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Home My WebLink AboutBLDX-23-15511 .•O�"Y`�R ;Office Use Only r 4 Jj'� ' ` - o IP r1 Z�-/ // O . . ,( . H !Amount j� ,�re�e,, MATTAGMECSE'J� 0"`°""`°gyp t Permit expires 180 days from tissue date EXPRESS BUILDING PERMIT APPLICAT C E I VE D TOWN OF YARMOUTH Yarmouth Building Department OCT 24 2023 1146 Route 28 B South Yarmouth, MA 02664 ° �� LDING DEPARTM (508) 398-2231 Ext. 1261 sr --_ CONSTRUCTION ADDRESS: / i 19 /19 Ce?ff i9 V.6- ASSESSOR'S INFORMATION: Map: L ' Parcel:/ /,' �� _tf� U OWNER: --ad ye e �'rR 7 e c If McL/Q& A-ur (/"•) /I ` �U"�J4 6 `5 36 N PRESENT ADDRESS (� f(TE . # CONTRACTOR: Oar l M -►r1 11 I`a_.5 k J K.N Li. (!..4-42 flf. R� ,g-be"'34 o"$071 NAME MAILING ADDRESS TEL.# esidential ❑Commercial Est.Cost of Construction$ / '06 Home Improvement Contractor Lic.# /4/yS� Construction Supervisor Lic.# o,j vy28 Workman's Compensation Insurance: �(c ck one) V ❑ I am the homeowner am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: 17 F9 ye-if.(i S Worker's Comp.Policy# Ga j4v 3-- 01 -1�3 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows: # Replacement doors: # Roofing: #of Squares a ( ,..--5 Remove existing* (max. 2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: V A -m o J4, 5 7 b ) Location of Facility I declare under penalties of perjury that the statements herein c;,tained 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 f° osecution under M.G.L.Ch.268,Section 1. Applicant's Signature �'L tNorE--4 Date: it/2 03 Owners Signature(or attachment) Date: ! Approved By: ‘:. A Date: 9 Bu. g r (o g ) DDRESS: Zoning District: Historical District: 0 Yes '❑ No Flood Plain Zone: 0 Yes 0 No 1 Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No ❑ Yes _ No M; /C ,p4 root@ 9 The Commonwealth of Massachusetts ll-, r Department of Industrial 1 Congress Street, Suite 100 T Boston, MA 02114-2017 WO 4,,,M _•..› 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): IINA 11. C , .L Sr..-4, t-i.t Address: City/State/Zip: c e ,`4uv-tv, ` (ice Phone #: t3 — 3, D — S D Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with employees(full and/or part-time).* 7. _New construction 2.K1,1m a sole proprietor or partnership and have no employees working for me in 8. E Remodeling any capacity. [No workers'comp. insurance required.] 9. C Demolition 3._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.Q 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: 7-4h At1 e ! r,$ Policy#or Self-ins. Lic. #: (,)10.6 1j///f ii/O5--'--D 3 Expiration Date: 3�a q 274 Job Site Address: 1/ !71/,Ic&12 4'tr•— City/State/Zip: At-Meit--v . /1 - i Attach a copy of the workers' compensation policy declaration page(showing the policy nu er 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 under the pains and penalties of perjury that the information provided above is true and correct. ---"ej_gnature: ) 4_e___� Date: /V2V J 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#: MID CAPE ROOFING 312 Skunknet Road Centerville, MA 02632 Barry Merrill 508-360-8097 lob Site Address Mailing Address �t F r �' Name: Name r zrk \ d to Stree 1, r +ry Street: tl ' t� r;1'1(, City: iff�1 = r) City: .,1 � :6, 9 E� /�Gt. � �3 Telephone:. O g' gI "C/�r'. 7 Ce/I Email: C j ' We hereby propose to furnish all the materials and all the labor necessary for the completion of: roof replacement of the dwelling at the above addresses. Mid Cape Roofing proposed to remove and dispose of the existing roof. The roof will be replaced with Certainteed Landmark lifetime shingles. Aluminum drip edge will be installed along the gutter line. Ice & Water Shield installed on bottom edges to protect ice back-up. 15 pound felt paper will also be applied. The shingles will be installed using 11/4 inch roofing nails. New pipe vent collars will be installed. Ridge vent will be installed along the ridgeline of the roof to provide proper venting of the attic space. Mid Cape Roofing guarantees the workmanship for a period of 10 years. All walls and landscaping will be protected from damage; the property will be raked and cleaned of all debris. All material is guaranteed to be as specified and the above work is to be performed in accordance with specifications submitted for above work and completed in a substantial workmanlike manner for the sum of: $ '77`�v .00-All discounts have been applied. P � 1-rc:-."t 4 b_� Fox t_ - , ,Cint { yfcC> . , :11T jl�i e � ..+3rc Payment made as follows: � Ai Deposit of: $ ,r{! .00 the day the job is started and remainder to bepaid on completion, 76:,Li'--± .'fy /C: Any alteration or deviation from the above specifications involving extra costs will become an additional charge over and above the estimate and will be discussed with the homeowner. Respectively Submitted by Mid Cape Roofing �, _ c3 n 7_�L .� NOTE: This proposal may be withdrawn by Mid Cape Roofing if not accepted within 30 days. Acceptance of Proposal The above prices, specifications and conditions are satisfactory and are hereby accepted. Mid Cape Roofing is hereby authorized to perform work as specified with payments made as outlined above. Accepted: