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HomeMy WebLinkAboutBLD-19-4003 r �, Office Use Only r , 4,. ARS . 19c yep Id... Amount , :H `+';' - - .- - Permit expires 180 days from i - - issue date etRE CE VEDI EXPRESS BUILDING PERMIT APPLIC TON—__.___-".___".i 1 • TOWN OF YARMOUTH JAN 013 ?019 Yarmouth Building Department b 1146 Route 28 �30 . ,..a.l+Tri, �;U( South Yarmouth, MA 02664 —"' 2 J/ (508) 398-2231 Ext. 1261 / / � CONSTRUCTION ADDRESS: *J hcvis- /on" GLes/ ylekti ?Ov//- 10,4 c 67S ASSESSOR'S INFORMATION: • MLap: y )/ "Parcel: Xc • OWNER: �JJA. t 4411 4111/4414,14xf Ltw1S /feel p NAME -- . PRESENT ADDRE§S /J // TEL. # O CONTRACTOR:1#701A5 yCnat ,teximea4 ,4'AWl COr,{Gvv �/ �p �k -��� gas sea, I MAILING ADDRESS / TEL.# -- - esidential 0 Commercial Est Cost of Construction$ �'7� Home Improvement Contractor Lic.# Afrva Construction Supervisor Lic.# uii/g Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor ritve Worker's Compensation Insurance ,y Insurance Company Name: (nn/` 4't/c, I. Worker's Comp.Policy# of eAQ'sy / WO)k TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares if ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic fist. p( )Replacing like for like Pool fencing *The debris will be disposed of at t. ,/ y'� "1C' "��' GGG 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 revocation of my icense and for prosecution under MG.L.Ch.268,Section 1. � D Applicant's Signature: %�t07 Date: /—{�—�/R Owners Signature(or attachment) Date: Approved By: - i Date: ' , d — 1C1 Building Official( 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 I = Department of Industrial Accidents el- 1 Congress Street, Suite 100 • _S�_ Boston,MA 02114-2017 .49 .,_,. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMTITING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): ,M45 -c �roven-e4 Address: PD. tgn � City/State/Zip: r44/4 A44 ONO Phone#: 58 ?29 /61j✓ Areou an employer?Check the Yappropriate box: Type of project(required): 1. m a employer with ‹..." employees(full and/or part-time).* 7. ❑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 ❑ y [No workers'comp.insurance required.]r 10 ❑ Budding addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all 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 _ 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13. 00f repairs These sub-contractors have employees and have workers'comp.insurance.t 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other 152,§1(4),and we have no employees. [No workers'comp.insurance required.] *Arty 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 cont-actors must submit a new affidavit indicating such. tont-actors 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 subcontractors 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: 1ietivi 44 (t ; IZ C Policy#or Self-ins.Lic.#: jam/h/tac / Expiration Date: Job Site Address: �f' %AP( 6- City/State/Zip:ittei, 044 aX/f Attach a copy of the workers' compensation policy declaration page(showing the policy number and'expiration gate). 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 Signature: r, Date: l— r-ae Phone#: 'Q' ( ps ° ,q07 --- 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#: Inf• ormation and Instructions Malsachusetts 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." MOL 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 legbly. 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 Congress Street, Suite 100 • 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 -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: x210-;/j,' Homeowner Contractor /' ��'��7 i,r, THOMAS HOME IMPROVEMENTS LLC. PROPOSES TO PERFORM THE FOLLOWING WORK: Location of proposed work: Mr. & Mrs. Demetriades 75 Lewis Road West Yarmouth, MA 02673 Date on which construction should begin: Summer 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 lb 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: $5,380.00 30 yr.GAF/Elk Timberline HD Architectural shingle(Life Time Limited Warranty) Above proposal is per dwelling includes 2-layer strip Proposal to install Waterfall gutter guards per dwelling would be an additional $490.00 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$55.00 for a carpenter and $35.00 for a carpenter's laborer, plus the cost of materials.