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Home My WebLink Aboutbld-20-002075 ;$. . :Iv . lam! ' iPermit# O '1,01,it . 'i �Amount 1 .' , • M `"'°""° Ewa,• 1 Permit expires 180 days from ,;: i issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH OCT 15 2019 Yarmouth Building Department 1146 Route 28 C ' IS i D South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 !, A/ �� t� CONSTRUCTION ADDRESS: A 4 " 1N 5:elnita �d*r( G y,a't0iJ- , i Will ASSESSOR'S INFORMATION: / Map: Parcel: OWNER: / j 5e s /l/ �5L AV el PRESENT AD RESii�' ci 7� TEL. # !-i 3 907 1 NAME CONTRACTOR: 7? 74E.4.4L- ro.— 14 4"ioet f 4 444 (7,072 f 32)°,e3r NAME MAILING ADDRESS % TEL.# 9 ". esidential ❑Commercial Est. Cost of Construction$ g�i'�i f J f p �f✓�{, Home Improvement Contractor Lic.# / t'�ryt. Construction Supervisor Lic.# / Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor ' ve Worker's Compensation Insurance Insurance Company Name: ' ,Z/ .-- J A , <_l•"Cvl/ Worker's Comp.Policy# ;ern W .3 /WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replace t windows:# Replacement doors: # Roofing: #of Squares /d Remove existing' (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: d 4449 Location of Faci ity 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 for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: /�� Date: /4'/1—(PG,'/ Owners Signature(or attachment) Date: Approved By: L 4 Date: Id` S ' Kt 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 ❑ Yes , No ' The Commonwealth of Massachusetts r 4.", , Department of Industrial Accidents I 1 Congress Street, Suite 100 e ' r Boston, MA 02114-2017 tor 5./ 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): -/A44-415 4n-t it-44 Address: // icd In City/State/Zip: /Le O '.2 Phone #: i8 Y- i(4 .vi Are you an employer?Check t�appropriate box: Type of project(required): 1. m a employer with 6 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. ❑ 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.E 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.❑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: �r/AMA% rftn44, li �(y�„10, c. Policy#or Self-ins. Lic. #: AV( G✓ k f - Expiration Date: s`/O-ddtad Job Site Address: /J/ [��//t 4C1 /6 City/State/Zip: L pi4 Z)/ Attach a copy of the workers' compensation policy declaration page(showing the policy number a eapiration)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: "`--- Date: /A" '-,07 j' Phone#: S , 1,,, /dr r Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License gt- 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#: -Roof to be stripped and cleaned of all old shingles and debris -Roof to be installed with weather watch leak barrier,Synthetic roof underlayment,and installed with Timberline architectural shingles using galvanized nails. (Storm nailed) -8"drip edge&new pipe collars to be installed -Cobra ridge vent to be installed on all ridges -Timbertex premium ridge cap to be installed -A 30-yard container 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: I/o- _;e % Homeowner Contractor • CJlee�pom7 nanuseall a C'l�a HOME IMPROVEMENT CONTRACTOR Regulation Office of Consumer Affaifrs Busfneason TYPE:CoraoratiElKtatatall iration 1 06/08/2020 TROY THOMAS HOME IMPROVEMENTS,INC. _ 1 TROY THOMAS 499 NOTTINGHAM DR = Und® � CENTERVILLE,MA 02632 taty • Commonwealth of Massachusetts IFDivision of Professional Licensure Board of Building Re ulations and Standards ; ConV.ructio S ( r Specialty CSSL-099913 Tres 04/13/2020 i •A' a J TROY A THOMAS 499 NOTTINGHAM .r CENTERVILLE M263 Commissioner v'"` • 1 •Aco d CERTIFICATE OF LIABILITY INSURANCE DATEprwooravv) kw....---- 0420/2019 THIS CERTIFICATE IS ISSUED AS A TL'ER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS . CERTIFICATE DOES NOT AFFIRMA Y OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INS NCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AN THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Islan ADDITIONAL INSURED,the policy(es)must have ADDITIONAL INSURED provisions or be endowed. ' If SUBROGATION IS WAIVED,subject tb the terms and conditions of the policy,certain policies may require an endorsement A statement on the certificate does not confer rights to itms cis Mate holder in lieu of such heend rasment(s). PRODUCERNUNES Jen Davis Mark Sylvia Insurance Agency,LLC I • (508)957-2125 j,T„'w�Mak (508)9572781 404 Main Streetffs:.* markkmnarksyMaainsurance com _ . Centerville,MA 02632 I HHIUERR$)AFFORDING COVERAGE NAIC p INSURER A: Farm Family Casualty Insurance - INSURED j NNSUIIOI e: Thomas Home Improvements LLC I SURMtC: PO Box 177 EIMUN RO: Centerville,MA 02632 ts: jilliallitF COVERAGES CERTECATE : REVISIONNUMW 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 RE•UIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY • • AIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO AU.THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH . CIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CWMS. INSR TYPE OF INSURANCE ,1 HUMNt r% LENTS X COMMERCIAL GENERAL maim, OCCU i 1,000,000 CLNMS-MADE ❑X OCCUR l�"� u 1 $103,E _ I NSD EXP( onspusan) $ 5,000 A N 2001X1416 5/01/2019 5/012020 PERSONAL$kIVINJURY $ 1,000,000 • GEM I.AOOREGATELUITAPPLIESPER I • GENERAL AGGREGATE $ 2,000.000 X POLICY JTC¢T a LOC PRODUCTS-COMP/OP AGO $2,000,000 I OTHER N AUTOMOSLE UMIJTY EEMMInSINGLE LNAIT $ ANY AUTO BODILY INJURY(Par paw; $ — OWNED SCHEDULED BODILY INJURY(Per sodden; $ AUTOS ONLY AUTOS HIRED -OWNED_ AUTOS ONLY AAUTOSONLY $ $ UMIRELLA UAS OCCUR i • EACH ONCE $ EXCESS UAB CLANASMADE I AGGREGATE • $ DEO WORKERS I COMPENSATION I STATi1TE I I ; AND EMPLOYER"UAMUTY I . A OCFFI PROPRIETOMPARTNEREXECLMVE CERAIEMBEREXCLUDED4 Y CIA N 2001W8053 5/01/2019 5/01/2020 EI_EACH ACCAENi i 1,000.OIJO (Mandalay In NH) E.L.DISEASE-EA EMPLOYEE, • 1;0001000 rag=OF 11diOPERATIONS below El.,DISEASE-POLICY Lear $ 1.000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/YBIICLC�I(ACORD 101,AdditionaRamadawMRamada Salad"Say abalN Basra Is span waned) Carpentry I Insurance coverage is limited to the terms,c�onditions,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 aNOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCH.LED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Bade Building ACCORDANCE WITH THE POLICY PR NS. 200 Main Street • AUTNORQID RIBREOBRATIIIE • i ' - I Hyannis MA 02Q01 Fax: Email'. I • 019882018 ACORD CORPORATION. All rights reserved. ACORD 26(2016/03) 1 The ACORD name and logo are registered marks of ACORD