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Home My WebLink AboutBld-20-3858 '�,YRR 1 vmce use UM), .C.! 7. b�! t Permit# .-J r Ou 7 1.4 . H 'Amount s CD i MATTACM [SE l`°"''.aco E,d �� '3 R�S Permit expires 180 days from r.� issue date EXPRESS BUILDING PERMIT APPLICATION a, TOWN OF YARMOUTH Yarmouth Building Department cli 1146 Route 28 Cit d `L South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: (y 5 Pt / ,L 1)1/114P4-1712"ASSESSOR S INFORMATION: Map: Parcel: /� �Jo p OWNER: 1f 4"/"Ad' &.�` /,5l-C l `O jdt-4 Or A PRESENT ADDRESS TEL. # CONTRACTOR:/5W44 go? &&4#44v&• 1/1/e,a645d.i& ill -100 NAME MAILING ADDRESS TEL.##diei—ote' *Residential ❑Commercial Est.Cost of Construction$ Home Improvement Contractor Lic.# /f,4 y9 Construction Supervisor Lic.# es- yp/sr- Workman's Compensation Insurance: (check one) ❑ I am the homeowner°�� 0 II ammt the �/sole proprietor #I have Worker's Compensation Insurance/ ,) (� �/ Insurance Company Name: ( /AIXI/) Worker's Comp.Policy# oalate'0/6-o �7�p7� WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofin : #of Squares /Y ( 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 W 41461,060, ri�� /✓L��iw".�Ltion 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 evocation lice e and for prosecution under M.G.L.Ch.268,Section 1. / �/ Applicant's Sib ature:t.,,./'// Date: /OC �V XOwners Signature(or attachment) Date: _Approved By: ( ., 7 A" Date: // 3 '�-2o' Build or esrgnee TAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No ❑ .Yes ❑ No The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 °,„ .•`' www.mass crov/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): beg , � Address:_Z 4t/ C•/�K0ZUVi . City/State/Zip&400/1) % � Ovc,5r5-Phone #: 50-42, J `7 � Are you an employer?Check the appropriate box: Type of project(required): it)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. 9. _ Demolition ❑ 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. I4.❑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. 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: jfidi//�� (� ,�j� Policy#or Self-ins.Lic. ir��y� (/,� 7c/5 070 Expiration Date: Job Site Address: 075 kz `� City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number d 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 certi under the pains • d.en Ities of perjury that the information provided above� is0.t/,W true and correct. Sianatur : n , /U�/ Date: Phone#: SeY-DY ! Xgor 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#: 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: Reaistration Expiration Office of Consumer Affairs and Business Regulation 110649 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 re Commonwealth of Massachusetts 111 Division of Professional Licensure Board of Building Regulations and Standards Const, thiY pevisor CS-034718 l pires:09/19/2021 THOMAS A tjLLCHEY 82 OLD CHAYHAM f HARWICH MAJ0264ir� E Commissioner 4,/.�c � '"' I ,� 03/07/2019 14:00 Su I I i van Insurance (FAX)978 851 4848 P,001/001 /"—'11 pee (MMIDO/Y1'YYJ Rom' •CERTIFICATE 4F LIABILITY INSURANCE • 03/07/2019 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 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(les) 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 endorsoment(s). _.. PRODUCER Phone, me)e61.9800 Fax:tale)tlttease NONe OT Kim Caron SULLIVAN INSURANCE AGENCY oN! EN ram, (978)475.0400 tar,rml_ (97S)4T5.2171 885 MAIN STREET E-MIL TEWKSBURY MA 01876 ADDEEte' INSURER(S)AFFORDING COVERAGE NAIL# INSURER : XS Brokers Insurance Agency,Inc munry THOMAS A HILCHEY INBUREt a : ACE Group ' DBA THOMAS A HILCHEY CONSTRUCTION mimes c : _ 82 OLD CHATHAM ROAD INSURER 0; HARWICH MA 02645 INSURER E : :NCURER 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 CONDIIlONS OF SUCH P LICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INER ADM weft POLICY EFP PouCYEXP LIMITS OR` TYPE OF INSURANCE Ihg�_��yp POLICY NUMBER I IMY�^�+^^^ r1e `r+ - -- A SENER& uxsur 3AA302088 09/26/18 09/26/19 EACH OCCURRENCE a 1,000,000 Drir To RENTED $ 5D,000 X CDMMERCIAL GENERAL UA6ILITY PRf.MteEjlaxaronoo} jOLAIMS-MADE ['OCCUR MED,EXP(Any One preen) _$ 1,000 PERSONAL P.ADV INJURY $ 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN1 AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 , �JI POLICY a EL LoC $ AUTOMDBILE LIABILITY CEDa.ee�9N+GLE UMR $ �ANY AUTO BODILY INJURY(Pet person)+ $ ALL OWNED ---SCHEDULED_AUTOS AUTOSBODILY INJURY(Per accident)-S,HIRED AUTOS NOON N-OOWNEDo�E iDAtnAcaE $ �_AUTOS teler - — UMBRELLA UAE .OCCUR EACH OCCURRENCE $ Excel! use ~CLAIMS-MADE AGGREGATE $ DED I RETENTION$ ---1 S STATU- 0H R. woRNERS ANO CQ R ENMTIQN 6662UB-2E09540.0-19 03/15/19 03115/20 RYUMRB ER $ MIT PROPRIBTOMPARTNERIEIEDWIVE YIN EL.EACH ACCIDENT $ 100,000 OPPICERIM!MSER EIOLUUE07 N I A E.L.DIsEASIE-EA EMPLOYEE $ 100,000 pAendelory In Mt) II yea.downneunder El,DISFASE•PDLICY LIMIT $ 500,000 OB.CRIPTION OP OPERATIONS DS4ow DESCRIPTION OF OPERATIONS!LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more ewe le 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. AUTHORRED REPRE5ENTATIVE Attention: 1/4.....___thirck.LA Zbc:sPs..._ Amy R.Jose i'M e0Rp-7 - .ORO C.RPORATION. • I rights reserved. _J \