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Home My WebLink AboutBLD-23-000623 f' 1•YRR /1� ��!'E"'�1- r/c/z Office Use Only X. O 1Permit#_ t0/�. _ H !Amount ��.z)z) �pTTACn , .4. -1 cs-4 "°°""`°A�, ;Permit expires 180 days from i issue date 8tD-013-eo66.15 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department RECEIVED 1146 Route 28 - South Yarmouth, MA 02664 AN O 5 2022 • (508) 398-2231 Ext. 1261 / '^ BUILDING DEPARTMENT CONSTRUCTION ADDRESS: 6 44- p n40, eY: + ASSESSOR'S INFORMATION: _ � Map: Parcel: OWNER: t....'4IJ'4 ee i it+C, 'O/A-!J ., /y 12-1- 6 yik.--0.4-0,L9pa(-4---- NAME PRESENT ADDRESS TEL. # CONTRACTOR: C',NAW v-v-•.1 cv-. 1 3 t 2 S Ku Jo�,1, i..s' e...4,�V t (1 , 5 d .. 8..346-5C 1 MAILING ADDRESS TEL.# r!..R‘dential 0 Commercial Est.Cost of Construction$ ,b06 Home Improvement Contractor Lic.# /6/ 9'R Construction Supervisor Lic.# 6 SV4/23 Workman's Compensation Insurance: (sbeck one) 0 I am the homeowner i9-Tam the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: --rt.-4-U l r P.S Worker's Comp.Policy# //L13 -, 1/Ng yie -ca WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares IV/ Replacement windows:# Replacement doors: # Roofing: #of Squares 4 ( )Remove existing* (max.2 layers) Insulation Old iy�g�s Highway/Historic Dist. ( Replacing like for like Pool fencing OV----4047J!"'� V)gls17)- — 111U fr I t164 — 9Y" *The debris will be disposed of at: Yi4ieIg ' /7 5 Location of 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. Applicant's Signature: .tt..--1 ria_ Date: 3/2 Owners Signature(or attachment) es 1I //4 Date: Approved PP By: �� Date: E-5/75/..2-42__ Building Official(or. ign EMAIL ADDRESS: , 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 ❑ No f '\ The Commonwealth of Massachusetts fr Department of Industrial Accidents ,f 1 Congress Street, Suite 100 Boston, MA 02114-2017 s.•�''•• www.rnass aov/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): 67 i-n/ E. rr; J/ Address: 2/ ?. 'AL* j / City/State/Zip: (07.jPf 111/ Phone #: 5 2-- 3a)Q _ z) Are you an employer?Check the appropriate box: Type of project(required): 1.E I am a employer with employees(full and/or part-time).* 7. ❑ New construction ?. m 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._I am a homeowner doing all work myself. [No workers'comp.insurance required.] 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 5.11 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.D Roof repairs These sub-contractors have employees and have workers'comp. insurance.1 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[1]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: -DP' Policy#or Self-ins. Lic. #: jp /-rl� y,)g 5 105"._ -2/ Expiration Date: 3/2y/2_3 Job Site Address: y 12.4- /4 City/State/Zip: tom''vtrcv ;47lr6F Attach a copy of the workers' compensation policy declaration page(showing the policy n1nber and expir tio n ddte). 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. Signature: Date: t16—j2 Z 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#: [Type here] MID CAPE ROOFING 312 Skunknet Road Centerville, MA 02632 508-385-8801/508-360-8097 Barry Merrill&Paul Merrill [Type here] Job Site Address Mailing Address Name: Cet �y� � la Name: Cat ht.e6A-C, D0/ k Street: pit 6,4 Street: 2l4 R mAiie (,A City: I/4v- ��,-'�-- — City: y ce r (1-1 ,4-t pc - 02 15 Telephone: Telephone: 5og. �j� - 2,3SO 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 address. Mid Cape Roofing proposed to remove and dispose of the existing roof. The roof will be replaced with CertainTeed Landmark 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 6 roofing nails (11/4 inch). 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: $ 70vv. _ —All discounts have been applied. Payment made as follows: • Deposit of: $0200 . the day job is started and remainder paid on completion. 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 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: ' /, , ‘N)O1AA. Commonwealth of Massachusetts Division of Occupational Licensure Board of Building lations and Standards Con Re uionTWily-visor 1 CS-054428 ' * I spires:08/21/2024 • BARRY B MR 'i ', 312 SKUNN {'l I ,, ' / '" CENTERVILlt;M i 0 b 0 Commissioner ciai2z K. Y - of Cons mer Affairs&Business Regulation n ,r+ M E IMMOVEEM ENT i CONTRACTOR dual ReOlstrltifa F12/Ox irag2 ��. BARRY MERRILL 1 r BARRY MERRILL j,,,,..i,'GL.( t' 312 SKUNKNET ROB --- -- Is . CENTERVILLE,MA 02632 Undersecretary , r t RAVELERSJ� WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6HUB-4N84105-2-22) RENEWAL OF (6HUB-4N84105-2-21) INSURER: THE TRAVELERS INDEMNITY COMPANY OF AMERICA A STOCK COMPANY 1, NCCI CO CODE: 13439 INSURED: PRODUCER: MERRILL, BARRY DBA MID MARSHALL K LOVELETTE INS CAPE ROOFING 396 MAIN ST 312 SKUNKNET ROAD WEST YARMOUTH MA 02673 CENTERVILLE MA 02632 Insured is AN INDIVIDUAL Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 03-24-22 to 03-24-23 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ 100000 Each Accident Bodily Injury by Disease: $ 500000 Policy Limit Bodily Injury by Disease: $ 100000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B a a D. This policy includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS —EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 03-01-22 WC ST ASSIGN: MA OFFICE: RMD POOL 161 PRODUCER: MARSHALL K LOVELETTE INS 78BJB )17305