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HomeMy WebLinkAboutBld-20-000620 r .YA i Office Use Only R • HO -Permit# 1 ...too t; 1-3Amount 6b o N n In . .4. �°°�*c° Erd ` 'lb ` ;'Permit expires 180 days from >, 6c✓ 20 — CO w issue date RECEIVED EXPRESS BUILDING PERMIT APPLICATCF —1 TOWN TOWN OF YARMOUTH ! n Yarmouth Building Department AUGi ) 2D1� 1146 Route 28 !=3k!1L """' South Yarmouth, MA 02664 i- ay. v (508) 398-2231 Ext. 1261 / CONSTRUCTION ADDRESS: I ( (A( '(aTCJoo,J •QI_ C-i -k(A "'" rF 1 I"A v ASSESSOR'S INFORMATION: c(7_3 Map: Parcel: / OWNER: }c a(Sr /(A�'E �// -r-0-y G�OA 1 c?-9 '5 0)0 I !/ NAME PRESENT ADDRESS TEL. # CONTRACTOR:TIU leS CAP- cAPe— 4. « v'CA) P.G box 1-7`/S 0 8-)- r- 9 4 3 Z- NAME MAILING ADDRESS TEL.# do o -esidential 0 Commercial Est.Cost of Construction$ Home Improvement Contractor Lic.# S "1 . 14 O Construction Supervisor Lic.# C.5-- 1 J.) efo Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: (}!1 Z) frA-6 Pec Worker's Comp.Policy# W CAIO/`/rOSal WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding:l #of Squares ll Replacement windows:# Replacement doors: # ,/Roofing: #of Squares i/ ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: 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 revocation of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Sign. . : Date: Owners Signa re(or a .chment)nt Date: Z — t o l e. 1/ Approved By: r `�-r%'t) Date: f- 2 f 7' Building 0 c' r e 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 0 Yes 0 No The Commonwealth of Massachusetts r Department oflndustrialAccidents WA_ 1 Congress Street, Suite 100 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 Legibl Name (Business/Organization/Individual): )0JL114,S LApi>Sc/PL $ CC.PS IY1 C 1 sc,'J Address: U - 0 O c ( 7.rF S4GAMcvPr. e(24 /v e f1 - Ore-s--Z City/State/Zip: Phone #: fop- Prf' v3Z Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 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.] 4.❑I am a homeowner and will be hiring contractors to conduct all work on mYproperty. I will 10 E Building addition 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. These sub-contractors have employees and have workers'comp.insurance.$ 13. Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El 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. $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 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: 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 under the pains and penalties of perjury that the information provided above is true and correct. ‘` Signature: /!/W 7 Date: �'— r- 701 - 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#: Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constuatiojitetlfrvisor CS-113409 .• " ires:08/30/2022 RITA PO BtEXF A x :. Commissioner • omcs of Consumer Ariake&Bmilrs Regulable HOYE • , CONTRACTOR -D2/Ist2021 TRAVERS a `•" • & WEATHe TT• DITArFRASE ;�-y 0 152 CRAMERR H�I'T SAGAMDIiE,MA 02561 qc�� DATE(MM/DD/YYl'Y) A.-.. CERTIFICATE OF LIABILITY INSURANCE 08/01/19 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: PHE United Insurance Agency,Inc. (ArcNN.Extt: 508-759-6595 A/,No): 508-759-3822 199 Main Street E-mAIL P.O.Box 1013 ADDRESS: Buzzards Bay,MA 02532 INSURERS)AFFORDING COVERAGE NAIC# INSURER A: Nautilus Insurance Co INSURED INSURER B: Atlantic Charter Travers Landscape Construction INSURER C: Engineering Sr Weatherstone Restoration LLC P.O.Box 1748 INSURER D Sagamore Beach,MA 02562 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. INSR TYPE OF INSURANCE ADDL6U6R POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD ,(MM/DD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE $ 1,000,000 DAMAGE TO REN rED CLAIMS-MADE E OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 A — NN1018053q 07/31/19 07/31/20 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY❑JE r n LOC PRODUCTS-COMP/OP AGG $ 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 HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) , $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED I RETENTION$ $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'UABIUTY STATUTE ER N B OFFICER/ME BER EXCLUDED ANY ECUTIVE Yri N/A WCV01450500 05/01/19 05/01/20 E.L.EACH ACCIDENT $ 100,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Landscaping,landscape construction including masonry&tree work,carpentry including roofing CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Michael Fraser ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1748 Sagamore Beach,Ma 02562 AUTHORIZED REPRESENTATIVE Kris Dexter I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Travers Landscape Construction Engineering & Weatherstone Restoration HIC# 187006 P.O. Box 1748 Sagamore Beach, MA 02562 Travers.Mike @yahoo.corn (508) 888-9432 Kane, Kelly July 30, 2019 41 Tanglewood Dr. West Yarmouth, MA 02673 (918) 925-1101 /KellykaneOlna.hotmail.com Contract Proposal The following contract proposal is for the roof restoration at the above address in phases as follows: 1. The back of roof was punctured during storms on 7/23/19 a. Sheathing will need to be fixed/replaced on back roof addition b. Rake boards will need to be fixed/replaced c. Soffits will need to be fixed/replaced $1,500 2. The re-roofing of back roof a. 3 layers/ 13 squares b. The installation of CertainTeed roof runner&ice and water membrane c. CertainTeed Landmark Pro's/Pewterwood (color) $7,500 Deposit: $2,700 Additional payment of$(30%of total cost)is due at the midway milestone.Final balance is due upon job completion. - -I-Save the utmost trust ih your hew roof kv1owivis it is 19e419 ihstalled by a Certaiv!Teed ShiviSle Quality Specialist avid Certaiv!Teed Master Shiv!91e Applicator - SHINGLE Shingle Technology Shingleallast" IPPIU:%TOR Thank you for considering Travers for all your landscaping and home improvement needs! Customer reviews can be seen at HomeAdvisor.com.Specific References,Workman's Comp and Liability Insurance certificates are available and provided upon request.We look forward to hearing from you. VISA die J • PayPal Please note a 2%processing fee is applied