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HomeMy WebLinkAboutBLD-19-002311 of rf a ce tJse Only to G - __�� �. v Permit expires 180.days from - ^%50.:'':" issue date . EXPRESS BUILDING PERMIT APPLICATION • TOWN OF YARMOUTH Yarmouth Building Department RE C E 9 V E t- 1146 Route 28 South Yarmouth, MA 02664 OCT 18 2018 . (508) 398-2231 Ext. 1261 1 1 !> CONSTRUCTION ADDRESS: e o gots — 0- L / N KwA yLifiii2253---77-ctsviti ASSESSOR'S INFORMATION: • Map: Parcel: OWNER AP D / l -C) HG 90 QoB—o—L/ M/C '.d }r '7 'l '-/ 7a? /o87 NAME PRESENT ADDRESS TEL # con&croR /YlkRK kVLL.) 14 7 CO Mikis mAR/{- w.$y ' /A6- s—or-),2/pS9/ NAME MAILING ADDRESS TEL If Residential 0 Commercial Est Cost of Construction$ Home Improvement Contractor Lic.# /6 7 2-5' Construction Supervisor Lie.# /O i•C.)-7 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance ' Insurance Company Name: Z 0 e l c_14., Worker's Comp.Policy* 6 Z Z US3 ' K ;/7 sS-26 it WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares S Replacement windows:# 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 at / 4 R 11 o u ( d"l/ 0 um P 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 jus:cause for denial or revocation of my license and//��for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: i.. tet, " 1,4�`�.. Date: to - /8' -/11 Owners Signature r attach Date: i Approved By: v - Date: t)v — 4P---,/, B Official(or designee) EMAIL ADDRESS: ar Zoning District historical District: ❑ 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 The Commonwealth of Massachusetts ,) @ _ =k' Department of Industrial Accidents ==ai= 1 Congress Street,Suite 100 se. • Boston, MA 02114-2017 " ..,_t 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): Mark M 'i fln Address: 7 Gbhnemara w9 City/State/Zip: tu. 1A-RYnouT0 ink Phone #: tag 22/ 8'59 / Are you an employer?Check the appropriate box: ' Type of project(required): 1.1.0.-am a employer with 3 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 8. 0 Remodeling • any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required]t 9. ❑Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Budding addition exam that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑I am a general contactor and I have hired the sub-contractors listed on the attached sheet These sub contactors have employees and have workers'comp. insurance? 13.Q Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 157,$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 their workers'compensation policy information. t Homeovmers who submit this affidavit indicating they al";doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must abed an additional sheet showing the Dame of the sub-contactors and state whether or not those entities have employees. If the sub-contactors 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: 211 R \ C /` Policy#or Self-ins.Lic.#: ro Z.Z OBI Kay SS 26 Pr Expiration Date: 3 — 7 / Job Site Address: Yo B01 -0—L/NK City/State/Zip: WEST' YA-RM& Pr)/ 014 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). oDh 73 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 ceerrrrt�tiib under the pains and penalies of perjury that the information provided above is true and correct Sismature: d` r/� i Date: /0—/8—/8- Phone#: ic 69- 221 gc9y 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. EIectrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: a , • 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 es "...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 rounds 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 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), addresses) 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 renamed 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 bum 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 ®� 1.UI!II!1UnWea1111 ul IVlassecnuseus Division of Professional Licensure • ...Board of Building Regulations and Standards _ Cons`NAi$,rifOrvisor CS-104076 ` Expires:09/07/2019 4-1 MARK M MULLIN , 7 CONNEMARR��,,WAY 7ASk' 1 . WEST YARMOUTF1 MA,, 02673 t R'S 11 Commissioner J G9 a TC'ommonweaf/A O/o ffa aeAaseft a m Office of Consumer Affairs&Business Regulation • HOME IMPROVEMENT CONTRACTOR TYPE:Corporation 'I RealstratlonA Ezolratlo0 I. 167261v -i 09/12/2020 MULLIN ROOFING AND SIDING INC • MARK MULLIN -- �' \Q_Cd2 7 CONNEMARA WAY cc•. U W.YARMOUTH,MA 02673 �' - - Undersecretary H • • MULLIN ROOFING & SIDING INC. CONSTRUCTION CONTRACT This Construction Contract (the "Contract") is made and entered into as of 10-12-18(Date), by and between Andy Fong (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: 40 Bob-O-Link way West 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 white cedar shingles from the driveway facing gable end of the house. Remove the white cedar shingles from the back of the house on the far left of the house. Install a seamless gutter on this section with a downspout that goes around the comer, past the gate with a sideways elbow directing the water away from the house. Remove the white cedar shingles from the cheek wall that faces the driveway. Remove the corner board from the bottom of the cheek wall and replace with a composite corner board. Remove the white cedar shingles from the right side of the sliding door to the corner board on the back of the house. Move the dryer vent in order to have it fit inside of the new water table board. Install an Azek water table board out of one by ten trim, (actual dimension of 9.25"), on both sections of siding on the back of the house. Cap the water table with copper drip cap before installing new shingles. Install a piece of Azek over the bulkhead and cap that piece with aluminum cap. Install Typar home wrap over the bare walls. Install new Grade A white cedar shingles by SBC with varying course sizes from 4.75" up to 5.125" using galvanized staples and stainless steel nails for finished courses on all areas where the shingles were removed. Repair the seam in the rubber roof by properly joining the two pieces of rubber. Install a downspout elbow on the bottom of the downspout at the bottom of the cheek wall to be sided. Install new window well covers over the cellar windows. . Contractor's Responsibility. Contractor is an independent contractor for all Work to be performed here-under. 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. Contract Sum: In consideration of the performance by the contractor of its duties and obligations, here-under,the Customer shall pay to the Contractor the sum of 53,000 Payment Schedule' Customer shall pay 50%of contract upon signing the contract minus The $300 received on 10-12-2018, 0%upon start of contract work, and the remaining 50%upon completion. Jnsurance. 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: Print Andy Fong Mark Mullin Mullin Roofing&Siding, Inc. 7 Connemara Way,W.Yarmouth MA 02673 508 221 8591 Address:40 Bob-O-Llnk way West Yarmouth, MA Date: 10-12-18 Date: 10-12-18 Phone number. 774-722-1087 License No. CSL 104076 HIC 167281 Email address:jfw681©yahoo.com Email address mullinroofing©gmail.com A o D® CERTIFICATE OF LIABILITY INSURANCE DAT (MWDOlna 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(les)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 CONTACT NAME: Debra Martin MARGARET J GRASSI INS AGENCY (A/C"No.Eat. (508)295-2007 FAX (AIC.No): E-MAIL Ins ADDRESS: debmJgins@comeast.net j9 C 1188 MAIN ST INSURER(S)AFFORDING COVERAGE NAIC$ 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: WYARMOUTH MA 02673 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 LTR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP INSD WVD POLICY NUMBER (MM/DDI1'YYYI (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ee occurrence) $ MED EXP(Any one person) $— N/A PERSONAL SADV INJURY $ _ GE 'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S POLICY n JET E LOC PRODUCTS-COMP/OP AGO $ OTHER: $ _ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) - _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per acddenl) $ _ _ NON-OWNED PROPERTY DAMAGE $ - _ HIRED AUTOS AUTOS (Per accident) $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE _ $ _ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTIONS $ WORKERS COMPENSATION X PER OTH- ANDEMPLOYERS'LIABILITY STATUTE ER ' ANYPROPRIETORIPARTNERIEXECUTIVE YIN E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUDEW Ial N/A N/A 6ZZUB1K24552618 03/07/2018 03/07/2019 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEES 500,000 NESC IPTION OFO DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more apace 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/lwd/workers-compensation/investigations/- CERTIFICATE HOLDER CANCELLATION - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Chris Herman ACCORDANCEWTTH THE POLICY PROVISIONS. 7 Yacht Ave AUTHORIZED REPRESENTATIVE D West Yarmoluth MA 02673 Daniel M.Cr 4 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