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Home My WebLink AboutBLD-19-951 r.01';Y:94?_ 3 Office Use Only :I J .. :. A•'!; t aO 3 Permitil O ..,1 !rt , ,0 '4 Amount e `� s N ra Permit expires 180 days from . �.. issue date EXPRESS BUILDING PERMIT APPLICATION I. Lb-1 9-Cooqs1 TOWN OF YARMOUTH Yarmouth Building Department ? E C E g V E D • 1146 Route 28 ' South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 AUG 172013 CONSTRUCTION ADDRESS:�fi) 7r 4wlf ncvc/ `;�'BItelb:k <3,3 T ASSESSOR'S INFORMATION: Map: Parcel: A _ SD (-7•7 - - 69a / r OWNER /VA• C MA4. Qe-tint r AAA !(ne/ a9 9' _ ow NAME PRESENT ADDRESS TEL. / TEL. # CONTRACTOR 7-"A-MAS /176 WO crave w.Js fib &< /7/ �` -//�! ea pit/ 3g- AME •�' I MAILING ADDRESS TEL## BResidey ntial ❑Commercial Est Cost of Construction S I �3�. � J Jr Home Improvement Contractor Lic.# /,3 Construction Supervisor Lie.# i Tl fa a• Workman's Compensation Insurance: (check one) // ❑ I am the homeowner 0 I am the sole prooPrietorp.17tave Worker's Compensation Insurance Insurance Company Name: l✓t �A$tf r5 apse/ 7 . Worker's Comp.Policy# /lnJ9Qil 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 Old Kings Highway/Iiistoric Dist. ( )Replacing like forulike Pool fencing *The debris will be disposed of at Tt/ 14.%.J�`/T'f` '� °cation 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 e and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Si::.anne: Date: In-/7 va/, Owners Si; atnn(ora . / Date: Approved By •�. P Buildinga-:+•:^rT!'� + Date: / "I�'�� . •,� gne 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 • ,.•�' r. ..� The Commonwealth of Massachusetts J lagrilM•klr Department ofIndustrial Accidents `k.==el= 9 r 1 Congress Street,Suite 100 Sire"- I' Boston, MA 02114-2017 .0 www.mass.gov/dia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): 'awn 4,,t4,f *e.itt'(M„e, Address: ai &Jr f3.; City/State/Zip: /t' Phone #: fie ?AD nr" Are you an employer?Check the appropriate box: Type of project(required): 1.24[1 employer with 4 employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling • any capacity.[No workers'comp.insurance required.) 3. I am a homeowner doingall work 9. ❑Demolition ❑ myself[No workers'comp.insurance required]t 4.❑I am a homeowner and will be hiring contactors to conduct all work on my property. I will 10 El Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the subcontractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance.: 13. Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,$1(4),and we have no employees.[No workers'comp.insurance required] *Any applicant that checks box kl must also a out the section below showing then workers'compensation policy infonnalion. 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 workers'comp.policy number. I ant an employer that is providing workers'compensation insurance for my employees. Below is the policy arzd job site inform'rrion. Insurance Company Name: fi/4.4-. Cata, Policy#or Self-ins.Lic.#: 0p-/ 14-)A11 Expiration Date: J ret airy Job Site Address: 71 •s f City/State/Zip: /2i' +)wvil� MM �j 5 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration d'ate). 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 under the pal.' 6 d penalties of perjury that the information provided above is true and correct Signature: ',� Date: Jt 4a11f Phone#: L 'S �• /? itOs./ 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 cbnstruet building 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 contact for the performance of public work until acceptable evidence of compliance with the insurance • ' requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)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 advisedmhat this affidavit may be submitted to the Department of Industrial • Accident 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 Accident. 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 permit 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 1 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/dia -Roof to be stripped and cleaned of all old shingles and debris -Roof to be papered with weather watch leak barrier,Synthetic roof underlayment,and installed with Timberline architectural shingles using galvanized nails. (Storm nailed) -8"drip edge & new pipe collars to be installed -Cobra ridge vent to be installed on all ridges -Timbertex premium ridge cap to be installed -A 10 yard dump trailer will be needed on site;and will be removed at completion of the job • -Contractor will be responsible for all building permits needed at the property NOTICE REQUIRED BY LAW • With the agreement of the contract$500.00 of estimate is due. Further payments under this contract are as follows: 1/2 of the estimate due at the start;and remainder due at completion of the job. Balance of all materials and labor shall be payable in full upon completion of work described in this contract. Payment as agreed upon shall be made when due. Any payments which are delayed shall be subject to a finance charge of 1.5% per month. The contractor warranties the workmanship completed under this contract for a period of ten years from the date of completion. During the stated warranty period the contractor shall be responsible for the service of the repair or adjustment, but the contractor shall not be responsible for the normal maintenance, repair due to abuse,misuse,and or normal wear and tear,which shall be the responsibility of the homeowner. All warranties for the materials supplied by the contractor shall be passed directly to the homeowner. The homeowner may be required to register or mail in such warranty card or evidence of ownership in order to activate such warranties. Homeowner failure shall not create any responsibility for the contractor under the warranty provisions;the choice of repair of replacement shall be at the discretion of the contractor. The homeowner acknowledges that the form,content,and notices contained in this contract are intended to comply with the applicable portions of the Mass. General Law Chapter 142A, and regulations promulgated there under. In the event of any instance of non-compliance,only such portion shall be invalid and the remainder of this contract shall be in full force effect. In addition,any such portion not in compliance shall be read and interpreted so as to have its intended meaning to the maximum extent allowed under such law and regulation. Signed as a sealed instrument on this date: Date: 1-/0-a/J,' Homeowner Contractor / A g • DATE(MMA)DIYYYY7 ° ' CERTIFICATE OF LIABILITY INSURANCE I os(MWDONe 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 INSURED,the SURED provisions or be endorsed. M SUBROGATION IScWAIVED,subject to theterms and L ( haveicy(les)must ADDITIONAL condtt ons of the policy,certainpolici smay equire an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). . PRODUCER CONTACT NAME: Donna Ostrowski Mark Sylvia Insurance Agency,LLC PHONE F.,r(508)957-2125 I(Ale,NeI;(508}957.2781 Centerville, AS Main Street tArADDREss.mark(�marksyIVIaInSUrance.Com MA 02632 INSURER(S)AFFORDING COVERAGE NAIC 0 INSURER A:Farm Family Casualty Insurance INSURED INSURER 8: Thomas Home Improvements LLC INSURER C: PG Box 177 INSURER D I Centerville,MA 02632 INSURER C: 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 MICH 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 REDUCCED BY PAID Y EFF L IY MS. LIMITS OLSR 'ADM SLAM POLIPOLICY NUMBER (MM/DOIYYYY) IMMIDDIYY'M A TYPAL GENERAL IA Non YND 5/01/2018 5/01/2019 1,000,000 A x COMMERCULLGENERALLIABRJTY 2001X1416 DAMAGE TO S �I DAMAGE TO RENTED 100,000 I CLAIMS.MADE I (OCCUR PREMISES IES occurrence) S MED EXP(Any one peen) S 5u __ PERSONAL B ADV INJURY S 1,000,000 — GENERAL AGGREGATE $ 2.000,000 cmAGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGO S 2,000,000 --- POLICY ED JEOT Q LOC l OTHER S CUMBINFD SINGLE LIMir $ AUTOMOBILE LIABILITY (fa BINED rmdenn — BODILY INJURY(Pm'person) $ ANY AUTO '� OWNED SCHEDULED BODILY INJURY(Per accident) S — AUTOS ONLY _ AUTOS PROPERTY DAMAGEGE g HIRED NON-OWNED (Per*coition()l — AUTOS ONLY _. AUTOS ONLY S EACH OCCURRENCE S UMBRELLA UAB OCCUR AGGREGATE S • EXCESS WB CLAIMS-MADE DED I I RETENTIONS 5/0112018 5!01!2018 I S7nT STATUTE ( '7.ORH A AND S LSATION 2001 W8053 1,000,000 AND EMPLOYERS'LIABILITY EL.EACH ACCIDENT S (Mandatory M mdSI IT In NRIPARTNER/El(ECUTIVE YIN N IA E.L DISEASE-EA EMPLOYEE S 1,000,000 OFFICERIMEMBER EXCLUDED" Q DESCRIPTION NH) EL.DISEASE-POLICY LIMIT S 1,000.000 IIas.d PdnTD under n OPERATIONS below DESCRIPTOR OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more span le moulted) Carpentry Insurance havealtered,age Is limitedeto o the terms, conditions,ege o cions,provided the limitatons provisions.d endorsements. Nothing contained in the certificate of insurance shall be deemed CERTIFICATE HOLDER • CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATEE THE EOF, NOTICEOTWILL BE DELIVERED IN Troy Thomas ACCORDANCE S. 499 Nottingham Drive Centerville,MA 02632 AUTHORIZED REPRESENTATIVE tip . '0. '-t i . ) ®1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD • • • • • s Commonwealth of Massachusetts ®) Division of Professional Licensure , Board of Building Regulations and Standards Constructio014 rSpecialtyrr Expires:04/1312020 CSSL-099913 ' :4';; JU.c>v JU.174 - - 4U44$ , _ - - 30.94 =3010 " ' 30.271,. 30.25] - `' 30,3114 30.271,..? 30.249 - - - 308s ^.JJ 30.217,1 ' 30 289 -J 30272 - 30.252 J w.•..n 1 • i 30.315-.r - ,! 30.251. 30.288 - °r - r{ .30.266 i- -30.250 ,a 50.257 ' 30.216 ij• � �,•' 30• .265 JO 284 > - t 30.255 - - r- J 30-2.64 30.268 30.215 - : 70.258 f • 3.4 _ _ 30.285 30.282 j - _ _ J 30.269 70.262 J 30.1 30.281 - 30258 I - 'f' - f - 30.261 30.259 30.214 30.2 30.288 '30.260 30.270 , _ - _ /, .„.-^ 22110 . / J r• . - ,• 30.260 22111 - �, -', • x2 47 12'46 - 2279 22.80 *1107 ^.` - 32112 -_ 22119 - 2261 - 2285';215 as2281�r - 22871,123 - ° • 22108 , - 12.118 r ' 2268 - • 1 - - 22.105 _ - '.1' 22.63 l _ ' .- - ' 5 22104 ' '�.,, 22.117/ a 22.121 t • 22.78 '22.89 ••,, 22103 - '� 2291 r ./ - .'.,.v 12.61 .2290 ;. t f 22101 '. 1 [92: - f J = 21.122 • - 22304 22651 .,( .- 2295 a • • 227 R.,-I 11.169, • 22310 ^ 2270 1 i - ,.j _ - ,- 22.97- f - _x2.156 • . - _ - 22305 22.301 - - --: 22.ix' xx.xae 22311 22.309 _ _ J _ 22.98 22.155 _ 22.300 22.291 _ • '•'I \ 22.]06 221871 1'\ 22325• .- J'1`• 2171 - 12299 /1 in, 2227]` - e •„�Ic,i 75 LEWIS RD WEST YARMOUTH, MA 02673 j; 74 finch = 134 feet W p-E S Data and scale shown on this map are provided for planning and informational purposes only.YARMOUTH (MA) and Vision Government Solutions are not responsible for any use for other purposes or misuse or misrepresentation of this information. 8/17/2018