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HomeMy WebLinkAboutBLD-19-003929 • O�-Y4 Ofce Use Only A ' it! A+'' Permit# t asitg C • _ O ...We • H Amount -w •71 Permit expires 180 days from issue date... EXPRESS BUILDING PERMIT APPLICAT l C E �f "� TOWN OF YARMOUTH Yarmouth Building Department JAN 03 1019 "i 1146 Route 28 J . ° South Yarmouth,MA 02664 Nr"C (508) 398.2231 Ext. 1261 _-`� ___ CONSTRUCTION ADDRESS: �// lceil R oaf S Afm a ASSESSORS INFORMATION: f Map: Parcel: OWNER f AIQ �bkAJ We i(/ et 4q /0/7 4J S y / o�2 N f PRESENTTAADDRI•S/S , . r. r TEL. # S'Oa 3?V•-_79r0 CONTRACTOR: NAME rv\ ( —rL/ L tabl ChD Q Wht./S/ =y1 fed 1V. Li be fm 0 11 T 1-\ RESS if • esidential 0 Commercial Est.Cost of Construction s i Home Improvement Contractor Lia# /"7 0 7 O / "Construction Supervisor Lia it / Workman's Compensation Insurance: (check one) LIIamthe homeowner 13Iemthe sole proprietor l0Ihave Worker's CompensationInsurance W (�" / b Insurence Company Name: "M G U AR d Worket's amp.Policy# Y`a C a /�" WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: # f Squares'" a S Replacement windows:# Replacement doors: # Roofing: it of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Histori „c 'Diisst. !(()Replacing like for like Pool fencing *Die• e debris wilt be disposed of at; --.1)(f �y E `�Location ULocation of Facility1. .;. -,� I declare under penalties of perjury ' ernents herein contained are true and correct to the best of my knowledge and belief..I ynderstan)that any false answers) win be just rause for denial or >tc1,72s4:ad for prosecudon under M.O.L.ch.268,Section 1 'v t ' Applicant's Signature: / - Date: / -b p"r Owners Signature(o hment) c-ta- . n7ac-% Date: / a /i t /q1 ApprovedSys 4ra.rc.h Date: / 3 // I ding Official Cot designee) _ ; ..EMAIL ADDRESS: r Zoning Dlptrict: Historical District: 0 Yes tf/ No Flood Plain Zone: f1 Yes U No Water Resource Protection District; _ .. : Within 100 ft.of Wetlands: 0_.Yes 0 No 0 0. Yes O. -No The Commonwealth of Massachusetts I ---7_ vire:e/ Department ofIndustrial Accidents t =pial= "& 1 Congress Street,Suite 100 1,4 =�_i= Boston,MA 02114-2017 '`*�s,' www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lezibly ' Name (Busineess(Orrganixation/Individual): y(> 6- C-4n Sc/ dr0s are-co vi L Lc._ Address: 6 2 ( )Ns/n.1 571a-- iZcl Ci /State/Zip:w tiltov A s, A o4. 6 Phone#: CboF 3 C o — n.7 V , Ar you as employer? he the appropriate box: Type of project(required): I. I em 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 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall work t 9. ❑Demolition ❑ myself[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 I0 0 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.❑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 MOL c. 14.❑Other 152,¢1(4).and we have no employees.[No workers'camp.insurance required.] *Any applicant that checks box$I 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/ob site information. ' Insurance Company Name: f ' ' Cu iR/e_e / • Policy#or Self-ins.Lic.#: /2 c) W C Y J"6 / Expiration Date: Job Site Address: Ai/ /(C/%jz j SI. Lj,V1nau City/State/Zip: MA 6 a 6 C Attach a copy of the workers' compensatio olicy declaratio 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 Ad pefialties of perjury that the information provided above is ue and correct. 'lanai-are: a(Vnabio Pate: • / -7•` /O�i phone#: CO C o— ) 7 )c S 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#: A`� MI d: CERTIFICATE OF LIABILITY INSURANCE DATEIMOD/YYYY) 12/12/2018 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 NAME: Cheryl WOOdSIde HUB INTERNATIONAL NEW ENGLAND LLC INC.No.Fni (978)661-6678 iFAC,No): E-mAIL ' ADDRESS: Cheryl.woodsiderghubintemational.Com 600 LONGWATER DRIVE INSURER'S)AFFORDING COVERAGE NAIL/ NORWELL MA 02061 INSURER A: AMGUARD INSURANCE CO 42390 INSURED _ INSURER B: ROOFING &SIDING OF CAPE COD LLC INSURER C: INSURER 0: 68 WINSLOW GRAY ROAD - INSURER E: WEST YARMOUTH MA 02673 INSURER F: COVERAGES CERTIFICATE NUMBER: 347414 • 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. NOTWTHSTANDING 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 TYPE OF INSURANCE ADDLSUBR POUCYEFF POLICY EXP LTRINSD WVn POLICY NUMBER IMMIDONYYY) IMMIDD/YYYY) LIMITS COMMERCIAL GENERAL UABILITY EACH OCCURRENCE S • CLAIMS-MADEOCCUR DAMAGE TO RENTED PREMISES Me occurrence) S — MED EXP(Any one person) f — — N/A PERSONAL&ADV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE IS POLICY H JECT PRO- '�I • LOC PRODUCTS.COMP/OP AGG S — OTHER: S AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT s (Ea accident) — ANY AUTO BODILY INJURY(Per penton) S ALL OWNED SCHEDULED — _ AUTOS _ AUTOS N/A • BODILY INJURY accident) i HIRED AUTOS NON-OWNED PROPERTY DAMAGE - — AUTOS (Per accident) S _ S UMBRELLA UAB OCCUR EACH OCCURRENCE S — EXCESS LIAB CLAIMS-MADE N/A AGGREGATE S DED RETENTIONS S WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN - X STATER ERH ANYPROPRIETORPARTNER/EXECLfiVENIAEL EACH ACCIDENT S 100,000 A OFFICER/MEMBEREXCLUDEDT WA WA R2WC905035 12/20/2018 12/20/2019 (Mandatary In NH) E.L.DISEASE-EA EMPLOYEES 100,000 d SCRIP ION under E.L.DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATORS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be itmched If man spice Is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees In states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the Issue date of this certificate of Insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.govAwdMorkers-compensationfinvestigations/. CERTIFICATE HOLDER • CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN RJC Building & Maintenance LLC ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1532 AUT IORIZZED REPRESENTATIVE ` South Dennis MA 02660 3--0(`` I Daniel M.Croy,CPCU,Vice President–Residual Market–WCRIBMA ©1988-2014 ACORD CORPORATION:All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Massachusetts Department of Public Safety Board of Building Regulations and Standards License CS-102600 y DZMITRY LABKOVICH ^ ' 68 WINSLOW GRAYRD WEST YARMOUTH MA 02673 "circ?-f- %.ta Expiration: Commissioner 03/27/2019 •74r lir u,rr".i,mn.it/e./ ie./et,.A. Office of Consumer Affairs 3 Business Regulation Registration valid for Individual use only TYPE:PENTCONTRACTOR HOME IMPROVEMENT before the expiration date. If found return to: LW Office of Consumer Affairs and Business Regulation 1Registration x r i 10 Park Plaza-Suite 5170 170787 12!18!2019 Boston,MA 02118 ROOFING AND SIDING OF CAPE COD,LW. 7 DZMITRY LABKOVICH \+�-CC /, (/{AUL f 68 WINSLOW GRAY RD =s Not valid withoUt signature W.YARMOUTH,MA 02673 Undersecretary •A • / 7 1/44,754 II L CA A I ba Roofing and Siding y BBB of Cape Cod,LLC • tree 68 Winslow Gray Rd West Yarmouth, MA 02673 508-3602749.e-mail: rsocc@yahoo.com HIC REG #170787; LIC# 102600 Name: MARIA WINNELL Job Address: Address: 41 KELLEY RD Town: City: S.YARMOUTH Job Phone:508-394-3950 ZIP: Estimator: SCOTT DICKSON 12/14/18 We hereby submit specifications and estimates to furnish and install new GRADE A White Cedar Shingles on the following areas: left side and back Specifications as follows: 1. Remove existing siding and dispose of debris; 2. Inspect sheathing for rot or other deterioration and advise homeowner of any additional work; 3. Inspect existing waterways at window, door and corner boards and notify homeowner of any additional work; 4. Install Typar breathable house wrap. 5. Install new window and door drip cap flashing; 6. Install double first course of siding. Install new siding using 0.Fl}l1 VAL1114LM .1 UAFlUJLL1Lr 111 LL111t51 o 4114 UV11V111J V1 VY HMV VY u LIMA UJVt VF 53 Lw/WV WV Mu (Tay not be possible at all). • 7. Siding to be secured using rust-resistant fasteners '/2 inch to 1 inch above next course line; 8. Shingle joints to be at least''/,"away from fasteners and 1"away from previous course joints (to minimize exposed fasteners when siding shingles). 9. Clean yard of all debris and utilize magnet to minimize exposure to property or personal damage from nails left behind; 10. Remove and re-install electrical fixtures; 11. Last course to be hand nailed using#5 box stainless steel nails; 12. WHITE CEDAR LABOR AND MATERIALS: $9350.00 FOR ADDITIONAL COST OF $570.00 we will replace and repair rotted rake and corner board for a total of 53 ft If acceptable, initial here:pCMIA..) Job is estimated to commence approximately weeks after deposit received unless otherwise noted here: Work is scheduled t, be substantially completed in approximately: .� days If acceptable, (both) initial here: NON\W Start and completion times are approximate and subject to change due to, but not limited to, the following circumstances: weather delays, additional work on previous jobs, permitting delays, etc. This is the entire agreement. Any discussions or verbal agreements are superseded by this agreement. Such agreements,even those of the smallest nature,must be in writing to be recognized. Any work above and beyond the specifications outlined in this proposal will be priced on request. All additional work, including travel time and lumberyard runs, will be subject to extra charge. In the event of rot repairs, roof repairs or any related work requiring immediate attention, we will proceed without customer approval. We look forward to working with you;please call if you have any questions. Sincerely, ROOFING AND SIDING OF CAPE COD, LLC !WW111\V AA\L 01L11\V V1 VAl Li '.V1J, LLIi VT 111 }1l V VLUs V1YW14p VI/ 4 VVLL41lLLl11 V4A1J 4lLLL all debris will be removed from site.All products installed by ROOFING AND SIDING OF CAPE COD, 'LLC will be to manufacturer specifications. All work will be performed by insured professionals. All material is guaranteed to be as specified and the above work to be performed in accordance with the drawings and/or specifications submitted for above work and completed in a substantial workmanlike manner. There will be no refund for special-order windows, doors or any other nonstocked materials after three days from approved proposal. All warranties will be null and void if account is not current and paid in full. Owner to move all personal objects,furniture, etc.,from work areas. All items against walls should be considered for removal during any exterior siding jobs,additions,etc.to guard against damage. In the case of any roofing and ridge venting, dust and debris should be expected and any items in the attic should be removed. ROOFING AND SIDING OF CAPE COD, LLC is not responsible for any damages if said items remain in place. Curtains, drapes and window and door treatments may need proper reinstallation or replacement by customer due to sizing on any window or door replacements and is not included in jobs contracted with ROOFING AND SIDING OF CAPE COD, LLC My alteration or deviation from above specifications involving extra costs will be executed only upon written orders and will become an extra charge over and above the estimate.All agreements contingent upon strikes,accidents or delays beyond our control. Owner to carry fire,tornado and other necessary insurance upon above work. Workmen's Compensation and Public Liability Insurance on above work to be taken out by ROOFING AND SIDING OF CAPE COD,LLC. Owners who secure their own construction-related permits or deal with unregistered contra ors will be excluded from access to the guaranty fund. / This Contract not valid unless signed by Corporate Officer: - A . Acceptance of Estimate The above prices, specifications and conditions are satisfactory and are hereby accepted. ROOFING AND SIDING OF CAPE COD, LLC is authorized to do the work as specified. Payment will be made as such:/ 1/3 Deposit_$3305.00 ✓ ?PIS 3266. et lapin 1/3 Beginning of work_$3305.00 1/3 upon completion$3310.00 t I I , Signatures:kk St . ♦. ._ • Note: No work shall begin prior to the signing of the contract and transmittal to the owner of a copy of such contract. You, the buyer may cancel this transaction at any time prior to midnight of the third business day after the day of this transaction.