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HomeMy WebLinkAboutBLD-23-000017 Bth:2 3—D CW 1—7 Al.---IYAliN, 1 Office Ilse Only Lim. Amount 3 5".66 Permit expires ISO days from issue date EXPRESS SHED PERMIT APPLICATICri TOWN OF YARMOUTH KECE1VED Yarmouth Building Department 1146 Route 28 e[24,0_ -1.122 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT i CONSTRUCTION ADDRESS: 29 4),Q kw- i•-) L.,.., , etl.ere- -u-itto,..A. Afiro767.c ()INNER: (,/1&AA. 4 ...Ak NAME PRESENT ADDRESS ....._,.._ / TEl . 8 coNTRAcToR:"r-v-Fr--(ilea( Z,..tc, I 297_. .,(AiN, ii,./ra,./A Sik. 600 603—9z/- 14/3 NAME "-ii MAILING ADDRESS " TEL,4 4, ,..,.... orl‘iidential Commercial 1st.Cost of Construction$ a Home Improvement Contractor Lic.# I 97,/ y Construction Supervisor Lit. Workman's Compensation Insurance: (check one) I am the homeowner I am the sole proprietor have Worker's Compensation Insurance Insurance Company Name: ..7,44.,",,,...„„_- c,tor-ao ) Worker's Comp.Policy# Al iv c $1 z.,31 222_ _ SHED INFORMATION New Size L 10 x W (9 x H & Corner Lot: Yes No ......._ Per Town of Yarmouth Zoning, Br-Low Sec 203.5 Note E: Side and rear yard seibacks fir at cessom.buildings containing one hundretfhliv(150)square feet or less and single story, shall be'sir Offeet in all districts, but in no ease shall said accessoo,buildings be Inith doscr than twelve i12,4 '1'`.tset to ant' other budding on an adjacent parcel, All shciA ore required to In'Mewed thirty IA ket kohl(upfront lot line, Replace existing* Size L x W x I/ *"1-he 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 atm,knowledge and belief I understand that any false=swats) will be just cause for denial or revo:Lion of :license an 'or prosce on under M.G.L.Ch.268,Section 1, Applicant's Signature: Date: 7 I EZ Owners Signature(or attachment) , Date: / Z 2 —7"--°Z— Approved Bv:_ ___ , .------ Date: 7 l itiikling Official(or ,..n EMAIL ADORE, Zoning District: historical District: Yes No Flood Plain Zone: , Yes No Water Resource Protection District: Within 100 ft.of Wetlands:*** Yes No Yes . No ***Note:Conservation review required it'within WO ft.of Wetlands 3122 The Commonwealth of Massachusetts "=�--- 1, Department oflndustrialAccidents = IER= 1 Congress Street, Suite 100 i TaTil." Boston, MA 02114-2017 ..''Y www.mass.gov/dia moo Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectriciansfPlumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information /J Please Print Legibly Name (Business/Organization/Individual): tc- . ,4. Kp Address: 2 c-1 o L City/State/Zip: 0e3;- �md h. MA- 07675 Phone#: • • Are you an employer?Check the appropriate box: Type of project(required): l.I]I am a employer with employees(full and/or part-time).* 7. L_I i iew construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.) 3.C /' 9. C Demolition m a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 [E Building addition 4.C 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 11.7 Electrical repairs or additions proprietors with no employees. 12.E Plumbing repairs or additions 5.0 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. I3 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. 14.[]Other 152,§l(4),and we have no employees. [No workers'comp.insurance required.] *Any applicant that checks box 41 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. tContractors 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. 1 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 S250.00 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 a der the ns d penalties of perjury that the information provided above ' true and correct. Signature: Date: 7/ Phone#: / �] _� o / �(, / 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): I.Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 5,Other Contact Person: Phone#: • PLOT PLAN FOR LOT # ,,,,_ - Indicate location of garage or accessory building Additicos with dashed lines Sewerage disposal: (cesspool.) 69Well rig I p �... .,,,,,. I ( ................ft. rear) I I Abutter's 4---— - - No# 6f — L yr rt. 1 Abutter's — 1 Name Lot# Lif this is a , REAP YARD corner tot, If this is a write in V corner lot, name of street. 1 ft• write in I /' name of street. 1 t4 1: : SIDE YARD SIDE• YARD • HOUSE ; . • • • • • SET BACK 44. f : I (lot. tt. fotage) t I / 1 / (NAME OF STREET) 1 Information Supplied by �, z V K T O mwm jjCC = = CCD O = m o Co _ - MO p � -I o � n 1cca Ey Zvi 1 m co -• -1 xj c 'T1 o — iva �0c rU) � p ( nl -o p m 7U 2 O z .A = !"mn _ Cm C SZy = 0 -4Q' o - 0 m omsi' nc n) J • o ooxo O5 133 o v ; -1 ccoo oU) ey xiw0 C o = n �' 0 70 z _. CD O C C CD in xi », CD m O= 0 CD C) - oo 1 C) ,< ll3 CD 3 5. > 0 00mm CD- # .— ,moo o L ,4. U) OU o m F m � � O = nart Ecn0mo O - U) Z n � o = -t U) CD CI E.,' � �• e S• ai v CD a) CO a. co (I) 0- Wc * >,.... Fv a 74: HOC C cco •=4a m OD �I �. o if m � oo � c �, , O JJ • o ai c• m c .. . CD I ikt � c� o a ° OD 0 CO m .• = as - N � � A— ) m • o06 o a• co (0 Oa vc COD D IF co _ o o c) ,-. a. N O. xi CD C 3 C) a) C. , , The Commonwealth of Massachusetts Department of Industrial Accidents 14 4 ' ;� Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers'-Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):Tuff Shed Inc. Address:1777 S. Harrison St#660 City/State/Zip:Denver, CO 80210 Phone #: Are you an employer? Check the appropriate box: Type of project(required): 1.❑■ I am a employer with 25 4. ❑ I am a general contractor and I 6. ❑■ New construction employees (full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. El Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub contractors have g. L Demolition workingfor me in anycapacity. employees and have workers' p y• 9. ❑ Building addition [No workers' comp. insurance comp. insurance.+ required.] 5. ❑ 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 12.0 Roof repairs insurance required.] c. 152, §1(4),and we have no SHEDS INSTALL employees. [No workers' 13.❑ Other 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: IMA, Inc - Colorado Division Policy# or Self-ins. Lic. #:MWC31257222 Expiration Date:03/1/2023 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 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Sabrina Baptiste Digitally signed by Sabrina Baptiste Date 2021.11.090942:19-05'00' Date: Phone#: (603) 421-6873 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(check one): 10Board of Health 20 Building Department 3❑City/Town Clerk 4.0 Electrical Inspector 5EIumbing Inspector 6.❑Other Contact Person: Phone#: AC I$. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 2/24/2022 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 have ADDITIONAL INSURED provisions or 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 IMA, Inc. -Colorado Division NAME_ IMA Denver Team PHONE 1705 17th Street, Suite 100 L FAx E-MAILNo Ext: 303-534-4567 we Nit Denver CO 80202 E-M ADDRESS DenAccountTechs@imacorr com INSURER(S)AFFORDING COVERAGE 1 NAIC# INSURER A:Old Republic Insurance ComRan� 24147 — — INSURED _ --- - ---- - - - TUFFSHE Tuff Shed, Inc. INSURER B:Allied World Assurance CompanL(U.S)Inc. 19489 1777 S. Harrison St.#600 INSURER C: Denver CO 80210 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:158629024 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. LTR --- TYPE OF INSURANCE - -. INSD I ,_ �-- -. -._—_-._ -INSR � ----- X �SUBR, POLICY EFF POLICY EXPO-- LIMITS --- IADDL WVD j POLICY NUMBER (MM/DD/YYYY)I(MMIDD/YYYY � LIMITS CLAIMS-MADE GENERAL LIABILITY ) MWZY31257122 3/1/2023 EACH OCCURRENCE _ $1,000,000 A I X 1 COMMERCIALGENE X I — OCCUR 3/1/2022DAMAGE TO RENTED - _ _-- -------- PREMISES/Ea occurrence $500,000 Contractual Liab I MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: -- -- �, - -- - I 1 POLICY' - PRO I GENERAL AGGREGATE i $2,000,000 --JECT X j LOC r • $2,000,000 i X j OTHER: $5M Agg Proj/Loc MWT631257022 I COMBINED SINGLE LIMIT t PRODUCTS-COMP/OP AGG J $ A AUTOMOBILE LIABILITY 3/1/2022 3/1/2023 I $2,000,000 JANY AUTO ;tea accident I— --- ------- HIRED I SCHEDULED '� BODILY INJURY(Per person) $ AUTOS ONLY _ ---- it - BODILY INJURY(Per accident) X I X NON-OWNED X X PROPERTY DAMAGE --- -- I AUTOS ONLY L AUTOS ONLY $500 Col Ded (Per accident2 $ B UMBRELLA LIAB X $250 Cm Ded I$ iXii OCCUR 3/1/2022 3/1/2023 EACH OCCURRENCE $1 000,000 r EXCESS X IA RETENTION$ III 03127492 CLAIMS-MADE; AGGREGATE $1,000,000 A ;WOREMPLO MWC31257222 Y/N t nnn $ N 3/1/2022 3/1/2023 X PER OTH WORKERS COMPENSATION ,AND YERS'LIABILITY 1 ANYPROPRIETOR/PARTNER/EXECUTIVE _I STATUTE ER _ States Below OFFICER/MEMBER EXCLUDED? N/A E.L EACH ACCIDENT $1,000,000 (Mandatory in NH) -— If es,describe under E.L.DISEASE EA EMPLOYEE,$1,000,000 DESCRIPTION OF OPERATIONS below r' E.L.DISEASE-POLICY LIMIT$1,000,000 DES CRIPTION OF OPERATIONS .. '/LOCATIO NS/VEHICLES I ACORD 10 Ail States ( 1,Additional Remarks Schedule,may be attached if morespace Included in Workers Compensation:AL,AR,AZ, CA,CO,CT, FL,GA, IA, ID, IL, IN, K ,s required), NM, NY, NV, NC,OK,OR, PA,SC,TN,TX, UT,VA,WI,WVS, KY, LA, ME, MD,MA,MI,MN,MO,MS, MT, NE, NH, NJ, RE:Store 960. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Tuff Shed, Inc ACCORDANCE WITH THE POLICY PROVISIONS. 1777 South Harrison Street Suite#600 Denver CO 80210 USA AUTHORIZED REPRESENTATIVE ACORD©1988-2015 CORPORATION. All rights reserved.- ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 144 .?•# o, ; ce f x 70 Town of Yarmouth conae�atib„otr Conservation Commission Building Permit Sign-off Application Ya�ti7oUt6 o co TO BE FILLED OUT BY BUILDING PERMIT APPLICANT �r"�s on�at'on Building Site Location: - GlDoke/ /3Alt n Map # + -.. Lot(s)# E C ir Property Owner: ,. �"' Date filed: 7 S eo Z, 'Applicant: eti. Applicant Address: '�' ,w.,. ,`fit-A),;,,, cj* ��+� 0110 Email: .( c am.„.:_ 4_ •.G r,-,. Telephone: �'l �► - Please Note:By submitting this application the applicant grants permission to the Conservation Office to enter the location to conduct a site visit(if needed). Proposed Project Description: f[00d i.N1%-itkl ''• sk, d t - f Y•.,,(. 4..1,if tY'k "firiol4iri cit Site Plan Title/Date: 7 r z c_ RECEIVED TO BE FILLED OUT BY CONSERVATION ADMINISTRA O : L i Does the :: 0sed p project require a permit? rQ 0 JUL 06 2022 Refer t0: S3- BUILDING DEPARTMENT or DOA permit eY__ _ Comments from Conservation Commision: Approved) Conditionally Approved Rejected Conservation Commission Sign-off Signature: 4 ---4' Date: [ *TO APPLICANT: All work-related debris shall be taken offsite or disposed in a legal upland location. At the end of each day, the area shall be clean and no debris shall be in the Resource Area. If work is permitted under an Order of Conditions, please arrange a pre-construction site visit with the Conservation Administrator. At the time of site visit, the MassDEP File Number sign must be installed, along with the erosion control/work-limit line. A copy of the Order of Conditions must remain on-site during construction. Please refer to the Order of Conditions for further details. ill o'f vA'Zi, ' Mot the fhr}y i. (7r r.a Amount 3 Pumsi ccpoes ifin dsyr from issue rime EXPRESS SHED PERMIT APPLICATION----------- ; V E D TOWN OF YARMOUT1t E Yarmouth Building Department 1146 Route.28 5:1412s1 a22 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 yilt.,0144. BUILDING DEPARTMENT CONSTRUCTION ADDRESS: 2 4)✓ Le�,..l .1.. ei. �/�' ��� OWNER:4 CA? . 4ie,s. Z-4/ A11/44 ) C4'.1< e/ yv.,..,,x,t{, _._ Ci!`I- 01`6 fi NAME PRESENT ADDRESS TEL. 4 CONTRACTOR:Tt✓'f .Skltrt/4 t Vic. 1197So, .4 , g nf.�,r .. (,o (�4S-94- Ld i3' NAME MAILING DRESS TEL.ii • csidcntiat Cl Commercial Est.Cost of Construction$ if-r°47) Home Improvement Contractor Lie.H I (/? / y Construction Supervisor Lit.u Workman's Compensation Insurance: (check one) I am the homeowner I am the sole proprietor ave Worker's Compensation Intittrance Insurance Company Name. ,--E - C ' C.)foNA* 41:qorrker's Comp.Policy 4, IV G ✓ SHED INFORMATION New Size L 10 x W lA x H G Corner Lot: Yes No7< Per Town of Yarmouth Zoning Br-Law See 203.5 Note E: Side and rear yard setbacks for accessory buildings containing one hundred f fly(150)square feet or less and single story, shall be sir(6)feet in all districts. but in no case shall said accessory buildings be built closer than twelve(12i feet to any other building on an adjacent parcel. All sheds are required to be located thirty(30)feel from aizy front lot line • Replace existing* 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) wilt be just ,sr for denial or rev ion of •license an or proscc on under M.G.L.Ch.268,Section I. Applicant's Signature: Date: r%G Owners Signature(or attachment) Date: I ' Approved By Date: / ����" Building Official(or rn EMAIL ADORE. Zoning District: Historical District: .. Yes ii No Flood Plain Zone: .. Yes No Water Resource Protection District: Within 100 IL of Wetlands: • Yes _ No " Yes , No ** Note:Conservation review required if within 100 ft.of ii 3/22