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Home My WebLink AboutBLD-19-3183 • is Use Only q, ! '' 1.‘t,%- t bre#D-5 -0 � fl OH Amount 90 3 Permit expires 180 days from 1. issue date EXPRESS BUILDING PERMIT APPLICATI 0 : E C E I V E 13 TOWN OF,YARMOUTH � I Yarmouth Building Department 1146 Route 28 NOV 20 2018 South Yarmouth, MA 02664 :�,.,nE{,•D < `TMkn n / c I ((55008) 398-2231 Ext. 1261 • 8y. _ _ v CONSTRUCTION ADDRESS: C53 Rk (.€ I . W. Y ott y[�� ASSESSOR'S INFORMATION: • Map: Parcel: OWNER: ftalfi,SH I^L altedt • N pppp(��,��'� // �, ',n PRESENT ADDRESS Q� TEL. # CONTRACTOR: 5 t(T1W I+I J�t/✓EitI sor.760 NAME / MAILING ADDRESS TEL# ❑Residential Q Commercial . Est Cost of Construction$ 4 ow.0 Home Improvement Contractor Lie.# 1101g 1 Construction Supervisor Lic.# I OZ60tO Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietorfetElti have Worker's Compensation Insurance RUC ,ply / Insurance Company Name: 'N/ �'1t% Worker's Comp.Policy# IZiwc O� b e WORK TO BE PERFORMED Tent _ Duration n (Fire Retardant Certificate attached?) . Wood Stove Siding: #of Squares !/• Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. (�)OReplacing like for like Pool fencing "Th `� �'r'(.e debris will be disposed of at /" 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 or1 n of my license and for prosecution under M.G.L.Ch.268,Section 1. / / Applicant's Signature: ors'—i i(.(�i(� Date: tt Gf ` Owners Signa Date: /�� Approved By: itim/ G Date: /7 Ov eze Du' g al(or designee) 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 Department oflr:dustrialAccidenis 1 Congress Street,Suite 100 : =3 �=� 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 n Please Print Legibly Name (Business/Organization/Individual): (2SOCC Address: 68' k)ajicau aj-2t_ City/State/Zip: '1t/, Y/112✓tou41/ ,AAA— Phone#: CDR'260- 27 Ylj' Are you an employer?Check the appropriate box: Type of project(required): II am a employer with 3 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 t 9. Demolition❑ ❑ ys [No workers'comp.insurance required] 10 ❑ Building 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.❑ 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.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other 152,i 1(4),and we have no employees.[No workers'comp.insurance required.] 'Arty applicant that checks box 41 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. tComractors 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: Arti fiIG}l1n Pri Policy#or Self-ins.Lic.#: 22tA - S3158C Expiration Date: 12 20/w Job Site Address: CC3 Rf-t 22 City/State/Zip: W, drgi3'Ipil,ry 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 U s.:..: he ains andpenalties of perjury that the information provided above is true and correct Signature: Date: 1I fr0/(f Phone#: Wil'' ?60. 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#: Pik/ ,n n,n„umn t%o ff' ® iviassacnuseus uepanment or rming Jatety ` ��nessRegulat ,� Board of BuildingRegulations and Standards Office of Consumer Affairs Business Regulation 9 HOME IMPROVEMENT CONTRACTOR - License: CS-102600 TYPE:LW • Construction Supervisor Registration. Expiration 170787 - 12/18/2019 t e • ROOFING AND SIDING OF CAPE COD,LLC. DZMITRY LABKOVICH 68 WINSLOW GRAY RD.1/:c .,, WEST YARMOUTH MA 02673, DZ1vMITRY LP.BKOVICH : /'..CCQv air r 68 WINSLOW GRAY RD C� __ • W.YARMOUTH,MA 02673'- Undersecretary /J �A , i Jd-rc(-acs' MPLa-•-- Expiration: Commissioner 03/27/2019 f Roofing and Siding of Cape Cod,LLC ,. � i LBBB 68 Winslow Gray Rd West Yarmouth, MA 02673 508-360-2749 e-mail: rsocc@yahoo.corrl roo fingand sidi ngofcapecod.cam HIC REG #170787; LIC # 102600 Job Address: Name: Punish Patel Town: Hunters Green Motel Job Phone: 508-775-5400 Address: 553 Rte 28 Other Phone: City: West Yarmouth E-mail: info@huntersgreenmotel.com State: MA Estimator: Dmitry Labkovich ZIP: 02673 08/23/18 We hereby submit specifications and estimates to furnish and install new trim on following areas: Soffit Trim including soffit strip vent Specifications as follows; 1. Strip existing trim and dispose of all debris. 2. Install new trim. 3. Use "Coretex"screws and plugs system if using PVC,stainless steel nails if using Primed Pine. Labor and Materials: $3,000.00(PVC,Small Building one side) Ifacceptable, initial here: p-p' • Labor and Materials: $5,300.00+900(additional)=6,200.00(PVC,Large Building one side) If acceptable, initial here: re Job is estimated to commence approximately 4_ weeks afterdeposit received unless otherwise noted here: Work is scheduled to be substantially completed in approximately: days If acceptable, (both) initial here: Start and completion times are approximate and subject to change due to, but not limite 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 ROOFING AND.SIDING OF CAPE COD, LLC will provide cleanup on a continuing basis and 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 non-stocked 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 remgycd. 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 Any 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 contractors will be excluded from access to the guaranty fund. 4 This Contract not valid unless signed by Corporate Officer: ��> * / 4rcejilmee 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: ,�g( 1/3 Deposit �i CY�YJ Dorn', ,' &i to f o�-1 )t e `a �l 1/3 Beginning bf work fff 1/3 upon completion Date: J Q Signatures: i A A Note: No work shall begin prior tothe 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. ACCORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYTYY•) 01/02/2018 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(les) 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: Anne Sanzo HUB INTERNATIONAL NEW ENGLAND LLC PHONE ypd)u508)945-7863FAX INC_LNO). E-MAIL anne.sano( hubintemationalcom 265 ORLEANS RD INSURERtSLFFORDINOCOVERAGE NAICI _._ NORTH CHATHAM MA 02650 INSURER A: AMGUARD INSURANCE CO 423900 INSURED INSURER B: ROOFING & SIDING OF CAPE COD LLC INSURER C: INSURER D: 68 WINSLOW GRAY ROAD INSURER E: WEST YARMOUTH MA 02673 INSURER F: COVERAGES CERTIFICATE NUMBER: 226618 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 ADOL SUM POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD v ,o POLICY NUMBER IMMIDDIYYVY) (MMIDD/YYYYI LIMITS COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE s CLAIMS-MADE OCCUR IAMAGET614EN TED PREMISESIEIPcuxnn e) $ MED EXP(Any one person) f N/A PERSONAL 8 ADV INJURY f GENL AGGREGATE LIMIT APPLIES PER: - GENERAL AGGREGATE _ $ POLICY 1 PEP n LOC PRODUCTS_COMPIDP AGG S OTHER: f AUTOMOBILE LIABILITY _LE4COMBINEDeccidenD SINGLE LIMIT f ANY AUTO BODILY INJURY(Per peon) f ALL OWNED SCHEDULED N/A NON-OWNEDBODILY INJURY(Per ecodenn AUTOSf AUTOS PROPERTY DAMAGE f HIRED AUTOS _AUTOS jeer'cadent) f UMBRELLA UM _ OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE N/A AGGREGATE S DED RETENTIONS I' f WORKERS COMPENSATION X PER PERTUTJ I ER µ AND EMPLOYERS'UABILITY ANYPROPRIETORNRi ARTNERXECLITIVE YIN E.L.EACH ACCIDENT f 100,000 A OFFICEHIMEMBEREXCLUDEDT ® N/A N/A R2VuC855686 12/20/2017 12/20/2018 (Mandatory N NH) E.L.DISEASE•EA EMPLOYEES 100,000 Ir yea,RIPTIO N under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 500600 N/A DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional RemarIaSchedule,may be attached N more apace Is names) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 08 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.masa.govllwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Roofing & Siding of Cape Cod LLC 68 Winslow Gray Road AUTHORIZED REPRESENTATIVE West Yarmouth MA 02673 r"'0 Daniel 4y' Daniel M.Cr y,CPCU,Vice President—Residual Market—WCRIBMA OD 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD