HomeMy WebLinkAboutBLD-19-003254 �., tOffice Use Only n
.'A4.41.. . 1 4 �3 Permitl!
(.`., �s 75
. . �l H Amount /
ail:
Permit expires 180 days from
=c:+t issue date
EXPRESS BUILDING PERMIT APPLICA ION C E I V E D
TOWN OF YARMOUTH
. Yarmouth Building Department IiDV 27 2018
1146 Route 28
South Yarmouth, MA 02664 BU r~a ' T
i'3pp (508) 398-2231 Ext. 1261 By'
'yam
CONSTRUCTION ADDRESS: &el 'cat- rem-,Aalien ,vi4 9d'7Y
ASSESSOR'S INFORMATION: •
1 /) Map: Q� Parcel: ���
OWNER: j'vrl c �nrt k 33 U Q 4 -' �0.4L IA-r`mmitB Afrd (gar-
NAME 1 PRESENT DRESS I TEL. #
CONTRACTOR: rw4s �i e eMvedivi' )0.14 4e( in .,s !�' �l�f/� 00167.2 Ste_ C / �J
NAME / MAILING ADDRESS ) TEL.# Jar/6,. .
esidential ❑Commercial Qj Est.Cost of Construction$
J j- e?9
Home Improvement Contractor Lic.# 0 - /O J Q Construction Supervisor Lic.# 15717173 '5
Workman's Compensation Insurance: (check one)
0 I am the homeowner 0 I am the soleproprietorI have Worker's Compensation Insurance
Insurance Company Name: apt Cm, h (.et>'✓44// C Worker's Comp.Policy# '�01 A/,Q0.5?
WORK/TO BE PERFORMED
Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares 3 Replacem windows:# Replacement doors: #
Roofin : #of Squares ( Remove existing*(max.2 layers) Insulation
tt Old Kings Highway/Historic Dist. ( Replacing like for like Pool fencing
ve.4...,,e mos)
'The debns will be disposed of at -tic.N T y44 .
Location of Facility mire*
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 revocation of.y license and for prosecution under M.G.L.Ch.268,Section I.
Applicant's Signature: ��! Date:
/l/"" d yZ dell°
Owners Si: 'ature(or attachment2/Date:_ �7 47
Approved By: �e��t Date: //
Building Offic' • op.; ggnee) EMAIL •1170' 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 Massadhusetts
-;/ l -- =-_ I Department ofIndustrial Accidents
nle1-11 Congress Street,Suite 100
e Boston, MA 02114-2017
,?,F www.mass.gov/dia
\Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH TUE PERMITTING AUTHORITY.
Applicant Information Please Print Legiblt
Name (Business/Organization/Individual): 8,1445 tKc t y%nYr c4
Address: Ra etc /9/
City/State/Zip: C',,itt,,,(/,e 444 and Phone #: saa a' ydy1✓
J
Are you 2 1 employer?Check the appropriate box: Type of project(required):
a employer with 3 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.]
3.0 I am a homeowner doing all work myself.[No workers'comp.'insurance required.]r 9. Demolition
4.❑1 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 11.0 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.ZI.R6Eicepair
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 e. 14.0 Other
152,11(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: <4.4 £f,,.r„/ e,T,
Policy#or Self-ins.Lic.#:pSett/ /A.*? Expiration Date: $ - / -8M7
Job Site Address: is Fir- 5144_ City/State/Zip: lA^I�� r>� /`w on(
Attach a copy of the worke ' compensation policy declaration page(showing the policy n mber and es iration 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 pal' and penalties of perjury that the information provided above is true and correct
Signature: / Date: /'6 1P ate
Phone#: ! �" ?a° /CISH
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 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 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 bum 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
•
I ' } ''I
HOME IMPROVEMENTS
PH. 508.328.1635
Exterior Remodeling Experts B:g-
Web: www.thomashomelmprovements.net Fully Licensed & Insured
P.O. Box 177 Construction Supervisor Lic #99913
Centerville, MA 02632
THOMAS HOME IMPROVEMENTS LLC. PROPOSES TO PERFORM THE FOLLOWING WORK:
Location of proposed work:
Ms.Tudy Thiele
33 Bray Farm South
Yarmouthport, MA 02675
Date on which construction should begin: October/November 2018
The homeowner hereby acknowledges and agrees that the scheduling dates are approximate
and that such delays that cannot be avoided by the contractor shall not be considered as a violation of
this contract.
The contractor agrees that when such delays become known to the contractor,the contractor
will advise the homeowner as soon as possible.
The homeowner hereby acknowledges that in certain remodeling work,the demolition process
may reveal defects in the existing structure which must be repaired, creating additional work which may
need to be carried out in order to complete the work described in this contract. In such case the
homeowner agrees that the duration of the work and the schedule date of completion may differ,and
that such variation is not to be considered a violation of this contract.
Cost for labor and materials under this contract: $9,350.00
30 yr.GAF/Elk Timberline HD Architectural shingle(Life Time Limited Warranty)
Install of 2 Velux VS skylight(manual opening) no shade $3,040.00
Install of AZEK PVC trim on all members of rake edge, back corner board,above back deck area
& back stairs would be an additional $2,235.00
Thank You for Givinlu Us the Opportunity to Help You Improve Your Protect
In the event that while stripping the roof we find rot that needs to be replaced,the homeowner
then has to agree and authorize any replacement or restoration. Then in addition to the above contract
price,the homeowner agrees to compensate the contractor for any repairs or restoration at the hourly
rate of$65.00 for a carpenter and$45.00 for a carpenter's laborer, plus the cost of materials.
-Roof to be stripped and cleaned of all old shingles and debris
-Roof to be papered with weather watch leak barrier,Synthetic roof underlayment,and
installed with Timberline architectural shingles using galvanized nails. (Storm nailed)
-8" drip edge& new pipe collars to be installed
-Cobra ridge vent to be installed on all ridges
-Timbertex premium ridge cap to be installed
-A 10 yard dump trailer will be needed on site; and will be removed at completion of the job
-Contractor will be responsible for all building permits needed at the property
NOTICE REQUIRED BY LAW
With the agreement of the contract$500.00 of estimate is due.
Further payments under this contract are as follows:
1/2 of the estimate due at the start; and remainder due at completion of the job.
Balance of all materials and labor shall be payable in full upon completion of work described in
this contract. Payment as agreed upon shall be made when due. Any payments which are
delayed shall be subject to a finance charge of 1.5% per month.
The contractor warranties the workmanship completed under this contract for a period
of ten years from the date of completion.
During the stated warranty period the contractor shall be responsible for the service of
the repair or adjustment, but the contractor shall not be responsible for the normal maintenance, repair
due to abuse, misuse, and or normal wear and tear,which shall be the responsibility of the homeowner.
All warranties for the materials supplied by the contractor shall be passed directly to the
homeowner. The homeowner may be required to register or mail in such warranty card or evidence of
ownership in order to activate such warranties. Homeowner failure shall not create any responsibility
for the contractor under the warranty provisions;the choice of repair of replacement shall be at the
discretion of the contractor.
The homeowner acknowledges that the form, content,and notices contained in this
contract are intended to comply with the applicable portions of the Mass.General Law Chapter 142A,
and regulations promulgated there under. In the event of any instance of non-compliance, only such
portion shall be invalid and the remainder of this contract shall be in full force effect. In addition,any
such portion not in compliance shall be read and interpreted so as to have its intended meaning to the
maximum extent allowed under such law and regulation.
Signed as a sealed instrument on this date:
Date:
ret Homeowner
/ate 3 Contractor
V - -
•
DATE N
ACORD CERTIFICATE OF LIABILITY INSURANCE
05/23/2018
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(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 such endorsement(s).
CONTACT
PRODUCER - NAME: Donna Ostrowskl
Mark Sylvia Insurance Agency,LLC c Na
Main Street (aE,dy(509)957.
(A/C,No1:(509)957-2787
EMAIL
Centerville,MA 02632 swam markfbmarksylviainsurance.com INSURER(S)AFFORDING COVERAGE NAICS
INSURER A:Farm Family Casualty Insurance J
INSURED - INSURER a: I
Thomas Home Improvements LLC .
INsuRER e:
PO Box 177 INSURER D
Centerville,MA 02632
INSURER B:
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 POUCY 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.
INSRIADDL SUER POLICY SFP I POUCY EXP UNITSLTR TYPE OF INSURANCE IINc r).MND POLICY NUMBER (MM/DO/YYyVI IMM/DDIYYYY)
A X I OOMMERCULL GENERAL LIABILITY 2001X1416 5/01/2018 5/01/2019 EACH OCCURRENCE 3 1,000,000
•
Ii 1'
CLAIMS-MADE I A I OCCUR PREMISES Me occurrerrel $ 100,000
MED EXP(Any one person) s 5,000
— PERSONALS ADV INJURY 3 1,000,000
GENERAL AGGREGATE $ 2,000,000
GENE AGGREGATE LIMIT APPLIES}PLIES PER
X POLICY!J)ECT I I LOC PRODUCTS•COMP/OP AGG S 2.000,000
3
OTHER' DDMBINLD SINbLE lIN1tY $
AUTOMOBILE LIABILRY (Ea accident)
ANY AUTO BODILY INJURY(Per person) $
— OwNEO SCHEDULED BODILY INJURY(Per accident) S
_ AUTOS ONLY AUTOSPROPERTY DAMAGE $
HIRED - NON-OWNED I??accldenU
— AUTOS ONLY AUTOS ONLY $
UMBRELLA LIAB OCCUR EACH OCCURRENCE 3
— EXCESS LIAB CLAIMS-MADE GGREGATE S
•
OED I I RETENTIONS LOTH-
A 'WORKERSEMPLOYERS'
COMPENSATION 2001 W8053 5/01/2018 5/01/2019 (STATUTE I ,SER
AND EMPLOYERS'LIABILITYEL EACH ACCIDENT $ 1,000,000
ANYPROPWETOPARTNER/EXECUTIVE Y/N NIA 1,000,000
OFFICEP/MEMSEREXCLUDED? EL DISEASE•EA EMPLOYEE $
(Mandatory in NH) 1,000,000
II yyea.deaenhe under E.L.DISEASE•POLICY LIMIT S
CESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES((CORD 101,Additional Remarks Schedule,may be attached If mon space Is required)
Carpentry
Insurance coverage Is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be
deemed to have altered,waived or extended the coverage provided by the policy provisions.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Troy Thomas ACCORDANCE WITH THE POLICY PROVISIONS.
499 Nottingham Drive
Centerville,MA 02632 AUTHORIZED REPRESENTATIVE �
t 7'et--
I
ED 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD .
commonweann or massacnuseru
Division of Professional Licensure r e uemonieraid ot2& uadreir/r ''
Board of Building Regulations and Standards-, ti Office of Consumer Affairs&Business Regulation
Con jFhlctioR S'IIfJ&or Specialty HOME IMPROVEMENT CONTRACTOR
/I TYPE:Corporation
CSSL-099913 > -:. F Ek Ives ➢4/1,3/2020 Registration Fxoiration
185422 06/082020
TROY THOMAS HOME IMPROVEMENTS,INC.
TROY ATHOMAS L.
r CyI
^r i
499 NOTTINGHAM DRIVE
CENTERVILLE MA 02632 -t TROY THOMAS \2..
.."- '�Olttti�\` .� T3 . 499 NOTTINGHAM DR. U
-�. CENTERVILLE,MA 02632 Undersecretary
Commissioner •
•