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HomeMy WebLinkAboutBLD-23-002536 ' ("*. 0 6( /iL `( '/ )f/ 2 Office Used Only �/O,�,YR) ! / / Permit# ��/e /L + Amount ,/U•6 G ,, ,,,,R„ Cie $. . Permit expires 180 days from r�0ut%��NrCrewi issue date 6c,-D -02-3 -&1,2 536 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 NOV 0 7 2022 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT CONSTRUCTION ADDRESS: / S 1"/Ajf iz6 S a 4'`"7-/4 v_i_<2iy / ASSESSOR'S INFORMATION: I IMap: I Parcel: OWNER: ,, 1"7y D A/94Ca. I Sri 4 >Z p TEL. #3) 4-0 6 3 NAME' PRESENT ADDRESS 3 sS- 39 e;D CONTRACTOR: .84 yS iD.c /3 u/.cD i- R,c4/tJac,4 'Arc svTE # NAME MAILING ADDRESS t c,)-C-r j !�e •J1C/iL. "1- 0_4k 7/ ,esidential 0 Commercial Est.Cost of Construction$ 7 (.9$ o-0 Home Improvement Contractor Lic.# , -o3_Sa,b Construction Supervisor Lie.# o h_13 D Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor have Worker's Compensation Insurance Insurance Company Name:dcfg /f G .L,S/c.h%/ /Ail t!! "0AZ Worker's Comp.Policy#03 Al.Lt9 C &S3 /75))- WORK TO BE PERFORMED Tent Li Duration (Fire Retardant Certificate attached?) Wood Stove I I Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares ! 7 ( em I ve existing*(max.2 layers) Insulation El I I Old Kings Highway/Historic Dist. IrA► Replacing like for like Pool fencing *The debris will be disposed of at: S 9/ ,.T •, --XC 0 DizArArt S G9/1 Location of Facility I declare under penaltie . perjury •.th•ir ements herein contained 4 true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for d ial or rev.•. 10 . , cense and for pro- • v under M.G.L.Ch.268,Section 1. Date: l/ 7 30 r� Applicant's Signature: �� ` S to 6t r/, iA -- Date: Owners Signature(or . chment) // 2_ ,� Date: Approved By: Building Official(ors: igne>,.• EMAIL ADDRESS: Zoning District: Historical District: Yes No Flood Plain Zone: Yes 1 No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No The Commonwealth of Massachusetts aze=1 _-- Department of Industrial Accidents umma 1 Congress Street, Suite 100 t _' `=�' Boston, MA 02114-2017 yl � 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): Sys--a,c, ¢- '`mod _4" Address: /e-fo City/State/Zip: t;J-c.,LA- 036y, Phone#: SY c;--5"rs."-32 Are you an employer?Check the appropriate box: Type of project(required): I.Di<ri a employer with / employees f li_trnd/or part-time).* 7. ['New construction 2.0I 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 3.0I am a homeowner doing all work myself[No workers'comp_insurance required.]t 10 ❑Building addition 4.n 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.El Electrical repairs or additions proprietors with no employees.' 12.Q PI ing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. oof repairs These sub-contractors hay.e-employees and have workers'comp.insurance.: 14.[]Other 6_0We are a corporation and its officers have exercised their right of exemption per MGL c. 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. iContractors 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: 4CR 1 rc.4N 6 �'d- Policy#or Self-ins.Lic.#: 6,3 Io ?-- tf/3 (o a33 Expiration Date: o /i? �3 d-)-66y Job Site Address: /ST/hiJ SOLSOLI/hi1 fo � -i -Mo iy 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 cgtO d{the)ins and p a9es of perjury that the information provided above is true and correct Signature: e"6 Date: /7/7 a(3..- Phone#: , 37 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#: v4;,4 \ ^ • oil of prof-,s+onai ...,c ' tsw e . Boars:n1 Br ions and StanCar€s C00efrirOt pih'Snpieroisor .S-0)6230 Exinres:O6/10/20273 ROBLRT Fbf 4 301 RED TOP; BREWSTER MA 02631 • Commissioner , u • HOME IMPROVEMENT CONTRACTOR TYPE Corporation Registr4tion Exairation 202506 07/08/2023 BAYSIDE BUILD AND REMODEL,INC ROBERT WARD 79D FINLAY RD ,a./&# . ORLEANS,MA 02653' Undersecretary • F • • A ,D' CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)09/12/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Paris Bourdeau SULLIVAN GARRITY &DON ELLY INSURANCE AGENCY INC (AIC No.ExtE (508)453-2582 (A/C,No): E-MAIL ADDRESS: Paris.Bourdeau@sgdins.com 10 INSTITUTE RD INSURER(S)AFFORDING COVERAGE NAIC S WORCESTER MA 01609 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: BAYSIDE BUILD & REMODEL INC INSURER C: INSURER D: P O BOX 427 INSURER E: WEST HARWICH MA 02671 INSURER F: COVERAGES CERTIFICATE NUMBER: 813238 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOI INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH TH1. CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERM: EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LIMITS EACH POLICY EFF POLICY EXP LTR R INSR OF INSURANCEINSD WVD POLICY NUMBER (MMIDOIYYYY) (MMIDOIYYYY) EACH OCCURRENCE S COMMERCIAL GENERAL UA8IUTY DAMAGE TO RENTED PREMISES(Ea occurrence) S CLAIMS tAADE OCCUR MED EXP(Any one person) S N/A PERSONAL&AOV INJURY S GENERAL AGGREGATE S GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S PRO- LOC S POLICY JECT OTHER: I COMBINED SINGLE LIMIT s +AUTOMOBILE LIABILITY (Ea accident) BODILY INJURY(Per person) S ANY AUTO _ BODILY INJURY.(Peraccident) S OWNED SCHEDULED NIA AUTOSONLY AUTOSNON-OWNED PROPERTY DAMAGE S HIRED AUTOS N ONLY (Per accident) AUTOS ONLY AUTOS ONLY S EACH OCCURRENCE S UMBRELLA LIAB _OCCUR EXCESS LIAR CLAIMS-MADE j N/A AGGREGATE S S OTH- DED RETENTIONS IWORKERS COMPENSATION ) X STATUTE ER •AND EMPLOYERS'LIABILITY Y 1 N E.L.EACH ACCIDENT S SOO.000 FFICE .M MBER EXCLUDED, UTrvE INIAI NIA ram O56ZUDORO5317522 O9/10/ZO22 OOl1O12O23 500,000 A (Mandatory in H)excr.uoeoz E.L.DISEASE-EA EMPLOYEE S (Mandatory in NH) If yes.describeunder E_ .DISEASE-POLICY LIMIT S 500,000 DESCRIPTIONN OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS 1 LOCATIONS!VEHICLES(ACORD 101.Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B.no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires.or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes th. issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Iwdiworkers-compensationlinvestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFO THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED ACCORDANCE WITH THE POLICY PROVISIONS. For Insured's Records PO Box 427 AUTHORIZED REPRESENTATIVE 1 'eldest Harwich MA 02617 Daniel M.Crowley.CPCU,Vice President—Residual Market—WCRIBM/ ©1988-2015 ACORD CORPORATION. All rights resei ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD A� ® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 9/12/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZEE REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement or this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACTNAME: Pans BourdeaU Sullivan, Garrity&Donnelly PHONE 5p8_7r _1767 (A/C.FAX 508 754 1885 10 Institute Rd. IL E>nr E-MAILE-M Worcester MA 01609 ADDRESS: paris.bourdeau@sgdins.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Markel International Insurance Company Limited INSURED ROBEWAR-04 INSURER B Bayside Build&Remodel Inc INSURER C: PO Box 427 West Harwich MA 02671 INSURER D: • INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER:1409465188 REVISION NUMBER: THIS IS TO PERIO INDICATED. NOTWITHSTANDING POLICIESERTIFY THAT THE ICY ANY REQUIREMENT. TERM OR CONDITIONIABOVE HAVE BEEN ISSUED TO THE INSURED NAMED T OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TOLWHICH THI CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERM EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUER POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD!YYYY) (MMIDD/YYYY) A I X COMMERCIAL GENERALUABtLITY 3AA599175 9/10/2022 9/10/2023 EACH OCCURRENCE S 1,000.000 DAMAGE TO RENTED S 50.000 CLAIMS MADE X OCCUR PREMISES(Ea occurrence) MED EXP(Any one person) S 5,000 PERSONAL&ADV INJURY , S 1.000.000 GENERAL AGGREGATE S 2.000.000 GEM_AGGREGATE LIMIT APPLIES PER: PRO- X POLICY PRO- LOC PRODUCTS-COMP/OP AGG .S 2.000.000 JECTS jl OTHER: COMBINED SINGLE LIMIT AUTOMOBILE UABILITY S (Ea accident) BODILY INJURY(Per person) S ANY AUTO OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY (Per accident) S UMBRELLA LIAB OCCUR I EACH OCCURRENCE S EXCESS LIAB -CLAIMS-MADE AGGREGATE S S DED RETENTION S WORKERSCOMPENSATION I STATUTE OT I PER OTH- AND EMPLOYERS'LIABILITY ER Y/N E.L.EACH ACCIDENT S (Mandatoryin EK EXCLUDED?Ec`.rvc I I ,y'q (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S If yes.describe under E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES(ACORD 101.Additional Remarks Schedule,may be attached it more space is required) Residential Carpentry,Landscape/Hardscaping CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFOI THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED ACCORDANCE WITH THE POLICY PROVISIONS. FOR INSURED RECORD PURPOSES ONLY AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reser, ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD BAYSIDE BUILD & REMODEL, Inc. 100 Route 28 WEST HARWICH, MA 02671 (508) 255—3900 Betty Redding 1 Stiles Rd. South Yarmouth, Ma 02664 RE: Re-shingle Asphalt Shingle Roofing. Description of Project: Remove and Discard Existing Asphalt shingle roofing. Remove and Discard Satellite Dish All Refuse to be discarded at S&J Exco Facility Dennis, MA Installation of New Ice and Water Barrier,30#Felt Underlayment, New Certainteed Architectural Landmark Pro Series Asphalt Shingles— Weatherwood Color New Ridge Cap Weatherwood Project Cost ( Materials and Labor) $ 10,725.00 Less Promotional Discount - 1,030.00 Total Project Cost after discounts 9,695.00 Payment Schedule: 50% Upon Signing/Product Order $ 4,848.00 C 'i/f/Lc 50% upon Completion $ 4,847.00 ETC: Completion Time within 3 to 4 weeks ( based on product availability and Town of Yarmouth express permit issuance) Professional Workmanship Warranty 5 years - Warranty does not include acts of nature such as high wind,hail,torrential rains, - Hurricane,Tornado or earthquake. Product Warranty - Certainteed Landmark Pro Series Asphalt Shingle Products as Specified by Manufacturer as Limited Lifetime warranty. Please see brochure for information and warranty registration. The above description of project, project cost, payment schedule, project estimated completion timeframe, and warrantys are agreed and acceptable as outlined above. ri.,(44- 4(yyz./.7 Betty Red /Homeowne obert Ward/Project Man ger Bayside Build and Remodel, Inc. CSL#096230 HIC#2025,6 s�