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Home My WebLink AboutBLD-19-2773 r Office Use Only (g , Ammmt 'cld` }Permit apt Res 180.days from = t issue date EXPRESS BUILDING PERMIT APPLIC • T i C V 2 0 • TOWN OF YARMOUTH NOV 06 2018 Yarmouth Building Department 1146 Route 28 BUILDING DEPARTMENT South Yarmouth,MA 02664 __ p //^ (508) 398-2231 Ext. 1261 Hit CONSTRUCTION ADDRESS: /p D/ Vet— 3r/. c, /arV"ow+L . H11 ASSESSOR'S INFORMATION: Map: i7 7 IU Parcel: ay OWNER: 1 Ur) use/) HO al /,y O`1 ,ver s'. s; Ver oJ4 NAME PRESENT ADDRESS , / / TEL # CONTRACTOR.: (3aQiic Cor Kg i„� 940 Saktuir /�/N�err"�wti ' & 774-azg-34(2 NAME Li MAII'T�Y-''`4DSDR sts runes 44 /�' S_3O Residential 0 Commercial 'c V fid Est Cost of Construction on$ o//. �7 Home Improvement Contractor Lie.# /9 3 Z 3 7 Construction Supervisor Lic.# J 44 !-? Workman's Compensation Insurance: (check one) \ 0 I am the homeowner/ 0 I am the sole proprietor �/� pL I have Worker's Compensation Insurance Insurance Company Name: /3 ciele/.s stns cc. ,/ t•t//d t., Worker's Comp.Policy# 1✓�'?/ S'-' 3 p 4 1-211‘. d ) 2 c// WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares /2 • ()( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like D Pool fencing The debris w01 be disposed of at Ye(P Sr-d t PicCO C e.� i-c� — Location of Fac 'ty I//"' 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 revoc ' f my license and for pro cation under ROI.Ch 268,Section 1. Applicant's Simmture: ./c Date: WO s //g Owners Signature or atn ehment) Date: �Q Approved By: O Date: 1I •�(p '�(J Buil tial(or d EM.4Ii.ADDRESS: Zoning District ILstorical District 0 Yes 0 No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No �' S_S . The Commonwealth ofMassadhusetts dr " - -r—49Department ofIndustrial Accidents =-..smi-a 4 1 Congress Street,Suite 100 i ?= f�_ Boston, MA 02114-2017 itc,�,.# 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): ?ai fee Cp �,,. / 1)t•Li /�C Address: 9/0 So- ., ;L Vie tai o w. c. (/ p. City/State/Zip: I-64"Si we Kills/ S r 14 Phone#: 7 74 —2 2-P - 3 I(1 Z Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.❑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]r 9. ❑Demolition 4.01 am a homeowner and will be hiring 10 0 Building addition ❑ contractors to conduct all work on my property. I well ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 12.0 Plumbing repairs or additions These sub-contactors have employees and have workers'comp. insurance.: 13.0 Roof repirs 1 r 6. e are a corporation and its officers have exercised their right of exemption per MGL c. 14.�Other s r to Vit 4 {� 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 contactors 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 subcontractors have employees,they must provide their workers'comp.policy number. I am an employer that is providutg workers'compensation insurance for my employees. Below is the policy and job site information. /� / Insurance Company Name: /3 1744 -. 61-,-. 0/ ,Q cc al't/olK Policy#or Self-ins.Lic.#: WC S— 315 — "c0`t 1 qZ `1.t —0 24 Expiration Date: 3/2 C//) 5 1 i le Job Site Address: f t Q,( t./2J ' �./, City/State/Zip: S . Ya r (01-e.' 111 NA- 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 a pains and penalti-. of perjury that the information provided above is true and correct Signature: / J//Q (1 /2 Date: Phone g: 774- 22g — 3412 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#: yie) • • 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 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 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. Limned Liability Companies (LLC)or Limited Liability Partnerships p (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 returned 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 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, MA02114-2017 Tel. # 617-7274900 ext. 7406 or 1-877-MAS SAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia • • onwealth of Massachusetts _ rofessional licensure comm ulations and standards Division of P Reg of V)) Board of Building I$5pgrvis ConstriSt ao2izot9 -094476 '' s REVtKASEROApI o LINA E °261 CENTERVI2 Y- L MA\ /cc;VSL Commissioner . ee Fimmcvuteat,ey.1.4aaJ¢rimell.. Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE;Corporation Realstration - Expiration .193237;-=_ 09/27/2020 BALTIC COMPANY,INC.= Ati LINAS REVINSKAS '-i..- \exca --- 940 SANTUIT NEWfQWN RD ,] MARSTONS MILLS,MA:`12648 Undersecretary • z 1 Contract # 737 CUSTOMER INFO: JOB LOCATION: t Muriel Hallet 18 Oliver St ?' S.Yarmouth, MA I i z AGREEMENT BETWEEN: I Muriel Hallet 10/26/2018 AND Baltic Company,Inc Linas Revinskas - fl E_JOSP WE-- Baltic Company Inc, hereinafter referred to as General Contractor (GC), on the one x hand and Property Owner Muriel Hallet hereinafter referred to as Customer, on the other hand,have concluded the present contract as follows: • r., 1. THE SUBJECT OF THE CONTRACT 1.1 Contractor undertakes hereby to supply all labor and materials necessary to complete the Home Roofing Upgrade Project as proposed in the job estimate # 1066 (10/17/2018), said proposal being an integral part of the contract. 1.2 Customer undertakes to pay in the order and terms established by parties in the present contract. 5. 1.3 All work is to be performed according to the specifications submitted, in a substantial workmanlike manner, per standard practices. Any alteration of or deviation from the submitted specifications involving extra cost will become an extra charge over the estimate, but any extras must be submitted between parties of this contract. - ,./711 q11' '' Baltic Company 940 Sanmit-Nctown Rd.Marstons Mills,MA 02648 Linas Revinskas 774-228-3462; M.C.S.Lic.9 094476 NJ.0 M 152372 a ?t:'. P 1 rn ,:.i:.i x .:n S,!:d...1{. .G'.``v. Ar,.it R:r.'„ ...r-..w•..,. 2. THE PRICE AND THE TOTAL SUM OF THE CONTRACT 2.1 Estimated price for the home upgrade project: $ 13,530.00 3. DESCRIPTION OF THE PROJECT: s . } Re-roofing permit obtained, Roofing materials supplied, • Cupola temporarily removed, Direct TV satellite dish permanently removed, Existing roofing removed, New drip edge installed, , Ice &Water shield applied on entire roof area where solar array will be installed, Ice & Water shield applied on the roof eaves and on roof side edges, Synthetic underlayment applied on the rest of re-roofing surface, Roofing shingles(Certainteed Landmark) installed, Ridge vent installed, Ridge caps installed, Cupola re-installed, Roofing debris removed and disposed. Attic ventilation system equipment supplied (Gable wall mounted fan with thermostat and humidistat), Existing roof mounted fan and air intake caps removed, Halls in the roof deck repaired, Gable end louvered windows cleaned and prepared for fan installation Wall mounted fan with thermostat and humidistat installed • •4. TERMS OF PAYMENT • 4.1 Customer undertakes to pay in two payments schedule 4.2 30%Deposit of the estimated amount($ 4,059.00) 4.3 Remaining amount after roofing completion($ 9,471.00) g • r tJ Baltic Company 940 Santuit-Nctow'n Rd.Marstons Mills,MA 02648 ✓/ 1 Lines Rcvinskas 774-228-3462; M.C.S.Lk.8 094476 H.1.0#152372 L' 1:i:.. n v.. .x.:.;y„tl3"d4±+.:aLYJ 3ed v.�'..+:.a Y1..',y.,A:y n r.v. ". : k4Yn r YW.n':.a'.i•+v/.an.j.. � �Y`* wvY..th.- t«s :n3: . Y�=+M'..,-erh Y.�.au ..:<f:s•r..��i: *4'PA ,',^cMeari atnnaerl +' raldo.aea92gar,.rn=Mr e!t�avp,sY aO,grtifraVIMCMAZtalt 'xhYWw639'.antgX3argrl Ya 42tn33T!'a 5. OTHER CONDITIONS 5.1 All changes and additions under the given Contract are valid, if they are accomplished in writing and signed by both parties of the Contract. The present Contract is made in duplicate of one for each of the parties. All copies have an equal validity.The contract inures from the date of its signing. After signing the Contract all previous negotiations and correspondence on it lose force. ki 5.2 GC may at its discretion engage subcontractors to perform work hereunder, provided GC shall fully pay said subcontractor and in all instances remain responsible for the proper completion of this Contract. 5.3 GC agrees to remove all debris and leave the premises in broom clean condition. 5.4 GC shall not be liable for any due to circumstances beyond its control including strikes, casualty,weather conditions or general unavailability of supplies and materials. Contractor Linas Revinskas Customer Muriel Hallet i.: • s 4 ti Signatures: _Livia&Revivtaca% Signatures: { 11444-` Date: 10/26/2018 Date: Z y Y 1. • •3 5 4 _ t }k 15 • 1 8 ` y(! Baltic Company 940 Santuit-Netown Rd.Marstons Mills,MA 02648 Lines Revinskas 774-228-3462, } M.C.S.LIc.#094476 H.I.0#152372 '. amasw.s ::=41 ,a.,... allascm ate.-kAralSkalas raansays sw aaa>aoxsO, nal294eamacrra•ten