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HomeMy WebLinkAboutBLD-23-00606 .5-////OZA Y Office Use Only l-f ,Permit# �, r'%i32_t:1l, C 0 p4, ',A y Amount %. C/c *‘+* u , 6 0_07J og0 Permit ex ires 180 I . s LIVED EXPRESS BUILDING PERMIT APPLICATI NMAY 03 2023 TOWN OF YARMOtTTH Yarmouth Building Department Irnit40441-8.912_, 1146 Route 28 South Yarmouth, MA 02664 / (508) 398-2231 Ext. 1261 ' A CONSTRUCTION ADDRESS: / 1 v 0 Ce-'/�" f ' e'- /"1°' c-' 5 'e t1./ " t s ASSESSOR'S INFORMATION.. � �/ �(�,(1U Map: Parcel: ` OWNER: .--5-c>t 6 ‘ y" A/ rt lt/1/r 6 %h /( - J I ,k 36 4 a NAME ! PRESENT ADDRESS /� TEL.(# CONTRACTOR /,J 1 Si+Lw- cc L — /" 3‘c- -a T4Y NAME � II)ADDRESS TEL. CIF- CIResidential onunercial Est.Cost of Construction$ ) V) ' t Home Improvement Contractor Lie.# l -7 0 -7 2y nstruction Supervisor Lic.# CS /Q L a co Workmates Compensation Insurance: (check one) 0 I am the homeowner y 0 I am the sole proprietor have Worker's Compensation Insurance ^ ti Insurance Company Name: -t.-l./d Worker's Comp.Policy# \ .1 3 /'l � WORK TO BE PERFORMED T ,LI Duration (Fire Retardant Certificate attached?) Wood Stove Elof� Siding: #of Squares - Replacement windows:# Replacement doors: # Roofing: #of Squares (❑)Remove fisting*(max.2 layers) Insulation L nOld Kings Highway/Historic Dist. Replacing like for like Pool fencing I l *The debris will be disposed of at: Qi€_ t 'J e-- J / -7 Ydt/r-t 7 k J. /d/1I1 a i Location of Facility 1 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'` ,. li a use and for prosecution under M.G.L.Ch.268,Section 1. diDs. i A S-r Applicant's Signature: Date: 3 .2 , Owners Signature(or attachment) S! L Qi7-% '"'� Date: `;/ --) 4/7 --2- Approved By: Date: Building Official(or gn EMAIL ADD Zoning District: Historical District: C1' Yes =..I No Flood Plain Zone: C] Yes No Water Resource Protection District: Within 100 ft.of Wetlands: L Yes 0 No LI Yes 7, No ne Lummunweuun of vlussucnusetts Department of Industrial Accidents "_�• ==r Office of Investigations l�r• i_4 `� W = Lafayette City Center �LL ,01 2 Avenue de Lafayette, Boston,MA 02111-1750 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/individual): Roofing and Siding of Cape Cod LLC Address:68 Winslow Gray Rd City/State/Zip:W Yarmouth , 02673 Phone #:508-360-2749 Are you an employer? Check the.appropriate box: Type of project(required): 1.❑ I am a employer with 4• I am a general contractor and I 6. [� New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ T am a sole proprietor or partner- listed on the attached sheet. '. (l Remodeling ship and have no employees These sub-contractors have 8. E Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp. insurance — comp. insurance." required.] 5. _ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ P umbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.E oof repairs insurance required.] _ c. 152, §1(4), and we have no employees. [No workers' 13. Other comp. insurance required.] "Any applicant that checks box 71 must also fill out the section below showing their workers'compensation policy information. I.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:Amguard Ins Policy#or Self-ins. Lic. #:R2WC354245 Expiration Date:12/20/2023 Job Site Address: / -1 0 5 V City%State;Lip: AfyYkrift D� Attach a copy of the workers' compensation policy declaration page(showing the policy nu ber and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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 S250.00 a day against the violator. Be advised that 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 tr e and correct. Sisnature: al)ahialr7 Date: $ / L 3 Phone#: 508-360-2749 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (check one): 10Board of Health 20 Building Department 3.00ity/Town Clerk 4.0 Electrical Inspector 5Elumbing Inspector 6.EOther Contact Person: Phone#: , 3/23/23,8:57 AM Scan.jpeg IIt' Ctunmonweaith or Massacnusetfa Division or Occu{saiianal Licensure Board of Building Reauiations and Standards Ccnstkliter,la rS tparv!sor s CS-182600 - ires 03/2 /2025 wEST YMM{Itj/t, .;:' av n F ''� x COrniniSSFOrter Ci..Z.e, K ��,...e.ue, THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Aff, €;8.Business Regulation Registration valid for individual use only before the HOME IMPROVE E11CONTRACTOR expiration date. If found return to: Office of Consumer Affairs and Business Regulation a•• ;,.,, -,�:,.j.w;•, 1000 Washington Street -Suite 710 sy -0,2$ Boston,MA 02118 2OOFING AND SIDIN E er„;- 'it,', . S.:4'''..' ''''''Fi i.=3":=4'. 1,;:r. 4e . ,,,..,,thzfor .., •,:„..,,,,.. .,. )ZMITRY IABKOVICH i00 RTE 134#2-12 `S.:. �'.4.74 i• ,OUTH DENNIS,MA 026. - .;- Undersecretary Not valid without signature A�R�® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YY THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. TI CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICI BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZ! REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the polic D provisions or be If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,y(les)certa nmusthave policiesAD may require an nendorsement. dorsem nt A star ment' this certificate does not confer rights to the certificate holder in lieu of such endorsement(s), PRODUCER CONTACT HUB INTERNATIONAL NEW ENGLAND LLC NAME: Cheryl Woodside PHONE — (A/C.No Ext): (978)661-6678 FAX — -- E-MAIL (A/C,No): _ 600 LONGWATER DRIVE ADDRESS: Cheryl.woodside@hubintemational.com NORWELL INSURER(S)AFFORDING COVERAGE MA 02061 NA+c x INSURED —" — INSURER AMGUARD INSURANCE CO 423PC ROOFING & SIDING OF CAPE COD & BOSTON LLC INSURERS: INSURER C; , — "-- 900 MA 134 INSURER D SOUTH DENNIS INSURERS MA 02660 INSURER F: COVERAGES CERTIFICATE NUMBER: 845736 REVISIN NU THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVEBER:FOR THE POLICY PERIOI INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THI, 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 ,ADDL'SUBR LTR TYPE OF INSURANCE POUCY EFF POLICY EXP INSD I WVD! POLICY NUMBER (MMIDD/YYYY)!(MMlDD/YYYY) LIMITS — COMMERCIAL GENERAL LIABILITY _ EACH OCCURRENCE $ CLAIMS MADE OCCUR DAMAGE TO RENTED -- PREMISES(Ea occurrence) $ MED EXP(Any one person) $ _ --- N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: — — POLICY j CT ' LOC GENERAL AGGREGATE $ PRODUCTS-COMP/OP AGG $ OTHER: • AUTOMOBILE LIABILITY $ COMBINED SINGLE LIMIT $ ANY AUTO _LEa accident) OWNED BODILY INJURY(Per person) $ ! AUTOS ONLY SCHEDULED N/A HIRED - BODILY INJURY(Per accident) $ NON-OWNED _ _ AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE $ (Per accident) i $ J UMBRELLA UAB OCCUR EXCESS UAB EACH OCCURRENCE $ CLAIMS-MADE N/A AGGREGATE $ ' DED ' RETENTION S — WORKERS COMPENSATION $ I AND EMPLOYERS'LIABILITY X PER OTH- ANYPROPRIETOR/PARTNER/EXECUTIVE YIN ! STATUTE ER A I OFFICER/MEMBEREXCLUDED? N/A N/A N/A R2WC354245 12/20/2022 12/20/2023 EL EACH ACCIDENT $ 500,000 (Mandatory in NH) , If yes,describe under E.L.DISEASE-EA EMPLOYEE' $ 500,000 DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT I $ 500,000 N/A DESCRIPTION OF OPERATIONS/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 the 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/Iwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Roofing & Siding Of Cape Cod & Boston LLC ACCORDANCE WITH THE POLICY PROVISIONS. Evidence of Coverage 68 Winslow Gray Road AUTHORIZED REPRESENTATIVE West Yarmouth MA 02673 Daniel M.Crowley,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD DocuSigrt-Envelope ID:3B369E0C-0B89-4405-BD20-500E444C62CE 0 on r �✓^✓ pziY >yw OF CAPE COD & BOSTON / 7A��fN s i ✓r r ✓i/ �� a�x �y 900 Rte 134 Unit 2-12 530 Atlantic Ave Unit 606 S. Dennis, MA 02660 Boston, MA 02210 855-800-9080 customerservicena roofingandsidingofcapecod.corn roofingandsidingofcapecod.com roofingandsidingofboston.com HIC REG #170787; LIC # 102600 Job Address: Name: Norbert Ginter Town: Ocean Breeze Motel Job Phone: Address: 170 Seaview Ave Other Phone: City: Yarmouth E-mail: info@oceanbreezeyarmouth.com State: MA Zip: 02664 Estimator: Dmitry Labkovich 04/03/23 We hereby submit specifications and estimates for the following work: 1. Remove existing T 1-11 from the front top side of the right building. 2. Install new T i-11 3. Replace freeze board with PVC trim Labor and Materials: $4,800.00 Dumpster fee: $500.00 Permit fee: $150.00 Total: $5,450.00 '—Ds If acceptable, initial here �11G RocuSign•Envelope ID:3B369EOC-O889-4405-6D20-500E444C62CE Job is estimated to commence approximately 4_ weeks after deposit received unless otherwise noted here: Work is scheduled to be substantially completed in approximately: days If acceptable, (both) initial here: Start and completion times are approximate and subject to change due to, but not limited to, the following circumstances: weather delays, additional work on previous jobs,permitting delays, etc. This is the entire agreement. Any discussions or verbal agreements are superseded by this agreement. Such agreements, even those of the smallest nature, must be in writing to be recognized. Any work above and beyond the specifications outlined in this proposal will be priced on request. All additional work, including travel time and lumberyard runs, will be subject to extra charge. In the event of rot repairs, roof repairs or any related work requiring immediate attention, we will proceed without customer approval. We look forward to working with you; please call if you have any questions. Sincerely, Roofing&Siding of Cape Cod&Boston Roofing&Siding of Cape Cod&Boston will provide cleanup on a continuing basis and all debris will be removed from site. All products installed by Roofing&Siding of Cape Cod&Boston will be to manufacturer specifications. All work will be performed by insured professionals. All material is guaranteed to be as specified and the above work to be performed in accordance with the drawings and/or specifications submitted for above work and completed in a substantial workmanlike manner. There will be no refund for special-order windows, doors or any other non-stocked materials after three days from approved proposal. All warranties will be null and void if account is not current and paid in full. Owner to move all personal objects, furniture, etc., from work areas. All items against walls should be considered for removal during any exterior siding jobs, additions, etc. to guard against damage. In the case of any roofing and ridge venting, dust and debris should be expected and any items in the attic should be removed. Roofing&Siding of Cape Cod&Boston is not responsible for any damages if said items remain in place. Curtains, drapes and window and door treatments may need proper reinstallation or replacement by customer due to sizing on any window or door replacements and is not included in jobs contracted with Roofing&Siding of Cape Cod&Boston. Any alteration or deviation from above specifications involving extra costs will be executed only upon PoouSign'Envelope ID:38369E0C-0B89-4405-BD20-500E444C62CE written orders and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado and other necessary insurance upon above work. Workmen's Compensation and Public Liability Insurance on above work to be taken out byRoofing&Siding of Cape Cod&Boston. Owners who secure their own construction- related permits or deal with unregistered contractors will be excluded from access to the guaranty fund. This Contract not valid unless signed by Corporate Officer: D?flht►^y£a61 ov1ch Acceptance of Estimate The above prices, specifications and conditions are satisfactory and are hereby accepted. Roofing&Siding of Cape Cod&Boston is authorized to do the work as specified. Payment will be made as such: 1/3 Deposit, 1/3 Beginning of work, 1/3 upon completion. Date: 5/3/2023 ,—o«usgnwby: Signatures; ivol'uet.aKkr No work shall begin prior to the signing of the contract and transmittal to the owner of a copy of such contract. You, the buyer may cancel this transaction at any time prior to midnight of the third business day after the day of this transaction. After three days, cancelation fee of $500 will be applied. The buyer agrees to pay the total balance due upon delivery or based upon the terms stated on the invoice. In the event of a breach of this agreement by the client, the client will be responsible for all collection costs, attorney's fees and other expenses incurred by Roofing&Siding of Cape Cod&Boston in enforcement of this agreement. By signing this agreement the client agrees that their signature will constitute a personal guarantee to pay for the work outlined herein.