HomeMy WebLinkAboutBLD-19-003579 ie; ce Use Only
'f Y ARS ' /4tt) 3 '. 75
r
I t C_.
o •a*y;4' �.1 Amountil
N!`mac crd' - Permit expires 180 days from
... • • issue date i
t�M1 I R
EXPRESS BUILDING PERMIT APPLICAT O
TOWN OF YARMOUTH iN --___L— ,..; Lai
DEC
Yarmouth Building Department
g
ullooin,�--
1146 Route 28 "r DET'A
South Yarmouth,MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: .7(5,:?,2 //(JG!/Ste >
` J„^/J?,„,,e 1
ASSESSOR'S INFORMATION: •
//�/� 1 Map: Parcel: /�
OWNER: (! 7/ 41?5/7/,-,o/C 22/5- ..C./0-1.44-4.4:.e• ' I,t�n ci e f 9y�io
NAME / PRESENTSE^ ADDRESS �, TEL. #
CONTRACTOR:/viy//:4, ®i, /Y/�'jr43///V 4F15,e7",ael"...•y-?i a n`T% c!> r-
NAME MAILING ADDRESS TEL.#
esidential 0 Commercial Est.Cost of Construction$47 3,2,
•
Home Improvement Contractor Lic.# 1,2_91P 97 Construction Supervisor Lic.# t5- ea"-94521-
Workman's Compensation Insurance: (clock one)0 I am the homeownerpi-am the sole proprietor have Worker's Compensation Insurance
Insurance Company Name: /7077.9"/-
s077.9" -Cary Worker's Comp.Policy# ("cc On dr., nn fina./P,S-
WORK TO BE PERFORMED
Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares Replacement windows:# V Replacement doors: #
Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation
Old Kings Highway/Historic Dist ( )Replacing like for for'like pPool fencing
"The debris will be disposed of at ��riy //yi��Q/YY. Glj2rt� �yJl t-2-ii rler
Location of Facility
I declare under penalties of perjury that the statements herein contained are true and correct to the best of my Imowledge and belief. I understand that any false answer(s)
will be just cause for denial . ocation of my license and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature:/ NL <
� ' _ /� Date: /2 477.2cre.---
Owners Signature(or attachment) Date:
Approved By: ..r - i Date: /2 -/3 /g
r d official(or designee) EMAIL ADDRESS:
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 Massachusetts
=•,..=.a=
';1 '�=,:,�_�/ Department oflndustrialAccidents
nlel_ 1 1 Congress Street, Suite 100
,=..
�t:__ Boston, MA 02114-2017
�.. • www.mass.gov/dia
\Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): �l�,7c"'. 41.,%, ✓ '1.
Address:
City/State/Zip: w�tiJ 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
2krirm a sole proprietor or partnership and have no employees working for me in $. 0 Remodeling
any capacity.[No workers'comp.insurance required.]
3. I am a homeowner doing all work myself. t 9. ❑ Demolition
❑ y [No workers'comp.insurance required.]
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 11.❑ 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 sub-contractors listed on the attached sheet
13.0 Roof repairs
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 c. 14.❑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.
?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.
Insurance Company Name: neP 4?.yS 41^ Clr
Policy#or Self-ins.Lic. #:Il/CGroeC 90/ 9?a /91- Expiration Date: 4V9��e/7-
Job
Job Site Address: 7142• 4-w/.-z -- rj' ' City/State/Zip:$7,,,, i err"-/, ,
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 that the inform. '.. ,rovided above is true and correct
Sismature: ,%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#
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#:
.1 • 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 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 permitilicense 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, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 02-23-15 www.rnass.gov/dia
r f"
-°
>>;t C0%6.. Page No. 1 of 3 Pages
o
f PROPOSAL
508_888_2112
CAPE*ABILITY CONSTRUCTION All home Improvement contractors and subcontractors
DAVID J. ANDERSON engaged in home Improvement contracting, unless
specifically exempt from registration by Provisions of
MA BUILDERS LIC. #CS069188 Chapter 142A of the general laws, must be registered with
MA HOME IMPROVEMENT REG. #124091 registration and status should be made to the Director,
13 Fort Hill Road,East Sandwich,Massachusetts,02537 Home Improvement Contract Registration, One Ashburton
Place, Room 1301, Boston, MA 02108 (617) 727-8598.
Submitted Martha Gilmore Owners who secure their own construction related permits
To: or deal with unregistered contractors will be excluded
7540 Willow Street from the Guaranty Fund Provision of MGL c.142k
South Yarmouth Ma
02664 REGISTRATION NO.124091
JOB LOCATIONWIIIOw St
PHONE508-420-0572 DATE10/17/2018
JOB NAMPJNO.
We hereby submit specifications and estimates for work to be performed and materials to be used:
Replace four windows at 750 willow st.
Windows described in Shepley quote #4888
1. Remove existing windows,prep as required
2. Insulate window cavities with fiberglass insulation.
3.Install new units trim interior/exterior.
4.Remove all construction debris.
5. Aquire express permit from town of Yarmouth.
6. No paint or plaster is allowed for in this contract.
7. Certificates of insurance available upon request.
Pp,t�t Ccns�r
QT 'i o
508-888-2112
NOTICE OF SCHEDULE CHANGES
The Contractor agrees that when delays become known to the Contractor, the Contractor will advise the Owner as soon as is
reasonable.
DELAYS IN COMPLETION DUE TO HIDDEN CONDITIONS
The Owner hereby acknowledges and agrees that in certain remodeling work, the demolition of portions of the pre-existing structure
may reveal additional defects, conditions or the need for additional work, which must bee repaired, altered or carried out in order to
commence or to complete the work described under the contract.
ADDITIONAL WARRANTY INFORMATION
All warranties for equipment supplied by the Contractor under this Agreement shall be those given by the manufacturers of such
equipment,which shall be and are hereby passed through directly to the Owner.Under such manufacturers'warranties,the Owner may
be required to register or mail in a warranty card or other evidence of ownership and use of such equipment in order to activate such
warranties. The Owner's failure to mail In or register such documentation, which failure voids the manufacturer's warranty, shall not
create any responsibility for the Contractor to warranty such equipment.
The warranty gives the Owner specific legal rights, and Owner may also have other rights which vary from state to state. Under
Massachusetts law,sales of goods carry an implied warranty of merchantability and fitness for a particular purpose.
All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any
alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an
extra charge over the estimate.All agreements contingent upon strikes,accidents or delays beyond our control.
SUBCONTRACTING
Contractor agrees that, notwithstanding any agreement for materials and/or labor between Contractor and a third party, Contractor is
responsible to Owner for completion of all work describe in a timely and workmanlike manner.
NO ACCELERATION OF PAYMENTS BUT ESCROWING ALLOWED
The Contractor may not require payments to be made in advance of the times specified in Payment Section (front)for the reason that
he deems himself or the payments to be insecure. If, however, he deems himself to be insecure, he may require, as a prerequisite to
continue the work described herein, that the balance or the payments under this contract that are in the control of the Owner, shall be
placed In a joint escrow account that requires he signature of both the Contractor and the Owner for withdrawal.
INSURANCE
Contractor will be responsible to Owner or any third party for any property damage or bodily injury caused by himself,his employees,or
his subcontractors in the performance of, or as a result of, the work under this Agreement. Contractor agrees to carry insurance to
cover such damage or injury.
CONSTRUCTION RELATED PERMIT ACQUISITION
The Contractor under provisions of Chapter 142A of the General Laws is required to apply for and obtain all construction related
permits. The Contractor shall not be deemed responsible for delays in the work described in this agreement caused by regulatory,
permit granting or inspectional agencies,authorities or individuals.
Notice: If the Owner obtains his own construction-related permits for the work described under this agreement or deals with
unregistered contractors,the Owner Is hereby advised that in the event of a dispute,judgment and nonpayment of
the Contractor,the Owner will not be entitled to make a claim to or collection from the guaranty fund established by
Chapter 142A,M.G.L'
MODIFICATION
This Agreement, including the provisions relating to price and payment schedule cannot be changed except by a written statement
singed by both Contractor and Owner.However,cancellation by Owner is allowed in accordance with the Notice of Cancellation.
COMPLETENESS OF AGREEMENT FOR EXECUTION
The Owner is hereby advised that he should not sign this Agreement unless and until all black sections have been filled in or
marked as void, deleted or not applicable, and until all exhibits and related or referenced documents that are incorporated
herein are attached hereto.
COPY OF AFREEMENT TO BE GIVEN TO OWNER
This Agreement is governed by the Laws of Massachusetts. It must be executed in duplicate,and an original,signed copy here of given
to the Owner at the time of execution. No work under the Agreement shall begin prior to the signing of the Agreement and transmittal to
the Owner of a copy thereof.
Initial
•
• . �,.vi Con St,
0 oC•
m t o
•O 7
508-888-2112
WORK SCHEDULE
Contractor will not begin the work or order the materials before the third day following the signing of this Agreement,unless specified herein writing.Contractor will begin the
work on or about 12/20/2018(date).Barring delay caused by circumstances beyond Contractor's controt,the work will be completed by 4/20/2018(date).The Owner hereby
acknowledges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the contractor shall not be considered as violations of this
Agreement.
WARRANTY
The Contractor warrants that the work furnished hereunder shall be free from defects in material and workmanship for a period of In following completion and shall comply
with the requirements of this Agreement In the event any defect in workmanship or materials,or damage caused by the Contractor,his subcontractors,employees or agents,
is discovered within one year after completion of any job,including clean up,the Contractor shall,at his own expense,forthwith remedy,repair,correct,replace,or cause to
be remedied,repaired,or replaced,such damage or such defect in materials or workmanship.The foregoing warranties shall survive any inspection performed in connection
with the agreed-upon work.
We Propose hereby to furnish material and labor—complete in accordance with above specifications, for the sum of:
5326 dollars ( ),
Payment to be made as follows: St
Name of Contractor/Designated Registrant
_% ($3,000.00)upon signing Contract
13_% ($0.00)upon completion of_; Str Foddress Rd
_% ($0.00)upon completion of_; East Sandwich 508-843-8075
City/State Phone
_°% ($2,326.00)shall be made forthwith upon
completion of work under this contract 508-888-2112 04 •
Phone Federal ID No.
Notice: No agreement for home improvement contracting work shag David J Anderson
require a down payment(advance deposit)of more than one-third of the Name of Salesman
total contract price of the total amount of all deposits of payments which
the contractor must make, in advance, to order and/or otherwise obtain DJA
delivery of special order materials and equipment, whichever amount is Authorized Signature
greater. Note: this proposal may be withdrawn by us B not accepted within 15 days.
Acceptance of Proposal I have read all pages of this document and accept the prices,specifications and conditions stated.I understand
that upon signing,this proposal becomes a binding contract.You are authorized to do the work as specified.Payment will be made as outlined above.
You, the Buyer, may cancel this transaction at any time prior to midnight of the third business
day after the date of this transaction. Cancellation must be done in writing.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
Signature Date II Sh8r
Martha Gilmore
Signature Date