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Home My WebLink AboutBLD-19-000944 ^•O£•VA.,* Urine Use Only .. 2 0 epermxt# C' O� v O � H: lAmotmt 5 _C - , 2' Permit expires 180 days from - t issue daze Lb--Iq —ocxgyy EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department - 1146Route 28 RECEIVEDI South Yarmouth, MA 02664 I �7 (508) 398-2231 Ext. 1261 AUG 172013 ? • CONSTRUCTION ADDRESS: jJ1" /...6.4...)& BUiCV* I • ASSESSOR'S INFORMATION: • Map: Parcel: OWNER: rill(' /n"c _ ?lizu. o 13/ LG.,s arms-77-.5(11 NAME PRESENT ADDRESS ` TEL. # CONTRACTOR: T roti/ I t0 WW2 I t3hX /�2 ('&tt e.-/QJ(( SDfr'-32t/c3S' NAME MAILING ADDRESS TEL/# D'Residential 0 Commercial . Est Cost of Construction$ d-/775. Home Improvement Contractor Lie.# 7 49 13Con etion Supervisor Lie.# `�S 92? Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor have Worker's Compensation Insuranc/e� Insurance Company Name: 16' r- • I r�'+Ync 1l/ c1% tA,el j Worker's Comp.Policy# odoo/elite-CIS 3 WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove r7 Siding: #of Squares �l Replacement windows:# Replacement doors: # Roofmg: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/fiistoric Dist. ( )Replacing like for like // Pool fencing 'The debris will be disposed of at I O CWitl a Fri int CV I-4 T(r Alus 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 o ocato• : my lic , d for' 'secution under MG.L Ch.268,Section 1. � Applicant's Sign.�.o -5.46; . /f Date: IS/�e/7_ /f/( Owners Si!. or a chmrme Date: i Approved BY: y Date: ? �I . :w�;, ) 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 Massachusetts J a,—a= g_=u, �'/ Department oflndustriaiAccidents =�+1= i .1 Congress Street, Suite 100 _ � Boston, MA 02114-2017 ik.,;,.i www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH TUE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): 7'7'lrj6c1 jV o_ .3 / 4c v Address: `' City/State/Zip: (_ „ .,A) t Phone #: `cj}`tj —?"'—/(YX' Are you employer?Cheek the appropriate box: Type of project(required): I. I am a employer with 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.] 3.0 I am a homeowner doing all work elf t 9. ❑Demolition toys [No workers'comp.insurance required.] 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑ Building addition ensure that all contactors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions s.❑I am a general contactor and I have hired the sub-contactors listed on the attached sheet These sub-contactors have employees and have workers'comp.insurance.: 13.0 Roof repairs 6.0 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#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 contactors must submit a new affidavit indicating such. :Contractors that check this box must atached an additional sheet showing the Dame 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 providingworkers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: riul lig/GUI t &,S`a&LS . �SO Policy#or Self-ins.Lic.#: QO0/1.0 MO S Expiration Date: 3-- O J— i Job Site Address: / c ,I til ,s (/9 City/state/Zip: /{J, Attach a copy of the workers' compensation policy declaration page(showing the policy num er 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 DR for insurance coverage verification. I do hereby certify neler the ains and penalties of perjury that the information provided above is true and correct Signature: .93„....- Date: 8`x'`7— Phone#: re: 2,2g---/3J 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): I.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 contact 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 ajoint 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,§250(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, §250(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 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-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 advised That 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 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 bum 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 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 wvwv.mass.gov/dia In the event that while stripping the siding we find rot that needs to be replaced,the homeowner then has to agree and authorize any replacement or restoration. Then in addition to the above contract price,the homeowner agrees to compensate the contractor for any repairs or restoration at the hourly rate of$65.00 for a carpenter and$45.00 for a carpenter's laborer,plus the cost of materials. -Siding to be stripped and cleaned of all old shingles and debris -Siding area to be papered with Typar house wrap -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: �o Homeowner Contractor C��V • DATE(MMn1D1YYYY) A O® CERTIFICATE OF LIABILITY INSURANCE I o5nWDOMY THIS CERTIFICATE IS TE HOLDER. THIS CERTIFICATE DOES NOT UAFFIRMATIVELYED AS A EOR NEGATIVELY AMEND,R OF INFORMATION (EXTEND OR AND ALTER THE COVERAGE AFFORDED NO RIGHTS UPON THE ABY 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(les)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 CONTACTNAME: Donna OSSfowski FAX Mark Sylvia Insurance Agency,LLC PHONyn Fyn:008)957-2125 I A(c,Na):{508)957-2781 404 Main Street we pDpa as mark�mark5YNlainsurence.com Centerville,MA 02632 INBURERISI AFFORDING COVERAGE NAIC I INSURER A:Farm Family Casualty Insurance INSURED INSURER BI Thomas Home Improvements LLC INSURER C: PO BOX 177 INSURER D: Centerville,MA 02632 INSURER e: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: • THIS is TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POWHICH THIS UCY PERIOD CERTIFICATE NOTWITHSTANDING MAAY I BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED DY�THEPOLICIES DESCRIBED TRACT OR OTHER HEREIN S SUBJECT TO ALLMENT W1TH RESPECT O THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCEDBY PAID IDuCLIAIMS. UNITS ADOI SUBR POUCY NUMBER POLICY (MMIDDIVYYY7 ATYPE OF IA IN4n WVn 5/01/2018 5/01/2019 EACH OCCURRENCE 1 1,000,000 A 1C COMMERCW.GENEPALDABR.I7Y 2001X1416 DAMAGE TO REN TEDI 100,000 PREMISES(Ea ocwaenrel 1 CLAIMS-MADE [-_-_-jOCCUR MED EXP(Any one person) 1 5,000 — PERSONAL B ADV INJURY 1 1,000,000 — GENERAL - i 2.000,000 —GGEENIIII L AGGREGATE OMIT APttPLIE�S� PER PRODUCTS•AGGREGATEAGG s 2,000,000 RPOLICY❑JELQT u LOC 3 OTHER. COMUINEU SINGLE Lux $ AUTOMOBILE LIABILITY CO(Ea eUudrxl _ BODILY INJURY(Per person) 1 _ ANY AUTO -� OWNED ^SCHEDULED BODILY INJURY accidri) 1 AUTOS ONLY _AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ — (Pr widen')AUTOS ONLY AUTOS ONLY I EACH OCCURRENCE _S UMBRELLA LIAa _ — EXCESS DAB CUIM9�OCCUREACH AGGREGATE 1 • ,,77�� 1 DED I 'RETENTIONS 5/01(201a 5/01!2019 I PER I .AGFA A WORKERSCOMPENSATION 2001W8053 1,000,000 AND EMPLOYERS•LIABILI Y YIN EL EACH ACCIDENT ! Mandatory In NH) NIA E.L DISEASE•EA EMPLOYEE $ 1,000,000 OFFICERRAEMSEREXCLUDEO" DESCRIPTIONkxy m NH} E L DISEASE•POLICY LIMIT S 1'000.000 if yes.aeaaW under OF OPERATIONS Sow - i DESCRIPTION OF OPERATIONSI LOCATIONS I VEHICLES(ACORD 101,Add(tlanal Remark*BchWul*,may be attached If more specs Is required) Carpentry Insurance coverage Is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER • CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPR TyNTHA ION DATE THE EOF, NOTICE BE DELIVERED IN Troy Thomas 499 Nottingham Drive • Centerville,MA 02632 AUTHORIZED REPRESENTARVE / I (61988.2015 ACORD CORPORATION. All rights reserved. • ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD • • • • • • C. Cortxmnwealth of Massachusetts +�S Division of Profes' onal Licensurelations d Standards / Board of Building �_ Moor Specialty • Gonstructiak f .:,, :.;Z noires:04/1312020 CSSL-099913 ""` y r TROY ATHOMAS to+' SrJ ;t 499 NOTTINGHAM DRIVE"t- M,y v` ��:; \ RVILLE CENTE 01632 ` -,�A MA , oc. Yls 5 Commissioner cTh<rem manweatl/r eta ttauaeAaielh Office of Consumer Affairs&Business Regulation 9 HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE Corooratlan before the expiration date. If found return to: Registra0on,.+ EXolratlon Office of Consumer Affairs and Business Regulation 185422�-`_'-.06/08,2020' One Ashburton Place•Suite 1301 TROY THOMAS HCNIE:MPR0VEMENTS,INC. Boston,MA 02108 TROY THOMAS /e 499 NOTTINGHAM signature CENTERVILLE,MA 022632632-" undersecretary Not .1 d without sig