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HomeMy WebLinkAboutBLD-19-4097 r - Office Use Only Permit# QQ � y • Amount 3 `� l fic Permit expires 180 days from "- >rf ' issue date EXPRESS BUILDING PERMIT APPLICAT CEI 1/ E I7 TOWN OF YARMOUTH Yarmouth Building Department JAN 14 2019 1146 Route 28 South Yarmouth,MA 02664 B LIP • ° '�� . (508) 398-2231/ Ext. 1261 / — - CONSTRUCTION ADDRESS: /f7 bvj/ /(52ao4/ 4jc'* -/ r,/4.2 tnaC%/ 1404,0 00967.7 ASSESSOR'S INFORMATION: • -//� //n Map: Parcel: ��,✓It O 6 e/Ve OWNER: �Qti.t€'c �nrrtrnyef /k N4 Lad 1` /�//atM.r✓C 041 NAME PRESENT ADDRESS / TEL. #/ - 27J/l3S.i � _ CJ 6 CONTRACTOR: wt�5 ✓d•+, l/" njt S Q�,✓�? �P- l4 //r itN,J cvt!.T,Z NAME MAILING ADDRESS TEL.# I esidential 0 Commercial Est Cost of Construction$ C©i d Home Improvement Contractor Lic.# ) '5't 2 Construction Supervisor Lic.# d 4 TVf/3 Workman's Compensation Insurance: (check one) � � 0 I am the homeowner(( 0 I am the soleepp_rr prietor 8'Ihave Worker's Compensation Insurance Insurance Company Name: Fe)"wl CNA-G sole ./ C Worker's Comp.Policy# a/WJGT, / WORK TO BE PERFORMED Tent _ Duration _ (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares /3 ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like forfolike/ Pool fencing *The debris will be disposed of at: L�r�cf yj6^ 0.44- / 6 ( 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 license and for prosecution under M.G.L..L.Ch.268,Section 1. Applicant's Signature a 1L_ .. eaDate: /—/3 —fir Owners Sign ® r llrr Date: V /'� Approved : _� ��'/ / r/ /.d PP y �._�� Date: Building•.r,1F.1 s gn.) 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 Department of Industrial Accidents roel= 1 Congress Street, Suite 100 AThr Boston, M4 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information ' Please Print Legibly Name (Business/Organization/Individual): —/,(,Zfrw j 44.441 c wraas Address: /'0gexIn City/State/Zip: CdC,_,i /14 GNB Phone #: 3trj' z2Qo Jar— Are you an mployer?Check the appropriate box: Type of project(required): I. am a employer with L/ 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.] 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.D 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 MGL c. 14. Other 152,$1(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 contactors must submit a new affidavit indicating such. :Contactors that check this box must attached an additional sheet showing the name of the sub-contactors 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: Policy#or Self-ins.Lic.#: / tr/e0S-3 dC Expiration Date:r/ ''ad/ 7 Job Site Address: it A 2:441 04*! City/State/Zip:4/er fi4t1z4', iZ4 6796,3' Attach a copy of the workers' compensation policy declaration page(showing the policy number and expira ion 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. Ido hereby certify under the pains and penalties of perjury that the information provided above is true and correct Si?nature: Date: /- 7 2odp 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#: • • 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 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." 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 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 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 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 r• ' Boston, MA 02114-2017 Tel. # 617-7274900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02.23-15 www.mass.gov/dia • 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$65.00 for a carpenter and$45.00 for a carpenter's laborer,plus the cost of materials. -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) -All new 8 " drip edge and pipe flanges to be installed -Cobra ridge vent to be installed on entire ridge -Timbertex premium ridge cap to be installed -All AZEK PVC trim to be installed with Cortex screws -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: 1130 1 ao 16 omeown I i Contractor ev- . . ... . _ _ .ACORD M, ® CERTIFICATE OF LIABILITY INSURANCE - DATE(MDD""") • '05/23/2018 ' 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 INSURERS), 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 CONTACT NAMEACT DOMa Ostrowskl Mark Sylvia Insurance Agency,LLC PHONE FAX 404 Main Street - RIC.No.Ears:(508)957-2125 ovc,No1:(508)957-2781 Centerville,MA 02632 - E-MAILDSS:markOmarksylviainsurance.com • INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Farm Family Casualty Insurance INSURED INSURER B: Thomas Home Improvements LLC • PO Box 177 - INSURER C: Centerville,MA 02632INSURER D: • _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 TYPE OF INSURANCE ADDL SUBR POLICY EFF— POLICY EXP LIMITS LTRINRO_Wen POLICY NUMBER IMMIDDIYYYY) IMMIDD/YYYY) A X COMMERCIAL GENERALLiABIuTY 2001X1416 - 5/01/2018 5/01/2019 EACH OCCURRENCE $ 1,000000 CLAIMS-MADE n OCCUR PREMISES(Eexcurrence) $ 1000,,-00 MED EXP(Any one person) 9 5,000 — • . PERSONAL&ADV INJURY $ 1,000,000 GGEEML AGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ • -2,000,000 • T 1 POLICY n jE 7 0 LOC PRODUCTS-COMPIOP AGG $ 2,000,000 I OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ • _ - (Ea arc' ant) ANY AUTO BODILY INJURY(Per parson) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY 1_ AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ • AUTOS ONLY _ AUTOS ONLY (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE 9 EXCESS LIA3 CLAIMS-MADE AGGREGATE $ ' • • DED RETENTION$ • 011-1- $ A WORKERS COMPENSATION 2001 W8053 5/01/2018 5/01/2019 PER STATUTE FER AND EMPLOYERS'LIABILITY YIN ANYPROPRIETOR/PARTNER/EXECUTIVE NIA E.L.EACH ACCIDENT $ ' 1,000,000 OFFICEFUMEMB REXCLUDED? (Mandatory In NH) • E.L.DISEASE-EA EMPLOYEE $ • 1,,000,000 M yes,describe lntler E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below - DESCRIPTION OF OPERATIONS)LOCATIONS)VEHICLES(ACORD 101,Additional Remarks Schedule:may be attached If mon space Is required) Carpentry Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained In the certificate of insurance shall be deemed to have altered,waived or extended the coverage provided by the policy provisions. • CERTIFICATE HOLDER CANCELLATION • • SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TroyThomas THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED• IN ACCORDANCE WITH THE POLICY PROVISIONS. 499 Nottingham Drive - - - . 1 Centerville,MA 02632 , AUTHORIZED REPRESENTATIVE • ®1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD • 4 • • Commonwealth of Massachusetts ®� Division of Professional Licensure ' Board of Building Regulations and Standards ft Con,traction-Supervisor Specialty CSSL-099913 Expires: 04/11/2020 TROYATHOMAS ' ' 499 NOTTINGHAM DRIVE�� CENTERVILLE MA 02632 " Commissioner Ae rC'nmmonevealIA nit`llauaeA+aaell Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Corporation Registration> fxolration 185422 :;= - 06/08/2020 TROY THOMAS HOME IMPROVEMENTS,INC. TROY THOMAS /� #9, 499 NOTTINGHAM DR. tJ CENTERVILLE,MA 02632 Undersecretary