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HomeMy WebLinkAboutBLD-19-870 :Office Use Only C. zt:41 -R . Permit# : ' cDuos 50— Ar •A' 7" ^ g.�: =Permit expires 180 days from issu ,date • EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH R E C E 1 V E LTI Yarmouth Building Department 1146 Route 28 AUG 08 2018 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 eu'_ 1` iIT CONSTRUCTION ADDRESS: /8 airs']5 e 9.0 s 5 . ASSESSOR'S INFORMATION: ' I - Map: Parcel: OWNER:67 .kiinicier- i8Ellea e Si S.4(,•.0,44 HAazc,co4/ * '3 -.zz/-s M NAME PRESENT ADDRESS TEL # Email Address: CONTRACroR:7 4-Line DnT `)o8 Shrewsbury HA ©Cir std'-962--661142 NAME MAILING;ADDRESS TEL# Email Address Residential Commercial Est Cost of Construction$ Sr 7 5 4 — Home Improvement Contractor Lie.# HA-1e HA-1eS Construction Supervisor Lir# 0 700 7 7 Workman's Compensation Insurance•. (check one) � I am the homeowner I am the sole proprietor &have Worker's Compensation Insurance Insurance Company Name:Ado; //1n ron h%'u_ 1/1 P./railer a Worker's Comp.Policy# 114/C 65-83 I t4 S CO S 1 ' WORK TO BE PERFORMED Tent _ Duration _ (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# I I • Replacement doors: # - Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like `The debris will be disposed of at Aft sit. /-/Lf/k cot"AI— J Location of Facility . I declare under penalties of... statements herein contained are true and correct m the best of my Imowiedge end belief. I understand that any false answer(;) t1will be just cause for denial or of my 'cense and for s. -• :,o under MAIL Ch.268,Section 1. � Applicant'sSignamre iiI�ILl.� Date: I- I-/t Owners Signature(or atta• — See cr 1- _ ccs Cater• e — 'ate: Approved By r" Date: f -9'/S Buil.'• g a/t•'(or.- ignee) Zoning District: Historical District Yes No Flood Plain Zone: Yes No Water Resource Protection District Within 100 ft.of Wetlands: Yes No Yes No Home Improvement Agreement: Page 1 Home Depot License Number(s): Visit www.homedepot.com/c/SV_HS_Contractor_License_Numbers for latest license info MA: 107774, 112785 Salesperson Name: Janice Campbell Registration No. (if applicable): Home Depot U.S.A., Inc. ("Home Depot") or service provider named below ("Service Provider") will furnish, install or service the equipment listed below at the price, terms and conditions as outlined on this form. Schneider Gary New England South 1-6A4106F Customer Last Name Customer First Name Store #/Branch Name Lead/Customer Order# 18 eldridge rd South Yarmouth MA 02664 Customer Address City State Zip (413) 221-5495 fdashes@comcast.net Home Phone# Work Phone# Cell Phone# Customer Email Address NOTICE OF RIGHT TO CANCEL: YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT HOME DEPOT USA INC., 2455 PACES FERRY ROAD, BLDG. B-3, ATLANTA, GEORGIA 30339 or EMAIL The Home Depot @ customercancellationnortheast@homedepot.com BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE • SUPPLEMENT PROVIDES A DIFFERENT CANCELLATION PERIOD. THE STATE SUPPLEMENT CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE. YOUR PAYMENTS WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME DEPOTS RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME DEPOT OR SERVICE PROVIDER, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE SAME CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED TO YOU. OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN SHIPMENT AT HOME DEPOT'S EXPENSE. THE LAW REQUIRES THAT HOME DEPOT GIVE YOU A NOTICE EXPLAINING YOUR RIGHT TO CANCEL. PLEASE SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL AND WRITTEN NOTICE 0-i;UR RIGHT CA EL. Acknowledged by: 07/15/2018 Cu "•mer's Si. nature Date Contract Price and Payment Schedule : Payment of the Contract Price is due upon signing unless a different payment schedule is required by law, specified below or in a payment addendum. Contract Price: 8734.50 Includes all applicable taxes. Excludes finance charges.* Sales Tax: 0.00 (If applicable) `Maximum deposit ONLY applicable in MD, MA, ME(33%), NJ, WI(99%) Dep. 25.0 % Deposit Amount 2183.62 Remaining Contract Balance 6550.88 The Home Depot-2455 Paces Ferry Road,N.W.Bldg.B-3,Atlanta,Georgia 30339-Customer Care: 1-800-466-3337 Customer Agreement(C,E,Q(31 Jan.18) v 50,1.2 • nns',,y11u��� OISSIU14/0-0 r uallet%dx3 ,r� f 1 ti 1 3 f wry.frYl NINA IOt y , uuadns Y,01}7g1111.1sC . •_ _ _ _ - novas-sea r ''. spat Pu.ss Pus suon.ln&a=d 6u1PVne10 pate .;,:41111 • „y8`.: Awdt% Duque'M duau•Y.dap.ua.nlda.AF7'... sesn+.+.+w-.�......,...ems.,._.. ..,...,.r.,...-._... ,. • The Commonwealth of Massachusetts CI Department of Industrial Accidents • :'•—_ Ba • Office of Investigations t —ff,wl- 'a 1 Congress Street,Suite 100 Boston,ilt4 02114-2017 www.mass.gov/dia Workers'Compensation InsuranceAffrdavit: Builders/Contractors/Electricians/Plumbers Applicant Information II I / Please Print Legibly Name (Busmeess/OrgeniO Indomindividnnl): .( OMPi/,,77.iAoT' — • Address: ( BBS/r `/w vcwp; g.- J Citv'State/Zip: CA/120.041,1t, 44 • 6/SYS. Phone#: 7 7171- a 75- - c2/—s—Si Are you an employer?Checkk the ilipropriate box: Type of project(required): 1.!7s. I am a empioyer with Uwnt 4. L I am a general contactor and I 6. New construction / `employees(full and/or part-time).* have hired the sub-contractors 0 2.0 I am a sole proprietor or partner- listed on the attached sheet. • 7. 0 Remodeling ship and have no employees These sub-contractors have I g• ❑Demolition worlon for me in any a employees and have workers' 0 g �P cnY• 9. Building addition No workers' comp.insurance comp•insurance.; y ❑ ar We ea corporation and its I Electrical repairs or additions , • . required.) 3.17I am a homeowner doing all work officers have exercised their I 11.0 Plumbing repass or additions { myself. [No workers' comp. right of exemption per MGL 12.0oof repass insurance required.]• c.152,§1(4),and we have no d employees. [No waters' I 13. Other w l r� • • • comp.insurance required] reek:ca/a Cir n air 5 •tiny applicant that checks box a1 must also 511 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 eosmaetoa must submit a new affidavit indienig such. :Conflates that check this box must amcbed an additional sheet showing the name tithe sub-connactma aid state whether or not those entities have =plower. S the sub-coneraaots have employees,they most 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 she information / _ nst�ce Company Name: eater Pee" 2 ;gal VNi Dist /QM, ?t /6 . Ca• Policy R or Self-ms.Lie.#i: X W Ci LK? 8/t Expiration Date: V3 //� /- 9 Job Site Address: /g gar id f a cU, City/State2ip: S.Y r Ji M A Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required ander Section 25A ofNIGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-y ., imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 3250.00 a day a•••" ,,•lator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DL% e coverage verification- I do hereby certify un•, e :IS i; • • , i.. , , .- at the information provided above is true and correct • I/,L� Date: �— Sia ire: d 1 E / p Phone#: 57;a — 9.1 - 6 1 9C2- Official use only. Do not write he this area,to be completed by city or town official • City or Town: Permit'License Issuing Authority(circle one): 1.Board of Arahh 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Otbcr Contact Person: Phone#: • L,G~ = ^'� /t- tt 0I 17.11 l?WeY:Ic . c/ to a deti e Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 • Home Improvement Contractor Registration Type Supplement Card HOME DEPOT USA INC Regipiration: 112785 2455 PACES FERRY RD C-11 HSC Erq irat on: 04/22/2019 • ATLANTA,CA 30339 ' • Update Address and return card. Mark reason for chance. 0 Address 0 Renewal ❑Employment 0 Lost Card Mee of Consumer Affairs it Business Regulation --- HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:SuDolement Card before the expiration date. It found return to: Recistration Expiration, • Office of Consumer Affairs and Business Regulation 112785 04/22/2019 10 Park Plaza-Suite 5170 NOME DEPOT USA INC Boston,MA 02116 ANDREW SWEET 'y-- �ii7, 2455 PACES FERRY RD C-11 HSC f� ATLANTA,GA 30335Undersecretary ' .4 ithou signature • ACORO" CERTIFICATE OF LIABILITY INSURANCE DATE YSTY) `../ THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CEBY THE POIJCIES BELOW. THISATE DOES NOT CERTIFICATEPOF'AFFIRMATIVELY DOES NOTLY CONSTITUTE CONTRACT BETWEEN THEND, EXTEND OR ALTER THE E ISSUING IGE NSURER(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). CONTACT PRODUCERMARSH USA.INC Kase ALLIANCE CENTER 110CE. Fon I FAX TWO r Not - 3560 LENOX ROAD.SUITE 2400 EMAIL ATLANTA.GA 30326 ADDRESS' NSURER(S)AFFORDING COVERAGE AMC* 0N101612069HmaD-GAW-1819 INSURER A:OW RepubpC11150M eCO 24147 INSURED INSURER 6:New Hampson'Ins Co 23841 THE HOME DEPOT.INC HOME DEPOT U.S.A.,INC. INSURER C:HareW3k Captive Insurance CBnpenY 2455 PACES FERRY ROAD NsuRER o; BUILDING G0 NSURER E: ATLANTA,GAA30339 INSURER F: COVERAGE CERTIFICATE NUMBER: ATL-00435343816 REVISION NUMBER:3 THIS IS TO CERTIFY THAT 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 AU.THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUNK POLICY EFf POLICY EXP LIMITS LTR TYPE OF INSURANCE 0450 WWI POLICY NUMBER (MNVDO/YWY7 MMTDIYYYYI EACH OCCURRENCE S A X 4I CLAIMS-MADE COMMERCIAL GENERAL LatinMWZY 312717 031012079 0310171019 DAMAGE TO HEED 900p000 I OCLUR PREMISES IEa eminence! 5 EXCLUDED LIMITS OF POLICY XS � MED EXP(Arty one person) S ■ OF SIR 31M PER OCC PERSONAL a ADV INJURY I F 9000.000 GEM.AGGREGATE Lain AP PLIES PER GENERAL AGGREGATE s ROM.1C © POLICY❑J D .00 PRODUCTS•COLD'rOP coAs 9.000 000 • s OTHER: A AUTOMOBILE LIABILITY MWTB312718 031012018 03/012019 (Ca aaINEED(SINGLE LIMIT 5 1,000,00C 111 ANY AUTO BODILY INJURY(Per person) 3 OWNED ^SCHEDULED SELF INSURED AUTO PAY DMC BODILY INJURY per acc enl) 5 AUTOS ONLY AUTOS PROPERTY DAMAGE . HIRED NON•OWNEO Mei ecWCnll 5 AUTOS ONLY AUTOS ONLY 3 UMBRELLA LIAR OCCUR EACH OCCURRENCE 3 — EXCESS MAD CLNMSJMDE AGGREGATE S DEC RETENTION 5 _ B WORKERS COMPENSATION WC 014122577(AX,NH,NJ,VT) °31012018 031012°7-9 x STATUTE ERER AND EMPLOYERS LIMIL TY YIN WC 014122578(WI) 03107201E 03/01/20196,.00.00. B ANYPROPRIETORVARTNEPJUECUTNE NIA El.FAG"(ACCIDENT S OFFICERIMEMSEREXCLUDED'+ E1.DISEASE.EA EMPLOYEE 5.000.000 (Mandatory M NH) 5.000.000 DESCRIPTION OFO CalenNed on ADdeonal Page EL DISEASE-POLICY LIMIT F Dc s Auld OF OPERAndJ3 below C ElCess Aub 297-1-10011-002018 031072018 0310171019 Umll. 4.000000 IDESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD Ill,Adeepol Remorse Schedule,may be attached II mon*pad a modem* EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION HOME DEPOT USA.INC SHOULD ANT OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 2455 PACES FERRY ROAD THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN BUILDING G20 ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA.GA 33339 • AUTHORLEED REPRESENTATIVE Of Marsh USA Inc. Manashi Mukherjee 2014s.,,^0oSa 4AaAJca. 4-e'L 1 C 1988-2016 ACORD CORPORATION. All rights reserved. ACORO 25(201 6103) The ACORD name and loge aro registered marks el ACORD • • AGENCY CUSTOMER ID: CN101642069 ----millLOC#: Atlanta AO ADDITIONAL REMARKS SCHEDULE Page 2 of 3 AGENCY NAMED INSURED MARSH USA.INC. THE HOME DEPOT,INC HOME DEPOT USA.,INC. POLICY NUMBER 2455 PACES FERRY ROAD BUILDING C-20 CARRIER ATLANTA,GA 30339 NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM ISA SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Workers Conpensation Continued Garner Indemnify Insurance Company of North America Pdtcy Number WLR C64783191(ALAR,FLID,IA KSJIY,LA,MS MONEMAND.OK,SC,SD TN,WV,WY) Effective Date 031012018 Expiration Date 03/01/2019 IEL)Cont 51000,000 Cirnar Nina Nanpdxrehntmnce Comm" Pc/icy Minter WC 014122576(DC,DLHLIN,MC,MN,MT,NY,RI) Effective Dal'03/012018 Exotration Dale 03/012019 IELI Lint:$1000000 - Comer ACE American Insurance Company Pricy Minter WCU C64783221(051)(AZ.CA,L,NC,OR,VA.WA) Elleceve Date 03212018 Expiration Dale 03/012019 IELI Lind 51,000,000 SIR 51,000000 SIR for the slates of AZ,CP.L,NC.OR,VA,WA Gamer Neeond Union Fie trance Company Pricy Number XWC 4595550(051)(CO.CT.GAMEMI,MV,OH,PA UT) Effective Date 03212018 Eapration Dale 03/01/2019 (EL)Unit.St 000,000 51.000,000 SIR Ir tiro althea of CO,MENV,MI,ON,PA,UT 5750,000 SIR for the stale of GA 5350,000 SIR kr the slate of aT ' Lamer,National Umon Fm Insurance Company Palmy Number XWC 4595581 Iasi)(kA) Effective Date 031072018 �� Expiration DaM.03/012019 (EL)Lent 51,000000 SIR 5500.000 TX Emdoyers XS Indemnity. amerilmas union Insurance Company Pdicy Number INS C4916693A ITX) Effective Dale.031012018 Enmrabon Dale.031012019 (ELILind 510.000000 SIR 51,000.000 - • ,CORD 101 (2008101) 88 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD