Loading...
HomeMy WebLinkAboutBLD-23-002651 i ' Ur)Set-ileth-dil,)(.tt--,e.-'10*/L- Ca' III 1(- . Y4 /l- 110 -22_ Of ` , Office Use Only C g Permit# (/ t.1)5 0Y I �J44nte Amount 3 S.00 Permit expires 180 days from issue date 80 sa3 - 66a405 ► EXPRESS SHED PERMIT APPLICATION E C E I V E D TOWN OF YARMOUTH Yarmouth Building Department NOV 14 2022 1146 Route 28 South Yarmouth, MA 02664 si I PAtIr—I tT (508)398-2231 Ext. 1261 By! r[ t CONSTRUCTION ADDRESS: 95 Wilfin Road, South Yarmouth, MA OWNER: John T. and Mary P. Barry 95 Wilfin Road, South Yarmouth MA 203-948-4556 NAME PRESENT ADDRESS TEL # coNTRACTORRhino Sheds Ronaldo Vieira 20 Harding St, Middleboro, MA 508-488-6612 NAME MAILING ADDRESS TEL.# ,Residential D Commercial Est.Cost of Construction$ $5,235.75 Home Improvement Contractor Lic.# 205971 Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) I am the homeowner I am the sole proprietor I have Worker's Compensation Insurance X Insurance Company Name: AEIC Insurance Worker's Comp.Policy# WCC-500-5019164-2021A SHED INFORMATION New X Size L 12 x W 10 x H 12 Corner Lot: Yes No X 6 1/2 ft.pitch peak Per Town of Yarmouth ZonlnR Br-Law Sec 203.5 Note E: Side and rear yard setbacks for accessory buildings containing one hundred fifty(150)square feet or less and single story, shall be six(6)feet in all districts, but in no case shall said accessory buildings be built closer than twelve (12)feet to any other building on an adjacent parcel. All sheds are required to he located thirty(30)feet from any front lot line Replace existing* Size L x W x H 0 U h se-/-1/A27 4n a p Par t /s- /s-Zz *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 revo at n of my license and for prosecution under M.G.L.C .268,Section 1. I Applicant's Signature: // Date: 1\ 11)2 Z.--Z �L�I�1J� / Owners Signature(or atta ment) Date: Approved By: Date: //Ze-7--. Building Official(or d ee) EMAIL ADDRESS: f.. oning 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 if within 100 ft.of Wetlands 3/22 • • \ The Commonwealth of Massachusetts - 5 r Department of Industrial Accidents t ""_` _ 1 Congress Street, Suite 100 MN.. G _°I1:i�. Boston, MA 02114-2017 ,,i www.rnass.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):Rhino Custom Sheds dba RV Manufacturing Inc. Address: 20 Harding Street City/State/Zip: Middleboro, MA 02346 Phone#: 508-488-6612 Are you an employer?Check the appropriate box: Type of project(required): l.Q I am a employer with employees(full and/or part-time).* 7. E 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.] 9. [Demolition ` 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]r 10 ❑ Building addition 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 11.E Electrical repairs or additions proprietors with no employees. 12.[l Plumbing repairs or additions 5.0 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:: 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.®Other Shed 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. 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. AEIC Insurance attached certificate of insurance Insurance Company Name: Policy#or Self-ins.Lic.#: wCC-500-5019154-2021A Expiration Date: 07/13/2023 Job Site Address: 95 Wilfin Road, South Yarmouth, MA City/State/Zip: 02664 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. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true'and correct. Information supplied by Rhino Shed attached certificate of insurance (�, ;A XSianature: //-41,t. / Lt11,'� � � 1%. Date: fr /i/-2Os cell 203-948-455 48-455Phane#: Mary's cell 203 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#: PLOT PLAN FOR LOT it S rndicate location of car or sc building Additinne with dashed lines Sewerage d pc (cesspool) 69Well izig I _... _... ...._ (1x t h i it. z r) I Abutter's k�f n `rt Name7 N,,`s =‘.\* b r � 'sLot# jamebutter c.� lot# I If this is a REAR YARD 1 �t corner lot, If this is a . write in ft. corner lot, name of street. } write in name of street. I • SIDE YARD • A. I b l i A HOUSE SIDE YARD : 030 1,/ :m • i na .be- . `� • SET BACK PIkS 1 (int it. frontage} qc \,. I n , 5 . (lax nib , \ {N AMB OF STREET) > (---- / Information k. `_ > by �� n Cund iuC rt ,�,� RVMANUI OP ID: RC ACORO CERTIFICATE OF LIABILITY INSURANCE DATE 11/0 /DD/VYYY} �.- 11/04/2022 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 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 CONTACTNAME: --- --- Conway Insurance Agency,Inc. PHONE FAX 781$26-3804 (A/C,No): 879 Washington E-MAIL c.No.Exo: Hanover,MA 02339- ADDRESS: - -- - - INSURER(S)AFFORDINGCOVERAGE NAIC# INSURER A:Nautilus Insurance Company 17370 INSURED RV Manufacturing, Inc. INSURER B:AEIC Insurance 20 Harding St,LLC INSURER c:Commerce Insurance Company 34754 20 Harding St. Middleboro, MA 02346 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD,WVD POLICY NUMBER (MM/DDIYYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 NN1290566 OCCUR 07/13/2022 07/13/2023 DAMAGE RENTED $ 100,000 CLAIMS-MADE X PREMISES occurrence) MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- LOC PRODUCTS-COMP/OP AGG $ 2,000,000 JECT OTHER: COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY (Ea accident) C ANY AUTO FQM516 06/29/2022 06/29/2023 BODILY INJURY(Per person) $ 250,000 AALL UTOS OWNED X SCHEDULED BODILY INJURY(Per accident) $ 500,000 PROPERTY DAMAGE $ 250,000 X HIRED AUTOS X AUTOS D (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ _ DED RETENTION$ PER WORKERS COMPENSATION X STATUTE OTH- ER AND EMPLOYERS'LIABILITY YIN WCC-500-5019164-2021A 07/13/2022 07/13/2023 E.L.EACH ACCIDENT $ 1,000,000 B OFFICER/MEMBER EXCLUDED?ANY PROPRIETOR/PARTNER/EXECUTIVE N N/A 1,000,000 E.L.DISEASE-EA EMPLOYEE $ (Mandatory in NH) If yes,describe under E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Ronaldo Vieira is excluded from the workers compensation policy as corporate officer. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Mary Barry 95 Wilfin Rd AUTHORIZED REPRESENTATIVE S.Yarmouth, MA 02664 cf)Kz _ ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD S116' Sales I No. 3016 Octobernv®ice 25, 2022 12 Rhino Sheds 20 Harding St. Middleboro,MA 02346 10 (508)488-6612 Sales Person: Paola Dionisio Buyer: Mary Barry 95 Wilfin Rd S.Yarmouth MA 02664 (203)948-4556 (M) Description Quantity Ext Price maryitech@gmail.com 10 x 12 Peak Storage Vinyl 6'wall height 1 1 1 $4,691.00 Siding Dover Gray 1 $0.00 Gable Vents(Pair) Shingles 3 Tab Rustic Black 1 $35.00 Black Door Hardware Kit Roof Type Peak - - Floor Yes Standard 4'Ramp 1 1 $0.00 Single Door None Medium Window 18 x 27 2 $39 0.00 Double Door Gable End Window Shutter(Pair) 1 1 1 $0.00 Shutters None 'Free Delivery and Installation 1 Surface Turf/Dirt 5 Year Warranty 1 Slope No Subtotal $5,116.00 Permit No Discount $0.00 Target Date: 12/6/2022 Final Subtotal $5,116.00 Customer Notes: Sales Tax @ 6.25% $319.75 Permit $0.00 On-Site Construction $0.00 Payment(balance due upon completion)will be made by: Total $5,435.75 CREDIT/DEBIT/CHECK/CASH Received $200.00 Balance Due $5,235.75 Rhino Sheds (hereafter referred to as RS),is not responsible for unforeseen ground conditions,such as but not limited to sprinkler systems,septic tanks,electrical wires,stumps, roots,or any other foreign debris that may hamper installation&delivery, including setting anchors or installing posts. Buyer is responsible for informing RS of any underground cables,gas lines,utility hazards,or relevant matters prior to commencement of installation,and agrees to hold RS harmless for any damage done to submerged lines, pipes, cables,or other utility instrumentalities during installation.Additional charges may apply for material,repairs and/or labor.The building is certified for storage only, not for human occupancy. m r's If this unit is not paid in full as agreed, o forr grants the specific performance of the contractermission to repossess unit however,atpremises option.upon which it is placed. This does not relieve customer fromliability Date Customer Signature 0 i z C 0» > 0 rr 0 0 a-I 00 c o 1 0 2° -n to rn K t't X 70 0 20 > 0 x ea 0 _o< 0 i, 0>' x E 49 0 ,-..,, - or... 0...... — C v. 0 Z-n i-:,- sl,, m P oo(2i 0, ,!J ---4 - .......m -.. r- C C > 73 t Z 0 a) Iv G) (..,) - - -.Tile, Dt3 Z JP z a) c) 0 ,,,,?,• F5 -1 (DI ...e 73 c I 0 rT1 CD 37 0 71 -I, 0 -o t/3 -a. C) 0 0 CD 0 g 0 3 0 0) CO K Ts 0 c z , A 0 „..,. (3 -, e r-- ---i ,./ ..4ir , ,,f, ,, or 4. ' i \j *: 9° W*1.11Y 0 5 !,1,,F, iT,,,,,,= 0.) 0 ,.......,,, -0. 'tITT'N'''''4! , -; Z Z 0 ty 0 Oh Q 42 tqa ;17 !,,,, s fill.100/1114 i, a ft** CO p... . at 4 t.,,,. ...P1 1,1,0 :,d, C/3- 0 0 7.... m >c _ t-.. it•; -- Al, XI t.0 c -,--. (I) -• A p • == = A m(D. c D 7-;- - > * '"" s 03 0.a '''''' •., t ' 90 -..." CD CD -. I 0 r0 --I ,...4. ....). ,- 0 c rz :1'.-G C 71;0.= 0, 0 0 T3 13 = D 0 al C) X CL:fi .4. (,,,,,, m C a S • o > N) -1 co= Cb a (f) ...,, i o 0, n C. 73 g _,..,co-o 3 -4. 0 v. ._-4 ,. 0 CO —0, 611 N.)—.•al = (0" e CO 0 0 ... C Po 1U rs.) 0 0. 0 0 P.,M 0 s. c 3 0 a .., ... 83 j La" 8Z 44.00' 0 J -s .c,\. c^ v---- , r,`. o o ; 1 rim �m1 l? ,z k orn =ox ( 0.'� •� ri ��rnz -.,1 m - \v•9\. 0 % m t ti ------'-- • • �d 00g�c.%� gg 62 ` i 6' C . tt 0 CONSERVATION '11 OFFICE bdirienzo@varmouth,rna.us Yarmouth Conservation Commission Administrative Review Applicant Information: Name: .s..)0kAr) 6Lir CLAVt— Vial/ Mailing Address: S ‘,‘ 1(4 6. ki.arryth-u)-17 ,1-ak, Phone: ao - .Lts - 9-30 Email: 1114.,/,/ @Ty-y(44 I hereby authorize the individual members of the Yarmouth Conservation Commission and its agent(s)to enter upon the property listed below for the purpose of gathering Information regarding this Adrninist tive Review form. A . Property/Location of Work: 6115' tAA"" U1-3) rrit-c tifiLk S et t4ame and Number() Signature: jiA 1,1,44.0 Detailed scription and Reason for Proposed Work: 4-- P(c -1-cif 9 5 I) LAS cl (.1-4t)e- ( 641110.• Closest Distance to Resource A ea: .4 — Proposed Start Date: 13No-x9. Company to do Work: ZA‘ikName: ‘- Address: au cucci %9c. IA\ t'cU iJ2o t Wtt. (D% SS5 Phone: a'+' Email: CYtty,5-6i15tkQd Administrative Ammo': c Sc PAVS) \/,'"( 3f(Jff ty ad 'C-0 't".0+-Q6e3 C , 4 V If rr This This approval is valid for one year. This Approval does not grant any property rights or any exclusive privileges;it does not authorize any injury to private property or invasion of property. Yarmouth Conservation Commission•1146 Route 28,South Yarmouth,MA 02664•(508)398-2231 Ext 1288