bld-20-004675 Office Use Only a
;`c'; t• ! 0 •
Permit# �p
O l i• V . ()J-I073 -:Amount
•iN,n�r7i�tn�cJd�• -
°""'".° 6 :• ,Permit expires 180 days from
' ::"'• =issue date
EXPRESS BUILDING PERMIT APPLICATIQK E C IE 1 V E 61
TOWN OF YARMOUTH 1
Yarmouth Building Department i i `7 :E) ,` 2]2 ;
1146 Route 28 k .
t
South Yarmouth, MA 02664 e t E L
(508) 398-2231 Ext. 1261 '``
CONSTRUCTION ADDRESS: ?
5 lYI 51e.4 Y XI Yer'fita,i1‘.1-
ASSESSOR'S INFORMATION:
Map: �f' >P�arcel: Q� �f/ l�
ii hi
OWNER: 7 H (O✓1 ►e.-0,r ( l l� i'yz,"!�° $ .- 77 -" /! 71
NAME PRE ADDRESS / TEL. #
CONTRACTOR: /4211../- �C
r/ 4ra (• e 1(
1 A-r 0- O( . '` # 5-c0 —6/ [ $l /!
NAME MAILING ADDRESS TEL
Q'Residential 0 Commercial Est.Cost of Construction 017 Zo e>
/�77C0 9 ¢
Home Improvement Contractor Lic.# Construction Supervisor Lic.# �s' Q /��U l
Workman's Compensation Insurance: (cl4.ck one)
0 I am the homeowner am the sole proprietor 0 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:# i 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: 504ti kiC_Q
7CC-ln --- ' ,7-;2d,s-•:,
Location Facilit
I declare under penalties of perjury that the . ements 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 revo ,n of. y license and for prosecution under M.G.L.Ch.268,Section 1.
App' ant's Sign. -• �� Date: ;/ 2 Y/2O
wners Sign• ' re(or a''a�t) Date:
Approved By: als%r Date: rGQ
Building 0.r i.- • desi;. ee) E .,' 'DRESS:
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 oflndustrialAccidents
_nrA 1 Congress Street, Suite 100
11
_ Ic Boston, MA 02114-2017
^�;s.•�'' 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): dirKt1 T . P.f1C1l i� ��%✓✓r )-
Address: 5!'
City/State/Zip: j. i1f7' QZ66 Phone #: S? 0.671-5V
Are you an employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with employees(full and/or part-time).* 7. ❑New construction
2.j 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
3.0 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.❑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.E 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_
tContractors 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:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
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 unde ze pains a nalties of perjury that the information provided above is true and correct.
Signature: ; ,�- — Date: 77/Z00 c/
Phone
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#:
le ai�zirz��aeal c Rez-s.,Jac4,,,e/A
Office of Consumer Affairs&Business Regulation
t HOME IMPROVEMENT CONTRACTOR Regi
TYPE:LLC befoi
Registration Exoiration Offiu
187700 = 05/11/2021 1000
HUDSON HOME RENOVATION LLC Bosh
JAMES HUDSON
80 AIRLINE ROAD aefGG./` '
SOUTH DENNIS,MA 02660 Undersecretary
1111111
v _
r Commo;iweaith of Massachusetts
Divisio, of Professicnal Licensure
•
Board of Bu'Jing Regulations and Standards
Cor:str tCt ritOpervisor
4
CS-092681 'p ires: 12/10/2019
JAMES E HUDSON f < ; ,.
110 AIRUNE RD -
SOUTH UENNISMA 02660 > s i
Commissioner CL
x
commotivviebottnwealt
� . Massachusetts
tUCterisure
C 011St
_E: :�v ', a iv �,- ;
SO Mitt* RCA -
I • #t
;. ��
CONTRACT
1'A i Pr ."I PrA
HUDSON HOME
RENOVATION
Making your dream home a reality!
FEBRUARY 11, 2020
80 Airline Road South Dennis,MA 02660
Phone 508-694-5419
hudsonhomerenoyation@gmail.com
TO Frank Montani
59 Captain Stanley
South Yarmouth,MA
{ JOB# START DATE PAYMENT TERMS COMPLETION DATE
TBD One Third at start, and full payment on TBD
completion.
WORK DESCRIPTION
Strip rake boards, air boards,and siding,pull out louver and replace with new PVC,pull out
old window and install new Harvey window,Typar house wrap,New Certainteed Cedar
Impression siding,New PVC rake boards with PVC bed molding,New PVC air boards,Dump
fees and permit cost
Original Proposal 7,650.00
Material cost difference 50.00
7,700.00
New Total
1
Any material requiring special order will be paid by the client. AU material is to be as specified and above work to be performed in a professional
manner. Any alteration or deviation from above specifications involving extra cost,will be executed only upon written orders,and will become an
extra charge over and above the estimate.All agreements contingent upon accidents,delays or unforeseen conditions beyond our control. Owner
to have fire and homeowners insurance in good standing. Liability insurance supplied by Hudson Home Renovation.
The above prices and specifications are satisfactory and hereby accepted. You are authorized to do the work as specified. Payment will be made
as outlined above. This proposal as ritten is valid for 30 days. J
Client SignatureJ9'(:� �i "�r � 1n( Date t / 3 d��
Contractor Signature ? 7r`"-'-""-w„ Date 2/f3/Za
/.
THANK YOU FOR YOUR BUSINESS!