HomeMy WebLinkAboutBLD-19-001001 Office Use Only
. O PamidF '
O ra+.' ti Amount •
`" 5`✓' Permit expires 180 days from
issue date
EXPRESS BUILDING PERMIT APPLICATION---- .
TOWN OF YARMOUTH ° ez C S d s, I:, ':- ri
Yarmouth Building Department i
1146 Route 28 AILS 15 2018 r1
South Yarmouth, MA 02664 '
(508)398-2231 Ext. 1261 Baur a
Baulk*.
CONSTRUCTION ADDRESS: 5 rtSGC— D k . •
ASSESSOR'S INFORMATION:
/� �Map: nf Parcel: '
OWNER: non C r1 S.�r, arrnxxft ?orf phi 0200.5 (5 & 36L-3�b
NAME PRIS` DRESS • ''ISH. n EmaitAddress:
CONTRACTOR:SAut6tA IJP. ofnolptes fa N, Rel/K0 86r Ow) 228-c evo
-�FttAME MAILING ADDRESS TEL.it Email Addre;
0 Commercial .
Est Cost of Concoction$
Home Improvement Contractor It# 17 a 2-43 Construction Supervisor Lie.# o 91`S7a 7
Workman's Compensation Insurance: (check one) .
I am the homeowner I am the sole proprietor A have Worker's Compensation Insurance t
Insurance Company Name: f REMEA S IPS• m � Worker's Comp.Policy# tOOA8/68'72 9-2 Cs
WORK TO BE PERFORMED
Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares Replacement windows:# 2 Replacement doors: #
Roofing:
uu#of Squares ( )Remove existing*(max.2 layers) Insulation
( lw/Ol K ngs Highway/Historic Dist.. ( )Replaacling/likke for like Cru. 44°O t— 4-o sr
k:ae
*The debris will be disposed of at LAW- 1 r'ttp•N plv'" 'tern , '
Location of Facility
I declare under penalties of perjury that the stat_ elms herein contained are true and coma to the best of my knowledge and belief. Iunderstand that any false answer(s)
will be just cans,fee denial ,don obMAILf m; se and forprosecodon under ML Ch.268,Section 1.
Applicant's Signature: Date: t�lls-ll r
Owner Signature(or attachment) ,Are Date: / , ���
Approved By. / 7-73,1,-.77.---},------ Date: (IJP/
Width ffi.: designee
• Zoning District:
Historical District Yes No Flood Plain Zone: Yes No
Water Resource Protection District: Within 100 ft.of Wetlands:
Yes No Yes No
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( '` and sen,anya to she ttadttti and/or rutin*of Sorlem New Entan)\''nakw,,il:C dA,la Karl._J
Kyr ea of Se'dl' agrees tranceon
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Salver anduatwW tot I _ -LoJeSlJ_ tebr ton aura Canoht'at bleb trva be ride bored(
i J ., tra dandm Ind/te penal(heck WA One%of ash
tareationa10 p
ayrr(s)amen sad..dte.tuas drat this Agnemeel ees.titeln Ito Win eadentaadi.g hetwtee the partite,and that
erre are ea verbal eel minding'ehaagleg say of the Knee of ells Aprtme.t.Bayne)atlmewledges that Buyer(•)
)has read obis Agreement,sedtnlaads the(tabs of tilt Agreemeet...d has inched a completed.signed,wad dated
met this Agrremtes,lalsdiag lbw two attached Notices ef Ca eflhiIoe,on the date Rom verbena abe.e and(2)was orally
ifor.itd of Buyers*right re navel tbhAgteement.DO NOT S1GNT111S CONTRACT If TII/REAM:ANT EL\.N•H SPACES.
(hod.lataA Samthoth Island Sea CAW Naice to Doyen(I)Dee ace age tMsAgrnemea if say st the armee i.'..1 4 for the agreed term.
i lbs tamest of the.mailable Informants an leftblaalr.(I)\ee an twitted is acopy of Ibis Agreement at the time you sign
(3)Thomay at,syfl,n,payoff the filinpald balsa.di.audit ihIsAxnqm..t..andI.redoingleunearbewaddedto
Kart a yards.*rebate ct the f sable sad taauraace charges.(t)The mate has se Agit oe taalawf fly ester your premises
r commit way breads of no peace to repossess goods perch led ender this Agreement.($)Yoe may cancel mita Antennae
(It has nM bar dgned at the mals edits or a branch Melee of the setleq prodded you sottfy the seller at hes or her main
(fico ottoman emee►bewe is ale Agreemeat byregistered or(retitled mall.Which shall be petted sat Tater than mldulghi
t the third taleoda-day afar uhe day ss which the herr signs eb.Agnrmeat,tttlodi.g Se.day mad say tow"e...pith
tg.lar mall deliveries ave sot made.See the aeernpaaytag soda of casnitadoe form for aseaplasatlee et buyer's rights.
lryrr);!Imbed the cesumrr taxation attvrirh pealed by delU.>,'.t lJard C<artnen keyera•inn Raul lfM.S t.,aaJ
F
Worn]br dints of OsensLowEingland Buyer(s1 Sudo.►)
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L , ... I7- t Sladd/. . . s c-Acinic
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.Pitt Named ilohKt ytau6er Pru„Name Pint Sant
COLS TUE 81..1FA(S), ?uY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OP TILE THIRD
1JSL\TSSDAYAFIERTI fE DATE OP71tIS TRANSACTION.SEETHE ATTACHED NOTICE OF CANCELLATION FORM S
'ORANI Pi.\NAT10NOFTIIISRICItT.
!K '' ]SO?]t:EO • IS.A�02f• Y NOTICE_OLCAtLCLLtATI.011 x
ate of Traniatdeii_—( " You may cancel Dam of Traaatdon .You my until
Ns tnnsacdon.&Smut any penayp or abandon.within this tr ntattian,without say penalty or obEgaden,within
0. by*.by*.dr,from the above date.If you canted,ary (lure.*mints.*nays front the above date.II you cantet a
=it In;traded ..airy payments made by you under the property traded in,any payments mads by you under theny
eCo�mwre t or Sale;and any nogedable Intewnent executed Contract or Sale,and any_nests a fmwmtnt estcuted
.You vita(be retried within ten bufinesl dart foSeein= by you wtli be returned wkl n ten business dys totlawing
PMOL br.ds.S&lse.of your caatgadon noece,and se? let by the Seller of your canceWtion notice,and any
�7 hewn(atialnyout Of t enzablctiont WI beseevr7t Inlwest 'Ailing out of the tramadon ws11 be
tants'Mien llyeurenktre s.ln Ywa is malts rnitabl0 to die Stifle tarCekd.tfyOu canol,you mutt make a,ailable to the Seller
roc tootMet �as a n at your residence,M substantially as good ceedidon as when
mien trans iaa ntraaeve tateed. delNtrtd t0 under this Contract or
Mme StbrregardNn�=torn ' fUozooctbnset; ±reitt,ryeueneb f you wetr:moyyyy wont"the lnswcdomef
ani=torn_
Dmeatofthe ggeds at the Ire
rgardng the nium sa3patent of the goods atAho
is 'N Ys•do maks"the goods agRabie.�f Salk"enema and this.Ifyw de make the goods aerial(
aid the Seth doer net pick(tam tp w,ddn to the Seller and the Setkr dots Mt pick them up within
�he
awa�y, fib, the date of t any Cunha;
you r—ra near eve tweoty dans of the date of tantttlatien,you may retain or
taxes snake thusoot vel Allah any tr.eh..r eb8gatiak Irleu I dales*of mho i whiten anyfurther ebbgatIon.If you •
ro rowmm the S s'taiashie to'the Setltner lfyou agree'.( fail a mats the goods avrtabls to the Wen Ifyeu agree
is the Roar and fa to de oa then y. to return the goods to the Seller and ful to do s0,then
You n'nd^ ter criertnt.of all*bandana••hoed and dated is trywaion,mall or dhareerr t the nCoawacc aln Te cancel th�'t transaction rola or dta�er
•.*nand snd dated dopy e1 this cannRaden
other te.01 astice.or send a neat,or any-I.a head and dated seer pr ted► telex. t nodso 00 en
AMsiysr,a/Ssuthem New n a R.nswstby', And wrlaen nw:to,or send a telegram to Rtotwut by
E Mand a 1.Ara,Road.'s Andaman of Sachem New CASS at 10 Resonate Reuel.
_ 2r�7 NOT t�17ERTHAN IlIDNICNT OF t Smiddiielel.R1 OIp17;NOT.LAYER THAN MIONIGHT OF
gay, Daa))
ESY fl MTRANSACTION.' . . . (Ogee)
a • - - °I HEREBY CANCELT111STRANSACTION. .
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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 -. .
LINCOLN, RI 02865
Update Address and return card.Mark reason for change.
Address _ Renewal _ Employment = Lost Card
-_pfce 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 Affair and Business Regulation
Registration: 178245 Type: 10 Park Plaza•Suite 5170
Expiration: 919/2018 Supplement Card Boston.MA 02116
'LJTHERN NEW ENGLAND WINDOWS LLC.
.NEWAL BY ANDERSON ��
UAN DENNISON
ALBION RD '.LrLa..)—.^ yJ`-
'COLN. RI 02865 l..C:ndetsecreiary Not valid without signature
`W' -Ytssach, 'serfsL'epar.m:,'t C "..brio aaje-i
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BRIAND DENNISONfr •
7 LAMBS POND CIRCLE >
CHARLTON MA 01507
(1/4-'71—A"
tVim_ yr --,'.
Commissioner 09,08/2018
The Commonwealth of Massachusetts
'_d it Department of Indzistrial Accidents
"_ 1 Congress Street,Suite 100 .
• 7.'4= Boston,MA 02114-2017
•
www.mass.gov/dia
• Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH TEE PERMITTING AUTHORITY.
Applicant Information
Please Print Legibly
• Name (Business/Organinion/lndividoal): �,ej�}{ e ,J U e Lip- 'G4ft*ct (. bclpws
Address: 4USJoJ
City/State/Zip: L. - Phone#: 4,Q( . 2k = Q gt:7 -
Are you an employer?Check the appropriate box:
Type of project(required):
1. I ani a employer with ZO!employe=(full and/or pan-time).,
2. 1 am a sole proprietor or8. ❑Newm Remodeconstrling❑ F.[Nos comp.4 and noemdloyees working for me in
tmy capacity.[No workers'comp.insurance required] 8. ❑Remodeling
3.0 1 am a homeowner doing all work myself[No workers'comp.insurance reoured.)t 9. ❑Demolition
mi
4.❑I em a homeowner and will be hiring contractors to conduct all work on my property. I will ]0❑Budding addition
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
50 I am a general contactor and I have hired the subconoatt rs listed on the attached sheet.
These sub-contractors have employees and have workers'romp.insurance.; 13. Roof r//e,p��tairs lag��
6.Et We are a corporation and its of5cers have exercised their right of exemption per MGL a 14. Other w(��C/4[/
152,f I(4).and we have no employees[No workers CoT*insurance required.)
•Airy,applicant that checks box in mus 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 hire outside contactors 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-eonoectors Imre employees.they must provide their workers'comp policy number.
J am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information f n
Insurance Company Name: Firemen S 1 u S. t-fj e1
Niimi
Policy#or Self-ins.Lic.#: u Cy4 3/St,2.9 - Z 0 Expiration Date: l,// 491
AJob
a
Site
t Address: .3— r rife- Me. City/State/Ztp: (vnt ' '-cna
copy of the workers'cot nsatibd policy declaration page(showing the policy ttt(((umber 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 WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of-the MA for insurance
coverage verification.
I do hereby certify under th ains and penalties of perjury that the information provided abov is tand correct
Signature: Dale: P-$')c
phone#: QOI- ZZ8%c('get'
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#:
A CERTIFICATE OF LIABILITY INSURANCE I °"""""D°"""
12129/2017
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: H 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).
'REDUCER CONTACT
CoBiz Insurance, Inc.-CO NAIVE:
ONE
1401 Lawrence St.Ste. 1200 INC No Er?303.988.0448 (AJC Net 303-988-0804
Denver CO 80202 ADDRESS- COMalleCOD iinsuranee.Com
INSURER(s)AFFORDING COVERAGE NAIC p
INSURER A:Acadia Insurance Company 91325
NSURFS ESLERCO-01 INSURER e:Firemen Insurance CO
Southern New England Windows, LLC. mpBrry of WA,D.C.
21784
dba Renewal by Andersen of Southern New England eminent c:Homeland Insurance Company of New York 34452 34452
10 Reservior Rd
Smithfield RI 02917 INSURER o.
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 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.
•.ATR TYIEPeVSVRANCE ADM SUER • POLIcy EFF POLICY EXP \
M50 VND POLICY NUMBER IMMIDDIYYYY) IMMIDDIYYYYI LIMITS
A X COMMERCIAL GENERAL LIABILITY CPA315B72e 1/12018 1/1/2016
EACH OCCURRENCE 31.DOG.epp
OWNS-MADE X OCCUR DAMAGE'0 10 RENTED
PREMISES(Ea ocorencel S=MIX
'— MED EXP(Any ale person) 310,000 _
PERSONAL a AM/INJURY 31,000,000
GENt AGGREGATE LIMIT APPLIES PER' GENERAL AGGREGATE _ 12000.000 _
POLICY E J � ED LOC - PRODUCTS•COMPIOP AGO 32000.000
OTHER 3
A LIABILITYAUTOMOBILE N CPA315872e 1/1201e 1112015 COLUMNED SINGLE LAM
(En ewdeml S t ply 000
X— ANY?aroBODILY INJURY(Par person) 3
ALL OWNED —SCHEDULED _
AUTOS AUTOS BODILY INJURY(Per adene 3
X HIRED AUTOS X OS WINED OBERT DAMAGE s
A FL UMBRELLA LIAB X I OCCUR CPA31 Sane 1/1/2015 112011 EACH OCCURRENCE 110 000.000
EXCESS LIAB 7 CLAIMS-MADE
AGGREGATE 310.000000
DED X RETENT10NIe -
e WORKERS COMPENSATION VOCA3158229-20 1/1/2018 111201E X
PER 0Tµ
AND EMPLOYERS-LNBILRY Y IM STATUTE I EA
ANY PROPRIETORPARTNERIEXECUD V E
OFFICER/EMBER EXCLUDED? ❑N/A EL EACHSE.LA StU00con
(elarldeevY in NH) EL DISEASE•EA EMPLOYEE51.001.000
eyesdescribe under
DESCRIPTION OF OPERATIONS balmy EL DISEASE•POLICY 11MR 31.000.000
C �U �, 7930073340000 1/12018 1nOccurrence019 Dien Occurrence 51.000.000
ade POI
ReboM9re Dees 06262013 I Oed 110,000 00
1ESCRIPnUN OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101.Addlealel Remade Schedule.nay M Mbcied R neve spec*Is required)
•
: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
r
®1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD