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Home My WebLink AboutBLD-19-000941 +-,4, Y aOffice The Only _Permit# S. p it H Amount �, • $ •Permit expires 180 days from 1 D-br n _ `L „ I issue dale EXPRESS BUILDING PERMIT APPLICAT a ► C E I V E D TOWN OF YARMOUTH AUGf 17 2018 Yarmouth Building Department U 1146 Route 28 South Yarmouth,MA 02664 BIB - e ° a /9 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: W-c4 ) 1b / rid Jl^/(_ ASSESSOR'S INFORMATION: • Map: Q-1i( Parcel: l co o . owxER: \ Cj� C I q ar ii xAMEPfset;rf n 1' S1L ( TI 4 PRESENT SS FA,r CO✓n.ers '0# ,�S'°yo�0 f -.CONTRACTOR: (R N MILINGADDRESS TEL if ❑Residential 0 Commercial'' Est Cost of Construction$ 5):/q (10 , Home Improvement Contractor Lic.# (1p 11 C'07 Construction Supervisor Lic.# /O 6 31 3 Workman's Compensation Insurance: (check one) 0 I am the homeowner p O II am the sole/Proprietor have Worker's Compensation Insurance ("foci Insurance Company Name: SC ( /Lye 1 Worker's Comp.Policy# N C I ( bfd 1 Q WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # 'Roofing: #of Squares (7 ( in Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist ( )Replacing like for like Pool fencing 'The debris will be disposed of at /1/6.-V v"%*Q if C Location of Facility I declare under penalties of perjury that the statements herein contained are true and correct to the best of my Imowledge and belief I understand that any false answer(s) will be just cause for denial or revocation y license4.57,....-- enand for prosecution under MAIL Ch.268,Section 1. Applicant's Signahu /p/e: Date: Avy (7 / O Owners Signa a(or attachment) / Date: Approved By: ..,.i'/� -/ Date: ---/7—/9 Building tial stgnee) 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 rl/, Department of Industrial Accidents wale= 1 Congress Street,Suite 100 _al • gI Boston, M4 02114-2017 www.rnass.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): r� C� ?ca 617 Lila* , fiC ,)r5 Address: �'�l >`luC Corn gr./ /7 / ///" City/State/Zip: Ce rA_- C Phone#: c b-4')-a jb 02— 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. 0 New construction 2.0 1 am a sole proprietor or partnership and have no employees working forme in 8. ❑Remodeling • any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing an work 9. 0 Demolition ❑ myself[No workers'comp.insurance required.]t 4.0I am a homeowner and will be hiring contactors to conduct all work on my property. I 10 0 Building addition wn11 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.t f t am a general contractor and I have hired the sub-contactors listed on the attached sheet. ese sub-contractors have employees and have workers'comp. insurance? 13.El Roof repali� 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 1// C /.06152•$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 then workers'compensation policy information. t Homeowners who submit this affidavit indicating they am doing all work and then hire outside contractors must submit a new affidavit indicating such. LContractors 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-contactors have employees,they must provide their workers'comp.policy cumber. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date:p Job Site Address: /9 OV K fd' City/State/Zip: a'V Y eta— f^-4 f^-4/4.4. Attach a copy of the workers' compensation policy declaration page(showing the policy number nd 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 line of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pai and penalties of perjury that the information provided above is true and(c`orrrect. Signature: Date: aCi (dr Phone#: 77 Sr cO f C( F.)- Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: • AAloom COREP CERTIFICATE OF LIABILITY INSURANCE °"TEINIXON"") • 2/12/18 THS CERTIFICATE IS ISSUED AS A MATTER OF*FORMATION ONLY MO CONFERS NO RIGHTS UPON THE CERIIRCAIE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR IEaGATNELM Nf0, EXTEND OR ALTER TIE COVERAGE AFFORDED BY THE POLICIES BELOW. THS CERTIFICATE OF INSURANCE DOE$ POT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERS),AUTHDMZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOIDER e IMPORTANT: If the certificate holder b an ADDITIONAL INSURED,LM policp(ies)rust be endorsed. If SUBROGATIONJS WAIVED,subject to the terms and conditions of the pricy,certain poicies may require an endorsement. A statement onfhis certificate does not confer rights to the certificate holder In Oeu of such endorsement(s). • IRCWCIaRNSErA�tT JIM HII ,N' Schlegel S Schlegel Ins Broker PHONE ma (sow) 771-0663 34 Main Street JIA�NLa , I508T elinsu771-8381 IAD NA: DIRESt achlegelinsutance(gaail.com West Yarmouth, MA 02613 PBAERSIAFFORMIC COVERAGE NADA INSURER A:TRAVELERS PROPERTY AND CAS SOURED INSURER IS: JINTA2A CAHOON INSURE!C: DBA CAHOON OONSTRUCPION INSURISRD: 16 WEQUAQUET AVE INSURER E. C NTE VILLE, MA 026323 INSURIIRF: COVERAGES CERTIFICATE N UMBER: REVISION NUMBER: THIS IS TO CERTFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAME)ABOVE FOR THE POLICY PERIOD INDCATC NOTWITHSTAPDNG ANY REQUIREMENT,TERM OR CONDITION CF ANY CONTRACT OR OTFIER DOCUMENT WITH RESPECT TO WHICH THIS CERTFICATE MAY BE ISSUED OR MAY PERIAN,THE INSURANCE AFFORDED BY TIE PCLIGES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, ECLUSIONS ANDCONDITIONS OF SUCH POLICIES..LITS SHOWN MAY HAVE BEEN R®l10ED BY PAD DUNS _ LTR TYPE OF INSURANCE ARM POUCY NUMBER D1OUCY xIID YTI�T (PAUPCYrY11, W ES GENERAL UABILITY EACH OCCURENCE e CDMMMERCIALGENEfaLLMBl1TY DAMAGE TO RENTED PREIMSFS fEa ammnul x CIANSNADE O OCCUR MED DIT(Ary one pawn) a PERSONAL a ACV INJURY e _ GENERAL AGGREGATE l GE/LAGOREGATELISTAPPLES PER PRODUCTS-ODLF/OP AGO S I POLICY n FRT n LDC e — AUTOMOBILE LIABILITY COELECTrt+INGL ELT ANY AUTO (SODLY NARY(Pa pwxrn) i ALLOWED SCHEDULED BOOtY Inter Pe Denson $ AUTOS AUTOS HIRED AUTOS NAUTOS OVO ED PR dn) t $ HVIDIELLA tiM �OCCUR EACH OCCURRENCE l EXCESS LAS CUTAS#ADE AGGREGATE l DED RETENTION; S A oNN PLPLO es�iV ATION r Y)x WC-1165040 2/13/1e 2/13/15 Iwe TIVnri:.�r[cI c�a- A/nPRaPRETORAARDEP/EXBZUTNE xrA EL EACH ACCIDENT l 100,000 OEFlLLM.EMIER CO DEN Imanffl.yia Al) EL DISEASE-EA EFI a 100,000 DESCRIPTION OF OPERATIONS below EL DISEASE-POVCYL a 500,000 DESCMP TON OR OPERATIONS I LOCATIONS/VENUS(PAWN ACORD 101,AAlOown Rewrb SANTA sawn Duos SU.W M) JINTANA CAHOON HAS ELECTED NOT TO BE COVERED UNDER HER CURRENT BOWERS CYZO?ENSATION POLICY CERTFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED N RICHARD =MADLY ACCORDANCE NM THE POLICY PROVISIONS. CENTERVILLE MA 02632 AVnlq✓®REIKSENTATNE 1 8-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered of ACORD Phare: Pax E-Mail: CAEEAULT7 COTOCAST.lgET • 1 . ✓ x. CA ZEAULT\ ROOFING & REPAIRS PROPOSAL Proposal No. 18-71018 July 10„2018 To: Hac-Megan Haley Work to be performed at 19 Orchid W. Yarmouth MA We hereby propose to furnish the materials and perform the labor necessary for the completion of: NEW ROOF 1. Remove existing shingle roof(2 Layers) 2. Install drip edge 3. Ice&Water bather first 2ft,all skylights and penetrations 4. Cover roof with Rhino Paper 5. Re-roof with 30 yr architectural shingle 6. Install ridge vent 7. Flash all pipes and penetrations 8. Remove all rubbish from project Labor and Materials$5,900 All material is guaranteed to be as specified, and the above work to be performed in accordance with the specifications and completed in a substantial workmanlike manner for the sum of Five Thousand and Nine Hundred Dollars$5,900 with payment as follows: Five Thousand an Nine Hundred Dollars due upon completion Respec b fitted, tfir Richard P.Can ult,Jr. HIC# 168607 CSL#100393 198 Five Corners Road Workmans Comp and Liability with Centerville,MA 02632 Leonard Ins of Ost (508)420-5482 Acceptance of Proposal No. 18-71018 The above prices, specifications and conditions are satisfactory and are hereby accepted. Ye . :'Lauthorized to do the work as specified. Payment is outlined above. Signature Date . - Commonwealth of Massachusetts Division of Professional Licensure ®j Board of Building Regulations and Standards ConstrtlttASn'Supervisor CS-100393 . Expires: 02/03/2020 4 • r C:-..."; RICHARD P CAZEAULT;JR' - 198 FIVE CORNERS ROAD CENTERVILLE MA 02632 11.-1'Ot, ,c1;\L- ` Commissioner ----- - - ✓17r'rduinr nneabi r/T(6.2.rrwie, Office of ConsutnerAfiatrs 8 Business Regulation -_'- "--- - -- --- - - y HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only ��1-k+,� TYPE:kldtAdual before the expiration date. if found return to: t x pegisteaffon Expiration Mee of Consumer Affairs end Business Regulation 03972018 _- 16Pak Plaza-Suite 5176 -1 t t'' ..- .. --BosTori,MA 02116 . - - . RICHARD P CAZEAULTJRi'; - - - DB/A R Cazeault Roofing&Repairs - . ' RICHARD CAZEAULT JRCC f/ ' 190 Fine Comers Rd - i �)' `� - i - - Centerville,MA 02632 Undersecretary Not valid wit signature -- n-'^r.-.. . '',-- --- —,----,.r.- i. osHA . °001116998 'a 4. ; ' . :1"ems tt ' U.S.Departmentot Labor - . Occupalronal Satety nd Heaith Administration jr,2.7.r�c4.r Richard Cazeault-4r.." Chas successiplly completed a 10-hour Occupational Safety and Health;%.i-„J,` r t f Taming Course in r . ," -r x - • r p y j -1 I 1 y �, ;;-,_' Constnic6on Safe 8 Health' , m ` . f . .. r ',(rra(rer1 _. , II '.ti : (Osie)..'!.