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HomeMy WebLinkAboutBLD-23-001189 of atX cal .Permit# Le�Af�-7_ F F -` ° -�� RcCGIVE ® A_$ - 1/4Ata ' "+CS�� � ermit expires 6 months from SEPO22022 slue date. \ 6i-P-- ..,2. 3 - EXPRESS BUILDING PERMI APPE . .` 'iT TOWN OF YARMOU // Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 �f (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: / , filef,I4 ASSESSOR'S INFORMATION: /-9/7-. gef - (37/ Map: Parcel: ` C'✓ v OWNE ' � '`ic(J dI a, „d� &o�Y hl NAME PRE ADDRESS # 1 f !ak v/I'— e, CONTRACTO , ot.,4115- NAME MAILING ADDRESS TEL.# Residential 0 Commercial 0 Est.Cost of Construction$�!'xi.�4 y o® Home Improvement Contractor Lic.# Construction Supervisor Lic.# ( 21g7/1- Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I/J�the sdeprrooprietor XI have Worker's Compensation Insurraance/' f J pC� (J �I �lP y eldil�/G� � et44 p yll S L'IE� -l 1 .11 I� fInsurance Com an Name: f Worker's Comp.Polic WORK TO BE PERFORMED 0 Tent (Fire Retardant Certificate attached) ❑Wood Stove Shed 0 Siding: #of Squares 0 Replacement windows:# 0 Replacement doors: # K,Re-roof: #of Squares !2 0 Insulation ()Stripping old shingles* ()going over 1 ers of existing roof ❑ Old Kings Highway/Historic District /� V�/� �/RAfing/Siding(Like for Like) *The debris will be disposed of at: Oigellt-(4)_.4,/:M/. "( ' ,,ol s li 4rl./'.07,2a) 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 °cation of my livens d or p secution under M.G.L.Ch.268,Section 1. Applicant's Signa Date:Owners Signature(or attachment) Date: 14 Approved By: 'Date: 2 Z Building Official(or d Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No ❑ Yes ❑- No 3/01 E . The Commonwealth of Massachusetts I n Department of Industrial Accidents �, 1i�� �/ Office of Investigations I. � � 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): C!��Gt� 44,/ ��j ✓ C //zzid..// , , Address:y 7% =v afo'4,,e,j)Z,Z1, City/State/Zip/ �� j ,e, d 5 Phone #:. --' J7: `-/ // Are you an employer? Check the appropriate box: - Type of project(required): 14 I am a employer with ��j— 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ 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 12X Roof repairs insurance required.] t c. 152, §1(4), and we have no 3a.❑ I am a homeowner acting as a employees. [No workers' 13.❑ Other general contractor(refer to#4) comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensatioti*olicy 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. i op/. ., obi:, Insurance Company Name: Policy#or Self-ins. Lic..ae `��6- /,19, Gr P=- -. - ,,2 Expiration Date: �s� - J / Job Site Address: 'c� 1 /''/0 r City/State/Zip: ii � Attach a copy of the workers' compensation policy d laration page(showing the policy number and 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 as 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 is true and correct Siggattu t; 402MI 1 Date; ,74)- Phone# i?-X j "',/' : 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 employer is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An sarp.yw is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged is a joint enterprise,and including tie legal representatives of a deceased employed 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 grotmdr or building apprteaant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, f 25C(6)also states that"every state rr local licensing agency shad withhold the Issuance or renewal e(a license or permit to operate a bushess or to construct buildings In the commonwealth for any applicant wise has net produced acceptable evidence of compliance with the iuiraaee caring.required." Additionally,MGL chapter 152,f 25C(7)states"Neither the commonwealth era 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 tie 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)aame(a),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. lien 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. Akre be sure to sign and date the affidavit 'fire affidavit should be returned to the city or town that the application for 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-imumace license member on the appropriate line. City or Tomsk Offielab Please be we 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 eumeat 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 oe marked by the city or town may be provided to the applicant se proof that a valid affidavit is on file for&tine permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or pandit 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 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 The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Oak*of Investigations 600 Washington Street Boston,MA 02111 Tel. /6 l 7-7274900 ext 406 or I-877-MASSAFE Revised 11-12a)6 Fax #617-727-7749 www.mass.gov/dia 06/16/2022 10:31 Howe Insurance (FAX)9784752171 P,001/001 .1- IM1 oDiYYY1t) 1 ACOR CERTIFICATE OF LIABILITY INSURANCE DATE itAI2022 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 ar, 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 Pax (978)475.2171 CONNTEACT Sullivan Insurance Agency SULLIVAN INSURANCE AGENCY PHONE 978 851-9500 A" 475-2171 4 PUNCHARD AVENUE (NC,Ns``'1 ( ac Nat, (978) E•AUIL ANDOVER MA 01810 ADDRESS INSURER(S)AFFORDING COVERAGE NAIC# INSURERA : Evanston Insurance Co INSURED THOMAS A HILCHEY IN a Ace American Ins Co DBA THOMAS A HILCHEY CONSTRUCTION INSURER : 26018 82 OLD CHATHAM ROAD INSURER D: HARWICH MA 02645 INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER: 36950 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 AF=ORDED 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 AD TYPE POLICY EFF POLICY EXP LIMITS LTa TYPE OF INSURANCE IN SR SVVD POLICY NUMBER (hY,VOoyYYY1 (MM'DO'YYYY1 A GENERAL LABILITY 3AA506580 09/26/21 09/26122 EACH OCCURRENCE Ts 1,000,000, I DAMAGE TC RENTED $ 1 00,000 X COMMERCIAL GENERAL LIABILITY 1 PREMISES(Ea see rence) CLAIMS-MADE X}OCCUR MED.EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 POLICY PRO LOG I $ COM91NED SINGLE LIMIT 1 AUTOMOBILE LIABILITY (Ea accident) _ $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED -I SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS - NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (MI student, S UMBRELLA LIAR I OCCUR EACH OCCURRENCE S EXCESS LIAS I CLAIMS-MADE AGGREGATE $ CEO I `RETENTION$ _ $ WORKERS COMPENSATION 6S62UB-4N9.ZSBS-6-22 05(05/22 05/05123 WCTO STATtA OTH AND EMPLOYERS' LIABIDIY Y 1 N EL.EACH ACCIDENT $ 100,000 ANY PROPRIETOIUPARTNERIEXECUTIVE ' �� OFFICER/MEMBER EXCLUDED? T NIA E. DISEASE-EA EMPLOYEE $ 100,000 (Mandatory In NHl I(yes,deacnbe under E.L.DISEASE•POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES(Attach ACORD 101,Additions;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 / 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 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.HILGHEY G't►(/e� CA%�" 82 OLD CHATHAM ROAD HARWICH,MA 02645 Not valid without signa Undersecretaryg I 1 Commonwealth of Massachusetts �C Division of Professional Licensure I Board of Building Regulations and Standards tettlYtipp.rvisor { C S-034718 Aires:09119/2023 THOMAS A HILCHE OLD CHM02 HARWICH 1 ARWICH MAA 0645 i 1 -^ Commissioner clay fi. St" '