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Home My WebLink About29 Scallop Rd Building Permit Application 3.31.2016�Hainlon Homes Norfolk MA Office Jack Scott Princip4: 4 Stony Road P.O. Box 217 Norfolk, MA 02056 3ffice: 508-528-2728 =ax: 508-694-7413 Cell- 508-328-6589 Email: HanlonHomes;ii-comcast.net R E C E I V MAR 31 2016 YARMOUTH Use Only Amount Permit expires 180 days from issue date Cape & Islands Office 1 17 Schofield Road P. 0, Box 994 DING PERMIT APPLICATION Dennis, MA 02638 WN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 6Leo,-• --iZ L,* CONSTRUCTION ADDRESS: 24 ScA f_t a ---f� a A-zlP Uk S r yk/�-0"e c.t-t fit r k"4 zjP-f 0a �7-3 ASSESSOR'S INFORIYIATION: Map: Parcel: �.� r'L 3.1 5l6 g � E 8c.t�A, /j t` 1 OWNER: -CHL �Ck ' nram. t t/ ;1y�� z� C �'y ILI //14 ✓CY 1 tJ3 N,A`NM 1' PRESENT ADDRESS I 'E,LJ# Email Address: CONTRACTOR: �7/l�LC1�cl �T�•u�. Q� �C/ X of 13 4 L•J•J1 S ll t4 J 00-�,3�'� NAME MAILING ADDRESS TEL#S0C <P- d74<�mail Address: Joe - Commercial Est. Cost of Construction $ (?„ � �Jr, Uad • ew Home Improvement Contractor Lie. # E NCOnstruction Supervisor Lie. # CS— �0 /%� J Workman's Compensation Insurance: 'check one) I am the homeowner I am the sole proprietor I ve Worker's Compensation Insurance Insurance Company Name: / I1 /11 -S _-�_ ah�-tsC.sErG /4r�2vC Worker's Comp. Policy# ( HU,8 "SS1-,6 OQ L'! 4, WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: # of Squares Replacement windows: # Replacement doors: # Roofing: # of Squares ( ) Remove existing* (max. 2 layers) Insulation Zid Kings Highway/lEstoric Dist. ( ) Replacing like for like TQ—r-r,, L— Z.—., Q *Tice debris will be disposed of at: f�V C h A S Location of Facility f 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 revocation of my license and for prosecution under M.G.L Ch, 268, Section 1. Applicant's Signature: Owners Signature (or 304-,.) F Date: _TA ( - Approved By: Date ------ --- Building Official (or designee) $' f Zoning District: Historical District: Yes No Flood Plain Zone: Yes Water Resource Protection District: Within 100 ft. of Wetlands: Yes No Yes No No } ! i 4�r1R ',] y Cif t s` The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street, Suite 100 Boston, MA. 02114--20.17 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbeis. TO BE FILED WITH THE PERMITTING AUTHORITY. Aoalicant Information Please Print Legibly Name (Business/Organization/Individual): AIA,_. e 1 14nc.-E. Address:_ E ..A,! .e.r1_0 / P- d d X 9 �r� .L�L� .` P�' OP- - r City/State/Zip: Phone M Are you an employer? Check the appropriate box: I .❑ I am a employer with employees (full and/or part-time).' 2.�I am a sole proprietor or partnership and have no employees woridng for me in �� any capacity. [No workers' comp. insurance required] 3.❑ I am a homeowner doing all work myself. [No workers' comp. insurance required] t d.❑ 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 proprietors with no employees. 5.❑ I am a general contractor and I have hired the sub -contactors listed on the attached sheet. Theca sub -contractors have employees and have workers' comp. insurance.t 6.❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4). and we have no employees. [No workers' comp. insurance required] Type of project (required): 7. ❑ New construction S. ❑ Remodeling 9XDemolition 10 ❑ Building addition 11.❑ Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13. ❑ Roof repairs 14. ❑ Other —I)c Zvi e9 a g Scant rU/i /Z L9 *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 worlm,4' 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: 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 $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. I do hereby certify render thepains andpenal&_s of erj that the in�� fformation provided above is true and correct �ol.tiJSc��` Sin nitre: � �✓ —� c_ �! �' Date: Phone #: �`4 — 3 l �U [J![" Official use only. Do not write in this area, to be completed by city or town offdaL City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Cleric 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone #: 9 e CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYYI ZATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.•THIS E DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES (HIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED ENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. .TANT: If the Certificate holder Is an ADDITIONAL INSURED, the pollcy[les) must be endorsed. If SUBROGATION IS WANED, sub}ect to .arms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the rificate holder In lieu of such endorsement(s). jDUCER NANTACT ME-- Claire Germano Ai.11is Insurance Agency, Inc. d/b/a PNONE - (508) 376-2700 FAX D L Murphy Insurance Agency L e • (508)376-22IG 916 Main Street ° Millis MA 02054 iNBU 8 AFFORbINGCOVERAGE NAICIr INSUR1eD—'RERAWautilus Insurance Com INsuRERe:Travelers Indemni Hanlon Homes, Inc. P.O. Box 994 INS[rRERC: Dennis 14i 02638 -- - --- L,r-M I IrIGA It NUMBER:CL11111600158 REVISION t11UMBER: THIS 1S 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, VTR TYPEOFINSURANCE POUCYNUMBLs'R LICYEFF pip Pj(p GENERAL LIABILITY UMrTS 7C COMM GENERAL LABILITY EACH OCCURRENCE 6 1,000,000 A C[A1M6MADEOCCUR 627623 1/15/2015 1/15/2D16 PREMISES Eaammenoe $ MED FJfP I. one P�aor1l s GENLAGGREGATE LIMIT APPLIES PER POLICY I I PRO- LOG AUTOMOBILE UABUTY ANY AUTO ALLOSOI AUTOSULEO HIRED AUTOS NON-0WNED UMBRELiA UA6 OCCUR EXCM Lug '..-.- WORMIRS OINAPENSATION AND EMPLOYERS, uAINUi7 Y I N ANY PROPRIEMPJPARTNERADMCfTIVE 3 OFFICERIMEMSER EXCLi1DEEP N❑FNI (..d. In NHS :ScRiPT1ou of OPERATIONS! LOCATIONS I VEHICLES (A"ACh ACORD 101, AddRAMMI Remarks Schedule, it more space is regWredl Ontract or Town Of Yarmouth Building Dept Yarmouth Town Hall 1146 Route 28 South Yarmouth, MA 02664 GENERAL AGGREGATE I 6 2,000,000. PRO DUCTS-eOMPIOPAw s _ 2,000,000. S BODILY iNJURY (Per persan) S BODILY INJURY (Per a-ckk a) S OPFItT ' DAMA S S EACH OCCURRENCE EL EACH ACCIDENT 6 100 000. E.LDISENSE-EAEMPLOYE S 100 -00. E.L DISEASE -POUCYUMIT S 50O 000. SHOULD ANY OF THE A80VE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORUED REPRESENTATIVE ClairIR e Germano/CLAS (��c<:v h ,025 (2Dfoos).al / oar •ORD o[20'10105) ®1988-2010 ACORD CORPORATION, All Fights reserved. The ACORD name and logo are registered marks of ACORD PL Ql � Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachwetts 02116 Home Improvement Contractor Registration -- - —_ Registration: 175580 Type: Corporation - _ -- .� ;: Expira6on: 512112017 Tr# 265213 HANLON HOMES INC. JOHN SCOTT 17 SCHOFIELD RD - -- -= - - ---- - - - - --- DENNIS, MA 02636 Update Address and return card. Mark reason for change. SCA1 2DM-W11 Address 0 Renewal []Employment n Lost Card _�- �/ec `�a��i�a��tuear� e�'Q•1i'iarta�iiselt Office ofConsumerAffalm & Business Regulation 9 __ )ME IMPROVEMENT CONTRACTOR swu on: :175M Types I=xpiralaon::'3lf20i7� Corporation HANLON HOMES INS::=_-~. JOHN SCOTT 17 SCHOFIELD RD : , :�.CN.W DENNIS, NIA 02636 Undersecretary — License or registration valid for individul use only before the expiration date. if found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 M --, IMassacliusetts Department of Public Safety Board of Building Regulations and Standards License: CS-076744 ROBERT J BROWN 10A WNDEMERE ROM . WEST YARMOUTH MA 02M f-,,jzUc CA, Expiration_ Commissioner 11/2712017 Construction Supervisor Restricted to: Unrestricted - Buildings of any use group which contain less than 35,000 cubic fleet (991 cubic meters) of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. UPS Licensing information visit: WWW.MASS.GOVIDPS