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INS %a U 'ha .5-411dl ,�4( :parr °WU1 � ,2 ,�1-Q?L agwnx3?mulad !PIln$, HIUL V U J3u • Ytuo esn ieM1330md nonoas STUN 8u1p961q,flturvg-o4u 10-DUO n a 1 A A N simoulaa.10 atveouag'1:vdaj Yon.e suoj o•L uouvarlddy4uuad 2u;ppn17 ZINIO 08L'apo0 Su!Pllna MIS sllasngossseyg 3., 7 9E80-86£-80C 3 I9t1 P i£ZZ 86£ 805 Z6-11-699Z0 WI'glnotmtA gynnS'8Z am o?I 9171I +o ;uamylsdaa Suipung glnouue i jo umoy 1U&U3d ONi IIl1H-A'INiO 4171XV1 OM.L 18 aNO - - .. . SECTION 5: CONSTRUCTIONSERVICES 5.1 Consstructioq Sud n isor License(CSL) 4 0 1S 7 Expiration ate0 'F) I-1�� e 'r/Jj LicenseNumber Name o CSLHolder t ' La • i )/►.4 c (E� ( �.,/, List CSL Type(see below) 1.1 0and reet �.y-��1 i,j�'�U 2 e �►+1J��9� U lv MA �V I�OJ . Unrestricted(Buildings up to 35,000 cu.R) City/Town,State 1 R Restricted I&2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances dOt@�' it 1 I Insulation Telep one E ' address •N D Demolition 5. a{g�fsteeed Home Improvement Contrac or(RIC) eLmI Q g293 (2) I� 450 rJ (sc. ,V � — C�0�� q RIC Registration Number Expirkon N �t c VryG rl'�Drn e. -rah - D 1R �3 ES -siski l Jh 1 Emailed �. City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(NLG.L.e.152.§25C(6)) • Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes O No O . -SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN " OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize Coo/ (A'/Q N proper,/to act on my behalf,in all matters relati work authorized by this building permit app cation. S NF.v I (Et. iv .�0)-13-/9. Print Owher's Name(Electronic Signature Date . SECTION 7lOWNER1OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is i - :,.• •• . .to to the best of my knowledge and understanding. '3 4 &kI A - � o s �TJ`3/Ort Print Owner's or Authorized Name(Electronic Signature) ��' 15ate` ` NOTES:. 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(MC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.aov/ocq Information on the Construction Supervisor License can be found at www.mass.aov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count 5 Number of fireplaces 1 Number of bedrooms 3 Number of bathrooms 3 Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" • The Commonwealth of Massachusetts it. =-) l=Cl Department oflndustrialAceldents . r. =i1ni= t 1 Congress Street,Suite 100 3ilc�=I' Boston,MA 02114-2017 :. .,r�' www.mass.gov/dia mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Eleetricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information O. Please Print Legibly Name(Business/Organization/Individual): c—(J P")(SCT) LI n( Address: — I- ,R Err R t ei City/State/ZipT iQLt 6 ) M 4 D� 0()'jhhone#: ' (9-s-1 S'1014 Are you as employer?Check the appropriate box: Type of project(required): 1.1121 am a employer with 3 employees(MI and/or pan-time)." 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in g. emodeling any capacity.[No workers'comp.insurance requited] 3.01 am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. Eemolition 4.Q I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition ensure that ell contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.01 am a general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance) 13.0 Roof repairs 6.0 We area corporation and its officers have exercised their right of exemption per MGL a 14.0 Other 152,11(4),and we have no employees.[No workers'comp.insurance required.] "Any applicant that checks box N1 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. /� Amp-pia/ft/4 Insurance Company Name: C� A- Cb —zY�S (,�,reg yt 0-- Policy#or Self-ins.Lie.0: ()L1 ,56 a�-?'a- Expiration Date: a Job Site Address: ?)0"j 120) Li it CtY� A - 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 that the information provided above is true and correct i SAjit 101 03 1 1 T ignature: Date. Phone • ♦ 51 I) 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#: acr TOWN OF YARMOUTH t�� ,G mac, BUILDING DEPARTMENT t, z<«, 1146 Route 28,South Yarmouth,MA 02664 508-398-2231 ext. 1261 HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DATE: /�� /� I JOB LOCATION: 309R (gf farm. : N STREET ADDRES SECTION OF TOWN "HOMEOWNER" Cfl.�s-(ihu 'sr F,mprPi r+R 1-q3R- i 0 13 l,l NAMElc OPHQQNE WORK PI,ONE PRESENTMAILINGADDRESS 9bME 3 NOr -il /►1ai'N ST hn- 4olF H CITY OR TOWN STATE ZIP CODE The current exemption for'Homeowner' was extended to include owner—occupied dwellings of one or two units and to allow such homeowners to engage an individual for hire who does not possess a license,provided that such homeowner shall act as supervisor. (State Building Code Section 110 R5.1.3.1) Definition of Homeowner. . Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is oris intended to be,a one or two family attached or detached structure assessor),to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner;such"homeowner"shall ' submit to the building official,on a form acceptable to the building official,that he/she shall be responsible for all such work performed under the building permit.(Section 110 R5.1.3.1) The undersigned 'homeowner' assumes responsibility for compliance with the State Building Code and other applicable codes,by-laws,rules and regulations. The undersigned 'homeowner' certifies that he/ she understands the Town of Yarmouth Building Department minimum inspection procedures and requirements and that he / she will comply with said procedures and requirements. HOMEOWNER"S SIGNATURE acIA (-- APPROVAL OF BUILDING OFFICIAL INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch.142. Yes No If you have checked ma,please indicate the type coverage by checking the appropriate box. A liability insurance policy Other type of indemnity Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass.General Laws and that my signature on this permit application waives this requirement. Check one: Signatu f Owner or Owner's Agent Owner Agent h:homeownrlicexemp of;y4- TOWN OF YARMOUTH ;4,0 BUILDING DEPARTMENT 3 rye e F �?+jqa x 1146 Route 28,South Yarmouth,MA 02664 &3 69 508-398-2231 ext.1261 Fax 508-398-0836 BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G.L. Chapter 40, Section 54 and 780 CMR,Chapter 1, Section 111.5, I hereby certify that the debris resulting from the proposed work/demolition to be conducted at 70e) (jjxa 1- F h A Work Address Is to be disposed of at the following location: V400 U 4f nr. Bps ,,t/ Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. 4106 1444, Silllir J of Application Date Permit No. I have read this agreement and agree to the terms and conditions. VIP date: ®��Op Owner signature-- —a-4 ' Contractor signatu :y �' 'Pr date: LA-03Q Job contractor, JBGC Inc. 42 Harriett Ave, Burlington MA 01803 857-251-5404 or 617-415-3264 www.medfordroofservices.com jbgccontractor@gmail.com HIC 188293-CSL 106753 Owner Information, Name : constitution property Address:309 rout 6a warmouth Ma City, State,ZIP : phone:781 738 6023 Prolect name home remodeling Job Description : Replace all the windows Replace the doors as needed Remodel one bathroom Add new bathroom in to the Master bedroom Update basement bathroom Remove the kitchen to the living room Create new bedroom where kitchen was removed Company Proposal Total:$52,000.00 Payments will be made according to the fallowing schedule 30% Down According with mass general laws: $ upon signing contractor $AT THE DAY START THE JOB by / / or upon completion of $ by / I or upon completion of 1 S'kepWy IO.J1 N have read this agreement and agree to the terms and conditions. , p�cS Owner signature <y� Vit date: 10- 3 � — Contractor signature date: /0/ 3//AC -`_ d ,'nnrnrnmmea(/A r/C ff(rureeknet6 s ----�. Moo of Consumer Maks a CuOnes.Reg Wagon 7- ' ? HOME IMPROVEMENT CONTRACTOR TYPE:Catoralkn f Mstr,Uon FxniratIoR It," 188293 07/13/2019 JBGC,INC. JOAO BAIA 42 HARRIETT AVE BURLINGTON,MA 01003 Undersecretary • Registration valid for individual use only • before the expiration date. If found realm to:. Office of Consumer Affairs and Business Regulation 10 Park Plaza.Suke 5170 Boston,MA 02116 • / Not valid without signature • • • • r c' Commonwealth of Massachusetts �:... . Division of Professional Licensure Board of Building Regulations and Standards ConstrytCttbA itispsrvisor rf Nomw :C$-106753 "°? �tires:07/22/20204 y • � rJOAO BAIA ••54 r i9 p 42 HARRIETT7VEs v BURLINGTON M/. 61 80 '-.SAO /h7>/�sti tick Commissioner V^" • A� CERTIFICATE OF LIABILITY INSURANCE DAT,(onsna YY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER LUNIALt NAME: AMAZONia Insurance Agency Inc. PIAH/cNqo EY(L. 617-625-1900 Ira No); 617.666-0037 66 Bow Street E-MAIL Somerville,MA 02143 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC N INSURER A: Western World Insurance Co INSURED INSURERS: ACE AMERICAN INSURANCE CO JBGC INC INSURERc: 42 HARRIET)'AVE - INSURER 0' BURLINGTON,MA 01803 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE 'DULOUBIt POLICY NUMBER POLIO EFF POLICY EXP LIMITS Jy$D YUUI (MM/DD/YEFF (POLIC YEXPI X COMMERCIAL GENERALUABILJTY EACH OCCURRENCE $ 1,000,000 MAGE TO RENED CLAIMS-MADE El OCCUR PREMSES(Ea ocicunence) $ 100,000 • MED EXP(Any one person) $ 5,000 A _ NPP8516220 09/29/18 09/29/19 PERSONAL ADV INJURY $ 1,000,000 GENLAGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 • POLICY 78-. LOC PRODUCTS•COMP/OP AGO $ 1,000,000 OTHER: $ AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT $ _ (Ea acYIen0 ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Pm accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE _ AUTOS ONLY _ AUTOS ONLY (Per accident) $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY Y)N STATUTE ER B OAFFICER /MEMBEREXCLUDEDD'X/ECLTTIVE N(A 8H35364818 09/29/18 09/29/19 E.L.EACH ACCIDENT E 1,000,000 (Mandatory In NH) E.L.DISEASE•EA EMPLOYEE 5 1,000,000 N yea,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 5 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached II more apace la required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Constitution Properties,LLC ACCORDANCE WITH THE POLICY PROVISIONS. 967 North Main St Randolph,MA 02368 AUTHORIZED REPRESENTATIVE AMAZONIA INSURANCE AGENCY ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD RECEIVED DEC 05 2018 Job contractor, pUILDING DEPARTMENT By --- JBGC Inc. cratc 42 Harriett Ave, Burlington MA 01803 857-251-5404 or 617-415-3264 www.medfordroofserylces.com jbgccontractor@gmail.com HIC 188293-CSL 106753 Owner Information, Name:constitution property Address :309 rout 6a warmouth Ma City,State,ZIP : phone:781738 6023 Project name home remodeling Job Description : Replace all the windows Replace one door Remodel one bathroom Kitchen remodel replace cabinets granite counter top Company Proposal Total:$38,000.00 Payments will be made according to the fallowing schedule 30% Down According with mass general laws: $upon signing contractor $AT THE DAY START THE JOB by / / or upon completion of $ by or upon completion of have read this agreement and agree to the terms and conditions. Owner sinature 11111/ git date:i d - J� — '$ Contractor signature .. CXr'S7 iN� ��ooR IAr/ Lb.vkraCfO/2 2JDfrC lUC . Lt) Horri€2 * 4v3urZN;I' Mei • 309 RoJe 6 A Ya rnn^a.w 4P/>zd 4 P! Ye:85 39 5 / 55'09 Pr OIvy h por+/Lla (7tNei k= CO/it-RIM J t'0+/ piO;ct TY ACOrrc.S cj 6 i; //o r-'n /'^ "V S 4 ? of el p,H Ala . pPo mil = l2 I- (}38 _bo 23 • /5T ek,s4,„„i rs.,S r i rig . cX ,S3,;N Ic-clrteOni {coo • TOWN OF YARMOUTH _-.... rcor,-J REVIEWED FOR BUILDING AND ZONING CODE COMPLI- I d0 I J i ANCE. ERRORS OR OMMISSIONS DO NOT RELIEVE THE Lf\ f APPLICANT FROM THE RESPONSIBILITY OF'AS BUILT' 1 �_ �,,�� COMPL/IA�NCE. � "-_" L DATE:A-•10 "1S 0 rFl B1 ILD ICIAL I • I I I .I - i _. i --L ---r- 1 GL -CL . • ezb• FILE COPY N zR . x.1 % ,.• ,� • • f x q.. • � � L CY ro I Gi`- r` .I t • y r s C-: 1 Q., '_) i • i 2 Y i r . .