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HomeMy WebLinkAboutBLD-19-001810 •704,Y ce Usa Only z� 40 '/9t7l]/ '/ZI t, , . 11 5 Amount r' Permit expires 180 da .. iissue d"-tom n 0 ' C . EXPRESS BUILDING PERMIT APPLICATION ' SEP 2 5 2018 TOWN OF YARMOUTH • ,gra P ,. Yarmouth Building Department 4/,Atpiplr DEN 1146 Route 28 '��--- South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: I i 4b f{c5(9.4 1 1, t- , .0Yanitt)W1-• ASSESSOR'S INFORMATION: • Map: �� ' 26 Parcel: rt OWNER � t(iptJv(I1 +0 �t nl)ae2 t (0,4-- Sok-160-27%9 NAME PRESENT ADDRESS/ p /� QTEE,L. # I, CONTRACTOR 1) �� JA p v:UUttL 60 C4aS A� `'`r/ Tehr )(O-Z/ Z f' NAME MATUNG ADDRESS TEL## Residential 0 Commercial p Est.Cost of Construction$ (2, tri).,` Home Improvement Contractor Lie. ( # I 0( O 7 Construction Supervisor Lie.# 1©2600 Workman's Compensation Insurance: (check one) v 0 I am the homeowner.[,,,�❑ I am the sole proprietorpC1 I have Worker's Compensation Insurance Q�� Insurance Company Name: / 1�` '(Lfi VLg Worker's Comp.Policy# Pitt2SS64' WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 3 Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Diist. P( )Replacing like for like Pool fencing `I" "The debris will be disposed of at L"^!"c`6C- 1/4, 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 revocatio license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Sigraurte: in Date: 2/2YAd" Owners Signature(or attaclune. / Date: /// /JAI 9-7 5T7P Approved By: Date: euild4Official or design) ADDRESS: << Zoning District Historical District 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 R of Wetlands: 0 Yes 0 No 0 Yes 0 No r�a_ The Commonwealth ofMassadhusetts '1/ r•a=='1 _�/ Department oflndrstrialAccidents • - I_ =`a= 1 Congress Street, Suite 100 _ f_ Boston, MA 02114-2027 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): 124/04" SWAT (re' (CF & .lit Address: 61 UJl1i3I w ( , '' 11 • City/State/Zip: .W. YAtnLOUAli f Mt Phone #: ¶0r560 -Zl le/' Are yop n employer?Check the appropriate box: , Type of project(required): 1. 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. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3.❑I am a homeowner doing all work myself[No workers'comp.insurance required]r 9. ❑Demolition 4. I am a homeowner and will bemy prop�y. I will 10 0 Building addition ❑ hiring contractors to conduct all work on 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 sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'camp.insurance.; 13.❑Roof repairs insurance.; 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 1 152,§1(4),and we have no employees.[No workers'comp. insurance required.] *Any applicant that check box el 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 2.5 davit indicating such_ :Contractors that check this box must attached an additional sheet showing the name of the sub-cont-actors 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. To Insurance Company Name: �g IJ ` 72 Q Policy#or Self-ins.Lie.#: R7,c c �'6SC Expiration Date:'./17 2)F Job Site Address: 1'1 L� i:P.46sL I V't City/StateZip: • Atiltowz, 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 51,500.00 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 ate pains and penalties of perjury that the information provided above is ue and correct Sisnature: he, W / 1Z1( / 2 ,�q / Date: / Z / Phone#-. '> - 340'i VV9 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#: e • 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 Bounds 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 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 contracting authority." Applicant 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 advisedthat this affidavit may be submitted to the Department of Industial • 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"lob 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 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.mass.gov/dia 717 Roofing and Siding BBB. of Cape Cod,LLC 68 Winslow Gray Rd West Yarmouth, MA 02673 508-360-2749 e-mail: rsoccl&vahoo.com HIC REG#170787;LK it 102600 Job Address: Name: carol livingston Town: Address: 17 WARBLER LN Job Phone:5028-760-2759 City: W,YARMOUTH Other Phone: ZIP: e-mail: LIVICAPECODQa VERIZON.NET Estimator SCOTT DICKSON 08/21/18 We hereby submit specifications and estimates to furnish and install new White Cedar Shingles on the following areas: Specifications as follows: L Remove existing siding and dispose of debris; 2. Inspect sheathing for rot or other deterioration and advise homeowner of any additional work; 3. Inspect existing waterways at window,door and corner boards and notify homeowner of any additional work; 4. Install Typar breathable house wrap. 5. Install new window and door drip cap flashing; 6. Install double first course of siding. Install new siding using approximate 5 "exposure hitting tops and bottoms of windows and door openings as allowed (may not be possible at all). 7. Siding to be secured using rust-resistant fasteners 'A inch to 1 inch above next course line; 8. Shingle joints to be at least 'A"away from fasteners and 1"away from previous course joints(to minimize exposed fasteners when siding shingles). 10.Remove and re-install electrical fixtures; 11.Last course to be hand nailed using#5 box stainless steel nails; LABOR AND MATERIALS: 52310 PLUS PVC BOARD AT BOTTEM ADD 500.00 If acceptable, initial here: C. .1-. Job is estimated to commence approximately weeks after deposit received unless otherwise noted here: Work is scheduled to be substantially completed in approximately: days If acceptable, (both) initial here: Start and completion times are approximate and subject to change due to,but not limited to, the following circumstances: weather delays, additional work on previous jobs, permitting delays, etc. This is the entire agreement. My discussions or verbal agreements are superseded by this agreement. Such agreements,even those of the smallest nature,must be in writing to be recognized. Any work above and beyond the specifications outlined in this proposal will be priced on request. All additional work, including travel time and lumberyard nms, will be subject to extra charge. In the event of rot repairs, roof repairs or any related work requiring immediate attention, we will proceed without customer approval. We look forward to working with you;please call if you have any questions. Sincerely, ROOFING AND SIDING OF CAPE COD,LLC ROOFING AND SIDING OF CAPE COD, LLC will provide cleanup on a continuing basis and all debris will be removed from site. All products installed by ROOFING AND SIDING OF CAPE COD, LLC will be to manufacturer specifications. All work will be performed by insured professionals. All material is guaranteed to be as specified and the above work to be performed in accordance with the drawings and/or specifications submitted for above work and completed in a substantial workmanlike manner. There will be no refund for special-order windows, doors or any other non- stocked materials after three days from approved proposal. All warranties will be null and void if account is not current and paid in full. Lu.aW &O va...y •UMSSn SSS a w6r ♦vuuu fj,vwa...Su% #ttMD www w%n f.ww�wSu wad S Sau u, uSv attic should be removed. ROOFING AND SIDING OF CAPE COD,LLC is not responsible for any damages if said items remain in place. Curtains,drapes and window and door treatments may need proper reinstallation or replacement by customer due to sizing on any window or door replacements and is not included in jobs contracted with ROOFING AND SIDING OF CAPE COD,LLC Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado and other necessary insurance upon above work. Workmen's Compensation and Public Liability Insurance on above work to be taken out by ROOFING AND SIDING OF CAPE COD, LLC. Owners who secure their own construction-related permits or deal with unregistered contractors will be excluded from access to the guaranty fund. This Contract not valid unless signed by Corporate Officer: Acceptance of Estimate The above prices,specifications and conditions are satisfactory and are hereby accepted. ROOFING AND SIDING OF CAPE COD,LLC is authorized to do the work as specified. Payment will be made as such: 1/3 Deposit Jr 9'3 7. 1/3 Beginning of work 1/3 upon completion Date: V kA7 Signatures: 0a Note:No work shall begin prior to the signing of the contract and transmittal to the owner of a copy of such contract. You, the buyer may cancel this transaction at any time prior to midnight of the third business day after the day of this transaction. ®� Massachusetts Department of Public Safety k 1 Board of Building Regulations and Standards fficeWorsu manerrid o nlnusrRegulaa Office of Consumer Affairs Business Regulation License: CS-102600 - _- _ HOME IMPROVEMENT CONTRACTOR Construction Supervisor -- TYPE:LLC ' __ �'� q" �•-_� fieaistration- Expiration TM 170787 -C.- 12/18/2019 DZMITRY LABKOVICH :} r' c5 k - - 68 WINSLOW GRAY RD,, % 'wt -q ROOFING AND SIDING OF CAPE_ COD,LLC. WEST YARMOUTH MA:. 2673W '� s ;C• A ` r . �."� • i `.'t DZMITRY LABKOVICH - �.•tivr .•` , • 68WINSLOW GRAY RD - L1 ' JJyy v• W.YARMOUTH,MA 02673- Undersecretary //'I �v 4--- Expiration: I ,Commissio er 03/27/2019 ' St- r