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HomeMy WebLinkAboutBSHD-26-106 application p� ,jT� La E C 3 4? E D Office Use Only OCT ��Uqq����.��nl {`0 `� tJl, 2026 Permit ilX1O—ado �.�' � , w•� .�.._� ' Amount 3-5 BUILDIN GD E r(�RTl \1r Permit expires 180 days from' '3v 04 0H LW- -r$ issue date EXPRESS SHED PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 27 Winsome Road, South Yarmouth, MA 02664 OWNER: White Crest Realty Trust 27 Winsome Road 774-994-1710 NAME PRESENT ADDRESS TEL. # CONTRACTOR: Pine Harbor Wood Products 259 Queen Anne Road, Harwich, MA 02645 508-430-2800 NAME MAILING ADDRESS TEL.# EMAIL:watson2232©gmail.com 13 Residential 0 Commercial ❑ Est.Cost of Construction$10,000.00 Home Improvement Contractor Lic.# Construction Supervisor Lic.# SHED INFORMATION New X Size L 15' x W 10' x H 11'-2" Corner Lot:Yes No X • Per Town of Yarmouth Zoning By-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 be located thirty(30)feet from any front lot line Replace existing* Size L x W x H *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 revocation of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Z.,-44 aQ L 0 c— Date: 10/27/26 Owners Signature(or attachment) ,12° ` Date: 10/27/26 Approved By: Date: Building Official(or designee) Zoning District:R-40 Historical District: ❑ Yes ❑ No **Conservation review will be required if shed is placed within 100ft of wetland,200ft from riverfront,or located within a flood zone** 6/24 fft-Tal.rf' fffl16 44 'f PLOT PLAN IPI . AtiG 1 9 MA ' FOR LOT # 70 Old kirAps Highway Indicate location of garage or accessory building Historic stork Distract Additions with dashed lines - ---..-------------- Sewerage P (cesspool) • Weil cif I ! I (let. ft. rear) I OM. MIMMI MIME. r.E Abutter's ' - " Sarno I 10 Abettor' Lot N I 151 Name , Lot :f this is a REAR YARD Shy xcnter lot, If this rsftie in name 1 ft. corner stC+eet. I write i 0 •... osof street. . • • SIDE YARD SIDE YARD • • HOUSE • • . Q 1 I . + • SET SACK ft 4 ti 1 (lot ft. t) �/ W�ngQ,Y,� Rai - (NAME OF STREET) Information ` Supplied by LARK NORTH POINT 26 - A1 Q4 The Commonwealth ofMassachusetts i'- I, Depar went oflndustrialAccldents -' _ �F= 1 Congress Streer,Suite 100_,'t= '�' Boston,MA 02114-2017 M . — + wwwntass.gov/ika • [Yorkers'Compensation Insurance Affidavit:Builders/ContractorslEkittriciattt/Plnmbets TO BE FILED WITH THE PERMITTING AUTHORITY. , . . . .form Lion ;r, _ P ' t ,• b Name(Business/Organization/Individual), Mw n intrilil L. Address: -2.J C (1,44„ ), ,Q. y,-t„, City/State/Zil b,Y 1 i V\ Q�� Phone#: fit)$ " Lt`-S 0 "'Z(6C�4 Are an a emptayer?Ct~eck etic apprapdate box: L C svth a employer witht4 wnpioyees Ifull v.v..p,t4irmy. Type of project(required): • 7. New conustnretioa 2.fl lam a sale proprietor or partnership and have no employees working for me'1R, : 8. L.J Rem od el any amity.[No w'comp.insurance required.] '' trig 3.0 I am a homeowner doing ail work 9.,Q Demolition myself.[No workers'comp.;nsvrhure required.]t 40 t am a homeowner and will be bitingy property l will 10(�Building addition �,.m.�wn to conduct all work m ro ensure that all coal:maors either have workers'comps ation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. s. 1 am a 12,0 Plumbing repairs or additions These sub-contractors have�t have hired the soh eunuaRxon listed on the attached sheet. t 3.❑Re of repairs ptoyees and have workers'comp.insurance.: 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. t 4.Dothan 152.11(4),and we have no employees.[No workers'comp.insurance requited.] 11 !Any applicant that checks box ill must also ell out the section below showing their woskets'compensation policy information. flomeoumers who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tCasd ractors that check this box must attached an additional sheet stowing die rams of the sub-contractors and state whether or not those entities have employers. If the sub-contractors have employees,they must. . ide their workers'comp.policy number. I art an employer that is providing workers'compensation insurance for my employees Below 1s the policy and job site infers anon° Insurance Company Name: a s . Qj11C Policy#or Self-ins.Lic.#: 'CC^(QC7Q— 12 4 9°-20 - Expiration Date:21211 1-2 7 lob 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 end a fine of up to S250.00 a day against the violator,A copy of this state nt forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ceny the r of perjury that the information provided above is true and correct Signature: pate: . / /7(1Z Phone#: C O 8 - Y3 0 - Z. r—O�uxal use oniu Do sot write In this area,to be completed or town official ...... .._ siPkk by�' ,�►aL City or Town: Permit/License# Lssning Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector 4 6.Other Contact Person: Phone#: HTL THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer AttaIPs'and Ruttiness Regulation 1000 WashIngpp~•Suite 710 BostortdaMION~118 Home tmproVir et ._ ration A~ Corporation Yv e rTH P^STa s;A aaseT , _ a i 32935 t 26DBMWEHAROORWOODPROD 269QUEENANNEAO. \ r 1 HARWIC►i,M4 02615 I, z. , » f j.. ._ _ Ufdle Merges eel Homo Card. THE COWIONW!AUN Of MA3LACHUIETT6 ORIa of Consumer Airke•lwlwo RegWeeon Rgbtelew eels Car DlAeldeel us*only Delon the HOME leiPPIOVCOWfRIFCTOR eapInelen MUM.l MOM Man Mc LT>►E,',Lb7p&'Non ORleeelCMwwr , Redeletfen filerfatiall 1000 t -.-s+ Seek"MA 'W MCGRATH POST A BEAM MA PINE E HARBOR i CKitl . JAMR.MCGRATH ,*•: ' •- :.: 2090UEEN ANNE RD. -. • 44e1!t.dAL Al , HWIOH.MA 02Nb LtW M • Commonwealth of Massachusetts Construction Supervisor 1&2 Family Division of Occupational Licensure Board of Building Regulations and Standards Constructioi ` peM4prt,1 & 2 Family 4.�\ s CSFA-073865 "' spires:03/14/2028 JAMES R MQGRAT 204 CRANVIVW RD•, BREWSTER I(1�A ! „'_ COI LfrdiV0 Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Commissioner \ ZWf Contact OPSI:(617)727-3200 or visit www.mass.gov/dpl/opsi ACD CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDOFFYYYI . 02/20/2026 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 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 INCH E EMI: (413)443-0077 lINC.Nol: 128 South Street E-MAIL Laude.Kohlenberger@aleragroup.com ADDRESS: _ INSURER(S)AFFORDING COVERAGE NAIL Pittsfield MA 01201 INSURERA: Selective Insurance Co of SC 19259 INSURED INsunER e: Selective Insurance Group,Inc. 12572 PINE HARBOR WOOD PRODUCTS LLC INSURER c: New Hampshire Employers Ins Co 13083 258 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.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. INs0. TYPE OFINBURANCE ADDLgoSH POLICY EFF POLICY EXP LIMITS LIRINSD WVD POLICY NUMBER (MM/DD/YYYYI IMM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 �/ DAMAGE 10 RENTED 500,000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 15,000 A S 2671577 02/28/2026 02/28/2027 PERSONAL A HOY INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY❑X 7ECT ®LOC PRODUCTS-COMP/OP AGG $2,000,000 �II OTHER. AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 _ IEeectltlenp ANY AUTO BODILY INJURY(Pet person) $ B OWNEDSONLY AUTOS X SCHEDULED A 9110876 02/28/2026 02/28/2027 BODILY INJURY(Per accident) $ AUTO XHIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY !�AUTOS ONLY (Per ecutlen0 $ X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS UAB CLAIMS-MADE AGGREGATE 2671577 02/28/2026 02/28/2027 $ 1,000,000 DEG I I RETENTION$ $ WORKERS COMPENSATOR XI STATUTE I I ER. AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.FACHACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N/A ECC-8004001249-2026 02/28/2026 02/28/2027 (Mandatory in NNl E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,RIPTIOn E.L.DISEASE-POUCY LIMIT $ DESCRIPTION beNtler under OPERATIONS below 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if mom apace is required) 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 oo teAu�2 I ©1988.2015 ACORD CORPORATION.All rights reserved. ACORD 25(2018/03) The ACORD name and logo are registered marks of ACORD