HomeMy WebLinkAboutBld-20-001271 (2) -r• .— Office Use Only
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EXPRESS BUILDING PERMIT APPLICATION
..,_APPLICATION
TOWN OF YARMOUTH SEP — 5 201Y i
Yarmouth Building Department
1146 Route 28 • '/Y'Ji
South Yarmouth, MA 02664
/� (508) 398-2231 Ext.11261
CONSTRUCTION ADDRESS: /Q/ ( nd 6'-d A�`' 5 L 7 ^y✓1(-4 L /, 6''-/
ASSESSOR'S INFORMATION:
/�/r� Map: Parcel:
OWNER: �;�-�'i 4") /A 4--
NAME / / 6gePRESENT ADDRESS / TEL. #
CONTRACTOR: [dM45 / As< /fidtdv4r /1. ,6Z,k-,/Ie. fiy ai6P S3? 3„Zj' / .1r NAME / ING ADDRESS [ TEL.#
cr..)
esidential 0 Commercial Est.Cost of Construction$ 4'/'i.
Home Improvement Contractor Lic.# /;'s zi Construction Supervisor Lic.# Ti/1/,-7
Workman's Compensation Insurance: (check one)
0 I am the homeowner 0 I am the sole proprietor/ lave Worker's Compensation Insurance
Insurance Company Name: ' TA44I- AI Xi C�d f vd1/j ;:< Worker's Comp.Policy# 21()i &\J 3 s
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: fiN/t✓ r ,,,,,l.'
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 licepse and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: d� .--72 Date: 9-6' Ali
Owners Signature(or attachment) Date:
Approved By: // Date: / —�
Building Offi ' ( esignee) E ADDRESS:
Zoning District:_
Historical District: 0 Yes 0 No Flood Plain Zone: 0 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 of Industrial Accidents
-W�?- 1 Congress Street, Suite 100
_I T_I" Boston, MA 02114-2017
4.`_�•�' www.mass.gov/dia
\Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print LegibI'
Name (Business/Organization/Individual): Q ;rrt ;VW .t.,--;
Address: gd: .g j "q.
City/State/Zip: trA,�l tie (4/4A C.J633;�. Phone #: `cob° ,5O
� 2 i6' 5—
Are you an employer?Check the a propriate box: Type of project(required):
1. am a employer with employees(full and/or part-time).* 7. ❑New construction
2.11 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.❑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.EI I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13. o0f 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:/n1 g�',j`i (c 5 .
Policy#or Self-ins.Lic. #: Odi /) '( 3 Expiration Date:S`"'i lam'
Job Site Address: /tl/ �P ,•-•• c I 1 ifp-04- City/State/Zip: i- ,4,-.-- ylp> (S`/
Attach a copy of the workers' compensation policy declaration page(showing the policy number a"d expiratibn 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.
SiPnature: Date: 5:7--1 /j`
Phone#: S Q ,74,28 ,/r
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#:
In the event that while stripping the roof we find rot that needs to be replaced,the homeowner
then has to agree and authorize any replacement or restoration. Then in addition to the above contract
price,the homeowner agrees to compensate the contractor for any repairs or restoration at the hourly
rate of$65.00 for a carpenter and$45.00 for a carpenter's laborer, plus the cost of materials.
-Roof to be stripped and cleaned of all old shingles and debris
-Roof to be papered with weather watch leak barrier, Synthetic roof underlayment,and
installed with Timberline architectural shingles using galvanized nails. (Storm nailed)
-All new 8"drip edge and pipe flanges 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$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:
Homeowner
Contractor /(A1/11
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Office of Consumer Affairs& �mess I
HOME IMP �c�e
IMPROVEMENT CONTRACTOR
Regulation
TYPE.Corporation
i it i
185422 Ex �r i
TROY THOMAS HOME IMPROVEMENTS, 1
ROVEMENTS,INC.
i
TROY THOMAS
499
CENT� HAM DR.
RVIL S
MA 02632 c U —�
Un.de
rsecretary
__ill. Commonwealth of
Division of pMassachusetts
Building
'one!Licensure
Board of
wilding R
Mons and Standards >:
Con$tructi�
CSSL-099g13 visor Specialty
EApires: 04/13q020
fl ;o
A THOIHAS
TTING ;; '>i"RVILLE MA ,
n Commissioner '!
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•
ACC CE
• RTIFICATE OF LIABILITY INSURANCE DATE`"INDD"""'
‘....---- 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 POLICIES
BELOW. THIS CERTIFICATE OF INSORANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder islan 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 1 CONTACT
ram Jen Davis
Mark Sylvia Insurance Agency,LLC PHONE arq. (508)957-2125 INC.Not: ( 08)957 2781
404 Main Street mark@marksylviainsurance.cam
Centerville,MA 02632 INSURER(S)AFFORDING COVERAGE NAIL 0
INSURER A: Farm Family Casualty Insurance
INSURED I INSURER 8:
Thomas Home Improvements!.LC SOURER c:
PO Box 177 • INSURER D:
Centerville,MA 02632 INSURERE:
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 POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
WAR
TYPE Of INSURANCE POLICY NUMBER IMMIDDNYTY1 01IWD VMITS
X COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE $ 1,000,000
� PREMISES TO RENTED
d) 100,000
CLAIMS-MADE n OCCUR
I MED EXP(My one person) $ 5,000
A N N 2001X1416 5/01/2019 5/01/2020 PERSONAL a Abv INJURY $ 1,000,000
GEN%AGGREGATE LIMIT APPLIES PER: j GENERAL AGGREGATE ' $ 2,000,000
POLICY JECT LOC + PRODUCTS-COMP/OP AGG $ 2,000,000
AUTOMOBILE Lit/MUTT /ta SINGLE LIMIT $
ANY AUTO BODILY INJURY(Per Person) $
OWNED SCHEDULED BODILY INJURY(Per accident) $
_ HIRED ONLY AUTOS
N-O PROPERTY
accident)
HIRED AUTOS ONLY
$
_ AUTOS ONLY _ AUTOS ONLY
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
— —
EXCESS LMAB CLAIMS-MADE AGGREGATE • $
DED RETENTION$ S
WORKERS COMPENSATION PER ATUTE ER AM n�,
AND EMPLOYERS'LIABIUTY YIN EL EACH ACCIDENT $ 1+wwAW
A O��D ��� Y� MIA N 2001 W8053 5/01/2019 5/01/2020
(Mandatory In NH) EL DISEASE-EA EMPLOYEE $ 1,000,000
itESCRIP yyesa,,deem be under EL DISEASE-POLICY LIMIT i 1,000,000
D ON OF OPERATIONS below
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached Emote space Is 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.
j
CERTIFICATE HOLDER ' CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Town of Barnstable Building Dept ACCORDANCE WITH THE POLICY PROVISIONS.
200 Main Street
AUTHORIZED REPRESENTATIVE _
I Hyannis
MA 02601
Fax: Email: ` 01988-2015 ACORD CORPORATION. All tights reserved.
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