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HomeMy WebLinkAboutbld-20-004043�.. w.O�;Y9R Office Use Only ‘1. • � k`t O Permit# 41', 1 .,H {Amount MATTACM :;,/, °`......°" a Permit expires 180 days from issue date 3uOs—a0—.LIDLi3 RECEIVED EXPRESS BUILDING PERMIT APPLICAT TOWN OF YARMOUTH JAN 23 2G,_.'. 1 Yarmouth Building Department _ ,j 1146 Route 28 BUI I p ^t 1/r By: '71 `I' South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: i2 ,Ti 42 !ems 0- (/2 t �� ,!Q✓rN't 0�'/'t �,� 0Z l7(j if ASSESSOR'S INFORMATION: e ��Aj Map: / Parcel: / p OWNER: Ha,yl� C,"Am EO. 'Ovl /2 A4t us O /+2 S VC_r►tit DC 1 g 4 O - -323632. I NAME /�'^- / (/ f PRESENI/ADDRESS p ' TEL. # 1 CONTRACTOR:JIL 1 COOS.T'f LPC-(1 o 4,JLe 2.0 h0f s e PO ot.cl (I, M V `wog- %, !A ©2 ' 3 NAME MAILING ADDRESS TEL.# 60 g_ 3 6 0_ 13 g3 ®Residential ❑Commercial Est. Cost of Construction$ Jr) 1134, O Home Improvement Contractor Lic.# ig 11 10 2 Construction Supervisor Lic.# `'OC a Workman's Compensation Insurance: (check one) 0 I am the homeowner ❑ I am the sole proprietor Iii I have Worker's Compensation Insurance �T /� / Insurance Company Name:A@l aeir14 GtS Ltram Ce- IOGo t v Worker's Comp.Policy# w VC ©l/V W 109 1' WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows: # Replacement doors: # Roofing: #of Squares 7'I/� ( .f )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing ,(� /;W� v-� Ka-r.4,.,��o � AIS' -em so..f Are,,A. � *The debris will be disposed of at: t OC 'D r-S 1 c d 14,/ / Oct-( 11- ✓t //I 0 2 O+4 2 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 revoca.pep of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: C /" Date: 0 Z Z / '26) Owners Signal re(or attachment Date: Approved By: Date: / — Z� -20. Building 0 I((o ignee' EMAIL SS: Zoning District: Historical District: ❑ Yes C No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: Yes 0 No 0 Yes 0 No - f • ._ ,,,- The Commonwealth of Massachusetts =,► _ Department oflndustrialAccidents vie= 1 Congress Street, Suite 100 _�a �_ Boston, MA 02114-2017 wM.:5�.`'y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information { � Please Print Legibly .Jr Name (Business/Organization/Individual): / / (C)In S I CLC-C-' ‘14 01.4 L 1(.� Address: 2 a, offor3._e-- pow,' /d ! � gtr-04_be., 1-4 / /im ©2-6'- ? City/State/Zip: Phone #: re)? -36n - / 3OS Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with 3 employees(full and/or part-time).* 7. ❑ New construction fil 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.]1. 9. Ell Demolition41 10 ❑ Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 1 ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions i proprietors with no employees. 12.❑Plumbing repairs or additions 6.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[ Roof 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. 14.0 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. l'as / Insurance Company Name: �' y �G kt . -ram pi,C.Q b Co Policy#or Self-ins.Lic. #: t✓Cil/ © -(4'2 I1'91 Expiration Date: 12, /a 6/292.0 Job Site Address: I a- al m-r S a✓Q, c. u1 l e44-OC City/State/Zip: MIY 0 266 I( 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 u er the pains and penalties of perjury that the information provided above is true and correct. Signature: I Date: o?'/2 �-/ Z02,0 Phone#: 'CO - j © - /38S. 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#: from Air Vent, Inc. Shingle vent II vinyl ridge vent provides your home with the necessary exhaust ventilation to prolong the life of the shingles and the wood heating to ensure a properly balanced ventilation system if used in conjunction with eave intake ventilation, and provide cooler attic temperatures in the summer and less moisture-laden damaging air in the winter. 10. Storm Nailing: Since we live a severe storm region,ALT Construction undertakes additional (storm) nailing in compliance with the recommendations of the National Roofmg Contractors Association and the manufacturer. Secure new roof with 50% more nailing, upgrade minimum standard (4) four nails per shingle to (6) six nails per shingle, 1 1/4" long. nails will be galvanized with a rust-inhibitive coating. 11. Remove and re-install new Lead Flashing around both Chimneys. 12. Dumpster will be sent to the job site. 13. Shingle installation: Supply and install CERTAINTEED LANDMARK: LIFETIME WARRANTY, 10 YEAR SURE START PROTECTION, CLASS A FIRE RATED, COPPER/ CERAMIC STONES for a FULL 10 YEAR WARRANTY AGAINST ALGAE CONTAMINENT, 250 POUND, EXTRA HEAVY WEIGHT, 130 MPH WIND (6 NAILS PER SHINGLE), MULTY LAYERED, LAMINATED ARCHITECTUAL STYLE, FIBERGLASS BASED ASPHALT SHINGLES. /� COLOR: a,je/_..,e- S /n.-2_ (�pix, L All material is guaranteed to be as specified. The above work will be performed in accordance with the specifications submitted and completed in a substantial workman-like manner for the , sum of: Five thousands four hundred thirty dollars(5,430.00$)with payments as follows: deposit of$1,680.00 and remainder upon completion *Any alterations from above proposal involving extra costs will be added under a separate written agreement and become an extra charge over and above said proposal. RESPECTFULY SUBMITTED • Aliaksandr au ACCEP ANCE OF PROPOSAL The above price, specifications and conditions are satisfactory. I hereby accept this proposal. You are authorized d th work and payments will be as specified above. SIGNATURE: *This proposal may e withdraw by said company if not accepted within 30 days. cilefo4ye/iitoyiutteaid Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type LLC ALT CONSTRUCTION LLC Registration: 194702 22 HORSE POND RD Expiration: 02/28/2021 W.YARMOUTH,MA 02673 • Update Address and Return Card. SCA 1 0 20M-05/17 // �,,��// � n�2n' c mmonwen'7/p O/Q4 ijjac uje& Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:LLC before the expiration date. If found return to: Reaistratiort Expiration Office of Consumer Affairs and Business Regulation 194702 02/28/2021 1000 Washington Street-Suite 710 ALT CONSTRUCTION LLC Boston,MA 02118 r'^ ALIAKSANDR TUROCU 44714 22 HORSE POND RD "- f` W.YARMOUTH,MA 02673 Undersecretary of valid/Without signature Commonwealth of Massachusetts 1®t Division of P Regulations and Standards ��f Board of Buiidin liii"qtr Specialty Construct r Aires:0411412023 CSSL-10616Y �1 + ALIAKSANDI G , 20 HORSE D WEST YARMG}IT t jw Commissioner 'iL „za, '11 s i a tr o a t”LA !. �R yp. .' ' s � . t a � , � s� yr' zr�N + rr� � Nor � � @ `, • • ¢ w y� *} � Ct4;:',�n; .."±,,aG` atri o r n?" '�`x..`�. .:.k„ . a ,ar�2^ •.k....tie,„w'w ' '�,� oxn�..., .e 5 0 1 . , .ck . ..11.1 im_., 3111M1 Atlantic Charter Insurance Company VDAC NCCI Co. No. 29211 Policy Number WCV01420401 1. INSURED: Prior Policy Number WCV01420400 ALT CONSTRUCTION, LLC Producer: Eastern Insurance Group, LLC 22 HORSE POND ROAD PO Box 79398 - WEST YARMOUTH, MA 02673 North Dartmouth, MA 02747 Federal ID Number 832032890 Business Type: Limited Liability Risk Id Number: SIC 1521 -236118 Residential Remodelers Other Named Insured: Other Work Places 2. POLICY PERIOD: The Policy Period Is From: 12/04/2019 To 12/04/2020 12:01 A.M. Standard Time at The Insured Mailing Address 3. COVERAGES: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here:MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A.The limits of our liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,000,000 each employee C. Other States Insured: Part Three of the policy applies to the states, if any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B D. This policy includes these endorsements and schedules: See WCE105 4. COVERAGES: The premium for this policy will be determined by our Manual of Rules, Classifications, Rates& Rating Plans. All information required below is subject to verification and change by audit. Code Premium Basis Total Rate Per Estimated Classifications Co Estimated Annual $100 of Annual Remuneration Remuneration Premium See WC 00 00 01 Minimum Premium: Deposit Premium: $575 $7,409 Total Estimated Premium $7,175 Interim Adjustment: Annually Surcharge(s) 234 Servicing Office: Total Premium and Surcharge(s) $7,409 25 New Chardon Street Boston, MA 02114-4721 ..t`'� Issue Date 11/26/2019 Countersigned By: � Date Copyright 1987 National Council on Compensation Insurance Form:100mvnt4