Loading...
HomeMy WebLinkAboutBSHD-26-65 application 1 V E D . Office Use Only JUL ?`3 20,25 Pernitut�jShh�—ae�-�� %per Q,•�t Amount Bl;l DING i' N' NT g�, D Permit expires 180 days from issue date EXPRESS SHED PERMIT APPI.ICATI()N TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: IQ l Gull wale tU y / Yar- OWNER: 1� �Lt (Q vo_Okic-4 t1- NAME _ PRI-til \T \1 TEL. CONTRACTOR:e V)'� air r, a_7! Ql — p1iitekj4.416&wiciq O i 400 Z b aO N\\If \I\ILING ADDRESS TEL. EMAIL' V'•O tpii(LZ VIa'CbOr..C_0(1/1 U 66 lommercial Est.Cost of Construction S � 1 Ilomc lntlnvts enient( ontractor I.ie.#_ Construction Supervisor Lic.# SHED INFORMATION I t f (/ New V Size L 1.4 x R' 10 x H tl Corner Lot: Yes No Per Town of Yarmouth Amine Br-Law Sec 203.5 Note E: .Silt'and rt'tn' Karol eethat lnrat"cessorl. hlt/Ming% t';Httainin/,'nnt' /Wnth'etl flltl' I l Ui At/Mire lee!or less and single story. shall he sir tt5, tee! in all Jisirit Is. hut in not the s/loll said aeee.ssorr buildings he built closer than n,e/t.t• t 1't feel nt ant• other hlll/i/HIL'on WI adjacent parcel. All.shetis are retlrlired to be located lhiro (..31 i jee'ilrunl ant-Iront_lnt-nett' Replace existing* Size I. x ►► // *The debris will be disposed of at: I ocation of I,i tits I declare under penalties of erjury tha the: e ems er in contained are true and correct to the best of my knowledge and belief. 1 u derstand that any false answers) : :: '::a:: d• is or recoc:u cona d for prosecution under M(i.L.Ch.268.Section I.e- Date'. 7// S ta( Ossners Signature for attachment) _ Date: I/i.s _Approsed lt} Building Official(or designee) Zoning District: Historical District: Yes No **Conservation review will be required if shed is placed within 100ft of wetland.2001t from riverfront.or located within a flood zone" 624 • • SHEDS LESS THAN 150 SO FT SHALL. RE PLACED A MINIMUM OF 30 FEET FROM THE FRONT LOT LINE AND A MINIMUM OF 8 FEET FROM SIDES AND PLOT PLAN k EAR LOT LINES. FOR LOT It Indicate lo0ation of garage or accessary building Addition, with dashed lines ----------------- vw x} disposal (ceaap1) wail co (lot../.©� i CT _ Abutter's , (,fT _ I Name Abutter's Lot d Name If this is a ) Lot OS REAR YARD write inlot, - t fl If this is a corner ft. corner lot, name of street. "R`' write in iiimh wMW name of street. I a a v 4 I d _f_. i SIDE YARD CI)cz • Fto DE YARD • • • SET BACK • • a (lot t7) ft. acn ) \ (PANS OF ST ET) / \ / \ Inform:Um . Supplied by he Commonwealth of illawsachissetts ►. r.--i .......,. �o,f f Department In tr�'al A,�ci�#e�czs —_:Flg1 t 1 Cowers, ei Siam ZOO -- _,� Bosh 02114-2017 `= >►t vw,>h i"S�gov/t ea Workers' Compensation Insurance Affidavit: Boilders/Contractors/EleetrkianatPlumbers. {, TO BE FILED WITH THE PERMITTING AUTHORITY. `22��gg o Name (BusioessfOrgenia1tionfintiividuai)11 igi v mk I yth„ ti++.,.... Ilell _ L Address: 4S " 0 * 1 Citylstate1Zipii t kl tZg 'S Phone#: &' 1 0 ''' Z ta__M Are :as employer'?Cheek the appropriate bee: r Type of project (required): I. [eon a� with? (full andiar '+ 7.VNew construction 2.01 ny ca}sole proprietor vvatioes�4p and have rya etnOoyee�s workin1 for me fi i S_ 0 Remodeling camp. i»sttranct requited.] ;. • r 9. 0 Demolition 3.0 I em a hoineowner doing all vault myself [No swims'tip. insurance require:Li t COI am a homeowner oat well be hiring contractors o conduct ill wick on eery property. t will Building addition emu=that all ennoactors tithes hav *imbue compensation insurance or are sole I LID Electrical repairs or additions propsiccnrs with m employs, 12.0 Plumbing repairs or additions SC I art a general contractor and I have hired the t,iamd on tile attached sheet ] Roo These sum have employees and have workers'comp, insurance.: frepairs 6.0 W,:area corporation and its officers tam combed their of DOt itr Per ArhGL c. I52,I 1(4),end we have no emploayees,[No workers`tom, required] i *Arty icant that checks box#1 muse also fill out she section below showing their week'compensation policy info ntation. 't Homeowners who 8Ubttit this affidavit indicating they art doing ail wort and then hire outside ourrtvectors must wait a new affidavit iadiesting such 'Contract=that check this box must attached an additional sheet showing the of the sub-con arnd pie wheiher or not those entities hive employees. ff the sub-aoraracton have cowl, .= they mutt , Ida their workers'camp.policy member. f tort an Employer that Is providing workers'compensation insurance for ng'employees Below is the policy and)oS site iufsrma ton. Insurance Company Name: .,,: •`a. t4 " t `rn 1 _ t *. e ' ♦, • c i 1 : Vrn5::.! Policy# or Self-ins_ Lie. #: C C . . aM.,a ..- alb"I ' ' 0 •• Expiration Date;Z Jet 1'2 Z Job Site Address: . City/State/Zip:- Attach a copy of the workers' compensation policy declaration page (showing the poles nember and expirat date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to 51,500.00 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 f: . ,ent •. , i forwarded to the Office of Investigations of the DIA for insurance coverage verification. 4. I do gy ce y '*` 1, •� iiW-ero pith- fibs hrfora o-n pn►vlisbove it Arse oat . - _. .._ Si#ratur a / 111 _ _ Date, 5'hit /t- 626- pine#: SO ? �- 3 o �-- 7. i L7-t) _.. w__.. -.-- _-. ---- __. _�____.____ -_..____ - i-i ....„..., Official Arse orrlyt Do mot write&e tidy area, to be cor�p�d by city or ►n official City or Town: Pcrmuitllfsanse # __ Isaniog: Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6, Other _ ._ . Coatec t Perna: Mae#. ACCTREI CERTIFICATE OF LIABILITY INSURANCE DATE A (MMKIDe�)02/20/2THIS 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 Laurie Kohlenberger NAME: ALERA GROUP/Berkshire Fairfield 'PHONE (413)443-0077 El.1A Ean: INC.Nol: 126 South Street AODREss: Laurie.Kohlenberger@aleragroup.com INSURERS)AFFORDING COVERAGE NAICa Pittsfield MA 01201 INSURERA: Selective Insurance Co of SC 19259 INSURED INsURERB: Selective Insurance Group,Inc. 12572 PINE HARBOR WOOD PRODUCTS LLC IS 00,ERC: New Hampshire Employers Ins Co 13083 259 QUEEN ANNE RD INSURER D: INSURER E: HARWICH MA 02645-2405 INSURER F: COVERAGES CERTIFICATE NUMBER: 26-27 MASTER 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.NOTNATHSTANDING 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. NI TYPE OF INSURANCE INNS POLICY EFF POLICY EXP LTR I WVD POLICY NUMBER (MMIDDNYYY) IMMIOOIYYYW LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE E 1,000,000 DAMAGE TO RENT ED I CLAIMS-MADE ®OCCUR PREMISES(Ea occumn s) E 500,000 MEDEXP(Any one person) S 15,000 A 5 2671577 02/28/2026 02/28/2027 PERSONAL XADV INJURY y 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE S 2,000,000 POLICY®jEo- ®LOC PRODUCTS-COMP/OP AGG S 2,000,000 OTHER: AUTOMOBILE LIABILITY Ea.BIN SINGLE LIMIT E 1.000,000 ANY AUTO BODILY INJURY(Per person) B OWNED SCHEDULED A 9110876 02/28/2026 02/28/2027 BODILY INJURY(Par accident) S AUTOS ONLY X X AU AUTOS HIREDTOS NLY X SON-O ONLD rpReCI E DAMAGE S O X UMBRELLA UBB X OCCUR EACH OCCURRENCE E 1.000,000 A EXCESS LIAR CLAIMS-MADE S 2871577 02/28/2026 02/28/2027 AGGREGATE E 1,000,000 DED I I RETENTION S �/I S WORKERS COMPENSATION STATUTE I I ERH AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT s 1,000,000 C OFFICER/MEMBER EXCLUDED? N IA ECC-800-4001249-2026 02/28/2026 02/28/2027 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S 1,000,000 It yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT E DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101.Additional RamaMa Schedule,may be attached K mole space la annuile.) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN TOWN OF YARMOUTH ACCORDANCE WITH THE POLICY PROVISIONS. 1146 ROUTE 28 AUTHORIZED REPRESENTATIVE S YARMOUTH MA 02664 �iusve ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD