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HomeMy WebLinkAboutBLD-19-001009 2„ omccUse onty Pemdt# ; �!E' .. e O� O - a , .; Amount 5 \"`r—aC2 Permit expires 180 days from• issue date ! • l EXPRESS BUILDING PERMIT APPLICATION1 OD� TOWN OF YARMOUTH • Yarmouth Building Department - 1146 Route 28 ED South Yarmouth,MA 02664 1 (508) 398-2231 Ext. 1261 LAUB 15 2018 J CONSTRUCTION-ADDRESS: /7 l✓n/-F•So/i RI, a -`"�� Y f ASSESSOR'S INFORMATION: • Map: '/1 Parcel: • OWNER: err0I (u nr.S /7a/Fion/ gyorn,vit1M_ 4 a2.c.a.4 cat-760-x-)51 NAME PRES DR)a� ^ TEL # t *PAM Email'Address: CONTRACTOR:,SAttlwn IJ.j;. Cdtho�vtos Gftll gL 7P 121 0286' CPO 22t4100 AME MAILING ADDRESS TEu.# Email Addrt 0 Cormnercial Est Cost of Construction$ 17/13 9 3 Rome Improvement Contractor Lia# 173 2.'j5- Construction Supervisor Lic.# o767D 7 Workman's Compensation Insurance: (check one) I am the homeowner I am the sole proprietor s have Worker's Compensation Insurane Insurance Company Name: f REn1tA-15 l P.s. esj]r) } Worker's Comp.Roller? 100,4 Nairn7-2 0 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares • Replacement windows:# Replacement doors: # 1 Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. .� ( )Repladng like for Ile • *The debris will be disposed of at: W rdt.+a n.jev...e---t'" — Z),co/n / lel: Location of Facility I declare under penalties of perjury that the ems herein contained are tree and correct to the best of my knowledge and belief. I understand that any false enswer(s) an be just cause for denialof re and or prosecution under M.G.L.Ch.268.Section 1. Applicant's Signer= Date: P- /S -/i Owners Signature(or attachment) '- : I .£ALtha: •0 - • Date: / I/� ef Approved Ely - f Dam: �� B gy a: (or designee) . / Zoning Distrito Historical District Yes No Flood Plain Zone: Yes No Water Resource Protection District Within 100 R.of Wetlands: Yes No Yes No Renewal Agreement Document and Payment Terms IyAndersen. dba,Renewal By Andersen of Southern New England Carol Uronis >0 �••. �• : Legal Name:Southern New England Windows,LLC 17 Wolfson Rd OR I re RI#36079,MA k173245,CT#0634555,Lead Firm#1237 south Yarmouth,MA 02664 N• wt000w as LAMM! 10 Reservoir Rd I Smithfield,RI 02917 H:(508)760-2991 Phone:866-563-22351 Fax:401-633-6602 Isales®renewalsne.com C:(774)368-3763 Buyer(s)Name: Carol Uronis Contract Date: 07/30/18 Buyer(s)Street Address: 17 Wolfson Rd, South Yarmouth , MA 02664 Primary Telephone Number: (508)760-2991 Secondary Telephone Number: (774)368-3763 Primary Email: Secondary Email: Buyer(s)hereby jointly 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: $4,393 By signing 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: 51,464 Balance Due: $2,929 Estimated Stan: Estimated Completion: Amount Financed: 50 8 to 10 weeks 8 to 10 weeks Method of Payment: Cash/Check 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: Yarmouth town hall Buyer(s)agrees and understands that this Agreement constitutes the entire understandings between the parties 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 08/02/2018 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 A,:Renewal By Andersen of S uthern New England Buyers) ga' `79 gitAsjE�e cam:_ Signature of Sales Person Signature Signature Ray Thivierge Carol Uronls Print Name of Sales Person Print Name Print Name UPDATED: 07/30/18 Page 2 / 10 J Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 173245 Type: Supplement Card Expiration: 9/19/2018 SOUTHERN NEW ENGLAND WINDOWS LL BRIAN DENNISON 26 ALBION RD ti L+NCOLN, RI 02865 • Update Address and return card.Mark reason for change. — Address — Renewal — Employment — Lost Card 7:-:Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the -•R+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: 919201$ Supplement Card Boston,MA 02116 'UTHERN NEW ENGLAND WINDOWS LLC. NEWAL BY ANDERSON .IAN DENNISON / - _ // ALBION RD \Z C-2[1: s yf�—� JCOLN,RI 02865 LL:odefsecreiary Not valid without signature • -`,^�racL. ;;tsc'ts Department •' .::,JC See; :i y ti card c..f Buildirig Reg.uIatbbns and Standards a&:; �Er 3 f?tr..£,-.:.;,:..1.-:,t BRIAN D DENNISON _ � 'k'' LAMBS POND CIRCLE d CHARLTON MA 01507 t `7'`"tib �./� Oomrnissiorler 09:0812018 The Commonwealth of Massachusetts • po Department ofIndustrial Accidents —itil I Congress Street, .tel_Sr 8] Suite 500 • Boston,MA 02114-2017 1..-1-? www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information • Please Print Lettibly • Name (Business/Organization/Individnal): SSI.(.. AJ e to .E j Irr^j (1'1 it)CJOws Address: _2(0 4f }r\loO 4 , �c M City/State/Zip: GiLlactp f R t 02.nr. Phone - 2 kr— 7&tX - Are you an employer?Check the appropriate box: Type of project(required): 1. 1 am a employer with 20 temployees(full and/or patitimel• • 7..0 New construction 2.01 am a sole proprietor or partnership and have no employees wmldng for me in 8. Remodelin any capacity.[No workers'comp..insurance required.) ❑ B 3.0 1 am e homeowner doing all work myself[No workers'comp.insurance required)t 9. 0 Demolition ]0❑Building addition • 4.0 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 mnnanee or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 50 I am a general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurances 13_0Roof repairs 6.0 We are a corporation and its o£ucers have exercised their right of exemption per MGLc 14.Bother D�;fv (-1(0dr 152,f 1(4),and we have no employees.[No workers'comp.insurance required) (/ A/case-len •Arty applicant that theela box#1 must also El out the section below showing their-workers'compensation policy infmmai on. t Homeownerswbo submit this affidavit indicating they am 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-contraction 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 d.d)ob site information. Insurance Company Name:FiremeAs IPS. OCTI ,[ Policy g or Self-ins.Lic.#': to 074//315¢ 7 2.9 - 2.0 / Expiration Date: i// /i Job Site Address: /7 /JO/'T.fo i 1 j��t City/State/Zip: 5.$'no,A 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 ptiaishable by a fine up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator.A copy of This statement may be forwarded to the Office of Investigations oftbe DIA for insurance coverage verification. I do hereby certifycertify under and penalties of perjury that the Information provided above is true and correct Sienatu re: Date: P - t 5 - 11' Phone t+: Q01-22.t t gee) 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 tr: ACN RCs CERTIFICATE OF LIABILITY INSURANCE I DATE IMMD/YYYY) 121292017 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 ADDmONAL INSURED,the policy(fes)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). 'RODUCER CONTACT .oBiz Insurance,Inc.-CO NAME: . 1401 Lawrence St, Ste. 1200 PHONE FAX IAC Na frtn 303-958-0446 we,Nok 303-988-0804 Denver CO 80202 ADDRESS. COMailtcobIzinsurance.com INSURER(S)AFFORDING COVERAGE NAIC 5 INSURER A:Acadia insurance Company 31325 ' MIRED outhem New England Windows, LLCE5 ERCO.01 INSURER a:FIremens Insurance Company of WA,D.C. 21784 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 CONDRION 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 CONDmONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. • ADDL SUER ' POLICY En POLICY EXP ITR TYPE OF INSURANCE Ms] Wm POLICY NUMBER M14/00/VYYV1 IMMIDDWYM I LAM ` A X COMMERCIAL GENERAL LABILITY CPA3158728 1/1)2011 1/1/2018 DGE TOREE 51000000 W dMS-IIgOE X O OCCUR DAMAGE REMISES RENTED Ocvnencel SsoD,000 MED DIP(Any one pemon) $10,000 PERSONAL 8 ADV(NARY $1,000,000 GENT AGGREGATE LIMIT APPLIES PErt GENERAL AGGREGATE _ 12.000.000 _ © POLICY O JPEST. '❑LOC PRODUCTS.COMP/OP AGG 12.000 000 OTHER* — S. A AUTOMOBILE LIABILITY N CPA3158728 I 1/1/2011 1/1/2018 COM&Nm SINGLE UMIT fEa amoen0 11 000 000 ©ANY AUTO BODILY INJURY(Per person) S . ALL OWNED SCHEDULED _ , AUTOS AUTOS BODILY INJURY(Par am0enp S X NON-OWNED PROPERTY DAMAGE 5 © HIRED AUTOS (Per'cadent 5 A X UMBRELLA LIAB X OCCUR CPA3158728 1/1)2015 1)1/2019 EACH OCCURRENCE _ 110 WO,OW EXCESS LIMB CLAIMS-MADE AGGREGATE 110E0 000 DED X RETENTIONSp S E WORKERS COMPENSATION WCA3158729-20 1/1)2011 1/1)2018PER p�Tly AND EMPLOYERS" YIR X STATUTE ER ANY PROPRIETOR'PARTNEWDZECDVE EL EACH ACCIDENT 51.000000 OfFICERR.EMBER EXCLUDED? N/A ive.clary 1119 leund EL DISEASE-EA EMPLO 51,000,000 y dserme Mier R DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LM R $1.000.000 LI51.000,000 C Poalton Liately 7930073340000 1/1/2018 1/1/2019 Each Omerence 11,000.000 MragaClam.Mad.Paley Retmar>rve Date 05202013 DDeeddumbk 11b 00000 IESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101.Adana*Remarla Schedule,may be*awned N mare specs M reouired) • ;ERTIFICATE 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 I ®1988.2014 ACORD CORPORATION. All rights reserved. kCORD 25(2014/01) The ACORD name and logo are registered marks of ACORD