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HomeMy WebLinkAboutBLD-19-1006 r,,:Zhis Office Use Only • Qf i"" •A. ti Amoum �` ..wvr'in ..$'Z �,,.„,/`� Fermi[expires 180 days from • issue date EXPRESS BUILDING PERMIT APPLICATION��y ow TOWN OF YARMOUTH • Yarmouth Building Department R E C E a '!f G_ it 1146 Route 28 J South Yarmouth,MA 02664 AUG15 2018 (508)398-2231 Ext. 1261 r� j j CONSTRUCTION-ADDRESS: /(o Gree, % ills/a. 1 ¢�l GI(�'P'jcr i ASSESSOR'S INFORMATION: . Map: Parcel: ' OWNER: fi?.i4'v.HIPiS5Aorser /4 9reear/(4/r r.�+�rf�A •SOP-362-CC* NAME FRES D�RRE,SKN� TEL # Email Address: L(e svrt CONTRACTOR1 Autism N.P. (,()rnolocns GIA) N. Tel o28ror 000 22t-9810 AME MAILING ADDRESS TEL# Email Addn Residential Commercial Est.Cost of Construction$ /1, 3/L — Home Improvement Contractor Lia# 173 2.45 Construction Supervisor tic.# 076-707 Workman's Compensation Insurance (check one) I am the homeowner I am the sole proprietor A.have Worker's Compensation Insurance Insurance Company Name: lRiJ11EA35 IPS. mt44/0/ Worker's Comp.Policy# toQA x!6882 9—2 0 WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate alta : .•. ) Wood Stove Siding: #of Squares Replacement windows:# rr Replacement doors: # Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation (-f 1/5Il�t Old Kings Highway/Historic Dist. ( ✓j Replacing like for like q *The debris will be disposed of at 4/S4 en4.it f \l eel ver— ,`.'n ca.ln/ •l L Location of Facility I declare under penalties of perjury that the. eats herein contained are true and correct to the best of my knowledge and belief. Ivaderstand that any false answer(s) will be Justcause fordenial o�ajocadon of m • se and forproseyudon under M.O.L Ch.268,Section 1. Applicant's SignatureDate: 7— t S---- I& -sr Owners Signature(or attachment) )..11.. • :1# . ate: 11 i 0-7S /& Approved By Date Building c}..,: . design-) Zoning District 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 ' 'Andersen. dba,Renewal ByAndersen of Southern New England 8l Edward&Ruth Welssberger 04;1Legal Name:Southern New England Windows,LLC 16 Green Teal Way Ar ��4jer . RI#36079,MA#173245,Cr#0634555, Lead Firm#1237 Yarmouth Port,MA 02675 WINDOW as ueanaar 10 Reservoir Rd I Smithfield,RI 02917 H:(508)362-5308 Phone:866-563-22351 Fax:401-633-6602 I salesOrenewalsne.com Buyer(s)Name: Edward & Ruth Weissberger Contract Date: 07/10/18 Buyer(s)Street Address: 16 Green Teal Way, Yarmouth Port, MA 02675 Primary Telephone Number: (508)362-5308 Secondary Telephone Number: Primary Email: eweissbergerl@comcast.net 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 panics 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: $14,312 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: $4,770 Balance Due: $9,542 Estimated Start•. Estimated Completion: Amount Financed: $0 8-12 WEEKS 8-12 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: 4770.00 deposit-CHECK;4771.00 due at arrival;4771.00 due at completion-CHK 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 of 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 07/13/2018 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) V Cfewst +✓4 tio13a�- v4irc ✓ Signature of Sales Person Signature Signature Chris Hutson Edward Welssberger Ruth Welssberger Print Name of Sales Person Print Name Print Name UPDATED: 07/10/18 Page 2 / 13 • 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: 9/19/2018 BRIAN DENNISON 26 ALBION RD LINCOLN, RI 02865 Update Address and return card.Mark reason for change. _ Address = Renewal _ Employment _ Lost Card 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: gi19/2018 Supplement Card Boston.MA 02116 OUTHERN NEW ENGLAND WINDOWS LLC. E ANDERSON ALAN RIAN DENNISON / �- 6 ALBION RD INCOLN, RI 02865 t-L'odersecreirary Not valid without signature ler a \1assachuse::s Department of Pubilc Safe:'- Board of Building Regulations and Standards _ cense: CS-095707 W_l� BRIAN D DENNISONw 7 LAMBS POND CIRCLE 9 CHARLTON MA 01507 '`"` Commissioner 09/02/2018 - • The Commonwealth of Massachusetts : Department of Industrial Accidents • =7td= 1 Congress Street,Suite 100 ��= �= Boston,MA 01119-2017 www.mass.gov/dia Workers' Compeusatibu Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information ` - Please Print Legibly • Name (Business/Organizafionnndvidual): , rjIal.�-c AJ AJ e u..) .11A4f f 11 b cJows Address: 26,AajoD --M , Jt� lM • City/State/Zip: li p R( 02S-45-- Phone 4: 11)/ - 2 X8= Q fW _ Are you as employer?Check the appropriate box: Type of project(required): I.Al2 am a employer with 20 temployees(MI mid/orpart-time). 7..Q New construction 2.019M a sole proprietor or partnership and have no employees worldng for me in g. Q Remodeling any capacity.[No workers'comp.insurance required.] 3.01 am a homeowner doing ell work myself(Ne workers'comp.insurance required.]t 9. Demolition 4.01 am a homeowner and will be being contractors to conduct all work on my property. I will ]0 O Building addition • ensure that all contractors either have workers'compensation insurance or are sole 1 LQ 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.insurance 13.0r . Alt.)r 6.0 We are a corporation and its officers have exercised their right of exemption per MGL . 14.LtJ Otbei Lobel t..) 152,§1(4),and we have no employees.(No workers'comp.insurance required.] rep teyretiff5 *Any applicant that checks box ill 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 bin outside contactors must submit a new affidavit indicating suck =Contractors that cheek this box must attached an additional sheet showing the name of the sub-contractors and state whether ornot 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 End job site information. Insurance Company Name: Fire Men S (pg. O{j(•riN(lii./ Policy#or Self-ins.Lie.#: k)CA 3�5-�7 2.9 - a0 / Expiration Date: ib // I Job Site Address: /6 GPet.�1 tem ( LeJa>/ City/State/Zip$tno„-Mp,rl 11A Attach a copy of the workers'compensation policy declaration page(showing the policy number and expifation date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$],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.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 th ains and penalties ofperjury that the information provided above is true and correct Signature: Date: 7- L S= / 8' phone*: 40 1-22.8%p Qct, 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 if: 'A O DI ® CERTIFICATE OF LIABILITY INSURANCE DATE 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 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 CoBiz Insurance, Inc.-CO NAME: 1401 Lawrence St,Ste. 1200 mrr Pi Ext}303-988-0448EMAIL iA C.Not 303-988-0804 Denver CO 80202 ADDRESS. COMail@cobizinsurance.com INSURER(S)AFFORDING COVERAGE NNC I INSURER A:Acadia Insurance Company 31325 INSURED ESLERCPDI INSURER B:Firemen Insurance Company of WA,D.C. 21784 Southern New England Windows,U.C. dba Renewal by Andersen of Southern New England INSURER C:Homeland Insurance Company of New York 34452 10 Reservior Rd Smithfield RI 02917 INSURER D MSVRER E: INSURER F: • COVERAGES • 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 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 AODCSUBR LTE TYPE OF INSURANCE MSD WYD POLICY NUMBER PINDIYEFF PUIDDNYY Y1 LIMITS A X COMMERCIAL GENERAL LIABILITY CPA31513728 1/12018 1/12019 EACH OCCURRENCE S 1,000,000 dWMS-MADE O OCCUR DAMAGE f0 RENTED PREMISES(Es ocourrencel 3200,000 MED ESP(AW one person) S 10,000 PERSONAL 8 ADV INJURY _ $1,000,000 — GEN?.AGGREGATE LIMIT APPLES PER GENERAL AGGREGATE _ 52,000,000 — X POLICY El J T O LOC - PRODUCTS•COMP/OP AGO $2,000,00 _ OTIER' S. I A AUTOMOBILE LIABILITY N CPA3158728 1/12018 //12019 COMBINED SINGLE LIMIT (Ea rodent) 310000 © ANY AUTO BODILY INJURY(Per person) S ■ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Pr rodent) S © HIRED AUTOS X Nq-OWNED rodent DAMAGE AUTOS (Per odent S S A II UMBRELLA LIRE X OCCUR CPA315672B 1/120133 1/12019 EACH OCCURRENCE 510.000,00 _ EXCESS LAB CLAIMS-MADE AGGREGATE ' $10,0000 DED X I RETENTIONS 0 3 e WORKERS COMPENSATION WCA3158729-20 1/12018 1/12019 X AND EMPLOYERS LIABILITY Y N PER STATUTE FRµ ANY PROPRIETORIPARTNER�CUTIVE EL EACH ACCIDENT $1000,000 OFFICER/MEMBER EXCLUDED? ❑NIA (Mandatory In NM EL DISEASE•EA EMPLOYEE $1,00,00 Dyes drake under ESCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT $1,00,00 C POMubo,UabN/ 7930073340000 1/1/2018 1/12019 Each Occurrence 11.00,00 Clamor ads PtY Aggregate $1,)00,00 Retroactive Dab 05/202013 Deem:ele 310,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is reeulred) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POUCY PROVISIONS. For Informational Purposes AUTHORIZED REPRESENTATIVE C J ©1985.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD } • mama 1 r µ r �yy� �/ C A�. OMS # F`' 7.. • kk... .„4= x , gi. .:,,,,,,,-� .�.. 4 A ,,w0:47 H 9 4f p, ' M ?,1 l � A' rbk.. ,, A�< i�4 j;'I IIL ►iiiIIIiIF,Ilii I i''‘ A, . rJy ' nl✓(� n e ; A.,,, 1 '1'" — i 4 :C- ,_ "' .� .s to r.by}:•t' .'.:eN.- --7 . .• t.r+wnt.MPjY .L .{.•.. w ` ' Y'Y 4 zt J :.J44 r�.., ;..4 �r" a�. �.� ti£ 7 k .r+5?9taz ' "�a+"�),,,fo t StTrc••-"q��my` »„ x4x ' -."".a "4 r. ''c " n,is ;t Kms`" - ya, y ,"v ->y .,.., .,,, t ,A F^ 'a• tier",Z. ; 3 il..r r i• MyfV, ; •`•.. . r v.114.7.'2.4. A ti gt zr � +s ;. 1.-if'.* 1bGIE ' / • ivoi ?)-12?_1- . f9 9 —.•,....:-;.:Ar . Mill ( r rin _,IA _...• / . . ... .;. ie Ilu Lc • ` 11111►u� � i III • �E -1122 '= ^- d .. . M1 sr>xr0X ..�,a ^T .yam . . -" r tt S d.“ `. .). :da.. 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