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BUILDING DEPAR rhl�
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261 (:4(0 �
CONSTRUCTION ADDRESS: C.) 4^,'IN%—• V��`,••)‘-' 11•1\((rC'N,..o-J"\ NCNV
ASSESSOR'S INFORMATION:
\ Map: Parcel: C,
OWNER: �O�\ .S` C-eik,,.r -if c•-5-- 'CNs;.,c.g-, 'S\NR.- VV y i-',\ .C -z t%
NAB PRESENT ADDRESS TEL. #
CONTRACTOR: \per Nci•cGr \1:-.0) 4cszc..� - \\\CAIN.S1,, c3,ac,o (o\- -Q\)l' (0a01
NAME MAILING ADDRESS TEL.#
Residential ❑Commercial Est.Cost of Construction$ \�)ClICC") •CZ
Home Improvement Contractor Lic.# \c\).�:")"1". Construction Supervisor Lic.# C5� \0\-+d.-k
Workman's Compensation Insurance: (check one)
❑ I am the homeowner `(�I 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: #
Roofmg: #of Squares .\ s\:1 (--')--Remove existing* (max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
*The debris will be disposed of at:')( 4 N .5/7c bum r S7t oo
• 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 r ocation of my license d for prosecution under M.G.L.Ch.268,Section 1. / Q
Applicant's Signature:- L Date: yr I.C./ I/
'cOwners Signature(or attachment) 7 74 C af Date:
Approved By: Date: 8— `;
Building 0 • ignee) EMAIL RESS:
Zoning District:
Historical District: 0 Yes ❑ 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 of Industrial Accidents
far
Office ofhtvestigations
-�� P 600 Washington Street
Boston,MA 02111
'`' :P r www.►nass.gotr/die
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annllcant Information /� Please Print Legibly
•
NamC(Business/Organization/Individual): ,,e-(7 f GYQ1.t f) G-f .. - .. -.
Address: /'7'7.� QC-ecx n <_S�`Y"- 2 e _ . / -- -•----
City/State/Zip:-/1•(( rSh field / - Phone iI: C.p l7- 42 2- 6200 9-,
Are you an employer?Check the appropriate box: Type of project(required):
1.D f am a employer with 4. Ea i am a general contractor and! b 0 New construction
employees(full and/or part-time).* have hired the sub-contractors
listed on the attached sheet. 7. ❑Remodeling
2.❑ 1 am a sole proprietor or partner-
These sub contractors have
ship and have no employees 8. 0 Demolition
and have workers'
working for me in any capacity. employees9. ❑Building addition
(No workers'comp.insurance comp.insurance
required.] • 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.❑I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself:[No workers'comp. right of exemption per MG1. 12.Q Roof repairs
insurance required.]t c. 152,§1(4),and we have no 13❑Other employees.[No workers' • . •--•---
comp.insurance required.]
'Any applicant that checks box y1 must also fill out the section below showing their workers compcnsatkm policy infonnatiott.
+I lomeo woe s who submit this affidavit indicating they ate doing ail work and then hire outside contractors most submit a tuna,nftidavit indicating such.
:Contractors that check this box must attached an additional sheet shonhig the name of the sulrconlr.ctors and sane whether or not those entities have
employees. if the sub-cnntractrxs have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation hrsurasce for nay employees. Below is the policy and job site
information.
Insurance Company Name: k.Jbea'.- (. hita..,L_ //245G.LJS.0 c-! _---•---
/b Expiration Date: city 2 20/q
Policy h or Self--ins.Lie.ti: ����,j/Jc-' (D.�(�(Q"v 0--- 1 — ---•— -• --
Joh Site Address:- __ ,. ..� -.-�-t-ity/StaterLip:_ __ -_ . -- . ..
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGI.c. 152 can lead to the imposition of criminal penalties of 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 line
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
investigations a insurance coverage verification.
1 do he eer nJrr the silts at, ties of,Perjrtrh that the: :I: JThmdhtJtbeix
foioide b true and correct.
r _ D Phone ti•: --- .- - -- - ---
1 Official use only. Do not write in this area,to be completed by riir'or town oflic•ial.
City or Town: I'crmit/l iccnzc II ---------_--.
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Verson' - •_____••. _------_-_ -_— Phone ______ ---------•
AC RD' O1=
CERTIFICATE OF LIABILITY INSURANCE zosorti
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY MO CONI ERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOTS NOT AFFIRMATIVELY OR NEGATIVELY AMk ND.FA TEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW THIS CERTIFICATE OF INSURANCE DOTS NOT Lt./meal11 UTE A CONTRACT?ETVIEN THE ISSUING INSURE/1(S1.AIITHORILED
REPINSLNTATMVE OR PRODUCER.AND THE CERTIFICATE HOLDER
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8/12/2019 Mail-Beau-Outlook
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Commonwealth of Massachusetts
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,' . : Board of Building Regulations and Standards
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SUPERIOR
EXTERIORS
ROOFING•CONSTRUCTION
Name Roy Mackintosh
Customer address 55 Maine Avenue,Yarmouth, Massachusetts,02673
Customer Phone Number (413)537-3788
Company Name
Company Phone Number 6179226062
Company Address 1775 Ocean Street Marshfield MA.02050
Mailing Address(It different from above) Business Phone Federal Employer ID or S.S. Number
Law requires that most home improvement contractors have a valid registration number
Home Improvement Contractor Reg. Number 192774
Expiration date 8/11/20
The Contractor agrees to do the following work for the Homeowner Roofing
(Describe in detail the work to completed, specifying the type, brand, and grade of materials to be used, use
additional sheets if necessary.)
Total Contract Price $15,855.00 and Payment Schedule 1/3 down
Required Permits-The following building permits are required and will be secured by the contractor as the
Homeowner's Agent: Superior Exteriors
(Owners who secure their own permits will be excluded from the Guaranty Fund provisions of MGL chapter 142A.)
Proposed Start and Completion Schedule -The following schedule will be adhered to unless circumstances beyond
the contractor's control arise
Date when contractor will begin contracted work.
The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of:
(*) Payments will be made according to the following schedule:
$ pp upon signing contract(not to exceed 1/3 of the total contract price or the cost of special G �y
order items, whichever is greater)$ by
or upon completion of
$ r,A c6 c•o G by or upon completion of
OIGT4,c,{,,\ IQ`C\1U/
$ upon completion of the contract. (Law forbids demanding full payment until contract
is completed to both parry's satisfaction)
The following material/equipment must be special$ to be paid for
ordered before the contracted work begins in order to meet the completion schedule.
(**}$ rj IaCS S.C;o to be paid for `,gMI i^,O\ C) pro SS ``T
NOTES: (*) Including all finance charges (**) Law requires that any deposit or down-payment required by the
contractor before work begins may not exceed the greater of (a) one-third of the total contract price or(b)the actual
cost of any special equipment or custom made material which must be special ordered in advance to meet the
completion schedule.
Express Warranty- Is an express warranty being provided by the contractor? r Yes r No
(all terms of the warranty must be attached to the contract) Subcontractors -The contractor agrees to be solely
responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by
the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for
materials and labor under this agreement .Contract Acceptance - Upon signing, this document becomes a binding
contract under law. Unless otherwise noted within this document, the contract shall not imply that any lien or other
security interest has been placed on the residence. Review the following cautions and notices carefully before
signing this contract.
r Don't be pressured into signing the contract. Take time to read and fully understand it. Ask questions if
something is unclear.
r Make sure the contractor has a valid Home Improvement Contractor Registration.The law requires most home
improvement contractors and subcontractors to be registered with the Director of Home Improvement
Contractor Registration.You may inquire about contractor registration by writing to the Director at 10 Park
Plaza, Room 5170, Boston, MA 02116 or by calling 617-973-8787 or 888-283-3757.
r Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can
confirm coverage, or ask to see a copy of a"proof of insurance"document.
r Know your rights and responsibilities.Read the Important Information on the reverse side of this form and get a
copy of the Consumer Guide to the Home Improvement Contractor Law.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!!Two identical copies of the contract must
be completed and signed. One copy should go to the homeowner.The other copy should be kept by the contractor.
You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,
provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted, by
telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement.
See the attached notice of cancellation form for an explanation of this right.
,_. aea"-,e/11624o$43.&,2.
Si re Date Signature Date
Contractors Signature Homeowner Signature
Date 08/07/2019 Date 08/07/2019
Contractor Arbitration
The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action (as an
alternative to court action) if they have a dispute with a contractor.The same right is not automatically afforded to a
contractor, however.The contractor would have to resolve any dispute he/she has with a homeowner in court unless
both parties agree to the optional clause provided below.This clause would give the contractor the same right to
arbitration as is afforded to the homeowner by the Home Improvement Contractor Law.
The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute
concerning this contract, the contractor may submit the dispute to a private arbitration firm which has been approved
by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be
required to submit to such arbitration as provided In Massachusetts General Laws,chapter 142A.
Signature Dat
Contractor's Signature
Date 08/07/2019
NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternative dispute
resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this
section is not separately signed by the parties.
Homeowner's Rights
A homeowner's rights under the Home Improvement Contractor Law (MGL chapter 142A) and other consumer
protection laws (i.e. MGL chapter 93A) may not be waived in any way, even by agreement. However, homeowners
may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law.
Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of
the Home Improvement Contractor Law. The contractor is responsible for completing the work as described, in a
timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor
guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties
provided by the contractor, all goods sold in Massachusetts carry an implied warranty of merchantability and fitness
for a particular purpose.An enumeration of other matters on which the homeowner and contractor lawfully agree may
be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you
have questions about your consumer/homeowner rights, contact the Consumer Information Hotline (listed below).
Execution of Contract
The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced
documents have been attached.Parties are also advised not to sign the document until all blank sections have been
filled in or marked as void, deleted, or not applicable.One original signed copy of the contract with attachments is to
be given to the owner and the other kept by the contractor.Any modification to the original contract must be in writing
and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy
of the contract,and the three day rescission period has expired
Additional Information
If you have general questions or need additional information about the Home Improvement Contractor Law or other
consumer rights, or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement"
contact:
Consumer Information Hotline
Office of Consumer Affairs and Business Regulation
10 Park Plaza, Room 5170, Boston, MA 02116
617-973-8787, 888-283-3757 or visit the OCABR website at http://www.mass.gov/ocabr/ If you want to verify the
registration of a contractor or if you have questions or need additional information specifically about the contractor
registration component of the Home Improvement Contractor Law,contact:
Director of Home Improvement Contractor Registration
Office of Consumer Affairs and Business Regulation
10 Park Plaza, Room 5170, Boston, MA 02116
617-973-8787, 888-283-3757 or visit the HIC website at http://www.mass.gov/ocabr/Go online to view the status of a
Home Improvement Contractor's Registration:
http://db.state.ma.us/homeimprovement/licenseelist.asp For assistance with informal mediation of disputes or to
register formal complaints against a business, call:
Consumer Complaint Section
Office of the Attorney General 617-727-8400
AND/OR
Better Business Bureau 508-652-4800,508-755-2548 or 413-734-3114
Version 2.1 - 11/22/2010
NOTICE OF CANCELLATION
YOU MAY CANCEL THIS TRANSACTION, WITHOUT PENALTY OR OBLIGATION, WITHIN THREE BUSINESS
DAYS FROM THE ABOVE DATE.
IF YOU CANCEL, ANY PROPERTY TRADED IN, ANY PAYMENTS MADE BY YOU UNDER THE CONTRACT OR
SALE, AND ANY NEGOTIABLE INSTRUMENTS EXECUTED BY YOU WILL BE RETURNED WITHIN TEN
BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOU CANCELLATION NOTICE, AND ANY
SECURITY INTEREST ARISING OUT OF THE TRANSACTION WILL BE CANCELLED.
IF YOU CANCEL,YOU MUST MAKE AVAILABLE TO THE SELLER AT YOUR RESIDENCE, IN SUBSTANTIALLY
AS GOOD CONDITION AS WHEN RECEIVED, ANY GOODS DELIVERED TO YOU UNDER THIS CONTRACT OR
SALE; OR YOU MAY, IF YOU WISH, COMPLY WITH THE INSTRUCTIONS OF THE SELLER REGARDING THE
RETURN SHIPMENT OF THE GOODS AT THE SELLER'S EXPENSE AND RISK.
IF YOU DO MAKE THE GOODS AVAILABLE TO THE SELLER AND THE SELLER DOES NOT PICK THEM UP
WITHIN TWENTY DAYS OF THE DATE OF CANCELLATION,YOU MAY RETAIN OR DESPOSE OF THE GOODS
WITHOUT ANY FURTHER OBLIGATION. IF YOU FAIL TO MAKE THE GOODS AVAILABLE TO THE SELLER, OR
IF YOU AGREE TO RETURN THE GOODS TO THE SELLER AND FAIL TO DO SO,THEN YOU REMAIN LIABLE
FOR PERFORMANCE OF ALL OBLIGATIONS UNDER THE CONTRACT.
TO CANCEL THIS TRANSACTION, MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS CANCELLATION
NOTICE OR ANY OTHER WRITTEN NOTICE,OR SEND A TELEGRAM TO[Name of Seller],
AT[Address of Seller's Place of Business] NOT LATER THAN MIDNIGHT OF
(date). I HEREBY CANCEL THIS TRANSACTION.
/efrICPC406
Signature Date
Buyer's Signature
Date: 08/07/2019