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HomeMy WebLinkAboutBLD-23-001163 ,YRitt AA Office Use Only `7 l Permit# 24 O . H 1 Amount ado./. ceM,A,T„..., c[s[ ���"..'0°"1'e, i Permit expires 180 days from i issue date 13E4) _ 3_60)6 3 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department ----- 1146 Route 28 SEP 0 1 2022 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT Vt BY ----- CONSTRUCTION ADDRESS: 2.--,..) w Ca h tc' v D t i'e f )!o.I v/l t 1 ASSESSOR'S INFORMATION: Map: Parcel: , ' /OWNER: ?-1Ah Ni)(an 2-3L 3 u U.hYea�C v'e 5-6Si- 2-A`j 'V(ate(NAME PRESENT ADDRESS TEL. # , CONTRACTOR: S i 0i-J t 13.tc,t.k'\-4`62-St,4-1.tsiuk,1 4 7c I,-`1,1-0 -0OS NAME MAILING ADDRESS TEL.# residential 0 Commercial Est.Cost of Construction$ / .9)52. /3 /Home Improvement Contractor Lic.# I cl (e act C� Construction Supervisor Lic.# C - Ob ek2,1.e Workman?Compensation Insurance: (check one) am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: C''v c CI U Md &&4.,c tkt rs Worker's Comp.Policy# 41-k L2 (b 't Ll 1 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # 'Roofing: #of Squares Z Z- ( 1 )Remove existing* (max.2 layers) Insulation ✓ Old Kings Highway/Historic Dist. (✓)Re lacing 'ke for like Pool fencing PR VW. aftk) 1 in 1 Oa- — ot- -- o ace-I .1/$J,y 'The debris will be disposed of at: Zd&/r7 CA//d AV/54 Location tf 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 of my license and for prosecution under M.G.L.Ch.268,Section 1. / r_ I V Applicant's Signature:(� 2ZDate: II Owners Signature(or attar ent) S eC Date: ! ///ZZ Approved By: Date: Building Official desee) EMAIL ADDRESS: 1 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 . Property Address The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 a, 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): 72(2(r ' ,,i1 .t— i' b..v l�j0S *r. , . (�L_Z., Address: / loral i I I 4-4.- 5,-t City/State/Zip 4(151-on i 1114 OL13....( Phone#: 1T... 4 — vdv` , Are you an employer?Cheek the appropriate hos: Type of project(required): 1.a I ant a innployer with y't ?lnvees(full andiur part-tole).* 7. 0 New construction 2_0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capxacity..[No workers'comp insurance required] 3.0I am a homeowner doing all work myself[No workers'comp,insurance required.' 9. ❑Demolition 10 0 Building addition 4.0I am a homeowner and will be hiring contractors to conduct all work on my property. €will tatstire that ail contractors either have stokers'compensation insurance or are sole 11,0 Electrical t epairs or additions pro mom. with no ernpkweea 12,OPlumbing repairs or additions 5, lam a general contractor and I have lured the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employee,and have workers'comp,insurance f � {� 1 6❑We,are it corporation and its officers have exercised their right of exemption per Wit.c. 14, ther -© ' e�l�c e 152,§I(4),and we have no employees [No workers'comp±.insurance require 1.' *Any applicant that chucks box t 1 nuts al:.f.till out the section below showing their workers'crmpens:atu n policy information. ltorneowners who submit this of tidavit indicating they ale doing all work and then hire outside contractors insist submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and.talc whether or not those entities have cmplovees- If the sub-s'c,nrractors have en pkn ecs,they roust provide then workers'cony p+'lics°number I am an employer that is providing workers'compensation insurance for ma'employees. Below is the policy and job site information. insurance Company Name: Policy#or Self-ins.Lic. ii: Expiration Date. Job Site Address: City/StatelZip: _ Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGI.c. 152, §25A is a criminal violation punishable by a tine 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 1 do hereby certify u f,r the nab - d penalties of perjury that the information provided above `s true ant!correct Official use only. Igo not write in this area, to he e,mrpleted by city or(men official. City or Town: Newton Permit/Lkense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical inspector 5.Plumbing Inspector 6.Other Inspectional Services Dept. Contact Person:John D. Lojek, Commissioner !hone#:617,796.1060 AC � DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 03/23/2022 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(les)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 Jeff Leavitt NAME: Lennox Insurance PHONE .Exit: (781)569-5321 FAX No): (781)623-4770 29 Albion Street,Suite 2 ADDRESS: efflennoxins mail.com ) �g Wakefield,MA 01880 INSURER(S)AFFORDING COVERAGE NAICII Phone (781)224-4108 Fax (781)623-4770 INSURER A: EVANSTON INSURANCE COMPANY INSURED INSURER B: HARTFORD UNDERWRITERS INS.CO. Roof Right Now Boston LLC INSURER C: 1 Braintree Street INSURER D: INSURER E: Allston MA 02134 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDLSUBR POLICY EFF POLICY EXP LIMITS INSR WVD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) O COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00 GE TO RENTED El CLAIMS-MADE © OCCUR PREMISES SES(Ea occurrence) $ 100,000.00 ❑ MED EXP(Any one person) $ 5,000.00 A ❑ 3AA463916 03/22/2022 03/22/2023 PERSONAL&ADV INJURY $ 1,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000.00 ❑ POLICY ❑ JEa ❑ LOC PRODUCTS-COMP/OP AGG $ 2,000,000.00 ❑ OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) - $ ❑ ANY AUTO BODILY INJURY(Per person) $ ❑ OWNED ❑ SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS ❑ HIRED ❑ NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) ❑ ❑ $ ❑ UMBRELLA LIAR ❑OCCUR EACH OCCURRENCE $ ❑ EXCESS LIAR ❑CLAIMS-MADE AGGREGATE $ ❑ DED ❑ RETENTION$ _ $ WORKERS COMPENSATION OTH- ❑STATUTE ❑ER AND EMPLOYERS'LIABILITY Y/N ANY B OFFICER/MEM ER EXCLUDED? CUTIVEn N I A HA1216441 03/25/2022 03/25/2023 E.L.EACH ACCIDENT $ 500,000.00 (Mandatory In NH) I II E.L.DISEASE-EA EMPLOYE $ 500,000.00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000.00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Roof Right Now THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1625 Massachusetts Ave,Lexington MA 02420 AUTHORIZED REPRESENTATIVE I _ _ ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03)QF The ACORD name and logo are registered marks of ACORD • • r 41, art �»«}q} y iluing Regulations Board rif in f Professional r Stanciarcis - „,' , -- 5.itpires: 091121202: • fr, MARSHFIELD MA 02050 Of e • Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: LLC Req i st.rati o n: 196396 ROOF RIGHT NOW BOSTON LLC Expiration: 09/26/2023 1 BRA INTHE:_E S I At 1.STON,MA 02134 Update Address and Return Card, SCA 1_0...20N1.O %1 Office of Consumer Affairs 8 Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:LLG before the expiration date. If found return to: Reg.stration Expiration Office of Consumer Affairs and Business Regulation 196396 09.26,2023 1000 Washington Street -Suite 710 ROOF RIGHT NOW BOSTON LLC Boston,MA 02118 JAMES CLARK 1 BRAINTREE S.T. ALLSTON,MA 02134 �...< Not valid without signature Undersecretary �... ...... ......w .............-..............a...f • t T vT ' 20. (d 0 I Issue warranty 45 days after job completion Material Warranty on selected shingle 0 Lifetime l 5Z ears form is submitted and job is paid in full. Items Not Included Labor and Workmanship on all installed materials / Years The price agreed upon for work is Additional Items included Total Price $ r I 7-32 d ( 3 c•�/ $( Sales Tax $ X.,./1/5 lir De br�3 £' 04, �c ct f v 1 4 Y/era ( Deposit $ Due at arrival $ Due at $ Due at completion $ Payment terms: Carpentry en l.) Cash 1. If needed,roof decking is removed, and replaced. The customer 2.) Finance 0 "Yes, I would like the contractor to set agrees that each 4'x 8' sheet of decking needed for replacement A up financing and I agree to execute all documents will cost an additional $150.00 per sheet plus material cast orR t `"°r required." $15.00 per linear footplus material cast for board lengths. --�`' If this contract is to be financed,the agreement for credit is 2. Repairs to damage such as dry rot, or split, or failing wood that contained in a separate document which is incorporated herein by requires replacement before a new roof will be completed are reference and made part hereof. I/we are hereby authorizing the added to the total above at a rate of$75.00 per hour plus the contractor to verify and review my/our credit record with an actual cost of materials needed to fix the affected area. Customer independent reporting agency and do release contractor from all is to receive receipts and photos of repaired areas. liability incurred from inadvertent errors or omissions. 'here arc no promises, agreements, nor understandings not expressed in this proposal, and this writing constitutes the entire agreement All agreements are contingent upon accidents, TEATHFR,or other causes out of our control,and are subject to approval and acceptance by the Contractor. If this is a credit transaction,credit documents will contain information as to heduled payments and interest rates. In case of legal action, Purchaser(s) agrees to pay all attorneys fees and costs of collections. In the event that the Purchaser has any dispute with the mtractor concerning damage of the premises by reason of the work of the Contractor,the Purchaser will pay the stated price plus any agreed upon extra fees upon presentation of the insurance Ley providing coverage for such claims and proof of submission of the claim to the insurance carrier to the Purchaser,by the Contractor. his message applies to door to door sales only:you,the Purchaser,may cancel this transaction at any time prior to midnight of the third business day after the date of the transaction.Purchaser derstands that if this agreement is canceled after the recession period,the Purchaser is liable for twenty-five percent(25%)of the total sales price as damages to the Contractor. This is not an 'stsmate';this is a legal binding contract. Important Notice:You and your contractor are responsible for meeting the turns and conditions of this ccnnract.If you sign this contract and you 1 to meet the terms and conditions of this contract,you may lose your legal ownership rights in your home.Know your rights and duties under the law. witness,whereof Purchaser(s)has hereinto signed his/her names)o the date of and acknowledges receipt of a true copy of this contract,it is the understanding of the tractor that the purchaser is ready for w to ustomer(s) Signed _ • Date dlesperson Signed � "'� Date . AIN 2L.