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HomeMy WebLinkAboutBLDX-26-1182 application I` E EIVED Yq _ Office Use Only Af� b', tt OCT 0 6 2026 Permit#X-aL-�V4a 3i ,l,. __.. � Amount �� BUILDINGPA�RjaE4T BY�.ORPONA1i ./ EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-22311 Ext. 1261 �f CONSTRUCTION ADDRESS: c3/ at- a S -/i jrr.n/v� , ACJ�O Zith OWNER: 4 A i/7 /lfr? ( :1 Ono NAME (( PRESENT ADDRESS neJ t n; TEL. # CONTRACTOR: re5 Mil f ,Q�i�+t�^s✓) ,�,� �(4 fa bath f`a e �Z /Cr NA E// //MAILING ADDRESS J TEL.# �s-�EMAIL: J /Wr.tr tr'j e alf Me-f 419 ❑Residential ommercial ❑Est.Cost of Construction$ End r' ` /6/ „ZdC1 Homeowner is Applicant? Yes No Home Improvement Contractor Lic.# 0//3644. Construction Supervisor Lic.# 6 frog WORK TO BE PERFORMED I Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares Replacement windows: # Replacement doors: # Roofing: #of Squares Insulation Temporary Mobile Home Temporary Construction Trailer Demolition—Interior only *Demolition Raze Structured/ 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: ��.NIJ t 7.4-4A Location of Facili I declare under penalties of perjury that the state nts 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 ense and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: J1'J 6 - .34'2D Owners Signature(or attachment) j 1Q C 0 nt S-&C-t Date: Approved By: Date: Building Official(or designee) Rev 6/24 The Commonwealth of Massachusetts Department of Industrial Accidents -- Office of Investigations 3 sp Lafayette City Center �`l 2 Avenue de Lafayette,Boston,MA 02111-1750 i' www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): DMAs Address: Po- fox i City/State/Zip: /4. MA Ol 72 Phone#: //)" Are you an employer?Check the apl/ropriate bo Type of project(required): 1.❑I am a employer with 4. I am a general contractor and I 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. 0 Re eling ship and have no employees These sub-contractors have g, a6emolition workingfor me in anycapacity. employees and have workers' P tY• 9. ❑Building addition [No workers'comp.insurance comp.insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.0 Roof 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. 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: /l./1,1 rrt./� �A�LeC(fi' r� Policy#or Self-ins.Lic.#: d//mot l edf 3 / Expiration Date: f-/ Job Site Address: 9j i a2? City/State/Zip: ("Wei f Attach a copy of the workers'compensation policy declaration page(showing the policy number 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Phone#: {.57 �JI /63j 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): l❑Board of Health 20Building Department 3❑City/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: 4 t , '1 HOME IMPROVEMENTS Pfl. 508.328. 1633 Exterior Remodeling Experts BBB, ACCREDITED BUSINESS Web: www.thomashorneimprovernents.net Fully Licensed & Insured P.O. Box 177 Construction Supervisor Lic #999I3 Centerville, MA 02632 THOMAS HOME IMPROVEMENTS & AUPPERLEE RENOVATIONS PROPOSAL TO PERFORM THE FOLLOWING WORK LABOR & MATERIALS UNLESS NOTED: Location of proposed work: Skull Island at Bass River Sports World 934 Rt. 28 South Yarmouth, MA 02664 $101,200.00 -Demo: Current plans include elevations and drainage. Owners agree to remove two small ball collection buildings. Poles will be pulled & stored by Chase & Merchant. We will remove all roofing & save heavy beams as discussed. Remove all concrete and block wall. Remove all unsuitable material. Poles on the east side of the project to be saved as discussed. Based on 18" average elevation. Chase & Merchant will truck in approx. 600 cubic yards of bank sand, grade & compact to the bottom of the slab grade. Above includes all labor & tipping fees. -Drainage: Install two separate drainage systems, as per plan. System 1 consists of four H-20 1,000- gallon pits tied into H-20 catch basin, placed approx. 92 tons of double wash stone. Two cast iron covers and one grate to finish grade. System 2 consist of an ADA compliant 96' French drain with handicap grates. Fourteen 6' middle drains & two 6' end drains. Above work will be contracted through Chase & Merchant Inc. Proposed building addition is not included at this time. Chase & Merchant is not responsible for any underground utilities, water/irrigation lines or tanks not marked by Dig-Safe. We are not responsible for trees, bushes, shrubs or plants, walkways or patios unless specified in writing by commercial owners. We will notify Dig-Safe. All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Loam & seed will be an extra charge. We are not responsible for driveway damage due to equipment,/machinery. We propose hereby to furnish materials & labor, complete in accordance with the above specifications, for the sum below. Acceptance: the above prices, specifications & conditions are satisfactory & hereby accepted. Thank You for Giving Us the Opportunity to Help You Improve Your Project -Contractor will be responsible for all building permits&inspections needed throughout the project • NOTICE REQUIRED BY LAW With the agreement of the contract$500.00 of the estimate is due. Further payments under this contract are as follows: 1/2 of the estimate due at the start; % &% upon completion of the project. Balance of all materials and labor shell be payable in full upon completion of work described in this contract. Payment as agreed upon shall be made when due. Any payments which are delayed shall be subject to a finance charge of 1.5% per month. The contractor warranties the workmanship completed under this contract for a period of one year from the date of completion. During the stated warranty period the contractor shall be responsible for the service of the repair or adjustment, but the contractor shall not be responsible for the normal maintenance, repair due to abuse, misuse, or normal wear and tear, which shall be the responsibility of the business owner. All warranties for the materials supplied by the contractor shall be passed directly to the homeowner.The homeowner may be required to register or mail in such a warranty card or evidence of ownership in order to activate such warranties. Homeowner failure shall not create any responsibility for the contractor under the warranty provisions; the choice of repair or replacement shall be at the discretion of the contractor. The business owner acknowledges that the form, content, and notices contained in this contract are intended to comply with the applicable potions of the Mass. General Law Chapter 142A, and regulations promulgated there under. In the event of any instance of non-compliance, only such a portion shall be invalid, and the remainder of this contract shall be in full force effect. In addition, any such portion not in compliance shall be read and interpreted so as to have its intended meaning to the maximum extent allowed under such law and regulation. Signed as a sealed i strument on this date: 10/06/2026. /11 r — Troy omas ntractor) i 04(it-tA , i__. Pass River Realty LLC. Licensee Details Demo 'aphic Information Full Name: — — _ TROY A THOMAS — — Owner Name: License Address Information "City: Centerville State: MA ZZipcode: 02632 'Country: United States License Information iLicense No: CSSL-099913 License Type: Construction Supervisor Specialty profession: Building Licenses Date of Last Renewal: 4/9/2026 Issue Date: 7/3/2008 Expiration Date: 4/13/2028 License Status: Active Today's Date: 5/4/2026 Secondary License Type: Doing Business As: Thomas Home Improvements Status Change Reason: License Renewal Prerequisite Information Licensee: THOMAS,TROY A _ Relationship: Attribute Of License No: CSSL-099913 Licensee: THOMAS,TROY A Relationship: Attribute Of License No: CSSL-099913 No Available Documents Home Improvement Contractor Registration Card Registration valid for use type, only before the expiration date. Type: Limited Liability Company (LLC) Number: 213005 Expiration: 08/22/2028 Issued to: * j' Thomas Home Improvements, LLC Troy A Thomas 499 Nottingham Drive Centervfille, MA 02632 ' Office of Consumer Affairs&Business Regulation Layla R. D'Emilia 1 Federal St.,Suite 0720,Boston,MA 02110-2012 Undersecretary I 'Accome CERTIFICATE OF LIABILITY INSURANCE DATE($MIJODrYYYt�I 05105,2026 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(ies) 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 NAME: Donna Ostrowski Mark Sylvia Insurance Agency,LLC PHONE a/c No.Ext). (508)957-2125 1 ,Not (508)957-2781 404 Main Street E-MAIL _AD aREss: mark aemarksylviainsurance.com Centerville,MA 02632 _ INSURER(S)AFFORDING COVERAGE NAIC N INSURER A: Farm Family Casualty Insurance INSURED INSURER B: Thomas Home Improvements LLC INSURER C: PO Box 177 7 INSURER D: Centerville.MA 02632 INSURERE: 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 POUCY 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. MISR DDL IAISUBRI i POLICY EFF i POLICY EXP i — LIR TYPE OF INSURANCE INISSD!WV POLICY NUMBER M D UMTTS X 1 COMMERCIAL GENERAL LIABILITY 1 j I EACH OCCURRENCE '$ 1,000,000 I �I I I DAMAGE TO RENTED CLAIMS MADE I X j OCCUR 1 PREMISES(Ea occurrence! _L$ 100,000 I I- —j MED EXP(Any one person) S 5,000 A i_ N N j 2001X1416 5/01/2026 5/01/2027 PERSONAL&ADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: !GENERAL AGGREGATE $ 2,000,000 X' POLICY JECOT I i LOC j i PRODUCTS-COMP/OP AGG I$ 2,000,000 i OTHER: I r I AUTOMOBILE LIASLITY i Es D SINGLE LIMIT $ 1 acddent) I I ANY AUTO f j i I BODILY INJURY(Per person) 1$ OWNED r—{SCHEDULED I BODILY INJURY(Per accident):$ HIRED ONLY I !AUTOS ON-O 4 I PROPERTY DAMAGE i HIRED :NON-0WNED , I 1 AUTOS ONLY _I AUTOS ONLY i(Per accident) I$ '$ UMBRELLA!JAB OCCUR y { i 1 _� i EACH OCCURRENCE_ 1$ i EXCESS LIAB I CLAIMS-MADEI I I I AGGREGATE t$ DED I j RETENTIJN$ Itt I I OTH- iI $ --_- I 1 I 4 WORKERS COMPENSATION I STATUTE TUTE , i ER AND EMPLOYERS'LIABILITY Y/N I I i ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBER EXCLUDED? N I N rA I N 12001 W8053 5/01/2026 5/01/2027 j (Mandatory in NH) 3 ( I E.L.DISEASE-EA EMPLOYEE{$ 1,000,000 n yes.describe under •DESCRIPTION OF OPERATIONS below 1 E.L.DISEASE-POLICY LIMIT I$ 1,000,000 • DESCRIPTION OF OPERATIONS I LOCATIONS t VEHICLES IACORD 101,Additional Remarks Schedule,may be attached if more space is required) Carpentry Insurance coverage is limited to the terms.conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN Town of Barnstable Building Dept. ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street AUTHORIZED REPRESENTATIVE Hyannis MA 02601 f P'ile =^— Fax. Email: ©1988-2015 ACORD CORPORATION. All rights reserved. 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