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HomeMy WebLinkAboutBLD-23-01190 (01' .-1 e���v_— l� /2e 'Permit#L4-`�1/`/,4 ?... ' _° RECEI _ ED 'Fee$ 73�,U ' x z Perot expires 6 months from MATTA A CS �^.rawWy9�' rsEpo220n j issue date. Z-1) — 3 -6//,0 Bu LE\ SILDING - PERMIT APPLICATIONey ` TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: d7' j4Y ASSESSOR'S INFORMATION: Map: Parcel: OWNER: NAMEY/1,7L124.1/6/4/ PRESENT ADDRESS TEL # 56v. A 4/ CONTRACTOR: & dAe / ��a .C�����/(,� /c' NAME MAII NG ADDRESS # 0 Residential 0 Commercial f f ❑Est.Cost of Construction$ did//© d Home Improvement Contractor Lic.# //(JLs? Y Construction Supervisor Lic.# a ;7 5 : Workman's Compensation Insurance: (check one) 0 I am the homeowner ) 0 I am the sole roprietor •I have Worker's Compensation Insurance /, Insurance Company Name: ,/ ,N Worker's Comp.Policy#/ �g` �(9":� WORK TO BE PERFORMED ❑Tent (Fire Retardant Certificate attached) 0 Wood Stove Shed (Siding: #of Squares /7 0 Replacement windows:# Q ❑Replacement doors: # ,(Re-roof. #of Squares /9 ❑Insulation ()Stripping old shingles* ()going over layers of existing roof ❑ Old Kings Highway/Historic District Roofing/Siding(Like for Like) *The debris will be disposed of at: A �/f �— � ,,,,„64 Location of Faci ty 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 ocation of my licens for p secution under M.G.L Ch.268,Section 1. l .�J Applicant's Signatures Date: �e/`O�� X/y f Owners Signature(or attachment) 7 ----)a --) Date /�. Approved By: r Date: 7 Building Offic. or d ee) Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No ❑ Yes ❑- No 3/01 1 gk • The Commonwealth of Massachusetts P Department of Industrial Accidents el , Office o f Investigations _ __•�= 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name (Business/Organization/Individual):l.�^�/�,� //�;1��;V � < ���_��� ; %(242L)/W bItir,/ 6i ______ , Address: � City/State/Zip- - eil Phone #: , /7-' y / d you an employer?Check the appropriate box: - Type of project(required): 1. I am a employer with Aro! 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6 El New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. [1 Remodeling shipand have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' comp. insurance.: 9. 0 Building addition [No workers' comp. insurance required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12oof rep irs insurance required.] t 3a.❑ c. p ly e and we have no 13IZOther .4/ dgeitMil I am a homeowner acting as a employees. [No workers' general contractor(refer to#4) comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensatiodtoolicy information. t Homeowners who submit this affidavit indicating they are doing all work Ind 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 g workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: /iti„ifs; / b'`dl�Cl Policy#or Self-ins. Lic.#:( E lAj Z —6 do, Expiration Date: - 7( A� �� Job Site Address( 1 4 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well a3 civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that 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 an penalties of perjury that the information provided above Li true and correct SiZliatUrt: Date: ,e;7/-ai w' - Phone fE: (�,—a ! 9: 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 i Massachusetts General Laws chapter 152 requires all employees to provide workers'compensation for their employees. Pursuant to this statute,an employes is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An stapler is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the focegoths engaged in a joint enterprise,and inchading the legal representatives of a deceased employer,or the receiver or trustee of as 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 grotmds or building appurtenant thereto shall not because of such employment be deemed to be an empbyer." MGL chapter 152, 125C(6)also states that"every stab or local licensing agency shalt withhold the Imams or renewal sf a license or permit to operate a business or to construct buildings is the cooasoawealth fer any applicant who has net produced acceptable evidence of compliance with the insurance coverage required." Additionally,MC3L 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(a),address(a)and phone number(:)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. Abe be sure to sign and date the affidavit The affidavit should be returned to the city or town that the application far the permit or license is being requested,net 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 iaoeuraeee license number on the appeopaiate line. City or Tun Otndab 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 nee to fill in the penult/license number which will be used as a reference member. In addition,an applicant that must submit multiple permitnicense applications in any given year,need only submit one affidavit indi-s,tng 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 mut be filled out each year.Mae a home owner or citizen is obtaining a license or permit not related to any business or comanrcial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. Case Department's address, telephone and fu number: The Commonwealth of Massachusetts Department of industrial Accidents Ofnes of Inresdptions 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax i#617-727-7749 Revised 11-22-06 www.mass.goy/din • 06/16/2022 10:31 Howe Insurance (FAX)9784752171 P,001/001 /-",- DATE (MlWDDt V A D° CERTIFICATE OF LIABILITY INSURANCE 06/1612022 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 Phone: (978)851.9600 Faz (978)475.2171 CONTAAE:CT Sullivan Insurance Agency NA/ SULLIVAN INSURANCE AGENCY PHONE 978 851-9600 F`� 978 475-2171 4 PUNCHARD AVENUE Ed1 ( ) lac Hal { ) E-MAILE-NAIL ANDOVER MA 01810 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURERA : Evanston Insurance Co t INSURED THOMAS A HILCHEY INSURER a : Ace American Ins Co DBA THOMAS A HILCHEY CONSTRUCTION INSURER : 26018 82 OLD CHATHAM ROAD INSURER HARWICH MA 02645 INSURER INSURER F : COVERAGES CERTIFICATE NUMBER: 36950 REVISION NUMBER: THIS :s 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. '.NSR ADO'L SUER POLICY EFF FOLICYEXP LIMITS LT TYPE OF INSURANCE I NSR VWVD POLICY NUMBER WV)yrYY) LMIATµyYrrl A GENERAL L ABILITY 3AA506580 09/26/21 09/26/22 i EACH OCCURRENCE 1$ 1,000,000 DAMAGE TO RENTED $ 100 QQQ X COMMERCIAL GENERAL LIABILITY PREMISES(Es oaurenre) CLAIMS-MADE X I OCCUR MED.EXP(Any one person) S 5,000 1 ! PERSONAL 8 ADV INJURY $ 1,000,000 - GENERAL AGGREGATE $ 2,000,000 GEN't.AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 1,000,000 - POLICY- JPERCT O - LOC , S AUTOMOBILE LIABIUTY (Ea ecIdNEO SINGLE LIMIT (Ea $ acder»j ANY AUTO BODILY INJURY(Per person) $ ALL OWNED -SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS --NON-OWNED PROPERTYCAMAGE $ HIRED AUTOS ,AUTOS (perscc:de,r.i $ UMBRELLA LIAR 1 I OCCUR EACH OCCURRENCE $ _EXCESS LIAR 1 CLAIMS-MADE AGGREGATE $ ICED I ?RETENTION S I $ ' WORKERS COMPENSATION 6S62UB-4N92588-6-22 05/05/22 05/05123 WO STATU- TORY OTH B UNITS ER S AND EMPLOYERS' LIABWTI' Y 1 N E.L.EACH ACCIDENT $ 100,000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? Y NIA EL DISEASE-EA EMPLOYEE $ 100,000 (Mandatory In NH) If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below • DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Thomas Hilchey is excluded from the workers compensation policy CERTIFICATE HOLDER CANCELLATION Town of Dennis SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ' ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE ..,e;tel>.. . ......________..., Attention: 774-408-7127 David T. Louis ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD G — 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 110649 11/02/2022 1000 Washington Street -Suite 710 THOMAS A.HILCHEY Boston,MA 02118 THOMAS A.HILCHEY ✓82 OLD CHATHAM ROADj C. lam/ HARWICH,MA 02645 Not valid without signatttt 61 " Undersecretary14 Commonwealth of Massachusetts t Division of Professional Licensure Board of Building Regulations and Standards Constr tth rvisor CS-034718 - 6c/pires:09/1912023 THOMAS A HILCHEY 82 OLD CHATHAM ROAR HARWICH MA 02645 Jo, c Si ONN-.t:10 Commissioner ciptiail