Loading...
HomeMy WebLinkAboutBLD-23-002204 �F YRR f M /0 /d-7. Lt ' t/ .�, # C�Y'�" 0��11 S 0 3 Permit expires months from ' MATTA cs issue date. � �` 8 L-D -g 3- 2lam �0 -� EXPRESS BUILDING PERMIT APPLICATIONA RtEIVED TOWN OF YARMOUTH --.-_____- - - -- Yarmouth Building Department OCT 242022 1146 Route 28 L1 ;(k'4/ /ed , South Yarmouth, MA 02664 -- (508) 398-2231 Ext. 1261 y_____ N� oE_���H7NIENT 1 '1 94allitiet#41/ ./ CONSTRUCTION ADDRESS: ASSESSOR'S INFORMATION: 4vee- 9'gr �%�� �,/ Map: Parcel: d .72gr- OWNER: 6_/ ' <dill& OA/ NAME PRESENT DRESS TEL # A (�j �fj /.9(1� l9 CONTRACTOR: O I . /e i G•� 'iet NAME MAILING ADDRESS TEL.# &Residential 0 Commercial 0 Est.Cost of Construction$_ '3ari, ©d �J Home Improvement Contractor Lic.# // 2 T j�9 Construction Supervisor Lic.# es - ci 9//, Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole oprietor 14 have Worker's Compensation Insurance Insurance Company Name:( ../10 t eek Worker's Comp.Policy#(� .� WORK TO BE PERFORMED 0 Tent (Fire Retardant Certificate attached) 0 Wood Stove Shed ❑Siding: #of Squares ❑Replacement windows:# ❑Replacement doors: # ARe-roof: #of Squares j'ef 0 Insulation Stripping old shingles* ()going over layers of existing roof ❑ Old Kings I3ighway/Hiric Ijgofing/Siding(Like for Like)District *The debris will be disposed of at: 14W/61411- rr ` ehaA j'�vl`/J Location oY.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 o revocation of my licens- •.d orp esecution under M.G.L Ch.268,Section 1. Applicant's Signa A/ / 4 Ld.%_. io ��j Date: el Owners Signature(or attachment) .A Irdp i WI, r,' Date: e Approved By: .��� I Date: `% ""' -... .-. Building Offi,: "-or(1-.'-_,:ee) Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No ❑ Yes ❑- No 3/01 i • The Commonwealth of Massachusetts a Department of Industrial Accidents v. .71i11—:r Office of Investigations �-�i= 600 Washington Street _ .... — Boston,MA 02111 .° s a .1 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Pleasellse Print Legibly c.Name (Business/Organizati on/Individual): /G /Ad) . /����J Address: 7, d / -2 ,-4,Re b City/State/Zip: /? /1,�.�! Phone #: � 7 / / Are ou an employer?Check the appr priate box: f Type of project(required): 4. 0 I am a general contractor and I 1. I am a employer with .„5 4. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' 9 Building addition [No workers' comp. insurance 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 I myself. [No workers' comp. right of exemption per MGL insurance required.]t c. 152, §1(4), and we have no 12.Pk Roof repairs 3a.❑ I am a homeowner acting as a employees. [No workers' 13.0 Other general contractor(refer to#4) comp. insurance required.] *Anyapplicant that checks box#1 must also fill out the section below showingtheir workers'co a pp mpensatiod�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 I I employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 1 I am an employer that is providing workers'compensation insurancejor my employees. Below is the policy and job site information � Insurance Company Name: ( & ø"c,Y� � (.�C /- 1r Policy#or Self-ins. Lic.#:4 zr , "-/1 .1 Expiration Date: ;_d;_ Job Site Address: 9l _..1:.itii-1 4 City/State/Zip: , G lit iCir Attach a copy of the workers' compensa policy declaration page(showing the policy number an 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 nydyer the pains an pe al • of perjury that the information provided above is true and correct Si atur : 41Date: /1Cljallti Phone 4: ..j.--/F. el`%*/ 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#: OF!16J2022 10:31Howe Insurance (FAX)9784752171 P.001/001 DATE (MMI01)!/YY1) A.CORLY CERTIFICATE OF LIABILITY INSURANCE oslas1iDD 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 1S 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 Fax (978)475-2171 Sullivan Sullivan Insurance Agency SULLIVAN INSURANCE AGENCY FAX 978 475-2171 PHONE EN): (978)851-9600 1AlC NaY. ( ) 4 PUNCHARD AVENUE EMAIL ANDOVER MA 01810 ADDREss: INSURER(S)AFFORDING COVERAGE NAIC# INSURER : Evanston insurance Co I,.IS„RED THOMAS A HILCHEY INsuRERB : Ace American Ins Co DBA THOMAS A HILCHEY CONSTRUCTION INSURER C : 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 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.ADM SUER POLICYEFF POLICY EXP LIMITS LTR INSR WVD NCR TYPE OF INSURANCE POLICY NUMBER MIMIDDM'YYI rMWDD'YYYYt A GENERAL LIABILITY 3AA506580 09/26121 09126/22 EACH OCCURRENCE , $ 1,000,000 DAMAGE TO RENTED $ 100,000X COMMERCIAL GENERAL LIABILITY PREMISES(Ea oceurance) MED.EXP(Any one person) $ 5,000 (CLAIMS MADE XSOCCUR PERSONAL 8ADVINJURY E 1,000,ODO GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 PRO- $ POLICY JECT LOC COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea= Nerd) $ BODILY INJURY(Per person) S ANY AUTO -SCHEDULED BODILY INJURY(Per accident) $ AUTOS OWNED AUTOS PROPERTY DAMAGE $ HIRED AUTOS ^_NON-OWNED (Per acr de ) __AUTOS $ EACH OCCURRENCE $ UMBRELLA UAB OCCUR - EXCESS LIAR CLAIMS-MADE AGGREGATE $ $ DEC 1 'RETENTION$ We sTATU- 0TH B WORKERS COMPENSATION 6S62UB-4N92588-6-22 05105/22 05/05/23 TORY LIMITS I ER $ AND EMPLOYERS' UABIUTY YIN EL EACH ACCIDENT $ 100,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L DISEASE-EA EMPLOYEE S 100,000 OFFICEWMEMBER EXCLUDED? I� N/A (Mandatory In NH)It yes,deaenbe Under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below • DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(Attach ACORD 181,Additional Remarks Schedule,it more space Is required) Thomas H(lchey 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 / es..,:ge Attention: 774-408.7127 David T. Louis 01988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) 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 y THOMAS A.MLGHEY -% 446/ 82 OLD CHATHAM ROAD / C ' L HARWICH,MA 02645 Undersecretary Not valid without signs Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Const:rt *% rk! !visor C S-034718 c� ires:09/1912023 THOMAS A IILCHEY 82 OLD CHATAM ROAD HARWICH MA f02645 C Commissioner t K. iy&y" w..