Loading...
HomeMy WebLinkAboutBLD-20-002107 o R'-, 7 � _, �: 1 Permit# r . {0 - • . H '!Amount 5O • n CTT�. nc� 1 :I •, °naato e.; .• *, ;; ; j Permit expires 180 days from issue date 1 j_aD—c)- ►D7 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH -RECEIVED Yarmouth Building Department - - ----1146 Route 28 South Yarmouth, MA 02664 OCT 16 2019 (508) 398-2231 Ext. 1261 I - - -- BU zt' NT ����� � c.3y CONSTRUCTION ADDRESS: 1(� i-F4.%)ciat-Q otA., / Sow V&r'n'10 Tri— ASSESSOR'S INFORMATION: Map: Parcel: OWNER: me-#mrS. 1)omeita 'PQcti, to N:qkkarS ask.. 07'SSO `4,17 NAME PRESENT ADDRESS , TEL. # CONTRACTOR:(9v,trl1 40501Q0 it V) PleaSan r rd tit), Clarw . 5-0g-31 g-in91 NAME MAILING ADDRESS ' TEL.# KITesidential ❑Commercial Est.Cost of Construction$ /v coo Home Improvement Contractor Lic.# / /(o23q Construction Supervisor Lic.# Qq 1317 Workman's Compensation Insurance:Lcheck one) ❑ I am the homeowner n am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 3D ( 44ecnove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: C4:/C/s' , bOn/1;c, MT 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 revocati n of my lic ns�r prosecut n under M.G.L.Ch.268,Section 1. Applicant's Signature: L Date: l //(O//l Owners Si ature(or attachment) Date: Approved By: `../ _�. . Date: 1U '1 6 " l c\ Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes D No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No ❑ Yes 2 No The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 e Boston, MA 02114-2017 . .1• www.mass.go v/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): G�q (rSenCt IT-- Address: /v O cgsgh.t- City/State/Zip: 0, �ur )�ZL tniA- Phone 4: ,5o8`39(4.-y743 Are you an employer?Check the appropriate box: Type of project(required): I.❑I am a employer with employees(full and/or part-time).* 7. ❑ New construction 2. 40-rrm a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp. insurance required.] 8. ❑❑ Remodeling���� 3. I am a homeowner doing all work myself. 9. t"rlJemolitlon ❑ y [No workers'comp. insurance required.] 4.❑ myProPe�3'•I am a homeowner and will be hiring contractors to conduct all work on I will 10 El Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions proprietors with no employees. 12.E Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.2-Rof repairs These sub-contractors have employees and have workers'comp. insurance.i 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E 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. ;Contactors 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 an:an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy ii or Self-ins. Lic. m: Expiration Date: Job Site Address: City/State/Zip: 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 n,er the pains and penalties of perjury that the information provided above is true and correct. Signature: /!� / Date. /!c /Y Phone#: 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#: Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual lassittatkin ENDiratiof 04/06/2021 GREGG ARSEt � w f .` GREGG W.ARSEI�T = ' 30 PLEASANT RD\ WEST HARW ICH,MA 02671 Undersecretary Commonwealth of Massachusetts ®� Division of Professional Licensure Board of Building Regulations and Standards • ConstrOti 1 ibtlpervisor CS-091397 E,pires: 01/26/2021 GREGG ARSENAULT 30 PLEASANT43 OAD M WEST HARWICI#,MA 02611 Commissioner Cl'"'" proposal Page No. of Pages / • Lic. #091397 -- RSENAULT Since 1990 • Reg. #146239 Roofing & Siding References and • Insured 30 Pleasant Road•West Harwich,MA 02671 Insurance Ccrttkates •Certified 508.398.4743 Avaita6le upon west PROPOSAL SUBMITTED TO JOB NAME `1)0n01la Pea STREET JOB LOCATION 1 n to 1- ;ctL as,c& Qom t-t., 1O •zc,�iar+Cl CITY,STATE and ZIP CODE 0 all, PHONE (� C�r mY' 1 y1 O JJBPHON iJ •�'1 `/CL('fYla i h ! (9l/".S. 10""q 7S . DATE r We hereby submittrpeclkatrona and estimates gl1 q /Zo►q tc R Campy*e, ce c aF StA%qcitA UY1ck>c, 663 -c„`' • Strip all existing roofing and remove debris. Ca Iayee'S or% G'ragyr • Inspect roof deck for loose boarding and renail as needed. • Install all new aluminum drip edge, pipe flanges, and counter flashing. ('01.-.,z J p .e.kotc • Apply a water and ice shield underlayment around all chimneys, pipes, skylights, in valley areas, and along bottom edge of roof. • Install a 151b. felt paper underlayment on all exposed roof deck. • Reroof with a specified roofing material. (see options) . • Six galvanized nails per shingle are used for high wind protection. • Chimney flashing will be sealed with a clear silicone sealant. • All gutters, siding, landscaping, etc. will be protected during construction and left spotless upon completion. la,xt,.+, ri1aTc."-jcIAS Shingle Options: Cer-rei�; tr_ck L-anctmc.r lc . pro c1 � . CO1oe: 3zrc.G, f ors 'Is flack 1 nciocieS: 4--,,,A �:c\gc. V'QAT Rc1 d �e�.r x rnog�Mi,'-1 Zgt��°. _ i 6 il,23o.22 kQ� The Propose he reby ereby to furnish material and labor—complete in accordance with above specifications,for the sum of: Tw c1.I at1 ojccu.,A T1-,•4.4, I-.I..A"La r c./ dollars($ 12, 3S Q o Payment to be made as follows: -- One half in advance and one half upon completion Deposit Paid: # 1-0`OS,©° 01127/1 cl (PLEASE MAKE CHECKS PAYABLE TO:GREGG ARSENAULT) AN material is guaranteed to be as specified.AN work to be completed in a workmanlike k q to standard practices.Any alteration or deviation from above specifications 9 8n ture C� /�/ involving extra costs will be executed only upon written orders.and wilt become an extra charge over and above the eatinete. AN agreements contingent upon strikes. accidents or delays Our workers are beyond our control.Owner to carry tiro.tornado and other necessary insurance. Note:This proposal mey be '? fully covered by Workman's Compensation Insurance. withdrawn by us if not accepted within >Arrepjanr, of Proposal—The above prices,specifications `- �C and conditions am satisfactory and am acc ted. to do the work as specified. P t hereby line am authorized Signature U� be made as outlined shave. Date of Acceptance: Signature