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HomeMy WebLinkAboutBld-20-001206 Y_- Office Use Only Permit# O "'2t*l .h Amount �V '=� nor' n cs 4', ;'Permit expires 180 days fromft.b ''• '= R - issue date R E ' x. EXPRESS BUILDING PERMIT APPLICATION - _ TOWN OF YARMOUTH # Yarmouth Building P De artment �3 �(11(3 1146 Route 28 ' •.VI±L4. - South Yarmouth, MA 02664 ...,..........___:!-;(1, (508) 398-2231 Ext. 1261 1 CONSTRUCTION ADDRESS: PA— V 6.14- L01 1 v 4 wv-c Z f/ 1 44� . 44 a9 VV ASSESSOR'S INFORMATION: Map: ,r �! Parcel: OWNER: ,�1ij��4'V 7�f,^-e� ri5 "^f" `i�G"ti ' �jjv ‘1.,..4I-- NAME / �r d PRESENT ADDRESS // TEL. # CONTRACTOR: 4�' 9,-45 vi ,,./A�.-//..( yr,,C Cl2CP (2 .��e/S3 NAME MAILING ADDRESS I TEL.# OTY esidential ❑Commercial Est.Cost of Construction$ 1 J�/ Home Improvement Contractor Lic.# Afrr id 9 Construction Supervisor Lic.# /q/f Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: / t4 f L"Y76, , 4-‘'XI? Worker's Comp.Policy# dee/ /A./611)3 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: /7' /���/ 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;vocation/my license and for prosecution under M.G.L.Ch.268,Section 1. 7 Applicant's Signature: 0; 7 ` Date: % /J ✓01' h Owners Signa re(or attachment) Date: Approved By: /PG Date: /��fBuilding Official( es• ee) EMAIL2.--3;/ DRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: ❑ 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 oflndustrialAccidents R„ mm I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.00v/dia '1M_ Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): 1-XP'Y'^S A64-41:' .07/4/te--ft-/2 Address: 'de, do' / ?- City/State/Zip: ( %11-r /4 Cltj Phone #: j 7 �� "? Are you an employer?Check thappropriate box: Type of project(required): 1.Xam a employer with 3 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. ❑Remodeling any capacity. [No workers'comp.insurance required.] 9. ❑ Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 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.$ 14.0 Other 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 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. tContractors 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: filik'n Policy#or Self-ins.Lic.#: 1).1 611,foo Expiration Date: Job Site Address: / /k..i ..% -Z City/State/Zip: Attach a copy of the workers' compensa Ion 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: � Date: Phone#: ref s'Oi 1b?tom 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#: (iAe o,nmanuveald c/cs llaataclruae Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Corporation Registration Expiration 185422 06/08/2020 TROY THOMAS HOME IMPROVEMENTS,INC. TROY 499 NOTTINGHAM DR. CENTERVILLE,MA 02632 Undersecretary �Lre.(onzmnnu,ealtl ot2.71auacluJe Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Corporation Registration Expiration 185422 06/08/2020 TROY THOMAS HOME IMPROVEMENTS,INC. TROY THOMAS 499 NOTTINGHAM DR. CENTERVILLE,MA 02632 Undersecretary Commonwealth of Massachusetts - Division of Professional Licensure Boa of Building Reg adards • Co.nrd ruction SUpervys0r ulations SpendStancialty CSSL-099913 EEpires: 04/13/2020 TROY A THOMAS - . 499 NOTTINGHAM DRIVE CENTERVILLE-MA 02632 s - Commissioner ACo' CERTIFICATE OF LIABILITY INSURANCE DATE `M" "YYY) 04/30/2019 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 POUCIES BELOW. THIS CERTIFICATE OF INSI4RANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder lelan ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject tt'h 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 MMTACT Jon Davis Mark Sylvia Insurance Agency,LLC ram. (508)957-2125 FA)( ,r,/: (508)957-2781 404 Main Street ppp s& mark©marksyMainsurance.com Centerville,MA 02632 INstRts)AFFORDING COVERAGE NAIL ra INSURER A: Farm Family Casualty Insurance INSURED j INSURER B: Thomas Home Improvements'.LC INSURER C: PO Box 177 • INSURER D: Centerville,MA 02632 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. NOTWRHSTANDING 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 POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSLTR R ADM SUER POUCY TYPE OF INSURANCE a POLICY HUMMER (M2DON m rYWVDDIYYYYYYI WRITS X COMMERCIAL GENERAL L AIM' EACH OCCURRENCE S 1,000,000 DAMAGE RENTED CLAIMS-MADE IX OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(My one person) $ 5,000 A N N 2001X1416 5/01/2019 5/01/2020 PERSONAL akvovum( $ 1,000,000 GENL AGGREGATE LIMIT APPLIES PER: j GENERAL AGGREGATE S 2,000,000 X POLICY n jECT I I LOC PRODUCTS-COMP/OP AGO S 2,000,000 OTHER: COMBINED AUTOMOBILE LLABILITY l SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS ONLY AUTOS HIRED AUTOS accident) S AUTOS ONLY __ AUTOS ONLNL Y S UMBRELLA UAB _ OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIIAS,MADE j AGGREGATE • $ DED RETENTIONS PER OTH S WORKERS COMPS SA110N STATUTE ER AND EMPLOYERS'LIABILITY A OFFICCERMEMMBE.R EXCLUDED? YY❑ N/A N 2001W8053 5/01/2019 5/01/2020 EL EACH ACCIDENT s 1,000,000 (Mandatory In NH) EL DISEASE-EA EMPLOYEE S 1,000,000If y DESCRIPTION OF OPERATIONS below I EL DISEASE-POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/vEIICLry'B(ACORD 101,Additional Remarks Schedule,may be attached N more apace Is requited) Carpentry • Insurance coverage is limited to the terms,conditions,exdusions,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 MOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Barnstable Building Qept- ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street AUTHORIZED REPRESENTATIVE I Hyannis MA 02601 :+ Fax: Email: • ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) i The ACORD name and logo are registered marks of ACORD -Gliding windows,white on white,full screen -Harvey new construction window to be installed as discussed -Azek PVC exterior trim installed with Cortex hidden fastener system -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: c ��� Homeowne Contractor