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_. SECTION 5:.CONSTRUCTION SERVICES •.. • . .
55..1 Construction Supervisor License(CSL) CV-044 C81.13 1.ZZ•Zi0
•1'
S. MALY/WM AN License Number Expiration Date
Name�)of CSL Holder
D3 M N List CSL Type(see below) LA/L M t
No.and Street' 1 . DescriPtion •
}T VD5 01.4 f 4 O l 7 L Q' U Unrestricted(Buildings up to 35,000 cu.ft.)
CipdTown,State,ZIP RestrictedMasonryI&2 Family Dwelling
• M
RC Roofing Covering
WS Window and Siding
SF50 8.3(4.Dl9.1/ , Prim 7 Plant lit/1(.t71►•1i.tU ' SolidFuel Burning AppliancesI Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 'Rv 4,612 • 17 )
fEUCOWUlU,Yi el/UA I/6 GD L.L_L le
Cany Name or C Registrant HIC Registration Number Expiration Date
7.1a3-161/210r > roN /1 0/741 1-4tcgEzolvNtivanovitau..am
No.and Street Email address
wi3301•Dial,
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes a No ❑
., SECTION lad OWNER AUTHORIZATION TO BE COMPLETED WHEN
• • OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
to act on my behalf;in all matters relative to work authorized by this building permit application.
•
Print Owner's Name(Electronic Signature) Date
• • SECTION 7ti:OWNER'OR AUTHORIZED AGENT DECLARATION .
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate o best of my knowledge and understanding.
'CAIJ t. MtedI tole-W
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty find under M.G.L.c.142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.aov/das
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) •
Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
&t•YAR,te TOWN OF YARMOUTH
S
,, e BUILDING DEPARTMENT
o .F H 1146 Route 28,South Yarmouth,MA 02664
• N "^r,„, :cce 508-398-2231 ext. 1261 Fax 508-398-0836
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
Pursuant to M.G.L. Chapter 40, Section 54 and 780 CMR,Chapter 1, Section 111.5,
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at IS C-ia--2.2 MAST L(Aesmetoot-A /144-
Work Address
Is to be disposed of at the following location: 2 b TOP ee G`1'LU 1JC,-
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
4` Ia. 26
Signature of Application Date
Permit No.
x c The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
r kg„ Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information
Name(Business/organixatienalnndixidual):Feltonville Building Company LLC
Address: 483 Main Street City: Hudson
State: MA 21p: 01749 Phonett: 508-361-0296
Are you an employer?Check the appropriate box: Type of project(required):
❑1. I am an employer with employees(full and/or part time)* ❑7. New construction
❑2. 1 am a sole proprietor or partnership and have no employees working for me In any ❑8. Remodeling
capacity.[No workers'comp.insurance required.]
09. Demolition
❑3. I am a homeowner doing all work myself.[No workers'comp.Insurance requlredjt 1:110. Building addition
04. I am a homeowner and will be hiring contractors to conduct all work on my property. 1 111. Electrical repairs or additions
I will ensure that all contractors either have workers'compensation Insurance or are IIJJ
sole proprietors with no employees. 2. Plumbing repairs or additions
Zs. I am a general contractor and I have hired the sub-contractors listed on the attached 13. Roof Repairs
sheet. These sub-contractors have employees and have workers'comp.insurance.±
6. We are a corporation and its officers have exercised their right of exemption per MGL ❑14. Other
c.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.
+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 attach 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.
lam on employer that is providing workers'compensation Insurance for my employees. Below is the policy and Job site information.
Insurance Company Name: Liberty Mutual Insurance Company
Policy U or Self-ins.1k.It:WC2-3`1x5/-J319361-0,47 Expiration Date:7/7/2019
Job Site Address: 15 CLOV'Z fZ .9 tive-s 4'keDiMo fin-\ MASS 02-613
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.
R✓ I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct,and that clicking this
checkbox and I my name in the field belo
w
t�will pact as my signature.
Name- 'At'j 6 /1 47WAN) Date: j.Q.Z4 r
Phone ll: 508-361-0296 Email: ian@feltonvillebuilding.com
It
�.1 THOMDAN-01 HOUNII
AR/fly CERTIFICATE OF LIABILITY INSURANCE DATE
A E(MWD ID
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
''LOW.. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
'RESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
^IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or 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 sucheTnTdorsement(s).
PRODUCER NAppMEpCT
Gallard Insurance Agency,Inc. PHONE 978 2633500 FAM
199 Great Road (A/C,No,Ere:( (NC,No):
Acton,MA 01720 Miss,info@galiantins.com
INSURER(S)AFFORDING COVERAGE NAIC e
INSURER A:Travelers Casualty 8 Surety Co.of America
INSURED INSURER B:Liberty Mutual Insurance Company
Thomas Danehy INSURER C:
Thomas R Danehy Co
32 Arcadia Road INSURER 0: •
Billerica,MA 01821 INSURER E:
• INSURER F:
COVERAGES CERTIFICATE NUMBER: 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.
(LTR TYPE OF INSURANCE NADSD SUBR POLICY NUMBER 1 POLICY IEFF MM/DDNY YXP
VYI LIMITS
A X COMMERCIAL GENERALLIABILITf EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE OCCUR 6805A612406 08/162018 08/16/2019 pRaFM14FS(E ENT xee1 s 50,000
MEXP ny ane nonl $
0 5,
PERSOEDNAL(Aa ADV MpeJURV $ 1,000,000000
GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE _f 2,000,000
POLICY jR& ❑LOC PRODUCTS-COMP/OP AGO J 2,000.000
OTHER 5
– WTOMOBILE LIABILITY , . - IEOMS ED en SINGLE LIMITtl
$
`•�.y'ANYAUTO- -. .. BODILY INJURY(Per person? _$ .. _
OWNED - SCHEDULED
_ AUTOS ONLY _ AUTOS
µNEp BODILY INJURY(Per accident) $
_ AUTOS ONLY _ AUTOS ONLY PROPERTY DAMAGE $
S
— UMBRELLA LIAR — OCCUR EACH OCCURRENCE $
EXCESS LIAR CLAIMS-MADE AGGREGATE $
DED RETENTIONS S
B WORKERS COMPENSATION XSTRTUTE Ohl-
AND
EMPLOYERS'LWBILITY WWC2.315-319361-048 07/072018 07/07/2019 100,000
ANYQNFPROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $
(MnntlitoryInNH)EXCLUDED?. U NIA ._..
.._ _.._._.___.100.000
If yet
_.._ ____. .. ... _. E.L.DISEASE-FA EMPLOYEE $
IOOO
NN under 500,000
OPERATIONS below E.I.DISEASE-POLICY LIMIT $
DESCRIPTION
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,AddflmMl Remarks Schedule,may be attached If mon specs Is required)
The workers compensation policy does not provide coverage for Thomas Danehy.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
lie Building Company,LLC
483 Main O W
483 Street
Hudson.MA 01749
ACORD 25(2016/03) ®1988.2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
•
,THOMAS R.DANEHY
GENERAL CONSTRUCTION
32 ARCADIA ROAD BILLERICA MA.01821 ._ .978=337=9753
-. _. _ Steve West
. 115 Clover Rd
West Yarmouth Mass
I i
THE FOLLOWING PROPOSAL DESCRIBES THE WORK TO BE DONE,MATERIAL TO BE USED AND A
PRICE BASED ON THESE DETAILS.PLEASE REVIEW THIS PROPOSAL AND SIGN BELOW IF YOU ARE
IN AGREEMENT.i HAVE ENCLOSED TWO COPIES,PLEASE RETURN THE SIGNED COPY TO ME AND
KEEP THE OTHER FOR YOUR RECORDS.
JOB SITE SAME
•
1 REMOVE AND DISPOSE OF ALL EXISTING ROOF SHINGLES
2;INSTALL 6 FT.OF ICE AND WATER SHIELD •
3 COVER REMAINING ROOF DECK WITH SYNTHETIC ROOF UNDERLAYMENT
• 4,INSTALL WHITE ALUMINUM DRIP EDGE ON ENTIRE ROOF PERIMETER
5 INSTALL NEW PLUMBING FLANGES
6 FLASH ALL CHIMNEYS(NEW LEAD)
7.INSTALL 30 YEAR ARCHITECTURAL SHINGLES
8 INSTALL NEW RIDGE VENT
9 REMOVE ALL JOB RELATED DEBRIS
•
•
NOTES
NOTES
ANY DAMAGED LUMBER BEYOND 32 BOARD FT.WILL INCUR AN
ADDED EXPENSE TO BE DISCUSSED AT TIME OF DISCOVERY
J _
I ,
$6,250.00'1
TO BE PAID IN FULL "ON CO -LETION.
4a •
4d
�
1' -
SIGNATURE � RESP � ITTEGPv1,SHYI
•
•
•
1
Conmonweatth of Massachusetts
'It Division of Professional Licensure Construction Supervisor
Board of Building Regulations and Standards Unrestricted.Buildings of any use group which contain
• Constructidn'Supervisor less than 36,000 cubic feet(991 cubic meters)of enclosed
space.
C54-0498'43 ., Expires 09/22/2020
IAN B MAZMANIAN .`'-r i „ q...
483 MAIN ST - ° P
HUDSON MA 61749 NI y5
Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this license.
Commissioner For information about this license
can(617)7274200 or visit www.mass.gov/dpi
Wilmot ConsumerA a Business Regulation --- _.—_._.-__._....
HOME IMPROVEMENT CONTRACTOR
TYPE:LLC
Ht ice EIapfrdlCD Reglstre0cn veld toIndividual use only
190497,;•: :.: 01/31/1020 before the expiration date. It found return to:
FELTONVILLE BUILDING COMPANY,LLC Office of Consumer Affairs end Business Regulation
10 Park Piers•Sults 5170
y,..• Boston,MA 02116 .
483 MAIN IAN A eaccal— /tom +
HUDSON,MA 01749 at
Undersecretary
• Not valid without signature
Control of
4 Building
Operation
x
ISSUED BY:
CAMBRIDGE INSPECTIONAL COMMISSION
This license to be carried on the work-site
�0.0 •"+-res .
r ��e�i"`"• '+to* ,�,ir, at all times and when signing for permits.
IF FOUND,PLEASE RETURN TO:
CITY OF CAMBRIDGE
INSPECTIONAL COMMISSION
LAST Mazmanian 831 MASSACHUSETTS AVE., 1st FLOOR
NAME CAMBRIDGE,MA 02139
FIS Ian B. (817)34948100
CLASS V
LICENSEE 301
EXPIRES ON 0510712019