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„,.. „.--,--) EXPRESS SI1ED PERMIT APPLICATION
_.---3--,-i--- - ' *7*. TOWN OF YARMOUTH‘ • •?, 1, 0 ITanan &%Ming Department
1 ‘ 1146 Route 28
-..-- c South Yarmouth,MA 02664
\ ', -• , , ,,--- . (508)39S-2231 Ext. 1261
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a s , IL• . • • ADDRRS&
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/ ZTI• 'S INFORMATION:
rZIIIIIIMM=IDIM 70V-5/6 -5/77 *
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NAME
PRIMP4T ADDRESS
TEL. II i i tr • i . %
NA 9 q -c:28-411)
M
MALMO ALORESS
TEL I
, ...."
0 Cammemial Est Coat ofCeestruction S___ C.) (,_) ....______
Rom , coatrater jue.pLZaisoasgrucdoa sepinber Lic,# . , ..C.S .A1 01 SV.I2 cl
W' • ''a Compeerotion Inmanaca (cloak ono)
4 I an dm hameormer 131 am the sole preprietor 47/10 have Walter's Compensation hem=
Germany Name: a rçiSnS.wodmes comp.possite C CaO0(11)00 9 51 -261R.11
SHED INFORMATION
New Size LI 0/ zw_lx .rtill7711 Corner Let Yea No
SYde , , rear sabaci 1 for accessory Wrings las than ISO square feet and singk stoyy,shall he 6fitet hi al 1 districts,but
In no - bulk closer lbws 12feet a ow other hulking
'•• • atisnag* Sze L x FY z If
*The wit be dimmed of et OS9 OL)tx-A-‘ A i-\IN_c- _•c( 41"Ptak) .--h
Loadoo*MAW
!edam paritho of , Man tallied am aro sad ocacalo Ibo bat ofig toodalse ad Idiot I oackalod Mot aor SW anotads)
mil bo •,, la&aid or ,, , hasag adixt pionaerat soder MALL.Clt.26/1.Sawn I.
' Sigoolote: ritah44,4 i A i NOVO"Ci. t_e,. .1. Dag: i I ILa 6 ___GQ
ilri ."'
Ovum. (or LI VI" 7‘X/egtuff Dew
Approsad - .
Dm= /-----2
adios - ' ' EMAIL dalS:
Zeal.,District
fistorical Distdot 0 Yes CI No Mood Plain Zoom 0 Yes 0 No
Water Resource We Didriet Within 100 2.of Wetlands:***
0 Yes 0 No 0 Yes 0 No
***Noc Conservation review required if within 100 It.ofWellaids
91113
UT/UV/2019 1Z:40PM FAX 16084301115+ PINE HARBOR 0041/0401
I
•
The Commonwealth ofMassoehoseas
l»�_ :--_,-:„7,.
1 � nt Of I 4eekknie
"'=_� y 1 CongressSt ee4 Suite 100
- _ - Boston,M4 02114-2017
, www:rrtossgep/&a
Workers'Cou peasa Insurance Affidavit BailderyC
TO BE FILED WITH THE PERMITTING AUTHORITY.
as/Plumbers.
Applicant Information
Name(Seeinessror�iv ): L y Y Y h r Legibly
Address,: �—
City/State/Zip•
taiittbAla WWII ?howl: ,30A Aj3( a8..
Are you an employee Cheek Me appreprinte bor.
1.0 I am a xaaployer with.— A1 Mil malt Rtrtdipae)• T , -of project(required):
ow
1 am a sale
roPrictor or
�ywqeepaciryp[ miters'comp parmership and have ao. ragmed.j }yeas waiting for mil'ipi r'•' • B. . N Remodeling
.[�I am a homeowner d ,, wantC required.]+ 9•:.III Demolition
1:11 am a hemernmer and mil be hiring commas toomrihhet all work on My property. I willi0 ■ Building addition
enure art all core rich:!tare market•competition iaa�or are Kok
Proprieoarx with no employees
11.I Electrical repairs or additions
I am a general contractortrtd I have fitted the fisted on the attached sheet.
12 Plumbing repairs of additions
There luau employees and have workora'comp,insvniace 13,in Roof repairs
6❑wa are a commotion and its officers have exercised their tip orb per MI3L e, 1 III •
tn2•¢t(a).and we have no employees.INoworkers'comp.insurance rogaired..1
'Amy applicant the checks boa N1 mast also fill out the smooch below shoe—their workers'
t Homaowephs who submit this affidavit y °°mP+�°a paiicY �,. .. :.
Tatutcatrors that Check this box moil artadhod an additional all work end then hire a suite o tract 'n� , .,.,anew not those indicating such.
eeeployaaes. lithe sub-eontaaeten kw* showing the Dame Comp.p policy
number.and State or not entities have
�cmm�► �°�'�`°11R provide their wodaers'eoanP.Policy manb�ar.
I am au en ployer Mot is proves worms'compensation�aumecs
tO f'�► Below axpotfYcy m+dlob sole
insurance Company Name:11601402pskaimpiaser5 J ctir ][
Pot cY#or Self-ins"Lie.!!: ��
Expiration Date; '5 L $1 P 0
Job Site Address: City/State/Zip:
T
Attach a copy of the workers'compensation policy declaration page(showing the policy Dumber and expiration date).
Failure to secure coverage as required under MGI.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 5250.00 a
day mgainet the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification. Al
Ids rr+�
y she fS► , ..�'' � ' &for aeation provided abovq trace a correct
w Pate
SalinglEr
•
Ph9a' #.
be merridcd by city or town Vicki
City or Tows: Permit/I,iCease#
barging Authority(circle one):
I. Board of Health L Building Deportment 3.City/Town Clerk 4.Electrical Inspector S Plumbing Inspector
b.Other
Contact Person: Phone#:
earr. ®ramp
I
�'....1 MCG POS-01 THORNE
.ACe0ZO`
;�..� CERTIFICATE OF LIABILITY INSURANC °"'E`"""'°°"""""'
TAY2019
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 TIE COVERAGE AFFORDED BY THE POLICES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN TIC ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: B the certificate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed.
B SUBROGAT•ON 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).
ppPRODUCER CT
WI te344 artily olpuance ,Inc ( E,0:(800)553-1801 1 ,I:(877)816.2156
South Den de,iM►02860 72y ,mall@rogersgray.com
INSURER'S) --, ' ;COVERAGE NAIC0
INSURER A:Travelers Indemnity t• l•- 25658
INSUREDINSURER a:New Hampshire . , - Insurance Compan 13083
11 Gmth Posit 44im INSURER c
dbe Pine Hp Wood Proms
EdahwRd SOUINSURER RER E:
' `� a L
x:. LL<: INSURER F:
COVERAGES =r . C ATE'1UMBER: R • NUMBER:
THIS IS TO CERTIFY THAT `HE POISHOP OF.:,..4, URAI D BELOW HAVE BEEN ISSUED TO THE INSURED ED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY ,i MENT, OR CONDITION OF ANY CONTRACTOR OTHER '. MENT WIT H RESPECT TO VN1ICH THIS
CERTIFICATE MpY BE ISSUED OR � +; AIN, THE IR AFFORDED BY THE POLICIES DESCRIBED 'EREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AhD CONDITIONS OF 5 LICIES.LIMITSSHOVN M Y HAVE BEEN REDUCED BY PAID CLAIMS.
mem ; POLICY EFF POLICY UP
A X COIaB AL 6EMBNL Malin` ( pdyYm ( p yYY) URNS
« OCCURRENCE $ 1,000,000
CLASS-MADE X OCCUR 1660- (I ht®8-IND-19� 1/31/2019 1/31/2020 r TOCEa �) S 100,000
r 5,000
EXP(Any one person) $
• ..• s ADV INJURY $ 1,000,000
GB�IL AGGREGATE L e'. = AGGREGATE $ 2.000,000
X POLICY LOB •, S-COMPpP AGG $ 2,000,000
OTHER.
•
ANYAUT D , t $
A mammas L y - :NED SINGLE LPAIT $
BA-4487B888.1 ,,
1 19 1 :•' Y INJURY(Per person) $
dVl� i;. SCIEOIA.ED
AUTOS ONLY `.X , ' BO• Y INJURY(Pet accident) $ 1,�r000
��EEpp c„ • b .t w 1 DAMAGE
X AUTDSONIY 'k: •4 •4 R r • - ) $
$
OnlA W OCCJ . ,OCCURRENCE $
EXCESS CUIM*M DE ` aY i
DED RETENTIONS i
l3 seams" TOII r _§ r e`t Hv ', OTn-
Alai- LARflE Ylff k 'ECC40 7 7 AIUCCI Elf
/82d19 t.
ANY PROPRIET�•EXCLUDED?
I M/A � � E. ' 4 ACCIDENT s i 500,000
y�,RW=�+�� E.L.� �F $ 500,000
SCR TION OP OPERATIONS below t { E.L UCY LIMIT '0�
sZn
D scHN•nON OF OPERATIONS/LOCATnNB/IDIOMS(ACORD 101.AdSfonsi Rwvts SNnddlj,4AR¢>TM IlN`I*cgs apec.Is"AMR")
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF TIE ABOVE DES POLICES BE CANCELED BEFORE
Of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED NN
Town ding
Toweling Dept ACCORDANCE WITH THE POLICY PROVISIONS.
Buil1146 Main St,Route 28
South Yarmouth,MA 02664 cro AUTHORED REPRESENTATAIE
ACORD 25(2016103) ®1988-2015 ACORD CORPORATION. Ali rights reserved.
The ACORD name and logo are registered marks of ACORD
•
v PLOT PLAN
. • '
FOR LOT
babe location of
Additionsdashed lin garage or accessoryaccessorySewers os
-----------
we l og t°essDo21 ® ---
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I not................it. rear)
Name -
Lot N I �/ i Abott r
Name
...__. Lot A
this is a REAR YARD \�
=oar 1 . .
if
trite name ........i....tt. this
of .
I
Corner
Write 1
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•O•I _. name of
other
met.
.
•
HOUSE
SIDE YARD
•E YARD •
.
.
.
•
•
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:
SET BACK
: .
....
•
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(lot. 'Pl,,p 4.. .-....ft. Frontage)
` //
(NAME OF STREET)
/ N. Int rmation
` Supplied by
ARK NO- H POINT
�".. Z/>'ie t/ GGac '?,e �.
-Q', -' Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massac -etts 02116 __
Home Improvement es �.,\: for Registration. .
- — Licensers
— �c seatth of Mass achusetts
tVICGRATH POST BEAM CO. 1_ l� Board of Bending Standards
_ — Constrfktio • 1&2
JAMES McGRATH _ �•,. � Family
259 QUEEN ANNE RD. CSFA-073865 * • r ice:93f1N, 0 g
- HARWICH, MA 02645- ta __ . — 1 ,.- ; -ie • 7r1,44:: .
�ev� JAMESRM,! - F O
s� v 7s
• T •ti'�`,e•f•a nr ���
..:__
Commissioner a
___... _
..
. .
. .
. ,9-,k- w 6),..AaJcAarri,e;e4e/4:
Office of Consumer Affairs and Business Regulation
ti
1000 Washing,.n Street- Suite 710
Boston, usetts 02118 •
Home Improve •. tractor for Registration
K �� Type: Corporation
MCGRATH POST&BEAM CO. v Registration: 132935
D/B/A PINE HARBOR WOOD PRODUCTS . iiiiiiiiiiagskiliiiiiia
�'_ ��: tOJ30J2020
269 QUEEN ANNE RD. —
FiARWICH,MA 02645 AV
I.
44.
slb
CA t 0 aortasm Update Piddrese and Return Card.
.9 is rsos fAiraeu ge.:, y i
Ogees of Consumer Affairs 1 Booboos Regulation
HOME P. -- • ,_ .ENT CONTRACTOR Registration valid for individual use only
k before the expiration date. If found return •
10f3020Z0 Office of Consumer Affairs and Business
MCGRATH .i t a; - �, i, 1000 Washington Street-Suite 710
D/B/A PINE !ot i` *DUCTS
Boston,MA 02 N8
JAWS R. e-:\` '-_
250 QUEEN ANNE , .
HARWICH,MA 02845 Undersecretary Not valid without signaturei
4