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HomeMy WebLinkAboutBld-20-005055 1 ) >,H vtc "c z,(' I " ntn1 Office Use Only ,aS O H. lir, r it ".° i1 e a L I' FROM SIRLI AND Amount _ y T. cs,4 „ E d•' Permit expires 180 days from :c-• issue date EXPRESS SHED PERMIT APPLICATIOrfQ J E D TOWN OF YARMOUTH • Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 iY • ' •R1 i r�-', keru �^ (508) 398-2231 Ext. 1261 L CONSTRUCTION ADDRESS: Jr-l E V Etuo VC.E E N 67. 5©VTh yo-te tc5u I l 4- ASSESSOR'S INFORMATION: Map: Parcel: OWNER: 51lVGAJ 5OV'4A 20 F�4ti��II=L(7 c5►. DEDh'4(4j 38it -4 NAME PRESENT ADDRESS TEL. # CONTRACTOR: eEEDS FL .s1 15 . T(AGy L n t.k 5�J .4)11 8eg.- �5- S1t{E'L?S NAME MAILING ADDRESS TEL.14 fa'Residential 0 Commercial Est.Cost of Construction$ 5 ( Home Improvement Contractor Lic.# Construction Supervisor Lic.# WorkmaVs Compensation Insurance: (check one) I am the homeowner ❑ I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# SHED INFORMATION / New Size L x W x H Corner Lot:Yes No V Per Town of Yarmouth Zoning By-Law Sec 203.5 E: Side and rear setbacks for accessory buildings less than 150 square feet and single story, shall be 6 feet in all districts, but in no case built closer than 12 feet to any other building. Replace existing* NO Size L x W x H *The debris will be disposed of at: 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's Signature: Date: Owners Signature(or attachment) Date: Approved By: Date: Building cial esi e) EMAIL ADD . Zoning District: Historical District: 1 Yes Li No Flood Plain Zone: ❑ Yes G No Water Resource Protection District: Within 100 ft.of Wetlands: *** ❑ Yes Ll No ❑ Yes ❑ No ***Note:Conservation review required if within 100 ft.of Wetlands 9/13 _ The Commonwealth of Massachusetts a ,� h - Department of Industrial Accidents =r 1= 1 Congress Street,Suite 100 I,Vd f Boston, MA 02114-2017 . ' wwwowe' .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): 5 TEU E kJ 5OO SA Address: 514 EVE ZC0 l2 fjAJ S. City/State/Zip: • V uvv j'l4 62(a GY Phone#: 7 ei -qv- • Are you an employer?Check the appropriate box: Type of roject(required): l.❑I am a employer with employees(full and/or part-time).* 7. 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.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition 10 ❑ Building addition 4.�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 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.1 6.0 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.#: Expiration Date: Job Site Address: City/State/Zip: 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. Signature:�— C � Date: Phone#: 7>s l /`1 Z yS Sl- 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#: !-�® A V DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 6/11/2019 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 policy(ies)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 endorsement(s). PRODUCER CONTACT Rhonda Noble NAME: THE ROWLEY AGENCY INC. ( /c°NE Est: (603)224-2562 FAX No): (603)224-son 45 Constitution Avenue E-MAIL rnoble@rowleyagency.com ADDRESS: P.O. Box 511 INSURER(S)AFFORDING COVERAGE NAIC 8 Concord NH 03302-0511 INSURER A:Phoenix Insurance Co. 25623 INSURED INSURERB:TraVelers Indemnity Co 25658 Reeds Ferry Small Buildings, Inc. INSURER C:A.I.M. 3 Tracy Lane INSURER D: INSURER E: Hudson NH 03051 INSURERF: COVERAGES CERTIFICATE NUMBER:19/20 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 CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR JI9SD WVn POLICY NUMBER (MM/DD/YYYY) (MM/DDIYYYYI X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTE A CLAIMS-MADE X OCCUR PREMISES(Ea o urrence) 300,000 CO-0L225931 6/2/2019 6/2/2020 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X 2E8: LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ B X ALL OWNED X SCHEDULED AUTOS X AUTOS 810- 1L90377A 6/2/2019 6/2/2020 BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS X AUTOS (Per accident) $X UMBRELLALIAB X OCCUR EACH OCCURRENCE $ 4,000,000 B EXCESS LIAR CLAIMS-MADE AGGREGATE $ 4,000,000 DED X RETENTION$ 10,000 CUP-OL228828 6/2/2019 6/2/2020 $ WORKERS COMPENSATION 3A States: NH and MA X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE No Excluded Officers E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N N/A C (Mandatory in NH) WMZ-800-8007285-2019A 6/20/2019 6/20/2020 E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Covering operations of the named insured throughout the policy term. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE "For Informational Purposes Only" THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE n Rhonda Noble/RLN KdKcta,-4-T)° - ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) Reeds Ferry Sheds r_TJ e).in/nano. c/t a n WaeAuiet, .s Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation REEDS FERRY SMALL BUILDINGS INC Registration: 119903 3 TRACY LANE Expiration: 09/16l2021 HUDSON,NH 03051 Update Address and Return Card. SLA, 0 24M-0=,117 /. ,,,,,,,, „/r/,y-tl,,,.,.,,�,,:.✓� Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corooration before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 119903 09/16/2021 1000 Washington Street -Suite 710 REEDS FERRY SMALL BUILDINGS INC Boston,MA 02118 MICHAEL D.CARLETON 3 TRACY LANE ' 44" / HUDSON.NH 03051 Undersecreta mot valid without signature ry Air f<ff if 1" ��J ° ��rf .'. j LAt'LVEISC 70411r/10'r-,�1i1" t{ 1AG ti,-11+ .1 «••.5 R1,4,t ri f3rril(hn�1 Re'{uA/�t,r� 1t 1 �'1 �LIr,7+ 588.,7 4. � 'KptrE 5 '1 Sri a'1 • MICHAEL CARLETON 202 HARDY ST. DUNSTABLE MA 01827 �. • 44 PLOT PLAN I. ►', , FOR LOT # Indicate location of garage or accessory building Additions with dashed lines Sewerage disposal (cesspool) Well 0 I I .� .._.. I (lot ft. rear) _ '0• Abuttos s + -- — - Name Abutbor' Lot # LtI Name 1 I Lot # f this a REAR YARD :orner lot, ft. If this vrite in name I corner 'f write v „. name of ,I, P. other tit street. 4'i 4 : SIDE YARD • HOUSE SIDE YARD • G-- — -ET' • . . • I . SET BACK • . . ft . 4 4 r 1 a (lot ft. frontage) • / Cq 1.%1)Eg&#_.&r----/V rie- ' ---7--- • / (NAME OF STREET) Information Supplied by • !ARK NORTH POINT