HomeMy WebLinkAboutBld-20-003214 O�'Wilt ` Office Use Only
Y ' .4 1.-.!fli C 1Permit#
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Caro"°c0°9 c jPermit expires 180 days from
• l issue date
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH ���_3a I
Yarmouth Building Department I3
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 0 A ✓ 41A6 l A-(A 5":„.t.L. pi., 4 a /
ASSESSOR'S INFORMATION:
//� ��M'Map: Parcel: �,� ' /7 5 5
OWNER: 4d6.ik..4 k& /-�y/JS k�r J /,J t ffre ,� o' /`0 d/r0
NAME !! PRESENT ADDRESS/t% TEL. #/,��/f
CONTRACTOR: / '.A.As ,/1'�''`'t -f tet. v�I ADDRESS"a
ref �77 avieA d4" q4 e # 0/(1,Y�1
NAME
esidential ❑Commercial Est. Cost of Construction$ .5215"-
Home Improvement Contractor Lic.# /e15-1/d 0 Construction Supervisor Lic.# /3
Workman's Compensation Insurance: (check one) �� �/
❑ I am the homeowner ❑ I am the sole proprietor i1I have Worker's Compensation Insurance
Insurance Company Name: A7AV t- g�`L/ t 1'141 f Worker's Comp.Policy# '/ t/✓G C157
(( WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares Replacement windows: # Replacement doors: #
Roofing: #of Squares /0 ( )Remove existing* (max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
*The debris will be disposed of at: ,r-/ ;( .r*"'L"tt `�✓ re "'
/// Ltion 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�io of m icense and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: � ! Date: /Q' — s---a--0, I
Owners Signature(or attachment) Date: s,
Approved By: `, Date: / 2 �— "1
Building 0 al esignee) EMAIL RES /S:
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 ❑ Yes 2 No
The Commonwealth of Massachusetts
r -ti Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
°�.taw,•`'' 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): yM5 /444e ° '
Address: i�U e•-ic
City/State/Zip: s w 1/f #49nx ., Phone 4: 57e , v?, -
Are you an employer?Check ih ..appropriate box: Type of project(required):
1.2,4da employer with J/ 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.❑Plu bing repairs or additions
5.E 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-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:_,1t"-- �!l sr�•y.L get.<71/
Policy#or Self-ins.Lic. #: ` Expiration Date:
Job Site Address: �/B --� /4' City/State/Zip: (6
Attach a copy of the workers' compensation policy declaration page(showing the policy number d 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$250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and pe lties of perjury that the information provided above is true and correct.
Signature: 7/1/4;---
Date: /2 r S !(/ 7
Phone#: %,v43 f
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
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t.:„.......:Hcoor CEkTIFICATE OF LIABILITY INSURANCE sue masoffvol
THIS CERTIFICATE IS ISSUED AS A I TER Of:INFORMATION ONLY AND.CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRM Y OR NEGATIVELY AaN, EXTORT OR ALTER THE(SAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF NCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), Ate''
REPRESENTATIVE OR PRODUCER,A T IM CERTIFICATE 1101.1Elek
IMPORTANT: If the certificate holder Isiah ADDITIONAL INSURED,the poBoy(Iss)Must May ADDITIONAL MSURED provisions or be endorsed.
If SU TION IS WANED,su6]ect etk The Henna and condition*of the Poll coNI IT policies may require an endorsement A statement on
this does not confer rights to le aerlElcate folder in Ilia of k
ream* ! Jsn Turk
Mark S Ma InsuranceAgency,LLC
TT Itocr, -212s !I .ter- csc6�:zrs1
404 Main Street
InellernedwitdainsuranCacom
Centerville,MA 02632 , stmetwast arrommecom NOMi
! erel,A: Farm Fend*Caul*Insurance
INURED . Neuaafm:
j Thomas Home improvements'.LC smNan_c;
I FAQ Box 177 mac:
Centerville,MA 02532 ! rya:
COWERAGes Jimmy'
TH 1$TO CERTIFY THAT THE LISTEDBROW HAVE MEN ISSUED TO THE HAWED A NOMz THE POLICY PERIOD
TED. NO1'M1HSTANDING ANY TERM OR CONDITION CF ANY CONTRACT OR OTHER DOCUMENT MN RESPECT TO WHICH THIS
i TE MAY BE ISSUED OR MAY °I THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL TIE TERMS,
1pEX AND CONDr11ONS OF SUCH - «(_r.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CURES.
I _ ST1fMBOfegINrANCE r
OOIn1EleQUlOF MUtAL LeleIl iTY r, Iwo mum mom A�1i S
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cxAaNNi+rAOE 0 � ,M" .y,1-v,�r. i 1,000,000
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.4_`"- ' cgcp oia i 100,000
A ij 1A a.psmon $5.0
t N 2001X1416 5101f� FORSOOK t8 51S1/2020 FORSOakbv INJURY i 1,000,000
�` '�""'T t_J JECr a LOC ! AGGREGATE $2 000.000
I PRODUCTS.CCIA'#OPAOo i 2000000
ANTONNoe a u,aNUTY SaNntSINCLE LNI
ANYAUTO tt OQDt.YMUURY(ParrnO i
OWED —SCHEDULED
AUTOS ONLYMED h0 t YN URY(PraocNINN $
AUTOS ONLY — AUTOS ONLY i
UNORILLA UM ioccult
+ EACH OCCURRENCE $
MMUS Woe CtAa s#rAOE fi AOGREGNIE • e
uANtaY • [came 1 1 NR
DNA N 2001W9t153 tEL.EACHAcaDENT i 1.000.000
It p�Yr N tI10I12019 5101PZ020 o ,^EAR $ 1,9001000
a`;` ,: • OPERATIONS e.wM, at Wass-POLICY mar i 1.000.000
O€SeD'rNONOFOralATIONS/LOCATIONS NYdef (ACOaD10f►/1i sidRnrds1186 NNW Om Isisiirsd)
Carpentry
insurance coverage Is limited to the terms, exclusions.other Beitsticce shay be deemed to have altered,waived or cdendedd.the(avenge provided by the end
�contained N the aerl abe of Msllranoe
.
CERT92ICATE HOLDER I INI .LATIQIr<
SHOULD Ater OF THE ABOVE DESCRIBED POUCES RE CANCELLED BEFORE
THE IlIOGIATION DATE THEREOF, NOTICE WLL Si DELIVERED IN
Tom pat
AMTOORDJYi(SMKTIiTtIEPOLIC1flN YI010NL
200 Aft Street
NnnoaaBAtm ..
m Hy nnis MA O2001 9., >. ry '
Fax: Email: i • 019 1I ACOffD CORPORATION. AN rights removed.
ACORD 116(2016103) j The ACORD mime and logo.are registered narks of ACORD
i
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1'ITHoMAS
HOME IMPROVEMENTS
PH. 508.328.1635
Exterior Remodeling Experts BBB.
ACCREDITED
BUSINESS
Web: www.tho ashomeimprovements.net Fully Licensed & Insured
P.O. Box 177 Construction Supervisor Lic #99913
Centerville, MA .2632
TH II MAS HOME IMPROVEMENTS LLC. PROPOSES TO PERFORM THE FOLLOWING WORK:
Loc:tion of proposed work:
Av- bukh Eynshteyn
8A ohns Path
Sou h Yarmouth, MA 02664
Dat, on which construction should begin: December&to be completed within two weeks of signed
agr:ement
The homeowner hereby acknowledges and agrees that the scheduling dates are approximate
and that such delays that cannot be avoided by the contractor shall not be considered as a violation of
this contract.
The contractor agrees that when such delays become known to the contractor,the contractor
will :dvise the homeowner as soon as possible.
The homeowner hereby acknowledges that in certain remodeling work,the demolition process
ma reveal defects in the existing structure which must be repaired,creating additional work which may
nee,, to be carried out in order to complete the work described in this contract. In such case the
ho eowner agrees that the duration of the work and the schedule date of completion may differ,and
that such variation is not to be considered a violation of this contract.
Cost for labor and materials under this contract: $5,675.00
30 yr.GAF/Elk Timberline HD Architectural shingle(Ufe Time Limited Warranty)
Above proposal includes 2-layer strip with rake metal to cover exposed plywood
In the event that while stripping the roof we find rot that needs to be replaced,the homeowner
the has to agree and authorize any replacement or restoration. Then in addition to the above contract
pric:,the homeowner agrees to compensate the contractor for any repairs or restoration at the hourly
rate •f$65.00 for a carpenter and$45.00 for a carpenter's laborer, plus the cost of materials.
Th. You for Giving Us the Opportunity to Help You Improve Your Project
-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
del.:yed 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 t-n 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
du 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
ho eowner. The homeowner may be required to register or mail in such warranty card or evidence of
ow ership in order to activate such warranties. Homeowner failure shall not create any responsibility
for he contractor under the warranty provisions;the choice of repair of replacement shall be at the
disc etion of the contractor.
The homeowner acknowledges that the form,content,and notices contained in this
con ract 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
po iion shall be invalid and the remainder of this contract shall be in full force effect. In addition,any
suc portion not in compliance shall be read and interpreted so as to have its intended meaning to the
ma I'mum extent allowed under such law and regulation.
Signed as a sealed instrument on this date:
Date: )Z�
,/defi�� Homeowner
Contractor
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