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Home My WebLink AboutBld-20-001515 ,Of.y�R Office Use Only S • Permit# O Ou . H �Amount G MATTACM CSC Tomoo ro End 'Permit expires 180 days from BLv�(5 ( issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department -- 1146 Route 28 ` South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 By 14-�c� ENT CONSTRUCTION ADDRESS: Z - S 57/r Tit M/ Afr aw.s._7_ ASSESSOR'S INFORMATION: Map: Parcel: OWNER: 7A 9iUOvt if N"OvJ'f A'& /EvtftP127 T)1//s 3 4 iv.r 'SL o is/ G PE y (to/4'10 NAME PRESENT ADDRESS TEL. # CONTRACTOR: 'F!Z G ceh r1zAC r01L Loge. 4.2 oLr(-eR ST 61 q -Gar? -Z 2 3 0 NAME MAILING ADDRESS TEL.# 4Residential )ommercial Est.Cost of Construction$ 40, 8O 0. 0O Home Improvement Contractor,Lic.# ( (9S4 6 Construction Supervisor Lic.# I7 3 SC'S Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor lit I have Worker's Compensation Insurance Insurance Company Name: A*A ZO "•A .✓.S (eh-$'C/f. Worker's Comp.Policy# 40 Q 60 242 3 9 2 o t9 A WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares �" Replacement windows:# Replacement doors: # Roofing: #of Squares '7 4f ( )()Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: g S (0CL5'tD h/ S r — d5.1-L(Z.ET'r ./41A . 02.15'$ 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 revocatio of lic se and for prosecution under M.G.L.Ch.268,Section I. Applicant's Signature: Date: O,/f�"/13 Owners Sign re(or attac ent Date: Approved By: �,.. Date: { ' )) "15 Bui mg Official(or designee) 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 Department of Industrial Accidents __L►AI- 1 Congress Street, Suite 100 til _ f_ Boston, MA 02114-2017 -,,„.,•`'' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/Individual): F2 6 C ..'- rg 1WG1dqt. cic,(L r Address: 42 Pe.►•veg. ST' City/State/Zip: EGexe-Y't _MA-.02 I ef 9 Phone #: 6(g-aq2- ZL3� Are you an employer?Check the appropriate box: Type of project(required): l.'I am a employer with 0 Z. 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 doing all work myself. 9. [1] 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.❑Plumbing repairs or additions 5.❑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.1 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. 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: fr-41 it 2 OAi ik t �/ovGc Policy#or Self-ins. Lic.#: 70O a4 Z r 2 3 9 Zo 79 A Expiration Date: O?•/2 1-/ Z . Job Site Address: 2ZS 51—ATY "- Ave City/State/Zip: >',A olsiOva"14 N1A. o2661. 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 'its a d penalties of perjury that the information provided above is true and correct Signature: .- sr. Date: 421/0 °J.JI 4 /t Phone#: 6(7 -G'Z - L Z3" 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#: /ArclILLt I. WORKER DOCUMENTATION CERTIFICATION: In accordance with Executive Order 481 the undersigned further certifies under the penalties of perjury that the Contractor shall not knowingly use undocumented workers in connection with the performance of this contract;that pursuant to federal requirements,the Contractor shall verify the immigration status of all workers assigned to such contract without engaging in unlawful discrimination;and that the it shall not knowingly or recklessly alter,falsify, or accept altered or falsified documents from any such worker(s). The Contractor understands and agrees that breach of any of these terms during the contract period may be regarded as a material breach,subjecting the Contractor to sanctions, including but not limited to monetary penalties,withholding of payments, contract suspension or termination. ARTICLE 8. CONFLICT OF INTEREST: The Contractor covenants, that (1) presently, there is no financial interest and shall not acquire any such interest, direct or indirect, which would conflict in any manner or degree with the performance of services required to be performed under this Agreement or which would violate M.G.L. c.268A, as amended; (2) in the performance of this Contract, no person having any such interest shall be employed by the Contractor or engaged as a subcontractor by the contractor; and (3) no partner or employee of the firm is related by blood or marriage to any Board Member or employee of the Awarding Authority." IN WITNESS WHEREOF, THE PARTIES HERETO HAVE CAUSED THIS INSTRUMENT TO BE EXECUTED UNDER SEAL. 1 CONTRACTOR 2AWARDING AUTHORITY FRG Contractor Corporation Yarmouth Housing Authority Name of Contractor Name of Housing Authority 40 Oliver Street Street 534 Winslow Gray Road Address Everett,MA 02149 South Yarmouth,MA 02664 C State Zip Si ture and Seal By.• tty Signature �-- and Seal Witness Title Attest: 1 if a Corporate n, ch not y of the Corporate Vote 2 If signed by someone other than a Housing Authority Board member,attach a authorizing si story sig tract. copy of Certified Board Vote authorizing the signatory to sign Contract. DHCD 11/7/16;RCAT RCAT 06/21/17 c.149$10k-$50 OWNER-CONTRACTOR AGREEMENT 2 of 2 00.52.10 Notice to Proceed YARMOUTH HOUSING AUTHORITY 534 Winslow Grey Road Yarmouth,Massachusetts 02664 Telephone(508)-398-2920 September 17,2019 FRG Contracting 40 Oliver Street Everett, MA 02149 Re: Yarmouth Roof Replacement(689-01)-Yarmouth H.A.Project-#351074 NOTICE TO PROCEED Sir: Pursuant to the terms of your Contract dated September 9th,2019 for Yarmouth Roof Replacement(689-01)- Yarmouth H.A.Project-# 5107 this Authority,you are hereby notified to commence work at the start of the business day on / D 7 / 9 . The time for the completion set forth in the Contract is Fort'-Fivq(4 con cutive calendar days,including the starting date which establishes // / / c / I as the Contract Completion Date. You are informed that Wendy Ohlson has been appointed Contract Officer and is duly authorized to administer your Contract for and in the name of this Authority. . You are instructed to submit,without delay,your Construction Progress Schedule and a breakdown of your Construction Price on a copy of the Application for Payment continuation sheet. A copy of the continuation sheet can be found at Appendix C-24 of the CONSTRUCTION HANDBOOK.You will receive under separate cover one(1)executed set of Contract Documents, Specifications,and Drawings. Please acknowledge receipt of this correspondence by executing and dating the original and three(3)copies of this Notice and returning the noted three(3)copies to this Authority. Our tax exempt number is#046367798. Sincerely, 6412444dliddfl'\ Wendy Ohlson Executive Director Accepted: FRG Contracting By: F--- ' �0 2- Z Dated. /5 Commonwealth of Massachusetts Division of Professional Licensure Board of Butkfrng Regulattens and Standards Cons Isar CS-113505 : l pires:0811212022 FA8IO DA : A . 40 OLIVER k EVERETT fir'Commissioner 4,4400yiroo-e4------ Construction Sopenrisor Unrestricted`..Buildhigs of any use grot*which contain less than 31,000 cubic feet($01 cubic meters)of enclosed space. • Failure to possess a currant edition of tho Massachusetts State floOding Code is cause for revocation of this ke nse. For information about this demise Call(sin}727-32oe or visit wwwmass govfdpt Office of Mummer Affairs&Business Regulation HOME at s ENT CONTRACTOR Registration valid for individual use only ram,Covcration before the expiration date. If found return to: Exiansiaa Office of Consumer Affairs and Business Regulation 11 31/2019 1000 Washington Street -Suitor 110 FRO CO •-,= a t. FQN Boston,MA 02118 40OUSILVA VERST APT 2 v ' 1� EVERETT,MA 02149 Not valid without signature Undissecretaiy 07/31/19 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: Sonia Pereira AMAZONia Insurance Agency Inc. PHONE,Extl; 617-625-1900 FAX c,No): 617-666-0037 66 Bow Street a-MAIL Somerville,MA 02143 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Western World Insurance CO INSURED INSURER B: AIM Mutual Insurance Co FRG CONTRACTOR CORP INSURER C: FABIO ROMULO DA SILVA INSURER D 40 OLIVER ST#2 EVERETT,MA 02149 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. I�7R TYPE OF INSURANCE ADDL BUM POLICY EFF POLICY EXP INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X 1,000,000 X 100,000 5,000 A NPP8604886 07/20/19 07/20/20 1,000,000 2,000,000 X 2,000,000 OTHER: $ AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS NON-OWNED PROPERTY DAMAGE $ _ AUTOS ONLY (Per accident) _ UMBRELLA LIAB EACH OCCURRENCE $ EXCESS UAB J u WORKERS COMPENSATION I PERTUTE I I ERH AND EMPLOYERS'LIABILITY Y I N B ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT OFFICER/MEMBER ER EXCLUDED? p] N/A VWC10060242392019A 07/27/19 07/27/20 $ 1,000,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) • SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AMAZONIA INSURANCE AGENCY