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Home My WebLink AboutBld-20-003754 Office Use Only ' ,O ' '� 'Amount L') U� MATTA M I Permit expires 180 days from = := issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 0' /5`7 Y / (508) 398-2231 Ext. 1261 qJ CONSTRUCTION ADDRESS: / o5/l c4 4.te Nve zoecl GfjQ�ttiii��•- j/1/�J e�6 0� ASSESSOR'S INFORMATION: Map: 30 Parcel: p?v OWNER: `/ , TOW/ yr f ft?, NLe', li✓' !�/�✓� NAME PRESENT ADDI2I SS / TEL. CONTRACTOR:IPAI.1,45 vye�r�-/,4.re /d ,77 ZJ L.# to- NAME MAILING ADDRESS sidentia1 0 Commercial Est. Cost of Construction$ Home Improvement Contractor Lic.# /493/ Construction Supervisor Lic.# O',7P/3 Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor //"� I have Worker's Compensation Insurance Insurance Company Name: /i-r"L / -ry., ( .✓�/� Worker's Comp.Policy# .260/W eesY WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 3 Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: / 00 Lotion 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- *cation of my license..: for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: / Date: %�. AA/ Owners Signature(' attachmen Date: _� 11 Approved By: /may;. Date: /' 2 " add 0 Building Official(or designee) EMAIL 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: ❑ Yes ❑ No ❑ Yes 0 No 7A;;1141,3=104/1.1 Plia CUv'C.rilic �O r^'lC'it / w The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 imp"" �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): wi.e Address: I. ea, City/State/Zip: �� ..► //&' mil ea.7.2 Phone #: szo 3a-f Are you an employer?Check the appropriate box: Type of project(required): a employer with ,5 employees(full and/or part-time).* 7. E 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. 9. ❑ Demolition ❑ - y [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 6.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E 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.❑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: )'"-4- Ic-l? J Policy#or Self-ins. Lic. m: c=2-(10/ 3 1$-3 Expiration Date: 5--/- aogd Job Site Address: 4 /44.4 " City/State/Zip:A"%r/74.t d'& CPO Attach a copy of the workers' compensation policy declaration page(showing the policy number/and ex ira f(on 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. Signature: Date: / - lrtge Phone#: ,9 ,f�49 / 7; Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License 4 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#: -Roof to be stripped and cleaned of all old shingles and debris -Roof to be papered with weather watch leak barrier, installed with Timberline architectural shingles using galvanized nails.(Storm nailed) -All new 8"drip edge and pipe flanges to be installed -Cobra ridge vent to be installed on all ridges -TimbereteX premium ridge cap to be installed -SBC cedar hingles to be installed in accordance to all manufactures warranty specifications -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: /77. .a,. or Homeow er Contractor Aciifyrd CERTIFICATE OF LIABILITY INSURANCE OATS($10/0DIYVYY) 04/362019 THIS CERTIFICATE IS ISSUED A MAtIER OF RIPORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS - CERTIFICATE DOES NOT • TWLY OR-NEGATIVELY MUM MORI OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE a INEANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZE) REPRESENTATIVE OR ,• . « APE?THE CERTIFICATE HOLDER. IMPORTANT: If the certificate • • Isian ADDITIONAL INSURED,the polkyOss)mast have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,dibiebt tb elb lobos and toldidow of els Par*.SOWN poNdes may require an endorsement. A statement on this certEcate does not confer rights to Ihe certMcato holder In Ibts Oda* MODICUM Jen Davis Mark Sylvht Insurance Agency,LLC go(5013)9574126 1 Iti ft), (606)957-27111 404 Main Shut maddlmarksyNiainstrance.com Centerville,MA 02632 SOROOSES1 AFFONONSICOVERAGE 4WD Junems:Fan Family Casualty Insurance INSURED Mums Thomas Home Improvements LLC soma c: - PO Box 177 INIUNNIL 0; Centerville,MA 02632 mitnesta 2 1 _mmomew: COVERAGES Cal hriF. IONDIPRININSt __EVISION MillIMER; THIS IS TO CERTIFYTHAT THE POLICIES OF INSURANCE USTED StitAwi HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTIMTHSTANDINO ILNy REQUIREMENT.TERM OR CONDMOPI OF ANY CONTRACT OR OTHER DOCUMENT PIM RESPECT TO WHICH THIS CERTIFICATE MAY SE ISSUED OR MAY PERTANI,THE INSURANCE AFFORDED SY THE POLICIES DESCRIED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND cONDITIoNS OF SUCH IiLUCIFILIMITS MOVE MAY HAVE BEEN REDUCED EY!MCLANE birt.„) WHEW IDISMANCI =mil=, Munson= MP& stratt* UNIT; X ccaniatcaLCIENERALUAINUTof ,/,,44, ..,.t..t. - - II 1,000,000 I CLAstS4AAIDE Ej occult ' -7.---.. ........$ $ loom° — sat or SWavir sow* $5,000 A — it N 2001X1416 510112019 50112020 PERSONALS AY*WRY $ 1.000,000 _Wpm AGGREGATE WAIT FPFUES P i anefoLseamoinv $2.000.000 X POLICY El M El LOC PRODUCTS-COMPIOP AGO $4000.000 OTHER , $ AUTOPADIELS UAW, EZZINHOLE UMIT $ — ANY AUTO SOLELY MUM/(Per mew) I — AUTOS _ AUTOS.wen -, HiftED $ — AUTOS ONLY — ATTOS—Wif Pt; . . $ , _— . USIONELIA LlAS occult EAOHOOOLINIEHICE $ MISS LIAO CIANISSIAOE ASIORSONIX • $ DEO I I RETEIMON$ $ - WONKIRSOOMININIANON . IVILT1E 1 I AND SINNAMINN LimoureE.L.roassccann• s 1.000.000 A AtivomcattaremPRirwe'reateMEcuTi" 1.2_,j OM N 20011N6033 5/0112019 5/012020 , s (11mdalery In NH) E.L.MEW-EA EMPLOVIE 1,000,000 itaampdillittri OF OPERAMONS blow EL WOE-POLICY tsar $ 1,000.000 DEACISPHool OF OPIRATIONIU LOcAnoNi mum!SICOND*I.Addiamill INANANSiNdule.esaybo illidri Soso spies Is nisted) CsrPentlY Insurance coverage is BMW to the terms,landfills's,excluslons,other imitations and endorsements. Plotting coritained in the certificate of Insurance shall be deemed to have altered,waived or talended the cove/age padded by the policy provisions. . . CERTIFICATE HOLDER - CANCELLATION INDULT*PM oF TIE ABOVE INISCREND POLICIES ea CANCELED WORE TIE ECINNATS)11 DATE 1HERE0F. NOTICE WALL SE OELN IN ACCORDANCE WM THE POLICY Town of Barnstable Building dept. PROVISIONSsiONL 200 Main Street - atmoodad MINVIONITANVE , AA* • 1 Hyannis MA 02601 Fax: Ernal: 0 111151-2015 ACORD CORPORATIOK All rights seemed. ACORD 25(2015/03) The ACORD name and logo aue noglataredineda of ACORD — — ...:..... • s. Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards :i Construction,sv}pervispr Specialty CSSL-099913 _ - fires 04/1,3/2020 Y v.L. . TROY A THOMAS f n-1f 499 NOTTINGHAM DR/ E.: CENTERVILLE MP,_0263 R # Commissioner ci*' Office of Consumer Alfa rs&Business,Regulation i HOME IMPROVEMENT CONTRACTOR Rai Corporation , I 185422 TROY THOMASHOME IMPROVEMENTS, ENTS,INC. TROY THOMAS acCENTERVINLEHMA 02632 ep Undersecretary