Loading...
HomeMy WebLinkAboutBLD-23-003459 pt:''1(R.4 <�,C!'. �/ [OfliCO Use Only r ! 0 i�n 10 Permit expires 180 days from issue date 6 ..34O34'59 EXPRESS BUILDING PERMIT APPLICAT ( C E I V E TOWN OF YARMOUTH Yarmouth Building Department FDEC 2 1 2022 1146 Route 28 South Yarmouth, MA 02664 _.." M BUILDING DEPARTMENT ' (508) 398-2231 Ext. 1261 By. CONSTRUCTION ADDRESS: // �/ !i(/..i� C 91G 110,/ ! ASSESSOR'S INFORMATION: Map: Parcel: OWNER: N L'L/ V..ii,/ " /-J—dg• � ,, NAME SENT AD SS TEL. # CONTRACTOR. g '7 ! / 'rn I -' ~//� `r/� NA! MAIL RESS Residential 0 Commercial Est. Cost of Construction$.� `�e/A Home Improvement Contractor Lic.# //04/9 Construction Supervisor Lic.# cA, -Ckg "7 17 Workman's Compensation Insurance: (check one) ❑ I am the homeowner alidal ❑ Iam tthe s lef proprietor ,! O\I have Worker's Compensation Insurance Insurance Company Name: 04?J K/ Worker's Comp.PolicY#4 zaps ' �/y/Q4.57:- 4). WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 410 Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing* (max. 2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: e,,a, / i 4i�� ��/� 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 evocation of my lice an for prosecution under M.G.L.Ch.268,Section 1. Applicant's Sib ature: Date: rec2 Owners Signature(or attachment) Dater Approved By: Date: Z,;2 -.�' Building Offici r gnee) ` EMAIL SS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No • The Commonwealth of Massachusetts Department of Industrial Accidents e - 1 Congress Street, Suite 100 Boston, MA 02114-2017 5 .www.mass ao v/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A.elicant Information Name (Business/Organi ation/Individual): / Please Print LeiTibl Address: / l City/State/Zip: , � �� %, Phone #: %. "'; /' /, . Are you an employer?Check the appropr ate box: 1 I m a employer with employeesType of project(required): (full and/or part-time).* 2.0 I am a sole proprietor or partnership and have no employees working for me in 2 C New construction any capacity. [No workers'comp. insurance required.] 8. [] Remodeling 3.❑I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. [ Demolition 4.0 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 10 E Building addition proprietors wits,no employees. - 11.El Electrical repairs or additions 12.n Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp. insurance.: 13.C Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. � 14.b 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. r 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. AInsurance Company Name: ,� � Policy#or Self-ins. Lic. #: �� 4 / I ' � =�Ci� Expiration Date: '� Job Site Address: 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 2 50.00 day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance a coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true'and correct. Signature: Date: Phone#: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Issuing Authority (circle one): Permit/License# 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing 6. Other b Inspector Contact Person: Phone#: 06/16/2022 10:31Howe Insurance (FAX)9784752171 P.001/001 Ac RD- CERTIFICATE OF LIABILITY INSURANCE DATE (M1MO0tYYYY) i 06/16/2022 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 1NSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE 1-10_DER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION 1S WAIVED, subject to the terms and conditions of the policy,certain policies may require ar endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Phone: (978)551-9000 Fax (978)475-2171 CO ACT Sullivan Insurance Agency SULLIVAN INSURANCE AGENCY PHONE �rl. {978)891-9600 F`x (978)475-2171 4 PUNCHARD AVENUE (Ac,NPI: ANDOVER MA 01810 LDRESS: INSURER(S)AFFORDING COVERAGE i NAICN INSURER A : Evanston Insurance Co INSURED A HILCHEY INSURERS : Ace American Ins Co THOMAS DBA THOMAS A HILCHEY CONSTRUCTION INSURER : 26018 82 OLD CHATHAM ROAD INSURER D: HARWICH MA 02645 INSURER S : INSURER F : i COVERAGES CERTIFICATE NUMBER: 369f,:0 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 MA"HAVE BEEN REDUCED BY PAID CLAIMS. 'HER ADDE SUER POLICYEFF POLICY IXP LTa TYPE OF INSURANCE Itascaa POLICY NUMBER rMM.MOrTYYY1 OtIMIDDITYTYl LIMITS A GENERAL LABILITY I 3AA51)6580 09/25/21 09/26/22 EACH OCCURRENCE 1$ 1,000,000 I DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES(Ea uurance) S 100,000 I CLAIMS MACE `OCCUR I MED.EXP(Any one person) S 5,000 j PERSONAL&ADV INJURY IS 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPtOP AGG S '1,000,000 1 POLICY -I J0� 7 LOG S 1 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) I S ALL OWNED SCHEDULED AUTOS AUTOS I BODILY INJURY(Per accident) S HIRED AUTOS r NON-OWNED I 1 PROPERTY DAMAGE I AUTOS I I(par accident) S i£ I UM3RELLA LIAs I I OCCUR EACH OCCURRENCE S EXCESS LIAB I I CLAIMS.MADE AGGREGATE S DEO I (RETENTION S S B WORKERS COMPENSATION 6S62UB-4N92588-6-22 05/05/22 05/05/23 I TORY UMITS ER S AND EMPLOYERS' LIA91L1 iY ANY PROPRIETORIPARTNERIEXECUTIVE YIN EL.EACH ACCIDENT S 100,000 OFFICER/MEMBER EXCLUOOEDT Y NIA EL DISEASE-EA EMPLOYEE S(,Mandstoryln NH) 100,000 i(yes,describe under DESCRIPTION OF OPERATIONS balm I El.DISEASE-POLICY LIMITS 500,000 I - I I DESCRIPTION OF OPERATIONS 1 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 4,1 ? Attention: 774-408.7127 David T. Louis ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Cons�itiAlAiS$rvisor CS-034718 .*. pires:09/19/2023 THOMAS A F#FLCH A Ott I 82 OLD CHATHAM a HARWICH MA,02.,r It <" Commissioner du a fi. Crniisk.., THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE:Individual, Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street -Suite 710 110649 1102/2024 Boston,MA 02118 THOMAS A, HILCHEY , (;:-. ----..---ArtFl ,,1 THOMAS A. HILCHEY it ��% ,11 tr'_ 82OL0 CHATHAM ROAD ,.� ' y�, ��� � 4 !% HARWICH,MA 02645 i -' Undersecretary Not valid without signature