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HomeMy WebLinkAboutBLD-19-001038 I. r +o�,•y�R�r �,once Use Linty N/ O;was!i 'y� H e Permit* Su I x . 27 ea Permit expires 180 days from issue date Blab-lq-D0103 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 AUG 2 i. 2018 (508) 398-2231 Ext. 1261 ��T 7q11 E��I '.�F� — g. CONSTRUCTION ADDRESS: .J / 4* m,vlN 59 Al!028 C ) yArtro u ASSESSOR'S INFORMATION: • / Map:a// Parcel: ..�pp {, de- OWNER 17M Loki 1.77r- 396 niv,,ci 51—€143 0)}/A vette., . /'15 % SV NAME PRESENT ADDRESS / TEL. # CONTRACTOR: an_ r v c f <vv,%/ // Co 55d tL Zo y NAME / MAILING ADDRESS TEL N ❑Residential E3'Co#mmercial Est Cost of Construction S c WOct bd Home Improvement Contractor Lic.# /G/ Sg59 Construction Supervisor Lie.# elSyyZe Workman's Compensation Insuranceeck one) 0 I am the homeowner I am the sole proprietor 0 I have Worker's Compensation Insurance'/ Insurance Company Name: Tl—F+u a J< - .5- Worker's Comp.Policy}# € f/0,3. 07/34/V3/ WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Rep cement windows:# Replacement doors: # Roofing: #of Squares 1 1/45- ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing "The debris will be disposed of at Location 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 ofmylicense and for prosecution under M.G.L.Ch.268,Section L 7� / Applicant's Signature: 5 Date: U/a/ Owners Signa e(orattachme'� Date: /''j ' Approved By: d Date: �i�V Building• cial/.•-i esi; ee) MAIL ADDRE 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 . I/ rt. — The Commonwealth of Massadhusetts J Is=Stir— 11 8 M—.72.111��'/ Department oflndustrialAccidents € =ink= 1 • 1 Congress Street, Suite 100 • `_ • Boston, MA 02114-2017 -4,• .---. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Bnilders/Contractors/Electricians/Plumben. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): 'J li4, g�� Address: /1 ,ec,is° _e..e/ City/State/Zip: `//9-rm©` Phone #: So8--3,95-:-.88,6) Are you as 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.Q j,ata sole proprietor or partnership and have no employees working for me in • any capacity.[No workers'comp.insurance required.] 8. ❑Remodeling 3.0 l am a homeowner doing all workmyself 9. ❑Demolition [No workers'comp.nnsutance required]t 4.❑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 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 am a general contactor and I have hired the sub-contracton listed on the attached sheet These sub-contractor have employees and have workers'comp. insurance, 13.El Roof repairs 6.❑We are a corporaton 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.] 'Arty 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 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: 7r flu•c /Lk- 5 Policy#or Self-ins.Lic. #: L Zip i3 02g G /NJ 3 l Expiration Date: / % 2/ '9 Job Site Address: _a A1#;jj 5t £ 2e City/State/Zip: W�rqiJ v, 'tnie ylyvR- Attach a copy of the workers' compensation policy declaration page(showing the policy numtfer and expiratio>idate). 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 under the pains and penalties of perjury that the information provided above is true and correct SisnaturerEch 7 rik, a a� Date: s/7//8 Phone#: SO g 3 6s—g s 0 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#: r i► ' • 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." MOL 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 contact for the performance of public work until acceptable evidence of compliance with the insurance requirement 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 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 resumed 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 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 Sheet, Suite 100 r• ' Boston, MA 02114-2017 • Tel. # 617-727-4900 ext. 7406 or I-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.rnass.gov/dia f MID CAPE ROOFING • 11 RUSSO ROAD WEST YARMOUTH,MA 02673 508-775-3799/508-385-8801 • Barry Merrill&Paul Merrill Job Site Address Mailing Address Name: L00 /.eJG . Sur-Alit Name: Street: 3p4,/Yjf-,;c/ . '. Street: City: City: Telephone: .Telephone: We hereby propose to furnish all the materials and all the labor necessary for the completion of: roof replacement of the dwelling at the above address. Mid Cape Roofing proposed to remove and dispose of the existing roof. The roof will be replaced with CertainTeed Landmark shingles. Aluminum drip edge will be installed along the Batter line.Ice&Water Shield installed on bottom edges to protect ice back-up. 15 pound felt paper will also be applied. The shingles will be installed using 1'A inch roofing nails. New pipe vent collars will be installed. Ridge vent will be installed along the ridgeline of the roof to provide proper venting of the attic space. Mid Cape Roofing guarantees the workmanship for a period of 10 years. All walls and landscaping will be protected from damage;the property will be raked and cleaned of all debris. All material is guaranteed to be as specified and the above work is to be performed in accordance with specifications submitted for above work and completed in a substantial workmanlike manner for the sum of: $:floe .00—All discounts have been applied. Payment made as follows: Deposit of: S . 00 the day job is started and remainder paid on completion. Any alteration or deviation from the above specifications involving extra costs will become an additional charge over and above the estimate and will be discussed with the homeowner. Respectively Submitted by Mid Cape Roofing NOTE: This proposal may be withdrawn by Mid Cape Roofing if not accepted within 30 days. Acceptance of Proposal The above prices,specifications and conditions are satisfactory and are hereby accepted. Mid Cape Roofing is hereby authorized to perform work as specified with payments made as outlined above. Accepted: ( t®1 Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constrafttf r1%dpervisor CS-054428 Eyires: 05/21/2020 BARRY B MERRILL' r l 0 . i 312SKUNNKFTTRU., n 0+ +k+ CENTERVILLE MA 02632 's ';b* Commissioner v^" 1 • e IIOINNl4NWfa/t1 e/b trinkl I IJ'4, Cfti.an.,Cot vim 1 Aflafra d GL• ;'-•:5 A . I' HOME lea"f..I r..e M..ENT.CC TfTR.. ', r ripe: Ptrtnership :. Bodo 5„•q '.' ••..aY-vrcuin.!4fA .....7.....02@i3' --, Lind::e: 1