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Home My WebLink AboutBLD-19-003301 • ,` � eeeUseOnlyA 301 0 Amount �( . .. y 0 • N r Permit expires 180 days from • �,�r,.•u^'e6`� issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH �` C E:: i :77: .__ Yarmouth Building Department /-� 1 1146 Route 28 �I�2 • 9 2018 v"�(i z, South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 BUILDItTc--, y/ l/��( tin{ 39 /}�� /�/ sy; q / ✓t4 J' /iii" tare -_� -_ 42_- // CONSTRUCTION ADDRESS: 1f ____ ASSESSOR'S INFORMATION: IMap: /7 I Parcel: /74 OWNER: S4e an I'Lan(S+ 9.5' Sarapipce (nniz 0/7 4_4ot i s / 2 NAME PRESENT ADDRESS TEL # Shane Mitt,ibe//Yec. `b R8 4,( cfc'S1 De un Ste'- &st/-795o CONTRACTOR: / /fltSO(OOcEV EL# on_S 5— NAME MAILING ADD IiSS !p /1 ^-� 0 Residential 0 Commercial Est.Cost of Construction S___6 yy 1. " Dome Improvement Contractor Lie.# I qo {go Construction Supervisor Lic.# 11)(D 3 Workman's Compensation Insurance: (check one) / L I am the homeowner //��0 I am the sole proprietor :have Worker's Compensation Insurance Insurance Company Name: knit Worker's Comp.Policy# Awe- -10 (05711 WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Repla ment windows:# Replacement doors: # Roofing: #of Squares lb ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/llistoric Dist. ( )Replacing like for like Pool fencing r'I'he debris will be disposed of at: S a 0 A • Location of Facility I declare undeerpnaltdts.is,:cjuvocthat the of my Ientseend fur prosecution contained arenue and d1.Lt toh.the best of 26Section]knowledge and belief. I understand that any false answer(s) will 11r9,e1� Date: Applicant's Signature: \ �.)/� _ Owners Signature(or attachment) Date: �Q Approved By: Date: //r't:�- 29 Building 0 ial est te) •" EMAIL.,ygg RESS: Zoning District: Historical District: ..:I Yes No Flood Plain Zone: Yes :, No Water Resource Protection District: Within 100 ft.of Wetlands: Yes r No f3 Yes rl No 1 i •.a• f .•\ 1 =-a— The Commonwealth of Massachusetts r y=till=_�t Department of Industrial Accidents _;,(- y 1 Congress Street,Suite 100 • " Boston, MA 02114-2017 I www.mass.gov/dia 1 Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information -r ! Please Print Legibly Name(Business/Organization/Individual): �jrl/Tedol /`f{7 ooCce q(c1%t[{, 5- i Address: o0 ler I C/A54 f✓iciit7/pc k.I l44 d City/State/Zip: p Phone#:4-0 p CS 4"7" ?l (j { Are yon employer?Check the appropriate box: i Type of project(required): 4 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 any capacity.[No workers'comp.insurance required.] 8. ❑Remodeling 3.0 1 am a homeowner doing all work myself.[No workers'comp.insurance required.]: 9. ❑Demolition 4.0 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 proprietors with no employees, l l.❑Electrical repairs or additions 5.0 I am a general contactor and I have hired the sub-contractors listed on the attached sheet. 12.0 Plumbing repairs or additions These subcontractors have employees and have workers'comp.insurance.: 13.❑Roof repairs 6.0 We are a corporation end its officers have exercised their right of exemption per MGL c. 14.❑Other I 152,11(4),and we have no employees.[No workers'comp.insurance required.] `Airy applicant that checks box NI 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 :Contactors 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. A Insurance Company Name: f'f I Y11 Policy#or Self-ins.Lic.#: 1 O'b 10 37 q Expiration Date: ell^a S-/ Job Site Address: Attach a copy of the workers'compensation policy declaration page(showing he 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 again t the v'olator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage ifical.n. I do hereby rt• ,, ik der the pains and penalties of perjury that the information provided above is true and correct. 4 Signature: .s I, I _ g sb— I Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# I. Issuing Authority(circle one): I. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing inspector r 6.Other f r 4 Contact Person: • Phone if: r =r. isCommonwealth of Massachusetts i. a STATE OF RHODE ISLAND° Division of Professional Licensure S •CONTRACTORS'REGISTRATION a 'Board of Building Regulations and Standards AND LICENSING BOARD • ConstrudioLtS'lpeMts9fSpecialty T un 1 CSSL-106123 " E�ires:07/14/2021 REGISTHATNIN NO - EXP DATE REGISTRANTS NAME l+ 1 V0 f Of:/1./2.'0' SHANE D MCGUIRE tA'D'VITAE.F;;l It-ObitI.i• LD�f�T .1.i.e• 8 ROYAL CREST ORME UNIT 3 .� ;aft.*sar) (. MARLBOROUGH MA 01752 '` AUTHORIZED REPRESENTATIVE ,.. Oflc'i1Or t i-;ia.r iielUiLE � i DEWAR5 UCENSEF CUTNE R 1 €. et u•II!1.t,tl Commissioner l/'� � 5 NmaioasiepUn, jzstio vws`cpnOt�fi>�=r^dw x Registration valid for Individual use only \ C"LNR3N.tl01534i0 VHxZi>J'a before the expiration date. If found return to: ff ; �- \:,3HOISOW?frols Office of Cons -: Affairs and Business Regulation i . I. /� One AshburtonPl. e-Sulte1301 7 • "1 Boston,M; 021•,: i •i -�`, s OT1 SUOJ.S4.1.N00 ONIdO014 15d3H1U0N I i. OZO-IJOZIZO braOZ[O6 ` U 14811611I inti iomrJ 134A1 ' Not valid without signature uolwm6ag sale ss g a uRw sawreisuuog wonaw • 1 -----Th NORTH09 OP ID:CHD ACOR0" DATE(MWJDD/YYYY) I`---- CERTIFICATE OF LIABILITY INSURANCE 11/27/2018 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(ies) must 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). _._ _ PRODUCER CONTACT - Segreve&Hail Insur.Assoc.lnc FAX FAX One Tech Drive AAA NOdX0:978-975.1300 wc,No):978-975-7596 Andover,MA 01810 EADDRLSS: Sean Segreve INSURER(S)AFFORDING COVERAGE NAIC I INSURER A:Atain Specialty INSURED Northeast Roofing Contractor INSURER 8:Commerce Insurance Co. _ _34754 Shane McGuire INSURER C:A.I.M.Mutual Ins.Co. 33758 9 Royal Crest Dr Marlborough,MA 01752 INSURERD: 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. tNSR - AODLSDe11 -PODCTUr )OLIc?EXP— LTR TYPE OF INSURANCE 1NSD WVD POLICY NUMBER (MMDDD/YYYV) (NAMIDDITYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE s 1,000,000 CLAIMS-MADE X OCCUR CIP353069 02/08/2018 02/08/2019-DAMAGE 5E5(EeENTE«currence) f100,000 MED EXP(Any one person) f 5,000 PERSONAL&ADV INJURY $ 1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: _GENERAL AGGREGATE f 2,000,000 POLICY PRO JECT LOC PRODUCTS•COMWOP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBI NED SINGLE LIMB $ 1,000,000 (Ea accident) B ANY AUTO RXL738 02/21/2018 02/21/2019 BODILY INJURY(For person) $ ALL OWNED XSCHEDULED BODILY INJURY(Per accident) $ _ AUTOS AUTOS --- HIRED AUTOS NON-OWNED PROPERTY DAMAGE f _ AUTOS (Per accident) _ $ UMBRELLA LMB _ OCCUR EACH OCCURRENCE _ $ _ EXCESS LMB CLAIMS-MADE AGGREGATE _$ DED RETENTION$ $ WORKERS COMPENSATIONPLR OTH- AND EMPLOYERS'LIABILITY X STATUTE ER C ANY PROPRIETOR/PARTNER/EXECUTIVE YIN? NIA AWC 7036374 04/25/2018 04/25/2019 Et EACH ACCIDENT S 100,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) I El.DISEASE•EA EMPLOYEE $ 100,000 I yes,describe under - DESCRIPTION OF OPERATIONS below Et.DISEASE•POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If mora space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN RoACCORDANCE WITH THE POLICY PROVISIONS. te 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE 0 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Northeast Roofing Contractors LLC MA lic#106123 HIC Lic#190720 RI#41897 P.O. West Hyannisport, ox 145 West MA 02672 NRCL Phone:4013457892 Contact:Thumbtack ROOFING ST Email:justin@northeastroofingcontractors.com CONTRACTORS LLC Customer Address Stefan Keniston 25-27 Sandpiper Lane West Yarmouth, MA 02673 6178429312 stefan.keniston@gmail.com Quote#: 382 Date: Oct 19,2018 Description Total 1. Property Protection $0.00 Cover the house,walkways,and shrubs in order to protect from roof debris. 2.Remove existing roof system $960.00 Rip 3.Ice and Water shield $200.00 Install ice and water shield yo the first 6'up from the ever,valleys,cheeks and any penetration(including skylights,vents, pipes and around chimneys) 4.Install Synthetic Underlayment $120.00 Install Synthetic Underlayment to remaining roof areas. 5.Drip edge $119.00 Install 8 Inch drip edge around the parameter of roof 6.Starter shingle $170.00 Install Certainteed starter around parameter of roof over the drip edge separated seams 7.Chimney Re-flash $450.00 Rip out existing lead flashing and caulking. Install new 9" lead base flashing around chimney and weave between shingles. 9.Shingle Installation 53,040.00 Install Certainteed Landmark shingles to manufacturer's specification(6 nails per shingle). 10.Ridge vent 5168.00 Install ridge vent to 1/4 Inch open ridge 11.Cap Application 5392.00 Northeast Roofing Contractors LLC I Phone:4013457892 I Page 1 of 3 • • • Items continued... Apply to the ridge of roof 4 nails per cap 11.Dumpster and disposal $500.00 Disposal of all debris 13.Permit $200.00 Obtain permit from local town 14.Warranty $0.00 10.Year workmanship warranty 14.Warranty $128.00 50 year Certianteed Warranty Total $6,447.00 Northeast Roofing Contractors LLC I Phone:4013457892 Page 2 of 3 • `/ _ Terms and Conditions Scope of Work:Company will provide services as described in the attached quote.Company will provide all services, materials, labor,tools,and equipment needed for completion of services. Payment Terms:A down payment of 35%is due upon acceptance of quote.30%is due the day the project begins.35%is due the day of project completion. Change Order:Any deviation from the above quote involving a change in the scope of work or any additional costs will be executed only with a written change order signed and dated by both the Company and Customer.Any plywoodrepiacement will cost$60 per 4x8 sheet and 4 dollars per linar foot of spring board. Warranty:Company warrants all work will be performed in a good and workmanlike manner.Any warranties for parts or materials are subject to manufacturer terms on such products. Conditions:This proposal is valid for 30 days. Company reserves the right to withdraw this proposal or re-quote the project if contract acceptance is beyond 30 days. /I. /_ � f 1I G - ZU1r -me , Date --Z9 — 0/..C/ Nam Date / S � / z6 - ZoE( G � S b, Q� S 4.„„ i, color 31/v.er 61E011 Northeast Roofing Contractors LLC I Phone:4013457892 I Page 3 of 3