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HomeMy WebLinkAboutBLD-19-003140 Use Only 'o 'YgR�. 14D 19- D Amount tY �a - $ I Permit expires 180 days from t issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department . 1146 Route 28 South Yarmouth, MA 02664 l (508)/398-2231 Ext. 1261 • f/GGONSTRUCTIONADDRESS: 9‘ CIa /oy-/ cre z .✓ ASSESSOR'S INFORMATION: • //y /J — Map: p/ / Parcel: / r//! vOWNER: 50a" /C.Yy/2179 9 s�4Ar/ /91? /3" Car- 777— 7S-SD i/ NAME �/ PRESENT ADDRESS� . �/ �/)/ TEL. # CONTRACTOR:ALAS- ThrZyM''(i v red 4if flai ex"' .at"F-L 2. —/V" // NAME (/ MAILING AD"an wig � ennia TEL79/...r: ## a0 V Residential ❑Commerrccial Est Cost of Construction S / 9//�— 1-Iome Improvement Contractor Lie.# /b k r6-z- Construction Supervisor Lie.# o97 9j C/Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the PAI proprietorie .2'!have Worker's Compensation InsuranceA/64 e,J'` '/ IPsctance Company Name:`, 411.0 JAS C ' Worker's Comp.Policy#/T/Urr T.3�74 �/ WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) 512'iY Wood Stove rn, ' yri4 Siding: #of Squareseplacement windows:# r ionreC'LCA/r Replacement doors: # OGD 4e/infova1 Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation I/o6Id I{ings Highway/Historic Dist. (lacing like for like J Pool fencing *The debris will be disposed of at , l Parisi� / v 6G Are/ F 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 ocatioa of my lic e and for prosec 'on under MG.L.Ch.268,Section 1. t...,/pplicant'sSignature: ' C t Date: en Signature(or att chment a Date: }� /� Approved By: Date: /"'& `/ d„: II.'!g Official(or.esi ee) MAIL ADDRESS: Zoning District: RECEIVE D Historical District: 0 Yes 0 NNo Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: O t Fr c 0 Yes 0 No 0 Yes 0 No NOV 20 2016 BUILDING DEPARTMENT Ely • ) ' The Commonwealth of Massachusetts '� i _it / Department oflndustrialAccidents •�• =lif- 1 BostonSMA0 114s Street, -201 ite �0 Zc,,=,,,� www.mass.gov/dna Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. IV TO BE FILED WITH THE PERMITTING AUTHORITY. • Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 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. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall work myself. 9. ❑Demolition ❑ ys [No workers'comp.insurance required.]t 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property.ro I will 10 ❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the subcontractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.; 13.E Roof repairs 6.❑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 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 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: Policy#or Self-ins.Lb.#: Expiration Date: Job Site Address: 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 than the information provided above is true and correct Signature: Date: Phone#: 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/I'own Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other • Contact Person: Phone#: • Information and Instructions Massathusetts 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 contact for the performance of public work until acceptable evidence of compliance with the insurance requirements 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), 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 Con?ess 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 ` • • GREATO5 OP ID:WH f►ct..,-- CERTIFICATE OF LIABILITY INSURANCE DATE 12/27/DNYYYj �� 12/2712017 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(lee)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the polity,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 Cindy Verhagen. Todd Associates,Inc. Pxana 440-461-1101 (aa.Na);440.446-0192 23825 Commerce Park Suite A !Arc.No. xn: Beachwood,01444122 n o BEssl Gverhaden@toddassoclates.com Edward J.Hyland INSURER(S)AFFORDING COVERAGE NAIC M • INSURERA:Union Insurance Company 25844 INSURED Great Day Improvements,ISO INSURER B: Great Day Holdings;LLC d/b/a Patio Enclosures Intim CI 700 E.Highland Road INSURERD r Macedonia,OH 44056 INSURER Et 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. NOTWITFISTANDINO 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. lb/SR TYPE OF INSURANCE ADDL GDBN POLICYEFP POLICY EXP UNITS WOwvD POLICY NUMBER (MMIDDIYYYYI (MMIDDA'YYYJ A X COMMERCIALGENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTEU CLAIMS-MADE 0 OCCUR CPA4358288 01/01/2018 0110112019 PREMISES(Ee OCcUrrenae) E 500,000 • $1,000 PD DED MED EXP(Any anspereon) $ 5,000 — PERSONAL EADV INJURY $ 1,000,000 — •''GGEETTML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY M 519y- El LOC PRODUCTS-COMP/OP AGO' $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ 1+000+000 A X. ANMAUTG CAA4358289 01101/2018 01/01/2019 BODILY INJURY(per person) $ ALL OWNED AUTOS LED AUTOS • BODILY INJURY(Per ecbldenl) $—NUTONWNEO PROPERTY DAMAGE $ _ HIRED AUTOS _AUTOS !Per eccldantll $ • UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LID% CLAIMSMADE AGGREGATE $ DEC RErENT1bN$ $ WORKERS COMPENSATION X I STATUTE WEE'. AND EMPLOYERS'LIABILITY A ANY PROPRIETOR:PARTNER/EXECUTIVE Y�NIA A (Mandatory In un)HPA4358288-OH EL 01/01/2018 01101/2019 E.L.-EACH ACCIDENT $ 1,000,000 OMndaRIMEMNER E%CLUOE07 I I WQA4381940-OTHER E.L.E. DISEASE-EA EMPLOYEE $ 1,000,000 s,Mewls under DESCRIPGON OFO E.L DISEASE-POLICY LIMR $ 1,000,000 DESCRIPTION OF OPERATIONS below , DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD(51,Additional Remarks Schedule,may be attached If mare space Is required) CERTIFICATE HOLDER CANCELLATION FORINFI SHOULD ANYO.F THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE REOF, For Information Purposes ACCORDANCE WITH THE OLICYPROVISIONSE WILL BE DELIVERED IN AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD • i�®c' Commonwealth of Massachusetts ) Division of ProfessionatLicensure Board of Building Regulations and Standards ,, Const i{%iS rvtsor 0.f.. Ali cs 994925 tress 09/03/2020 • PATI® ' STANEK'In f t GREAT DAY ENCLOSURES WINDOWS a� • [mrRnvsmcnre,Lw• ROBERTAO N," 0; ,� , 9 a aft 51 HILL SIRE , y , . . Improving Everything We Touch." NORTON MA 5745 .s.1"y0 ' 'M, • `""IvOt 10t j:,: -* _ 1 greatdaylmprovements.com patloenclosures.com I stanelcwIndows.com //�� I Commissioner 1!l�e,' ��'• • pl s a. - s� Office of Consumer Affairs and Business ess Regulation b. 1 10 Park Praza- Suite 5170 Lyy • Boston, Masetts 02116 • Home Improveme ractor Registration m Type: Supplement Card Registration: 168562 GREAT DAY IMPROVEMENTS, sA s Expiration: 03/07/2019 500 Myles Standish Blvd 7 te7. • Taunton, MA 02780 • c d IG e, Update Address end return card. Mark reason for change. Al 0 20M-05111 ❑,.Address 0 Renewal 0 Employment ❑ Lost Card M'r� ia 7�rs�nmoo¢weaa c�'lZ4�ac�cu�'C[a .lcgrtsy l'�r 1'e rstratft valid for In ijividul use only • tidbit the expiration date. If found return tp: � , _ OfRce of Consumer Affairs&Business Regutatlo s0i HOMEIMPROVEMENi COf1TRACTQR', • + •' •Offtce of Consumer Affairs and Business Regulatrop .5 ZTYPE:Supplement Card ' e:.. .10 Perk flees-Suite 5170 . ' - t1 '. : I S P ti +- . •Boston,MA 02116 ' , • ; Ta„ '• r�7i'cfgrstration )=xplratlori • 'I� • ;.o' , ____ -�a,e...r/�,7� 03/07/2019. GREAT DAY I'^^'rr��; OE E,8,CLC.. ' ' '� 1 it BOB GUENAR6 °� 0. 71f. 12 �' ' 160 Greentree fT (31 `p • � i . Doveil,DE 19904lie s, J� r ; 1. "i,;. • •• Not valid without signature • • : .1 • 'Undersecretary '' %. --e--fu-.. . •L_ )`s,','±A. ..ti:,... '4 m 4 _" @ 9 s p J _ 2 E "0 2r____, ....., . . . m m I I 3 p i • a a I N to, I 1-1 0 0 0 0 L „ .... N co Y cg 'C z 3 0 8 ow qEl= E `m o Q . 06 :I CD CU CI a N 3 . m O DI • a• y Q O OJ-1 'SS Q c \ 1 a _ s. pumi Is < E H ri C In 11 v m c o .m m % fil a 1 E m._ mrn p m � y.� :� l = . � .m '$,� Mcg, . m.rn7 CP� E \ ..�i ❑ ❑ - - a v zoLIJ d _. m m 7t ...m o - -.S @ON c - 17 ` fL— dmCfnI10 co CEJ -Q II g@ ptmtl W ��11�I1� �I� N • • I1��JIM i I ill"l� �I •N as r- k .1 W' @ a c N 0 o LL g 3 O d 'd -Q Z 11* w a{ o S@V @ (n W J In N C_ cWo ci N E rL>. .E t0 ❑ .0 m �'`�'t- j am'c F-7r O N o _�f.. N lb C ' p ccr-. I I C>�W U d a Ccr o as 1,57• J • 3 8 2 c d g i i U 6 Q ¢. d 500 Myles 6tandish Blvd. Contract I STAN EK' Taunton,M 02780 ' Page 2—tor MA Residents ��I Main:508-422-1966 MA Re t1685e2:RI Reg.#16768 Toll-free:888-333-1966 WINDOWS,n Fax:508-8 .1-9339 www.stane lndows.com I /1 1 C� eyranwraalMpRplQAB19,LLC ' - ' D..e 20 I Seller agrees to furnish labor and at:rials at Buyer' request,and for the ' 1 contract amount,t. complete the work described above, subject to the terms and' ondi ions whidh ap earon both Pagel i &Page 2 and Ion t e REVERSE sides of this contract. 1 i 1 t Work to start approximately V eeks torn the date of this contract and to be cortiplet•d approximately 1,--)._ weeks after commencement if nbt delayed b building per it,delivery of materials,weather, strikes,fides,or other conditions beyond Seller's control. The completion date i. not of the es ence. 1 1 j f I 1 Buyer represents and warrants tha)lest al title to the .roperty,which is to be Improved, id in t e 'allowing owner(s): II � 1 ryif tl 1. Ili I NOTICES 1.Seller and/or all subcontractor if. y,who erfo m on this contract, and who are ndt pal.,4nay have a claim against you , li ablelien laws. which may be enforced again t tho property being Improved in accordance with the i PP I I I 1l 2.YOU,THE BUYER, MAY CAN EL IS TRANSAbTION AT ANY TIME PRIOR TO MIDNII.Iii OF THE THIRD BUSINESS DAY AFTER THE TRANSACTION .TATE(THE DA—E ON WHICH YOU SIGN THIS CONT'AT). SEE THE ATTACHED NOTICE OF CANCEL TION OR FOR AN EXPLANATION OF THIS RIGHT.THIS RIG 'T'IS IN ADDITION TO ANY RIGHT YOU OTHERWISE MA • E TO REVOKE YOUR OFFER. I The contractor and the homeown-r hereby mutually agree,in advance,that in the -vent the contractor has a dispute concerning this contact,the contractor may submit such dispute to a pili .to arbitration service which has been a••rove• •y the Secret:ry of the Executive Office of Consumer Affairs a dBusi t-ss Regulations and the consum r shall •- requ' ed • submit to such arbitration as provided in MGLC.142A. 1 i � . i, L . I Owner _ t/ /R'at_ Contractor 01/1'` \ 1 'j NOTICE: The signatures of tie•- ties above apply ONLY to thelagr`ment of the •arties to •rnative dispute settlement initiated by the contra tor. The owner may initiate alternative dis•tate -sol ion e -n where this section is not separately sigtSed •y the parties) ' J WHERE REQUIRED,HOMEOWNER 0 GET PERMIT. Source of Sale I I I � S I • THE DOWN PAYM NT SHALL BE A Contract Price i $ y NONREFUNDABL: DEPOSIT ONCE THE THREE-DAY Down Payment $ / CANCELLATION P RIOD HAS EXPIRED. pzrVer I $ I ' 2yq I I �''A00 %k $ i / 7 YY I THIS CONTRACT 'ONSTITUTES THE ENTIRE Balance Due Upon ! 1 t 93 UNDERSTANDING O'THE PARTIES. Substantial Completion $ 7 l Customer acknowledges recei t of : copy of this contract,product warranty and duplic. • notices of cancellation. DO NOT SIGN THIS CONTRXCT F THERE ARE ANY BLAN SPACES r' Date Down Paym: clued :/ (',i ,S mer Signature) i • • III 1 By .a I.I.1 Ids I I ,�. -- •/' i (Cut. ler Signature) Subject t• terms and c' 4 tion-which appear on both Page 1 and Page 2 and REVER E sides of this contract. I CORPORATE OF :720 Highland Road E I Macedonia,OH 44056 I :000.2368301 GREAT DAYI GREATOAYIMP ENTS,COM I PATIOENCLOSURES.COM I TANS INDON4R.COM us- cEV2/18 1Ir 1 • 1 1 i t A i 5b0 Myles Standish Blvd. IPATIO " �S,TANEK° Plone 50 822,8 68 ENCLOSURES® YVINDOWS thin Fax508-821-9339 BY crecrcver IMPeaiscons,in1BYGREATG&Y IMPRCNhS 41 LLC I.MrI18B58LiERcj16TBB 11 1 Owner Authorization for Permit Application ; i 1 Pr I _ rwS '„ ..S. asi owner of the Subject Property located a 9 L cQA `\---p jA MOL- te?0 AA ) \---Clet."..-yyzoltul 1 NriaTic-h 1--A A Hereby authorize GREAT DAY Improvements LLC., Taunton, MA to act on my bha fin all matters relative to work ai.thorized by this Building P r it Application I A 4 ;! > �- ;740 ir Si.`, ature 01' 0 n• II ate i l 1 COR.ORATEOFFICE;t 720 Highland Road E I(Macedonia,OH 44058 1800-230-8301 GREAT DAY I grea daymprovements.com I patioenclosures.com I Sane ndows.com cp 1