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EXPRESS BUILDING PERMIT APPLIC ION__ `
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TOWN OF YARMOUTH
Yarmouth Building Department AUG 17 2018
11Route 28 PJ o"
South Yarmouth,MA 02664 uruu n' • r
(508)398-2231 Ext. 1261 ---- -
CONSTRUCTION ADDRESS: 39 5 7-UD tc Y C 4
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: 650RGE et=EN/5a cab' 4 99 S9/4
NAME "r�, P ENT ADDRESS TEL II
CONTRACTOR: 444C-mut t_/0 sot a?/ &s9/
NAME MAILING ADDRESS TEL I
❑Residential 0 Commercial Est.Cost of Construction$ 3, 00C')
Home Improvement Contractor Lie,# /4 7 a VI Construction Supervisor Lic.# /0 YOl7 4,
Workman's Compensation Insurance: (check one)
❑ I am the homeowner 0 1,am the sole proprietor I have Worker's Compensation Insurance R
Insurance Company Name: 2 fJ \C i Worker's Comp.Policy# 6 22u g/ Kc2 y aw--
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/Historic Dist. ( )Replacing like forlikePool fencing
*The debris will be disposed of at: (gnta'uTH flY—
Location of Facility
I declare under penalties of perjury that the statements herein contained are We 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 I.
Applicant's Signature: - s ,fYZ Date: r—.' /7 p-
Owners Sign ser a Date:
Approved By: a0 � � Date: e' •/` /'7 a
Building 0 t.roam' •. ) EMAIL ADDRESS:
Zoning District:
Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes ❑ No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes 0 No
The Commonwealth of Massachusetts
Ert Department of IndustrialAccidents
_' - a 1 Congress Street,Suite 100
5��_ " Boston,MA 02119-2017
'..*�•;,a-c` 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/Individual): ,z'A R K r1UL G//y
Address: 7 Cd#hf&/rA-4 (Amy
City/State/Zip: W, y/}z y vvrH /$14- ' hone#: sot?>-/ rCT/
Are you an employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with employees(full and/or part-time).•
7. El New construction
10 1 am a sole proprietor or partnership and have no employees working for me in
any capacity.[No workers'comp.insurance required] 8. ❑Remodeling
101 am a homeowner doing all work myself(No workers'comp.insurance required): 9. ❑Demolition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition
ensure that all contractors tither have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
13.❑Plumbing repairs or additions
5.0 I am a general contractor and 1 have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp.insurance: 13.❑Roof repairs
6.0 We area corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,11(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 thea 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 subcontractors have employees,they must provide their 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.
Insurance Company Name: 20 K Id-K
Policy#or Self-ins.Lic.#: 6 2-2 urn Ka- 95-5",x/r Expiration Date: �3 r'7-
Job Site Address: 3 $1 370/)LCI,V City/State/Zip: I,�/�I RI vv of
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 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 pains and penalties of perjury that the Information provided above is true and correct.
Simature: 2,,G 1-4A Date: 8/'7"fr—
phone#: cot p.21 fir r9/
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#:
f t
A D® CERTIFICATE OF LIABILITY INSURANCE
DAoaTE osnot�a
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 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 NAME ACT Debra Martin
MARGARET J GRASSI INS AGENCY j�NNy (508)295-2007 No);
AD
ADDRESS: debetj9 Ins comcast.net
1188 MAIN ST • INSURER(S)AFFORDING COVERAGE NAICa
W WAREHAM MA 02576 INSURER A: AMERICAN ZURICH INSURANCE COMPANY 40142
INSURED INSURER B:
MULLIN ROOFING &SIDING INC INSURERC:
INSURER D:
7 CONNEMARA WAY INSURER E:
W YARMOUTH MA 02673 r INSURER F:
COVERAGES CERTIFICATE NUMBER: 254984 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 TYPE OF INSURANCE IY
ACOL SUER POLICY EFF POLICY EXP LIMITS
LTRINSD WVD POLICY NUMBER (MM/DDIYYYYI IMM/DDYYYI
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
DAMAGE TO RENTED
CLAIMS-MADE 0 OCCUR PREMISES(Ea ocurrence)_ $
. MED EXP(Any one person) $
N/A PERSONAL SADV INJURY $
—
GEN'L AGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $
POLICY n JECT n LOC PRODUCTS-COMP/OP AGG $
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
(Ea accident)
ANY AUTO BODILY INJURY(Per parson) $
ALL OWNED SCHEDULED .
N/A BODILY INJURY(Per accident) $
AUTOS _ AUTOS
NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS (Per aaadann
$
UMBRELLALIAB — OCCUR EACH OCCURRENCE $
EXCESS LAB CLAIMS-MADE N/A AGGREGATE $
DED RETENTIONS V $
X
WORKERS COMPENSATION STATUTE ETH
AND EMPLOYERS'LIABILITY
A OF CER/MEMBER EXCLUDED?
WA WA N/A 6ZZUB1K24552618 03/07/2016 03/07/2019 E.L.EACH ACCIDENT $ 500,000
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000
DEsCdePeTcIONuOnOrP
ERATIONSbelow EL DISEASE-POLICYLIMIT $ 1,000,000
N/A
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached B more space Is required)
Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization Is given to pay
claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts.
This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the
Issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification
Search tool at www.mass.gov/wd/workers-compensatiorVnvestigations/.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Chris Herman ACCORDANCE WITH THE POLICY PROVISIONS.
7 Yacht Ave
AUTHORIZED REPRESENTATIVE
ea'(7
West Yarmouth MA 02673
Daniel M.Crgw y,CPCU,Vice President—Residual Market—WCRIBMA
®1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
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- -\` (',� ':t6M lnOj,�� • expiration data If found return to:
>- rh/,:.L� bbyW3 �I ibt Office of Consumer Affairs and Business Regulatio0
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- 'od 0. { "1 ' �', Boston,MA 02116
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MULLIN ROOFING & SIDING INC.
CONSTRUCTION CONTRACT
This Construction Contract(the "Contract") is made and entered into as of 8-16-18 (Date), by and
between George Oleyer (Name, hereinafter called the "Customer") and Mark M. Mullin, DBA Mullin
Roofing and Siding, Inc. having its principal office at 7 Connemara Way, W. Yarmouth MA 02673
(hereafter called the "Contractor").
Property Location: 34 Studley Rd. Yarmouth, MA
In consideration of the mutual promises hereafter set forth and intending to be bound hereby, the
parties hereto agree as follows:
Contractor's Obligations. Contractor shall complete the following Project herein described in
and shall provide supervision necessary to commence and finish the Project expeditiously, in a
workmanlike manner, in accordance with the "all applicable codes, laws ordinances, rules,
regulations and orders.
Description of"Work". Contractor shall do all the work in accordance with the terms of this
Contract, as described:
Remove the existing vynil siding from the front and left side of the garage when looking at the
house from the street. Install Typar home wrap over the bare walls. Install grade A white cedar
shingles using galvanized staples, and stainless steel nails for finished courses. Remove the
existing corner boards and install one piece composite corner boards by Versetex. Remove the
existing trim around the garage doors and install new Azek trim boards. Install new weather
stripping to the garage doors after installation of new trim. Remove and replace the roof on the
wood shed on the west side of the house with Landmark roofing shingles by Certainteed color
to be cobblestone gray. Replace the rotted wood rail pieces on the East side of the porch.
Replace East side porch door trim with Azek trim.
Contract Sum. In consideration of the performance by Contractor of its duties and o ligations,
hereunder, Customer shall pay to contractor the sum of e f 3o
Payment schedule: Owner shall pay the contractor 50% upon signing the contract,0% upon
start of contract work, and the remaining 50% upon completion of contract work.
Contractor's Responsibility. Contractor is an independent contractor for all Work to be
performed hereunder. The detailed manner and method of doing the Work shall be under the
control of the Contractor.All employees of the Contractor performing Work under this Contract
shall be and remain the Contractor's employees.
a. The Contractor shall supervise and direct the Work, using its best skills.
Job Safety. Contractor shall be responsible for initiating, maintaining and supervising all safety
precautions in connection with the Work.
Insurance. Contractor acknowledges and agrees that Customer or Owner shall not be
obligated to carry any insurance in connection with the Work for the benefit of the Contractor.
Contractor's Insurance. Contractor shall at all times maintain and keep in full force and effect,
at its expense, any and all insurance coverage which is prudent, necessary or desirable for the
protection of the interests of Contractor. Contractor shall furnish to Customer certificates of
insurance for the following types of insurance.
a. Commercial General Liability Insurance;
b. Workers' Compensation Insurance to cover full liability under the Workers'
Compensation Laws.
All waste associated with this project will be properly disposed of by the contractor.
IN WITNESS WHEREOF, the parties hereto have executed this Contract as of the day and year first
above written.
Customer Contractor Company
BY By:
wr
Print: George Oleyer Mark Mullin, Mullin Roofing & Siding, Inc.
7 Connemara Way, W. Yarmouth MA
02673 508 221 8591
Address: 34 Studley rd Yarmouth, MA
Date: 8-16-18 Date: 8-16-18
Phone number 508-694-5916 License No. CSL 104076 HIC 167281
Email address: oleyer@snet.net Email address mullinroofing@gmail.com