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Home My WebLink AboutBLDX-26-967 applicaiton ,�"�Y M Office Use Only �' DECEIVED ^/- (* 0dir% Permit#X O�1D� 7 t O , . - ► / AUG 24 2026 'Amount 5 \(`er " r ATTAMEEIE ~C�RPORAiE��`Aq ,„TP BUI ING O R6IIgp►<V.O'V EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 ;O C CONSTRUCTION ADDRESS: — z ' . J t C\' eS 0 OWNER: I `�"'o 3 O ./i., tq.� 5 ' GSr 9✓ y' NAME v PRESENT ADDRESS TEL. # CONTRACTOR: '70:4 Iv..6 // Si.e...Gr/rLZs.,G4/1."4" -2'.P 3ce 677.c- NAME MAILING ADDRESS TEL.# EMAIL: /�"OL ftiA,1i/l„arf%vj i G'M4/! rCoA4 d q � �-ftesidential ❑Commercial Est.Cost of Construction$ "C S 6 7 e--�' o 7 Homeowner is Applicant? Yes No f .7 Home Improsemeni Contractor Lie.# / Gi � 3 .2 Construction Supervisor Lie.# C S e cr 0 / a� y/ WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares Replacement windows: # Replacement doors: # Roofing: #of Squares 3 G Insulation_ Temporary Mobile Home Temporary Construction Trailer Demolition—Interior only Demolition Raze Structure Solar System — ESS System Chimney Fence *Please submit utility disconnect letters for electric&gas—structures over 75 years old require historical review *The debris will be disposed of at: ° Location eFacility 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 o a n of my license and for prosecution under M.G.L.Ch.268,Section I. /��gApplicant's Signature: _ 4'3 _. i Date: /6l z. Owners Signature(or attachment) Date: Approved By: Date: Building Official(or designee) Rev 6/24 The Commonwealth of Massachusetts Department of Industrial Accidents =5l Office of Investigations f,�ros 3 Lafayette City Center 2 Avenue de Lafayette,Boston,MA 0211I-1750 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): "ke 4 �a �- Address: / / _ l' Lvr46, 'J City/State/Zip: Phone#: JC 6 j3 o l y " Are you an employer?Check the appropriate box: contractor and I Type of project(required): 1 4. I am a fain a employer with ❑ general employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9. Buildingaddition [No workers'comp.insurance comp.insurance.: required.] 5.❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑I am a homeowner doingall work officers have exercised their 11.0 Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12 K-of repairs insurance required.]t c.152,§1(4),and we have no employees.[No workers' 13.0 Other 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. tContractors 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. _ /J Insurance Company Name: l,/Al A-t 1/ i(n, Policy#or Self-ins.Lic.#: A cf.,C `' cO Tod k tt 3 _d d,?t N Expiration Date: Job Site Address: 3 0 /� C,n �,, eye City/State/Zip: S Attach a copy of the workers'compensation policy declaration page(showing the policy numbe 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$250.00 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 cerkfy nddder the pains and _ �penalties of perjury that the information provided above is true and correct. Signature: /t/�(/tfi/ 1/7 'cf. - Date: 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(check one): 10Board of Health 20 Building Department 31:City/Town Clerk 4.1=1 Electrical Inspector 5f}lumbing Inspector 6.0Other Contact Person: Phone#: Commonwealth of Massachusetts . . 19j Division of Occupational Licensure *--'' Board of Building Regulations and Standards Constokklanu§40ervisor -.., .,„,..,; ,, CS-040124 4.7 , ,itre44,-.0, ..., expires: 03/29/2027 '‘,..,..,-A047:LIBERO J MacLltgii;15,,AVy; 11 SHEEP P"TeiR fi4 4.,7.,.., , , ,„,,,,v. EAST SA N DI&ICFr ' " o IC', 7 ..< '.,','7: v..•;'4,.. ,,4-,,,,, . , 1.,..i.„. 4b eS3 i,LAid . , Commissioner - ___. THE CGiviiiriOtivvtALTH OF MASSArIV:CETTS Office of Consumer Affair & Business Regulation HOME IMPROVEVIT CONTRACTOR TYPE: <actual Re ist -::::: :::-.Expiration le _IBERO J. : _IBERO J. ( 4-.._ 11 SHEEP PASTURE Wy'-‘ - 'ni=‘,...,.,-,,,,c--:- IP (-11 1-1'LLIA- EAST SANDWICH, MA 6280z..., -4,-..,,,-, Undersecretary • PROPOSAL AND CONTRACT Molinari Home Improvements t 1 Sheep Pasture Way East Sandwich,MA.02537 508-360-0745 molinariroofinq(a gmail.com Proposal submitted to Date Rockwell Ludden 8/22/26 Address,City,State and Zip Code 30 Captain Nickerson Road South Yarmouth,MA.02664 Phone 508-685-8364 P We hereby submit specifications and estimates for: Re-roof entire roof area at the above address 1. Strip off existing roofing 2. Install metal drip edge where necessary 3. Instill ice and water shield and synthetic paper the rest of the way 4. Install shingles(Architect)color to be Landmark Pewterwood 5. Check all flashing and counter flash where necessary 6. Thorough clean-up of all debris relating to the above work 7. Replace any rotted wood at and extra charge 8. Install ridge vent on main roof area 9. Install lead flashing around chimney *Dumpster to be delivered at an additional cost to this proposal *Limited Lifetime Warranty on Shingles *Fully Insured Workmen's Compensation and Liability Insurance Sum of: Eighteen Thousand Five Hundred Dollars ($ 18,500.00 Payment to be half upon agreement,with balance due upon completion. Payment as follows: Any alteration or deviation from the above specifications involving extra cost of material or Labor will only be executed upon written orders and will become an extra charge over the sum mentioned in this estimate.All agreements contingent upon strikes,accidents,or delays are beyond our control. Authorized Signature Proposal maybe withdrawn by us if not accepted within 30 days. ACCEPTANCE OF PROPOSAL The above prices,specifications and conditions are satisfactory Date of Acceptance and are hereby accepted.You are authorized to do the work as specified.Payment will be made as outlined above Signature Signature i,i IDDATE (MM/DD/YYYY) A CC:0 CERTIFICATE OF LIABILITY INSURANCE MMI026 THIS CERTIFICATIE 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 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 2209-3 NAME ACT 2209 2209/3 PSmith Brothers Insurance LLC (A/C,No, Ext)_ FAA/C, No): 300 Main St E-MAILDSS: cleng@smithbrothersusa.com Oxford, MA 0154Q., INSURER(S)AFFORDING COVERAGE NAIC# INSURER A : A.I.M. Mutual Insurance Company (400) 33758 INSURED INSURER B : Libero Molinari INSURER C Molinari Home Improvement 11 Sheep Pasture Way INSURER D : East Sandwich, MA 02537-0000 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFIrr`1HAT 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 INSD 7WVD POLICY NUMBER (MM DD Y POLICY YYY F MMIDD/YYYY LIMITS OLICY EXP LTR TYPE OF INSURANCE ) ( ) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO- POLICY JECT LOC PRODUCTS - COMP/OP AGG $ OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT(Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ __ AUTOS NED __ AUTOSCHES BODILY ABODILY INJURY(Per accident) $ HIRED AUTOS ,i NON-OWNED PROPERTY DAMAGE AUTOS (Per accident) $ $ t , UMBRELLA LIAB i OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION X WC STAT- O T H- AND EMPLOYERS'LIABILITY Y I N UTORY LIMIT ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 100,000.00 OFFICER/MEMBER EXCLUDED? N AWC-400-7008113-2026A 5/21/2026 5/21/2027 A (Mandatory In NH) N/A If yes, describe under E.L. DISEASE EA EMPLOYEE $ 100,000.00 DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,000.00 DESCRIPTION OF OPERATIONS/LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION Town of Yarmouth SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 11456 Route 28 ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE , 2 Ate 62( 6.-- O 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD