HomeMy WebLinkAboutBLD-19-002253 l Office Use Only
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.!C3�. ' Permit expires 180 days from
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EXPRESS BUILDING PERMIT APPLICATION
- TOWN OF YARMOUTH RECEIVED
Yarmouth Building Department
1146 Route 28 OCT 162018
South Yarmouth, MA 02664 LI
(508) 398-2231 Ext. 1261 EUl ,
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CONSTRUCTIONADDRESS: C.U.4 �/)/ `I,v' •wV4�i
ASSESSOR'S INFORMATION: •
Map: Parcel:
OWNER: (RdObttr 3 u_ye..4 'W3-3z-7Y0j
N" it 13PRESENT ADDRESS TEL #
CONTRACTOR: :I/wrni U.0 11 $08- 34o• 07�I`
NAME MAILING ADDRESS TEL#
Residential ❑CommercialEst.Cost of Construction S /y 7 c!/•uf11. cd
Home Improvement Contractor Lic.# /70787( Construction Supervisor Lic.# 6100
Workman's Compensation Insurance: (check one)
0 I am the homeowner ((Iaam the sole proprietor �I have Worker's Compensation Insurance r. /'
Insurance Company Name: A '� v,(� I( henc. Worker's Comp.Policy# KZWG asc 6t6
WORK TO BE PERFORMED
Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares ISM. 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 £ �V'rrjc
?Zi
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 of mlicense and for prosecution under M.G.L.Ch.268,Section 1.
' ' a 6 (P
/
Applicant's Signature• Date: (.4/i' r
Owners Signa re(or attachment) Date: // [
Approved By: /�.'� Date: /6 /lv _,/7
Building e:cial •r deli• ee) EMAIL . 'g 7 SS:
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
-, =
;i i�_; _y'/.
Department of'Industrial
4^ar)_ 1 1 Congress Street, Suite 100
=iF`=�" Boston, MA 02114-2017
www.mass.gov/dia
\Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): 650 W.,
Address: 68 6-kt S LI672— dip
City/State/Zip: til) Yarltou l f Phone#: '5b( '.Yd0 .0. r9"
Are you an employer?Check the appropriate box: Type of project(required):
L�I am a employer with 5 employees(Ml and/or part-time).* 7. 0 New construction
2 I am a sole proprietor or partnership and have no employees working for me in $. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
3. I am a homeowner doingall work myself. t 9. ❑ Demolition
❑ ys [No workers'comp.insurance required.]
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition
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.D 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. 14.0 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. J�.�.� � $ir
Insurance
!{..t{
Company Name: ",l
Policy#or Self-ins.Lk.#: P2GUG et 6P 12/20,e
Expiration Date:
Job Site Address: .2 lieflttS R9 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 certify under
the pains and penalties of perjury that the information provided aboo,e is tr a and correct
Signature: Stir Date: 10 16 ( e
Phone#: svP- 3& ' 77Y1
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 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."
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 contract 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. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 02-23-15 www.mass.gov/dia
•
•
1.
h Roofing and Siding
Baof Cape Cod,
N
68 Winslow Gray Rd
West Yarmouth, MA 02673
508-360-2749 e-mail:
rsoccPyahoo.com
HIC REG#170787; LIC#102600
Name: ROBERT BUYEA Job Address:
Address: 23 VENUS RD Town:
City: YARMOUTH Job Phone:413-325-7401
ZIP: Other Phone: •
e-mail: BUYEA01@ YAHOO .COM
Estimator: SCOTT DICKSON
08/21/18
We hereby submit specifications and estimates to furnish and install new cedar impressions by
CertainTeed .triple Sin on the following areas: whole home, ,we will also replace gutters with a Sin
seamless gutter and down spouts on the home for an additional cost of$1216.00„we can also wrap
all window, door, rakes and soffit areas with a pvc coated aluminum for an additional charge of
$1000.00
Specifications as follows:
1. 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).
9. Clean yard of all debris and utilize magnet to minimize exposure to
property or personal damage from nails left behind;
10. Remove and re-install electrical fixtures;
11. Last course to be hand nailed using#5 box stainless steel nails;
12. VINYL CEDAR IMPRESSTIONS
LABOR AND MATERIALS: $12750.00
GUTTERS $1216.00
TRIM WRAP $1000.00
y4C. 0-0
If c e a e, initial here:
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.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
nonstocked 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
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: . V '
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
1/3 Beginning of work /
1/3 upon completion O /
G o r . Pl Gt c]si n e
Date: / o/?/� P
Signatures:
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.
e Vint monfara/t/t op/6,uarArtaeNj
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
TYPE:LLC
Registration Expiration
170787 - 12/18/2019 '
ROOFING AND SIDING OF CAPE COD,LLC.
I ,y
DZMITRY LABKOVICH
68 WINSLOW GRAY Re.
W.YARMOUTH,MA 02673 Undersecretary
Massachusetts Department of Public Safety
- Board Board of Building Regulations and Standards
License: CS-102600
Construction Supervisor ',
DZMITRY LABKOVICH `
68 WINSLOW GRAY RD ,4:-
WEST YARMOUTH MA 02673
//i fru/2 0/n¢+.— Expiration:
'Commissioner 03127/2019