The URL can be used to link to this page

Home My WebLink AboutBLD-19-000837 4. Y i Office Use Only • p£' a g dT i !.I'•Z iry; ! O �PermiC! oy —y j Amount- 75 OD _ta nJr ., p V cO!,•• . Permit expires 180 days from • issue date RECEIVE. : : MIT EXPRESS BUILDING PERAPPLICATI N----- - TOWN OF YARMOUTH AUG 13 2018 ! Yarmouth Building Department j UorPAR 1146 Route 28 BLDINctNu:N1 South Yarmouth,MA 02664 Hy --_-- (508) 398-2231 Ext. 1261 BLD- 1q-007 CONSTRUCTION ADDRESS: 22_ tJG" / 'C-- ("' c ` N vWD ASSESSOR'S INFORMATION: • Map: /� Parcel: OWNER: C (4414--2.1 ZZ V'' M vt0€. 01155) OCC)-2W4 NAME PRESENT ADDRESS TEL. # �? CONTRACTOR &(e- W's't_ O o�776-�-t(o/7 1Z://' NAME MAILING ADDRESS TEL# ^'l dential 0 Commercial Est Cost of Construction S !4�W Home Improvement Contractor Lic.# �� Construction Supervisor Lie.# 66 is g7Oo Workman's Compensation Insurance: (check one) ❑ I am the homeowner �0 II am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: f1 r"cde{,5 Worker's Comp.Policy# \OS° WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares v Replacement windows:# Replacement doors: # Roofing: #of Squares V tiff, ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like fo�rr like Pool fencing l()�,(R/J *The debris will be disposed a• • `" ' 0 "— Location of Facility I declare under penalties of perjury • ` . i at erein contained are true and correct to the best of my Imowledge and belief I rmderstand that any false answer(s) will be just cause for denial or revoc.... Ii• re, d for prosecution under M.O.L.Ch.268,Section L Applicant's Sign... =V• Date: Q)CJ16 Owners Si;,attire(or a•.-,chment) / _ Date: /rr1�/'� f/3 If Approved By: ca-•— Date: Building a:. Al ort'1• EMAIL ADDRESS: Zoning District Historical District 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District Within 100 ft.of Wetlands: . 0 Yes 0 No 0 Yes 0 No .) The Commonwealth of Massadhusetts e-' sr=i ce_AIR Department oflndustrialAccidents A =�= • 1 Congress Street, Suite 100 i.:-i' Boston, MA 02114-2017 • "bz. www.mass.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/[ndividual): Wy ec&o aplatgir- i / Address: i7 e2 Latc4tects.feci 1L City/State/Zip: trPs c��5c4- Phone#: �€3.-2 --C4 Are you an employer?Check the appropriate box: Type of project(required): 1.0[am a employer with employees(full and/or part-time).+ 7. 0 New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling • any capacity.[No workers'comp. insurance required.] 3.0[am a homeowner doing all workmyself 9. ❑ Demolition [No workers'comp.insurance required]: 4.0 I am a homeowner and will be hiring contractors to conduct all work on mY property.ro I will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I a general contactor and I have hired the sub-contactors listed on the attached sheet ese subcontractors have employees and have workers'comp. insurance.: 13. Roof repairs 14.❑other '�cea'e''tu 6. We are a corporation and its officers have exercised their right of exemption per MGL e. VaA1-9 152,§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. 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 employee;they must provide thew 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. �,, � ,,C.�V1// Insurance Company Name: -1"Get4 //' Policy#or Self-ins.Lic.#: Expiration Date: 6 /I/'q �(, Job Site Address: ' cck We. City/State/Zip: a We ?4 OI ` ` Attach a copy of the work: ' compensation policy declaration page(showing the policy number and expiration date). Failure to secure cove..•: as r;quired under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imp '.., ] ent, : '-11 as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violas' .py o is statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. ilf }1 I do hereby certify un. • e p' .+t d pe aides of perjury that the information provided ab ye ' true and correct Signature: , Date: 12' 316 Phone*: [[[ 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#: • — • • • Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." • An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance • requirements of this chapter have been presented to the contacting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply sub-contractor(s)name(s), address(es) and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advisedthat this affidavit may be submitted to the Department of Industrial • Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit The Department's address,telephone and fax number. The Commonwealth of Massachusetts • Department of Industrial Accidents I Congress Street, Suite 100 r• ' Boston, MA 02114-2017 Tel. # 617-7274900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.rnass.gov/dla From!Glen White gwhne@whitesconstn:chon net Sublect: Proposal V.(1.' Date: June 26,2018 at 937P • =2.' To: CnssyW®msn corn WHITES CONSTRUCTION (PROPOSAL) CHRIS & DAN 22 PARK AVE WEST YARMOUTH, MA. Scope of project: (Garage re-shingle) 'Strip off old shingles(Note:If excessive rot is found an additional charge will occur) •lypar exterior wall *install new White Cedar shingles 'Install new corner board to match up courses 'flash brought to local dump 'Includes cost of permit • Total cost V-� n w $2675 er (Dry Wells) 'Dig up old piping from downspouts ( •Run new drainage piping tfri 'Dig in(3)new Flo-well Storm Water Leaching System /�i�.1 'Put In crushed stone elr) 'FM hole.Seed soil N0 0 Total cost .200 (Roof Repair) 'Remove shingles from roof as far as deck 'Remove sidewall shingles on walls 'Check for rot(Note:If excessive rot Is found an additional charge will occur) 'Ice&Water shield membrane to be Installed on the roof 'Architect Shingles to be Install.Color to match existing roof �/ •lypar walls *Install new White Cedar shingles on walls 'All trash brought to local landfill (� *Includes cost of permit ($ Total cost $4375 • Dump fee $375 Total costs )prects 4Z' (p4 MI. ►ter. Upon acceptance of proposal a deposit of$2500 Is due.1/3(32325)Is due upon commencement of project 1/3($2375)is due when(1)projects are completed.The balance($2975)is due upon completion. ///��,�� 1641,1040 ktCustomer sign: w CA---C144,44/ 1S• Contractor sign: Let me know as soon as possible so I can get you on my schedule. r fi Thank you, VI(I8 � Cly%�� Glen White l ./r"1 ' WD&GHIT-01 MWOLF ACORO' DATE(MMDD/YYYY) 4.. ..--- CERTIFICATE OF LIABILITY INSURANCE 08/13/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER License q 1780862 N%rMJ�ACT HUB International New England Pn"/C,"NO,Est):(781)7923200 FAA 600 Longwater Drive ( ): I(NC,No):(781)792-3400 Norwell,MA 02061-9146 /Do"ahas' • INSURERISI AFFORDING COVERAGE NAIC$ INSURER A:Main Street America Assurance Company 29939 INSURED INSURER!:Travelers Casualty Insurance Company of Americ 19046 D&G WHITE INC,DBA Whites Construction INSURER C: 512 Whistleberry Drive INSURER 0: Marstons Mills,MA 02648 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 SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WYD POLICY NUMBER (MMIDD/YYYYI (MM/DDIYYTY1 LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE �X OCCUR MPT4080S 06/1212018 06/1212019 PRFMLSw eaNTwv tinsel $ 500,000 MED EXP(Any one INJURY f 10,000 PERSONAL$ADV INJVRY S 1,000,000 GEN'L AGGREGATE LIMpIT.APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POUCYI IJECT LOC PRODUCTS•COMP/OP AGO 1 2,000,000 OTHER- 5 AUTOMOBILE LW BILITY COMBINED SINGLE LIMIT fEa accident) f ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTEO�S ONLY _ AUTOS BODILY RqINJURY(Per acddenl) E AURTOS ONLY _ NON-OWNED ONLY (PerremtlentRAMAGE $ f UMBRELLA LIAB _ OCCUR EACHOCCURRENCE $ EXCESS LUIS CLAIMS-MADE AGGREGATE I DED RETENTIONS S B WORKERS COMPENSATION PER X 272H- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE " 7PJUB2E290174 06/26/2018 06/26/2019 EL EACH ACCIDENT $ 500,000 1ManCaEtRoryEMBER EXCLUDED? Y NIA 500,000 E L.DISEASE-EA EMPI OYES E If yea,describe under 500,000 DESCRIPTION OF OPERATIONS below E I.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) • CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN South Yarmouth,MA 02664 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ®1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD • • Massachusetts -Department of Public Safety Board of Building Regulations and Standa,ds Construction Supeni.ar License: CS-108700 GLEN WHITE 512 WHISTLEBERRY DRIVE. Marstons Mills MA 026 $, •9:4••••• ..j� =-. 0, "` ' Expiration Commissioner 03/04/2019 • CYAe omikoreuieald t G'llaLadujelaa - Office QI Consumer Affairs Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Corporation • Registration Fxoiration 178929 06/01/2020 D&G WHITE INC. - GLEN WHITE - /`R- e- 512 WHISTLEBERRY DR. U MARSTONS MILLS,MA 02648 Undersecretary e