19 03115119 03/15/20 TOONYLM.WC ITS ER S g ARO EMPLOYERS' LIABILITY ANY ►RDPRIETORPARTNS1bEEECUnVE Y/N E.L.EACH ACCIDENT $ 100,000 OPPICEIULIEMBER PaoLUOEDT NIA E.L.DIsEAT[-EA EMPLOYEE S 100,000 IMsndslory In NH) oe tRIIPTiOaunder ERArroNS Wow _E.L.DISEASE•POLICY LIMIT $ 500,000 J. -, DESCRIPTION OF OPERATIONS!LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,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 02660 ACCORDANCE WITH THE POLICY PROVISIONS. AL/THOrnzED REPRESENTATIVE 6‘C '.Z Attention: v Amy R.Jose t£14QB0.9 CoRm 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: Registration Expiration Office of Consumer Affairs and Business Regulation 1.10649 - 11/02/2020 1000 Washington Street-Suite 710 THOMAS A.HILCHEY Boston,MA 02118 THOMAS A.HILCHEY„ 62 OLD CHATHAM ROAD. HARW ICH,MA 02645 Undersecretary Not valid without sig TO 1 Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards • Constrytt/bets pervisor S r CS-034718 spires:0911912021 {;. lt ! 7 THOMAS A F!LCHEY 3. 'c 82 OLD CHATHAM = Y c HARWICH MA?02845 Commissioner /t. ! ��