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Home My WebLink AboutBld-20-003405 (2) '�, ,O�Y`9R :7 L'u1ee use vary ' Permit � O . - H 1 Amount V_� MATTACII [S[ , N 4e^[n.uc°`°c�d$ 1 Permit expires 180 days from BC -Q 0-34 � i issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 CV4(E3 g- South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 �j w CONSTRUCTION ADDRESS: 7k' 't &4 'tcl''' //j�/l.✓orJ` A co ) ASSESSOR'S INFORMATION: / �Map: / ) 77 .�P✓arcel: / OWNER: f-�vert- phi- /45� 1 PRESE1NTADDR/rESS S/+ s/JrdrV'' ' NAME / /� CONTRACTOR: �v. .�r4l /.�v { 1/4041 e S A!iG, /77 C�'/4e ref y /6 if NAL lE iMAILING ADDRESS TEL.# esidential ❑Commercial Est.Cost of Construction$ Home Improvement Contractor Lic.# (12 4S / 'i `4-9- Construction Supervisor Lic.# 07714.E Workman's Compensation Insurance: (check one) 0 I am the homeowner E I am the sole proprietor D' have Worker's Compensation Insurance Insurance Company Name: 1'4'v A?MI l [ v4.47 Worker's Comp.Policy# Gxvi i,Jecfc-3 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows: # Replacement doors: # Roofing: #of Squares /7 ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: o.i 7 y�vi l -i(.'�-r 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 Signature: /00-4 /‘..,‘.. Date: J' s-if— t f Owners Sign ure(or attach ent) Date: / Approved By: /r Date: g /c ,, Building Offi . ( signee) EMAI 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 a Yes 111 No The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 ..5.•''� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): 7, .<lj 7`��,,yr �� ,.to• e^i{5 Address: a! �,Scx'J7 City/State/Zip: �; ...Il4 J414 c iJ) Phone #: jit7 ?.✓,:f Are you an employer?Check the appropriate box: Type of project(required): 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 [No workers'comp. insurance required.] 9. ❑ Demolition 10 E 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.[11 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. oof 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,§I(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-cont,-actors 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: /" 14fir7 '/ al:4 1/7 jc Policy#or Self-ins. Lic. #: ci/-Dr) e,,vv d5 7 Expiration Date: S' 1 -"cPd?0 Job Site Address:c..4f, -,-/►74e e't dia / City/State/Zip: S 7i/� C.f aRey Attach a copy of the workers' compensation policy declaration page(showing the policy number an 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 certi under the pains and e�s of perjury that the information provided above is true and correct. Signature: Date: /V— /I ad/7 Phone 4: 4, ' i? JO Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License n 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 4: -Roof to be stripped and cleaned of all old shingles and debris -All debris from the roof will be tarped covering all bushes&shrubs -Roof to be papered first 3 ft with weather watch leak barrier,Synthetic roof underlayment,and installed with Timberline architectural shingles using galvanized nails. (Storm nailed) 1''/.roof nails -8"drip edge&new pipe collars to be installed -Yard to be magnetized for nails&left clean as upon arrival -Cobra ridge vent to be installed on all ridges -Timbertex premium ridge cap to be installed -A 10-yard dump trailer 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: 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: (0 Homeowner ,/ Contractor • ��te‘Olowemn i wealr!alb ai kkre.,je Office of Consumer Affarrs&Business.Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Corporation Reaistratior( expiration 185422 06/08/2020 / TROY THOMAS HOME IMPROVEMENTS,INC. TROY THOMAS 499 NOTTINGHAM DR. CENTERVILLE• ,MA'02632 Undersecretary. t Commonwealth of Massachusetts IPDivision of Professional Licensure Board of Building Regulations and Standards- Con�truction,S p4Msor Specialty CSSL-099913 C�pires: 04/1,3/2020 TROY A THOMAS f / 1111, 499 NOTTINGHrAM DR / ;, CENTERVILLE MAJ)2632 w ". • ` ( ' Commissioner Cd d CEitTIFICATE OF LIABILITY INSURANCE DA'E"1VDD/Yrc" 04/30/2019 THIS CERTIFICATE 18 ISSUED AS A MATTER or INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS • CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY MEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POUCiES BELOW. THIS CERTIFICATE OF INS LANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(8), AUTHORIZED REPRESENTATIVE OR PRODUCER,mut THE CERTIFICATE HOLDER. IMPORTANT: If the certif c to holder islan ADDITIONAL INSURED,the poucy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject lob the bane and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to{he certificate holder in lieu of such endorsement(s). PRODUCER i CONTACTJan Davis AX Mark Sylvia Insurance Agency.LLC ,,,,pop(508)957-2125 F. ,a,: (508)957.2781 • 404 Main Street AnORF>!a mantelniestsyheainsurance.com Centerville,MA 02632 : INSURER'S)AFFORDING COVERAGE HAIO s i mum A: Farm Family Casualty Insurance INSURED I INSURER s: . Thomas Home improvements LLC INSURER 0: PO Box 177 i INSURER 0: Centerville,MA 02632 ` ere1111EStE: INSURER F: COVERAGES CER'fiFICATE MASER: 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 RNUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY P*RTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH ES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. L TYPE OFDISURAiCE !late POUCYWJ&UER ar�YW aliNID�I VWr1 UNITS X COUNERCULOENERAI.umsuTY ,«« = 1,000,000 1 CLAIMS-MADE ElOCCUR TOIEa000urrloel i 100,000 BED EXP()Team Poaon) i 5,000 A N N 2001X1416 5i012019 5i012020 PERSONALS IwINJURY $ 1,000,000 GEHL AGGREGATE i GENERAL AGGREGATE $2.000.000 POLICY • ❑ o PRODUCTS•CCMPIOPAGO $2,000,000 _°THER , $ ANY AUTO e00S.Y INJURY(Per Person) $ — OWNEDY SCHEMED i EOON.Y INJJURY(P(Pperr sodasnt) $ _AUTOS — HIRED ONLY — NCeetYANED aoddsnl $ AUTOS $ - uMS LA REL UAB occuR j EACH OCCURRENCE $ — EXCESS UAB CU MtsM ADE , AGGREGATE • $ DEO I RETENTION s $ WORMERScomoveAT1ON • I nun I i"' AND EMPLOYERV LIASBJTY Y A OFI PROPRIETORAVIRTNERAEXECUTIVE CERrMEMBEREXCLUosu+ [ tt(IA N 2001W8053 5i012019 5/012020 EL EACH ACCDENT a1,000,000 �Bleadebtry layye�ss EL DISEASE-EA I3PLOYEE $ 1,000,000 IIARIP ION boor, E.L.DISEASE-POLICY mar i 1.000,000 DESCRIPTION OF OPERATIONS i LOCATIONS i VBECl (ACORD Let,Adeeor el Rewwb SolwAdA any be Micheal limo ewes la requited) Carpentry Insurance coverage is limited to the terms,conditions,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 f CANCELLATION MIOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CAMILLE)BEFORE THE i.XPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Barnstable Bedding[apt. ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street • AUTHORS R ITATIVE ... ` I Hyannis I MA 02601 Fax: Email: ' • 0198E-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo.are registered marks of ACORD