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HomeMy WebLinkAboutBld-20-001072 Y Y 0 e Use Only o1.. RRa_ *4. Pi — J-o0/D_ 41',t, � o l . H Amount ,C''' ,Permit expires 180 days from v. 4wna.rco s fd l issue date -• EXPRESS BUILDING PERMIT APPLICAT .i.. C E I V E D TOWN OF YARMOUTH Yarmouth Building Department AUG 27 2019 1146 Route 28 ,JV PARTMEN�� .._R_.. South Yarmouth, MA 02664 :Y: _ ___ (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: !2 SC.„?C.. Pp a"— L,h , 1.4 1 e5 + 7Glf'/YI ou `L ASSESSOR'S INFORMATION: Map: Parcel: OWNER: d AA- Se r 1 /2 S�ADD�Sp 'reJ Z TEL. # NAMEPRESENT CONTRACTOR: e----1 05 e X P,,�,?l e "/ J C,$s c(,. L-L `z S':(.4 41.117- 2 ; / NAME MAILING AD SS TEL.# f"v }'a .!�0 R" esidential ❑Commercial Est.Cost of Construction$ $ 5'25 . (o Home Improvement Contractor Lic.# /] 7'p y 2 Construction Supervisor Lic.# C' ' ? .0 D Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor CAI have Worker's Compensation Insurance Comp.Policy# 52z -5-0:3 ? �,ZO,�Insurance CompanyName: � Worker's WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares (� Replacement windows:# Replacement doors: # Roofing: #of Squares 0 ( Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: YG/i)c.v 71 kt 01C,..1 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 license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signatur '""' -�'� Date: % .2 ?..h . Owners Signature(or attar ment) Q.€ Date: G \ Approved By: J�(.r Date: 0 - d%-) —1 r1 Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts r _ Department oflndustrialAccidents =14111 1 Congress Street, Suite 100 • _ai- Boston, MA 02114-2017 , . www.mass.gov/dig EO Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): 5,,e,FAA_ pc ) u/ 1//.^.�{'i/ Co Address: / Jr1 /.1ya»14,5 PI Ect'-. /e, a.2L?C City/State/Zip: Phone #: , O/j 3 6) 2?v? Are you an employer?Check the appropriate box: Type of project(required): l.❑Tam 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. E Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all work myself. 9. Demolition❑ ❑ y [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.❑Plum ing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13. o0f repairs These sub-contractors have employees and have workers'comp. insurance.x 6.❑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 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. Insurance Company Name: 4r t C Policy#or Self-ins.Lic.#: 0 5005' ? ?.� ,?d/!� Expiration Date: 2/,2 016 Job Site Address: J? 544 dP,pes- L n City/State/Zip: - YU,-h. c,f& 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 Signature: G/" � / �, Date: / Phone#: ,�d 9 -3 CC 21?O 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#: 508-562-2707 Stephen Duff Construction sadurrco@,9akoo.com 1.586 Hyannis Rd www.steve DuffConstruction.Com Barnstable, MA 12 SANDPIPER LN, WEST YARMOUTH Tuesday,August 20,2019 Project amount: $5,525 in total Project Outline Remove and replace entire roof on house. • Pull permit with town hall • Removal of old roof, down to bare plywood • Inspect all plywood for mold, rot,or damage(approval required for all add on/repairs needed) • Install Certainteed ice&water winter guard 3' in on all roof lines,valleys, chimneys etc. • Lay Certainteed synthetique roof runner under lay over all plywood • Inspect all flashing along gable/chimney-replace if needed • • Replace or install proper ridge vent, using Certainteed Cobra Vent. • Replace all pipe flange/boots with new • Install Landmark AR shingles(color choice TBD) COJOb k crLe41 • • New drip edge along all roof lines installed (white) • Roof is installed using hurricane nailing,per code and per manufactures specifications and products only. • Debris from entire job are removed and disposed of at local dump. • Magnet used to pick up any loose nails throughout yard and driveway. Gutters blown Ready to schedule. Materials, labor, disposal fee, permit fee are all included 5 year warranty on all labor Payment Schedule: 1/2 upon acceptance of this contract-8/20 received payment of$2,750 1/2 upon completion Stephen Duff - Homeowner u,.. of wlassacnuseus Division of Professional Licensure ��1e ��anranc«eall�a/<- �araaa/reJel I ®� Office of Consumer Affaifs&Business Regulation Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Constr4jttitSti I%tipervisor TYPE:Individual 1t Registration Expiration CS-086728 , e ' ;1 E Aires: 12/16/2019 159942 06/10/2020 'ri JOSEPH RENNIE i rr r, JOSEPH A RENNIEfif <4 WAYSIDE LANE - - t SANDWICH Mak2563 ; : JOSEPH RENNIE ��.-Cf�' 't f�ls's'.1t��V`• ,v ., 4 WAYSIDE LN. CAL- —SANDWICH,MA 02563 Undersecretary Commissioner CAL- i"' AC-OM? * CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 6/24/2019 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 CONTACT NAME: Larry Cowan Cowan Insurance Agency,Inc. PHONE ,t).978-372-1451 FAX tAlC.Not:978�214669 359 Main StreetE-MAIL SS: Iarryldcowaninsurance.com INSURER(S)AFFORDING COVERAGE NAIC# Haverhill MA 01830 INSURERA:Associated Employers Insurance Company INSURED INSURER B: Stephen Duff INSURER C: 1586 Hyannis Road INSURER D: INSURER E: Barnstable MA 02630 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 -n wvn POLICY NUMBER (MM/DD/YYYYI (MMIDD/YYYYI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ AMAGE CLAIMS-MADE OCCUR PRFM SESO(FaENTED occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PROT LOC PRODUCTS-COMP/OP AGG $ JEC OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Fa acrJdenq ANY AUTO BODILY INJURY(Per person) $ — OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY _ AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY — AUTOS ONLY (Per accident) $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ I EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY X STATUTE FR A OFFICER/ME BEANY R EXCLUDED?ECUTIVE Y1 N/A WCC5009775012018 02/10/2019 02/10/2020 E.L.EACH ACCIDENT $100,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Biuilding Dept. Carpentry contractor. CERTIFICATE HOLDER CANCELLATION Town of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE <SC> I Fax:(5011)790-6230 ka _ ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD