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HomeMy WebLinkAboutBLD-19-001809 Q Oce Use OvyIF Amount ('Permitices 180, exp days from 11 issue date 1 EXPRESS BUILDING PERMIT APPLICAT 0► • TOWNOFYARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 SEP 23 2010 South Yarmouth,MA 02664 1 (508)398-2231 Ext. 1261, r ,. > 1 9ARTM. sr: V D/r7 CONSTRUCTION ADDRESS: 13 no kloAq ASSESSOR'S INFORMATION: • � . �' Map: r MIA Parcel: /57 I •^" OWNER - Ram ( i t,-�t/ PRESENT ADDRESS TEL # CONTRACTOR ENIll UtigI VW/ Sb&-36027 if NAME MAILING ADDRESS TEL# O ResidentialCommerccial p Est Cost of Construction S l0,,�• � 1.70i Home Improvement Contractor Lie.# 0 7 Construction Supervisor Lie.# (02SO0 3/27h Q Workman's Compensation Insurance: (check one) / 0 I am the homeowner �❑p►I�ammtth�e sole oprietor ❑ I have Worker's Compensation Insurance /, v y(-{�j Insurance Company Name: fitht) tall % Worker's Comp.Policy# R,'^�C.O sJ o �‘ WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 10 Replacement windows:# Z Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing The debris will be disposed of atall relf 10 Location of Facility I declare under penalties of pajury that the statements herein contained are ave 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 y/lic_ense and for prosecution under M.G.L.Ch.268,Section 1. ll Applicant's Signanue: r Date: 9/Zy/�8 Owners Signature(or attachment) (//9 Date: Approved By: � G� Date: 7—.25-7, B al(or designee) ADDRESS: Zoning District: Historical District 0 Yes 0 No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 R of Wetlands: 0 Yes 0 No 0 Yes 0 No is fr r�� The Commonwealth ofMassadliusetts IMI ," Department ofIndustrial Accidents _ 1 Congress Street,Suite 100 n=1`9_ Boston, MA 02114-2017 tar- www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITHTHE PERMITTING AUTHORITY. Applicant Information /) Please Print Legibly Name (Business/Organization/Indiyiidual): GA4404' tstobuf c-i CCtIC- (-0 (Ca Address: £g CU/wepLU apt City/State/Zip: ti • Strafe r Phone #: 6b2-.36o•Z7y, Are you an employer?Check the appropriate box: Type of project(required): i. I am a employer with 5 employees(full and/or part-time).' 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] 8. Remodeling 3.0 I 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 wUl 10 Q Building addition ensure that all contractors either have workers'compensation inan nce or an sole 11.0 Electrical repairs or additions proprietors with no employees. 6.0 I am a general contactor and I have hired the sub-contraction listed on the attached Sheet 12. Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.: 13.0 Roof repair 6.0 We are a corporation and its officers have exercised their right of actin=per MGI.c. 14.E Other 152,§l(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 informanoa t HomemHners who submit this affidavit indicating they are doing all work and then hire outside contractor must submit a new affidavit indicating such. tContracmrs that check this hex 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: Th1491.241120 CAS / p Policy#or Self-ins.Lic.#: �Z 6UC�tQC Expiration Date: (2/ ��0 Job Site Address: 1300 al-474is1 Si' City/State/Zip: C 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 un' - r pains and penalties of perjury that the information provided above is ue and correct Signature: 1 '' � Date: 9 12-Y P Phone#: 'gel'- 60- ` / t'9 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#: '' • • • 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 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 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 requirements of this chapter have been presented to the contacting authority." Applicants Please fill out the workers' compensation affidavit completely,by checldng 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 advisedmhat 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 permitflicense 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 1 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 www.mass.gov/dia I • • w • ' Yt Roofing and Siding of Cape Cod,LLC 4Y BBB., L 68 Winslow Gray Rd West Yarmouth, MA 02673 508-360-2749 e-mail: rsocc@yahoo.corn roofingandsidingofcapecod.com HIC REG#170787; LIC # 102600 Job Address: Name: Tran Family,LLC Town: South Yarmouth,MA Address; 13QQ Main St dab Phan: City: S Yarmouth Other Phone: 508-398-5592 - /l- 9/0 — 6,Pi) State: MA E-mail: tonytran198119@yahoo.com C F// Li?: U2664 Estimator: Dmitry Labkovich 08/25/18 We hereby submit specifications and estimates to furnish and install new Red Cedar Clap-board on the following areas: Entire Building ,Specifications as follows: 1. Remove existing siding and dispose of debris; Telenet-1 cheathina for rot nr other AMarinratinn and advice homeowner of any aAAitinnal n nrlr 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 indo and deer dip cap flashing; 6. Use Stainless steel nails 16"on center, flush nailed; 1 7. Clean yard of all debris and utilize magnet to minimize exposure to property or personal damage from nails left behind; 9. Remove and reinstall signs and shutters. LABOR AND MATERIALS: $8,625.00(Finger-Jointed,Primed) Discount: $200.00 t '25):00 c (f$ . tazalsiriTimitt If-acceptable, initial herc ,t �o - C�� . to , 600 - 6` �� 11 as Roofing and Siding of Cape Cod, LLC BBB 68 Winslow Gray Rd West Yarmouth, MA 02673 508-360-2749 e-mail:rsocc@yahoo.com roofingandsidi ngofcapecod.com HIC REG #170787; LIC # 102600 Job Address: Name: Tran Family,LLC Town: South Yarmouth,MA Address: 1300 Main St Job Phone: City: S Yarmouth Other Phone: 508-398-5592 State: MA E-mail: tonytran198119@yahoo.com ZIP: 02664 Estimator: Dmitry Labkovich 09/06/18 We hereby submit specifications and estimates to furnish and install new Harvey, Classic DH, White Vinyl, New construction , Double Glazed, Argon filled, Low-E4 Glass (Each Sash), Grillls between Glass,Insect Screen windows as follows: 1. Remove exterior trim. 2. Remove interior trim. 3. Remove window sash,balance system, and window frame back to studs. 4. Install new window using exterior nail flange and new waterways. 5. Install new exterior trim using pvc trim. 6. Insulate perimeter of the window with foam. 7. Install new interior trim using primed colonial casing. • O Ira!! ..:mac -:11 V. 111J1M1111V Y11LW11V1 Jll1. Labor and Materials: $2,425.00(Two Windows) • If acceptable, initial here/j( 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: Matt and compietion 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. Any 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 runs, 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. 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. Owner to move all personal objects, furniture, etc., from work areas. All items against walls should be considered for removal during any exterior siding jobs, additions, etc. to guard against damage. In the case of any roofing and ridge venting, dust and debris should be expected and any items in the 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 1 ' 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 stnlces, 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, T.T.C. Owners who secure their own construction-related permits or deal with unregistered contractors will be excluded from access to the guaranty fund. ll abitt 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. n__..a...s....: s�... ...,,a„ .... . LV1.,. •LL�`111VLL1 hLLl UV lll(N!V 4J JLLVIl. 1/3 Deposit 3tTEDEO 1/3 Middle of work 1/3 Upon completion Date: 9/n /t Signatures: Lam_ 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.