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HomeMy WebLinkAboutBld-20-000154 • ��.�,�R Office Use Only s O pU , Il,- . ►H.3 (l �/Amount cQ 41ATTA i G3% , `` 0„.*E;d }`' Permit expires 180 days from 4' 22-9 Y. ,S ore/ issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 ` • (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 3/ eddidi1/ KCi ASSESSOR'S INFORMATION: Map: Parcel: OWNER: Ole 3/ /� • r Soy 0 p-..—F Z C,33-7 3 N7 J, PRESENT ADDRESS TEL. # / /��j CONTRACTOR: i(%� /L 'z ,h'j!¢t�d i ,'4t cc .7 m ' 09. 3 9i 7 l��'5 4 " 7` 11 NAME MAILING ADDRESS / TEL.# t Residential ❑Commercial Est.Cost of Construction$ / /f0D- Home Improvement Contractor Lic.# /7?,3e3 Construction Supervisor Lic.# /06 fJ5‘ Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietorNZ have 1 have Worker's Compensation Insurance Insurance Company Name:-h ? "1 itL 4.I' et i,i ea • Worker's Comp.Policy# (.) 0-16.-- L?'-loth 8/-2i / 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: f tte t2 i",44/l t 6 p(inf ekk 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 vocation oense and for prosecution under M.G.L.Ch.268,Section 1. p Applicant's Signature: /� Date: .7/O/ Owners Signature(or a achment) `�, Date: p� Approved By: �/,7.- ., Date: O Building Official(or designee EMAIL ADDRESS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 p Boston, MA 02114-2017 5.•'� 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): , /fg'a1 1' /Z4 417 O 0 a i9- jI dfite..4/4L , Address: /Z1Z mI914457 3G ///17,41 )/� )2 / City/State/Zip: `gl 'J f t/4- ent3 1// Phone #: 7 el_WZ—cf5*7 Are you an employer?Check the appropriate box: Type of project(required): 1.11 I am a employer with employees(full and/or part-time).* 7. E 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 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 pr 12.❑Plumbing repairs or additions rietors with no employees. 5. 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. 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: *� /�'y�% A Ill-5 Policy#or Self-ins. Lic. #:-Li the....- /op -j'.)-i 13 I 1 0I Expiration Date: 2,0)- Job Site Address: !jl Gi/& ) - City/State/Zip: C 24 73 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 cer ' nder the pains and penalti s of perjury that the information provided above is true and correct. Signature: ���%C/� Date: 74I, Phone#: Or—SU— c ._ 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#: • • Commonwealth of Massachusetts !." Division of Professional Licensure Board of Building Regulations and Standards Constructiotl: lip4r sflr Specialty CSSL-106134 E Aires: 04/24/2022 PAUL R WELCH 1775 OCEAN ST BAY 4 ` � MARSHFIELD MA 02050 Commissioner CI— _ zeait Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Type: Corporation INVINCIBLE METAL CORP Registration: 177383 D/B/A REVERED METAL ROOFING Expiration: 12/01/2019 1775 OCEAN ST BAY#4 MARSHFIELD,MA 02050 Update Address and Return Card. SCA 1 O 20M-05/17 Offfi;e oY C'1`ri'su'`ifiei5rsi�`i�Gyffi �l�ut�iiUon HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Registration expiration Office of Consumer Affairs and Business Regulation 177383 12/01/2019 10 Park Plaza-Suite 5170 INVINCIBLE METAL CORP Boston,MA 02116 DB/A REVERED METAL ROOFING d-4 1775 WEAN k~'""� • /Art,/�w�� PAU OCEAN ST BAY#4 MARSHFIELD,MA 02050 Undersecretary Not valid without signature DATE(AtIAIQDIYYYYi .AC Rd CERTIFICATE OF LIABILITY INSURANCE 02108/2019 CHR CERTIFICATEATEDO IS ISSUED AFFIRMATIVELY AS T VELYOR NEGR OF ATIVELY AMENDTION ,rEXTEND OR A AND RS NO LTER HEHTS UPON THE CERTIFICATE CO COVERAGE AFFORDED BY THE POLICIES S CERTIFICATE DOES NOT TE of INSURANCE 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). CONTACT Jillian Hollis PRODUCER NAME: FAX (500 209-0444 PHONE (508)209-0400 FAX No Hollis Insurance Agency Inc t C Na Ext The Pinehills ADDRESS: jhollis®ttollisa9enpy.com 1 Village Green North STE 121 INSURERIS)AFFORDING COVERAGE NAIC e Plymouth MA 02360 INSURER A: Capital Specialty Insurance Corp I INSURED INSURERS Safety Ins Company 39454 Invincible Metal Corp,DBA Revered Metal Roofing INssURERC: AIM Mutual Ins Co.ARWC ` 1775 Ocean Streat INSURER 0: I Suite 4 INSURER E: Marshfield MA 02050 INSURER F: COVERAGES CERTIFICATE NUMBER: 2019 Master REVISION NUMBER: NSURED NAMED ABOVE FOR THE ITHIS IS To NDICATED. NOTWITHSTANDING ANY REQUIREMENT.ETERM OR CONDITION E LISTED OF BEEN CONTRACT OR ISSUED TO OTHER DOCUMENT WITH RESPECT TOLICY WHICHTIOD HIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDmONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BYt PAID CLAIMS. t �cP uMITs ILYR ADDLIS ARI POLICY NUMBER (MM/DD/YYYY) (MMND/YYYY) 5 1,ODO,000 TYPE OF INSURANCE INSO IIYf/D EpC}{OCCURRENCE COMMERCIAL GENERAL UA6IUTY DAMAGE TO RENTER S 100,D00 X ('� PREMISES Ea occrrtencel 5,000 D'I CLAIMS-MADE I�I OCCUR MED EXP( one Person) S CS18000517-02 02/01/2019 02/01/2020 pERgO �ADVINtuRY I5 1,DDo,Ooo A 5 2.000,000 GEMERNAL&ADEGATE 2OOD,o00 GEN'POLICY GAicjttcy LIMIT APPLIES PER: PRODUCTS-COAiPtOPAGG 5 _ PRO- POLICY — cr LOG Combined 8I&PD s 1,000 OTHBL I COMBIINNED SINGLE LIMIT I s 1,000,000 FIeAL_AUTOMOBILE LIABILITY BODILY INJURY(Per person) S ANY AUTO 08027f2018 08f27/2019 BODILY INJURY(Per accident) 5 B OWNEO x SCHEDULED 6230281 PROPERTY DAMAGE 5 AUTOS ONLY AUTOS P LLeck nt HIRED NON-OwNEO X AUTOS ONLY X AUTOS ONLY Un accIdeured motorist BI 15 100,000 EACH OCCURRERCE I S UMBRELLA UAB _^ OCCUR S AGGREGATE EXCESS UAB CLAIMS.MADE S DED I I RETENTION S x(STATUTE I lOTH- i WORKERS COMPENSATION 1 5 100,000 AND EMPLOYERS'LIABILITY Y/N ACH ACCIDENT ANY CE /ME PROPRIETOR/PARTNER/EXECUTIVE NI E.I.VWC-100-8021131-2018A 02/28f2019 02/28/2020 500,000 C (Mandatory in NH) EXCLUDED? E.L DISEASE-EA EMPLOYEE S 100,000 If yes,describe cry in NHI E.L DISEASE-POLICY UMftT 5 If yes, N under DESCRIPTION OF OPERATIONS belo+r DESCRIPTOR OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101.Additional Remarks Schedule.may be attached II more apace Is'squired) 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. Town of Scituate 600 Chief Justice Cushing Hwy AUTHORIZED REPRESENTATIVEi) Scituate MA 02066 O EPIC l 419"(9-\ I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2015/03) The ACORD name and logo are registered marks of ACORD HOME IMPROVEMENT SALES AGREEMENT HOME IMPROVEMENT CONTRACTOR 1775 Ocean Street . =-0.--11 REG#MA.177383 Bay #4 REVERED FEDERAL ID#46-4167378 M ETAL Marshfield, MA 02050 ROOFING 1-781-536-4589 www.reveredroofing.com "Lifetime Roofing Solution" reveredmetalroofing@gmail.com .iliji THIS CONTRACT made the lee% V�'W day of " `p 20/?' between 41•4 74— y (Homeowner) , 5 r 9 t -137fe ,or- 9` 6;3,53 G 4-/i , J le I� p (Home Phone) �f (Cell Phone) ai of 'o J )/4� A'd- �04'. 0�-�G/J - �Address) ynez-theve (City) (State) (Zip) hereinafter the"HOMEOWNER"or"BUYER"and INVINCIBLE METAL CORP.(DBA REVERED METAL ROOFING)hereinafter the"CONTRACTOR",with all of the foregoing parties being collectively referred to herein as the"PARTIES".WITNESSETH:Contractor hereby agrees that it will,fort consideration hereinafter mentioned,furnish all labor and material necessary to install the following described work at premises located at Et Its/��-' ,the"WORK".The word "I","me",and"my"refer to each person who signs as Homeowner.If more than one person signs below as Homeowner,each person shall be jointly and severely liable for the promises made in this Agreement.The words"you"and"your"refer to the Seller or holder of this agreement. AGREEMENT:I agree that it is my decision to purchas he goods and/or services described below at the Total Cash Price of$11.7/Few.I promise and agree as follows: 28 OR 0 29 GAUGE,THREE FOOT WIDE METAL ROOFING SPECIFICATIONS OF CONTRACT NOTE:No surfaces will be covered unless specified. 1. Roofing Color: - C/�(/L OTHER WORK-DESCRIBE: ! Total 2. ❑Yes 0 No Ridge Cap /T/„ 44 s .eh, Sr Cash 3. k'Yes 0 No Drip Edge h (.s.' #i f'c JVeG4� .�c/�, Price /2/ 9°1) 4. ❑Yes 1AYNo Add Ridge Venting / -•! enieheth� �g ofi5. flil es 0 No 2"Exposed HurricarT€Har.war- I �� "� "f,,. ,v evi`�" Deposit With // , 19 6. es 0 No Clean up all job related debris and haul away s J' Order 7. Yes 0 No Chimney-Number of: �d d C/a / 8. /les 0 No� Stack Vent Boots-Number of: ��/S Additional 9. ❑Yes N'No Skylights-Number of: Deposit (113co � EXCLUDE: Due Date: 10.El Yes 12 Valley /� 11. YeNo s 0 No Rake Trim Endwall Q./O Sidewall❑ YG 12.❑Yes r No Transition Trim 65 ❑ ❑ / Balance 3 CO 13. Yes 0 No Ridge Closures /t U ed/ej• • JOB SIGN 60 90 120 Due On OK Completion / Days Days Days 14.0 Yes 54 Remove&Dispose Gutters Proposed Start and Completion Schedule: /1 //�� ,(�� 4-Yp U/ date when Contractor will begin contracted work. 7- .lam//6 Z date when contracted work will be substantially completed INVINCIBLE METAL CORP. (DBA REVERED METAL ROOFING)does not do any painting or staining and is not responsible for conditions or circumstances beyond its control including condensation resulting from or due to pre-existing conditions INVINCIBLE METAL CORP.(DBA REVERED METAL ROOFING)is not responsible for stripping any roof material prior to installation.Note:Fascia trim or strapping is not included unless specified DO NOT SIGN THIS CONTRACT IF THERE ARE Alf BLANK SPACES!!! 0 Cash 0 REVERED METAL ROOFING Assisted Financing ebit/or Credit Card 0 Check PROMISE TO PAY: I promise to pay INVINCIBLE METAL CORP. (DBA REVERED METAL ROOFING) the Total Cash Price prior to or on the date of substantial completion as agreed to herein. If payment is made by credit card,I understand that I may only cancel,reverse,or dispute the credit transactions within 3 days,and thereafter all credit card transactions are valid and enforceable. BINDING NATURE:I understand that this document does not constitute a valid an finding contract for any purpose until and unless it is signed and accepted by IMC. IN WITNESS HEREOF,the parties hereto have signed their names this / day of,3) 20 1 Signed• MARKETING REPRESENTATI 1 /� /�i,� HOME ACCEPTED: ��/'IGt��� �'�i�1 : Signed: OFFICER OF REVERED METAL ROOFING HOMEOWNER Notice:The terms of this agreement are contained on both sides of this page . INVINCIBLE METAL CORP.Copyright©2018