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Home My WebLink AboutBLD-19-2249 Office Use Only ' .� it ! Permit# ,1 O -• 11•'� $; Amount �V -H ..T �.c . Permit expires 180 days from - Btb-I q -Obaa` f issue date EXPRESS BUILDING PERMIT APPLICATIOI E T i { TOWN OF YARMOUTH Yarmouth Building Department ED OCT 162018 1146 Route 28 • South Yarmouth, MA 02664 �7 (508) 398-2231 Ext. 1261 a u Gj~ — CONSTRUCTION ADDRESS: 1 o claps! 02, k y , ASSESSOR'S INFORMATION: Map: P Parcel: may, /° OWNER: AYua5 GIZMO �"e.'$- 601/ N PRESENT ADDRESS TEL #4. Y_y//��+ CONTRACTOR: -`�-'(�)', L�j[Vial Sbcr l e?Peri / NAME J MAILING ADDRESS TEL it Residential ❑Commercial Est Cost of Construction$ 17 7C Q, OJ Home Improvement Contractor Lia# 17078. 7 Construction Supervisor Lic.# /02600 Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor Q I have Worker's Compensation Insurance � —/' p/' Insurance Company Name: fi / " )�r Worker's Comp.Policy# (7W COyJY O W WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 7 % )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing "The debris will be disposed of atc91. 0 47-�•t 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 oo IIy'cennse and for prosecution under M.G.L.Ch.268,Section 1. y�/ p Applicant's Signature: (/ fJQ.(J�� Date: tll I/(p Owners Signa . e(or attachment) Date: Approved By: (or s �! Date: /0 yC�g Building � (or ignee) EMAIL AD S; 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 �� The Commonwealth of Massachusetts —a= Department oflndustrialAccidents Wiggle Congressll 1 Street,, Suite 100 VW t Boston, MA 02114-2017 e,?,j� www.mass.gov/dig Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information )) �p Please Print Legibly Name (Business/Organization/Individual): Rcoc . Address: CR1� WIM(OW agelor pi W City/State/Zip: , Yharksurti Phone #: x-760 27 S i Are you an employer?Check the appropriate box: Type of project(required): 1 I am a employer with 2 employees(MI and/or part-time).* 7. E New construction 2 I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp,insurance required.] 3. I am a homeowner doingall work myself. t 9. ❑ Demolition ❑ y [No workers'comp.insurance required.] 4.0 I am a homeowner and will be hiring 10 ❑ Building addition wntractors to conduct all work on my property. I will 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.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.* 6.0 We are a corporation 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.] *Any 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: '42 r Policy#or Self-ins. Lic.#: I`2vic-�j ir6i6p Expiration Date: 1Z/20 a Job Site Address: I C £ C Si 92 City/State/Zip: 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 cerin;fy and r re pains and penalties of perjury that the information provided above is ue and correct. Signature: 0 • Date: Ala If Phone#: &V, 567Yq/ 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#: j` ! 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 contact 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,grounds 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 contracting 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 • Accidents 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 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 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 71 4 Roofing and Siding of Cape Cod,LLC 4 BIM 68 Winslow Gray Rd West Yarmouth, MA 02673 508-360-2749 e-mail: rsoccPyahoo.com HIC REG#170787; LIC#102600 Name: Thomas grimes Job Address: Address: 10 SURFSIDE Town: City:YARMOUTH Job Phone:508-846-6211 State: MA Other Phone: ZIP: _E-mail: TOM@GRIMESCO.COM Estimator: SCOTT DICKSON 10/02/16 We hereby submit specifications and estimates to furnish and install new commercial grade, .060 thick membrane, single-ply rubber roofing system,black, from RPI,with 30-year warranty as follows: Specifications as follows: I. Snip existing roofing and dispose of all debris. 2. Check all boarding. 3. Apply new ''/" recover-board roof substrate underlayment with screw and deck plate fastening system. 4. Install fully adhered E.P.D.M. roofing system. 5. Install white aluminum dripedge on full perimeter as needed for application. Accepted by2,--r_v/` � � date 7 6/� / THIS PAGEii12 PART OF AND CONFORMANCE WITH PROPOSAL No 2 -.' LABOR AND MATERIALS: $5750.00 I If acceptable, initial here: dint Color:Black Job is estimated to commence approximately 4_ weeks after deposit received unless otherwise noted here: Work is scheduled to be substantially completed in approximately: _4 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. 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. 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 Owner to move all personal objects,furniture,etc.,from work areas.All items against walls should be considered for rop yoval during any exterior siding jobs,additions,etc.to guard against damage. Accepted by 7- .I date / THIS PAG IS PART 0 •ND IN CONFORMANCE WITH PR PO AL No 3 ,.' 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 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.No lien or security interest will be placed on the residence as a consequence of the contract. Owners who secure their own construction-related permits or deal with unregistered contractors will be excluded from access to the guaranty fund. r This Contract not valid unless signed by Corporate Officer: (.Q.3)7 Acceptance / 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 iai/ L�� 1 # 3767 cAcck 1/3 Beginning of work 1/3 upon completion Date: JDA" /£S Signatures• 1,` 4------1 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. Accepted by%�/�G•�' /4�`�l�w*� date / 6//V/ r THIS PAGE IS PART OF AND IN CONFORMANCE WITH PROPOSAL No • Jenenmonevea7/Aof0„l6auae/reaelts Office of Consumer Affairs Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:LLC Registration Exnlration 170787 12/18/2019 ' ROOFING AND SIDING OF CAPE COD,LLC. DZMITRYLP.BKOVICH 68 WINSLOW GRAY RD W.YARMOUTH.MA 02673 Undersecretary Massachusetts Department of Public Safety Ir Board of Building Regulations and Standards License: CS-1026007 > a Construction Supervisor ref t'� DZMITRY LABKOVICH 'xr, yii; 68 WINSLOW GRAY RD Yz't 4Ift WEST YARMOUTH MA 02673 II rete sra..._ Expiration: Commissioner 03127/2019