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HomeMy WebLinkAboutBLD-19-001011 Office Use Only ,yp,°�' '7® !emit/ ; O ,,,e+. '. Amount v nl wi.T �^,.�,.„.j.' Permit expires 180 days from � gp� issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 F) C South Yarmouth, MA 02664 I V t., !:) (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: g__(2. 6.,Gean -f AUG. 15 2018 02 BUIL[ift A t A i ASSESSOR'S INFORMATION: By _Lr . r Map: Parcel: -� OWNER. Priid$CL/ Pr , 0 P,n 4 a S. p nu,,ii4 H • 22664 508- s6,(-g44C) NAME PRBS D• • TEL # Email Address: CONTRACTOR• outileIA h1.r Win010v .— A to g/enter Oco0z18-9tCd AME MAILING ADDRESS TEL# EmailAddre: Commercial . Est.Cost of Construction$ T, S L O — Home Improvement Contractor Lia# 173 2-'/S Construction Supervisor Lla# 07C7O 7 Workman's Compensation Insurance: (check one) I am the homeowner I am the sole proprietor A have Worker's Compensation Insurance \ �''��tt Insurance Company Name: /Ri:A'IEA�S S• C� • n'�lj'){xrWorker's Comp.Policy# U)Mai6r729-ZO WORK1f TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# 3 Replacement doors: # Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Sings Highway/Historic Dist. ( )Replacing like for like • "The debris will be disposed of at Luurtlon of Facility I declare under penalties of perjury that the eau herein contained ate true and correct to the best of my knowledge and belief. Iunderstand that any false answers) will be Just cause for denial ortayocadon of m'li se and for prosecution under M.O.L.C 1.268.Section 1. Applicant's Signature: Date: c- - /1;— / Owners Signature(or attachment) L/ �ar d+t Date:Approved 6 /� '/`..-� nate �J -1.��/CJ By: Building ( 'gnee) • Zoning District Historical District Yes No Flood Plain Zone: Yes No Water Resource Protection District Within 100 ft.of Wetlands: Yes No Yes No Renewal Agreement Document and Payment Terms brAndersen. dim Renewal By Andersen of Southern New England Kevin Lecuyer fi,#.2 A ,:? ,1 Legal Name:Southern New England Windows,LLC 28 Ocean Ave F/���4,.,, RI#36079,MA#173245,CT#0634555,Lead Firm#1237 South Yarmouth,MA 02664 ., • wino* as 'Ammar 10 Reservoir Rd I Smithfield,RI 02917 H:5085619440 Phone:866-563-2235 I Fax:40t-633-6602 I salestrenewalsne.com Buyer(s)Name: Kevin Lecuyer Contract Date: 08/02/18 Buyer(s)Street Address: 28 Ocean Ave, South Yarmouth, MA 02664 Primary Telephone Number: 5085619440 Secondary Telephone Number: Primary Email: kevinlecuyer911 Ogmail.com Secondary Email: Buyer(s)herebyjointly and severally agrees to purchase the products and/or services of Southern New England Windows,LLC d/b/a Renewal By Andersen of Southern New England("Contractor"),in accordance with the terms and conditions described in this Agreement Document and Payment Terms,any documents listed in the Table of Contents,and any other document attached to this Agreement Document,the terms of which are all agreed to by the parties and incorporated herein by reference(collectively,this"Agreement"). Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. Total Job Amount: $5,540—Bysigning this Agreement-,you-acknowledge that the Balance Due,and the Amount Financed must be made by personal check,bank check,credit card,or cash. Deposit Received: $2,770 Balance Due: $2,770 Estimated Start: Estimated Completion: Amount Financed: $5,540 8 to 10 weeks 8 to 10 weeks Method of Payment•. Financing We schedule installations based on the date of the signed contract and secondarily on the date in which we complete the technical measurements.The installation date that we are providing at this time is only an estimate.We will communicate an official date and time at a later date.Rain and extreme weather are the most common causes for delay. Notes: Depo paid gsky bal paid gsky tax Yarmouth Buyer(s)agrees and understands that this Agreement constitutes the entire understandings between the panics and that there are no verbal understandings changing or modifying any of the terms of this Agreement.No alterations to or deviations from this Agreement will be valid without the signed,written consent of both the Buyer(s)and Contractor.Buyer(s)hereby acknowledges that Buyer(s) 1)has read this Agreement,understands the terms of this Agreement,and has received a completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first written above and 2)was orally informed of Buyer's right to cancel this Agreement. NOTICE TO BUYER.:Do not sign this contract if blank.You are entitled to a copy of the contract at the time you sign. YOU,THE BUYER, MAY CANCEL THIS TRANSACTION AT ANYTIME NOT LATER THAN MIDNIGHT OF 08/06/2018 OR THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION, WHICHEVER DATE IS LATER.SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. Legal Names Southern New England Windows,LLC dba:Renewal By Andersen of Southern New England Buyer(s) r'"'"' C -�-r,�- Signature of Sales Person Signature Signature Cory Scanlon Kevin Lecuyer Print Name of Sales Person Print Name Print Name UPDATED: 08/02/18 Page 2 / 10 • Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 173245 Type: Supplement Card SOUTHERN NEW ENGLAND WINDOWS LL Expiration: 9/13l2018 BRIAN DENNISON 26 ALBION RD LINCOLN, RI 02865 Update Address and return mrd.Mark reason for change. Address _ Renewal = Employment _ Lost Card —7-Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the ..HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registration: 173245 Type: 10 Park Plaza•Suite 5170 Expiration: gm 9/2018 Supplement Card Boston.MA 02116 ILITHERN NEW ENGLAND WINDOWS LLC. NEWAE BYANDERSON OAN DENNISON ALBION RD f —�--- ICOW,RI 02865 "..C..C<!.,....h-- l-Ler Not valid without signature %"�—aal. .L:se:a Uc art-.ent Ji - ,.:MIC Ja;E:. U _card cf Building Regulations and Standards _ E-se. CS-095707 e, I„ ,,7,v 4 r BRIAN D DENNISON K!,..:'-.3"..ef; 7 LAMBS POND CIRCLE . .ie, ,,, CHARLTON MA 01507 t-='s-' issioner 09;0$;'2018 >,`_ The Commonwealth of Massachusetts Department of Industrial Accidents _IMS I Congress Street,Suite 100 �1= s Boston,MA 02119-2017 Nr, ~ www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lesibiv Name (Businessiorganization/Individnal): Ste*c ,J AJ e to -ell. . r r )b 4ots Address: .21a 4L/S/00 M , /� �ti�ct 1/V • City/State/Zip: _ 4, p _► . . - Phone 4: l(j/_2>. = Q get Are you au employer?Check the appropriate hot Type of project(required): IX!am a employer with 20 temployees(full andlorpan-timet• 7. Q New construction 2.0I am a sole proprietor orpartnership and have no employees wodtina forme in any capacity.[No workers'comp.insurance required.) 8. ❑Remodeling 3.01 am a homeowner doing all work myself[No workers'comp.insurance required.)t 9. ❑Demolition 4.01 am a homeowner and will be hiring contractors m conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or an sole proprietors with no employees. I1-❑Electrical repairs or additions 12.0 Plumbing repairs or additions 5.01 am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'romp.insurance? 13.❑Roof repairs /n/ � 6.❑We are a corporation and its officers have exercised their right of exemption per MGL a 14.[�'tjtber [.J n c�-._l 152,.§1(41 and we have no employees.[No workers'comp.insurance required.) rect.?c•s.; 'Any applicant that checks basin must also till out rrn the section below showing their workers'compensation policy information V t Homeowners who submit this affidavit indicating they an doing all work and then hire outside contactors must submit a new Affidavit indicating such. :Contactors that check this box must attached an additional sheet showing the name of the subcontractors and state whether ornot those entices have employees. If the sub-contractors have employees,they must provide their workers'camp.policy number. I am an employer that is providing workers'compensation insurancefor my employees. Below is the policy d job site information. /� Insurance Company Name:Fire re PIE A S 'N S. t-O(yl Policy p or Self-ins.Lic.*: '�to 315$7 Z 4 — 2-0 Expiration Date: I/I if V — Job Site Address: 2 e Ce'Pa n : — City/Statezip:S/n+a..744 h1A Attach a copy of the workers'compensation policy declaration page(showing the policy number 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 WORE ORDER and a frog 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 certifycerafy under ns and penalties of perjury that the information provided above is hue and correct Siznature: _ Date: p — / 5— ( e phone t±: era i-22.t T PIS Official use only. Do not write in this area,to be completed by dry or town official City or Town: Permit/License tr ' Issuing Authority(circle one): • 1.Board of Health 2.Building Department 3.City/fown Clerk 4.Electrical Inspector. 5.Plumbing Inspector . 6.Other Contact Person: Phone*: 4`O��® CERTIFICATE OF LIABILITY INSURANCE °"'E""M°°"""' 12/29/2017 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 be endorsed. if SUBROGATION IS WANED,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). '..RDDUCER CONTACT oBiz Insurance, Inc.-CO NAME: ri 1401 Lawrence St,Ste. 1200 Ise r;.erre 303-988-0446 Denver CO 80202 E-MAIL iA C.xoL 303-988-0804 ADORFSS• COMBIle5CONDOSurance.com INSURER(S)AFFORDING COVERAGE RAC e INSURER A:Acadia Insurance Company IISURED ESLERCO-01 91325 INSURER e:FiremenInsurance Company of WA,D.C. 21784 Southern New England Windows, LLC. iba Renewal by Andersen of Southern New England INSURER c:Homeland Insurance Company of New York 34452 10 Reservior Rd INSURER D: Smithfield RI 02917 INSURER E: INSURER F: :OVERAGES ' CERTIFICATE NUMBER:1252851165 REVISION NUMBER: 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 CONDETION 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, OCCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. •'reTYPETYPE OF INSURANCE ADOL SUM • POLICY EFF POLICY EXP ` MIO MD POLICY NUMBER INWDDIYYVYI IUMNDR'YVYI LIMITS A X COMMERCIAL GENERALUASSUIY CPA3158728 1/1)2015 11112019 EACHMAOCCURRENCE 51.000,000 DAr:LAILlS•rJADE X OCCUR PREMISES Roaunenee) $500.000 MED EXP(My one pe son) S 10.050 PERSONAL I ADV INJURY _ $1.000,050 GEM AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S 2.000.000 El POLICY E JPEReof .O LOC - PRODUCTS-COMP/OP AGG 52.000.000 _ OTHER $ A AUTOMOBILE LIABILITY N CPA3158728 I In2018 1/1/2019 COMBINED SINGLE LIMIT /Ee emdentl 51 ODD Ono El ANY AUTO BODILY INJURY(Per person) S - ALL OWNED SCHEDULEDAUTOS AUTOS BODILY INJURY(Per accident) 5 © HIRED AUTOS x AUTO V✓•JED PROPERTY DAMAGE )Peracad5M1 5 I S A ' X UMBRELLA LAB X OCCUR CPA315B72E 1(12015 117201E EACH OCCURRENCE $10.000.000 EXCESS LAB CLAIMS-MADE - AGGREGATE 510o00COO DED X RETEMIONFO e WORJI0t5 COMPENw SATION 5 AND EMPLOYERS'LABILITY CA315HT1FZ0 1/1/2011 1/22018 X STATUTE I ESRµ ANY PROPRIETOR/PARTNER/EXECUTIVE VIN 1'EE1II OFFICEROFFICER/ME/AMEXCLUDED? ❑ El EACH ACCIDENT S 1000 000 OFFICER/ME/AM NIA Mandatary m NIN DM° EL DISEASE-EA EMKO 51,000.005 Ryyess�d .lmeIdor TON OF OPERATIONS below EL.DISEASE- C Paley 7930073340000 POLICY LJeert 511.00 .0° Ciamwalate 1(12518 I/1/201S Fcdnble Occurrence 51.000.000 Remacaw Date 06/20/2013 Aggregate i10 WO°0° IESIRIJPTON OF OPERATORS/LOCATORS/VEHICLES (ACORD 101,AddiionS Remarks Schedule,may be seethed M more apace Is required) :FRTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. For Informational Purposes AUTHORIZED REPRESENTATIVE ®1988-2014 ACORD CORPORATION. All rights reserved. kCORD 25(2014/01) The ACORD name and logo are registered marks of ACORD