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Home My WebLink AboutBLD-19-001491 .OP•ico Use Only • 4:``'' o Permit" 5p/ a SII ''� ' •- c' Amount e µ yyjA Permit expires 180 days from• �_ issue date $C,b-Iq-001Uq L EXPRESS BUILDING PERMIT APPLIC • :1 E V E D TOWN OF YARMOUTH Yarmouth Building Department 6 2018 • 1146 Route 28 SEP - South Yarmouth,MA 02664 aril! T / (508)398-2231 Ext 1261 DUI CONSTRUCTION ADDRESS: `7 kelp line • ASSESSOR'S INFORMATION: � ((�� Map: Parcel: / OWNER: /I0�bestf Sib) /leo l/1 )/ .v 14.4 (1246V Car- 7r2 foo NAME f PRi:S DRISU • .. # EmateAddress I z� ton 228=9IVO CONTRACTOR•Seu'ltern N.li Wrn�D1P5 Grlu #'. rei ozuC � / AME MAILING ADDRESS TEL.# Email Addr Residential Conmiercial Est Cost of Constmcdon$ 2 I C o0 — Home Improvement Contractor Lie.* /73 2.45- Construction Supervisor Lie.# 076707 Workman's Compensation Insurance: (check one) I am the homeowner I am the sole proprietorhave Worker's Compensation Insurance Insurance Company Name: $REt//5L,t5 IRS. C/O/tett Worker's Comp.Policy# ID CA 31G8'72 9-2 0 WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: 4 of Squares Replacement windows:# 3 Replacement doors: # 2— Roofing: Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation • Old Kings Mghway/Histo/� le ric DiisDist ( )Eepladng like for like ('� *The debris will be disposed of ac Ct/�t /tan s ((Qtin e - rt Ce/n tip C Jammu a of Facilitt / I declare under pemldes of perjury that the s herein contained are true and correct to the best of my knowledge and ballet !understand that any false answer(s) will be just cause for dental arfayocadonofNtorProaecUuon se undcM.O.LCh.2f8,SeedonL p \IYf-�1'� Date /-- 5J -/k Applicant's Signanrre: Owners Signature(or attachment) r ate. Approved ByDare 7-67/8 B ding ( desidesignee) Zoning Dist Iiismrtcal 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 byAndersen. am Renewal By Andersen of Southern New England Robert Sergio Istel Legal Name:Southern New England Windows,LLC 4 Kelp Lane qr ��** WINai uaa«sxr RI# 36007r ,MASmithfield,1 4 029 710634555,Lead Firm#1237 South Yarmouth,MA 02664 RIH:5089828006 Phone:866-563-22351 Fax:401-633-66021 salesorenewalsne.com Buyer(s) Name: Robert Sergio Contract Date: 08/23/18 Buyer(s)Street Address: 4 Kelp Lane, South Yarmouth, MA 02664 Primary Telephone Number: 5089828006 Secondary Telephone Number: Primary Email: rsergio2710gmail.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: $21,500 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: s0 Balance Due: $21,500 Estimated StartEstimated Completion: . Amount Financed: $21,500 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: Plan 2521 12 month no pay no interest 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) I)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 ANY TIME NOT LATER THAN MIDNIGHT OF 08/27/2018 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 Namet Southern New England Windows,LW dba:Renew/An rs of Southern New England Buyer(s) nn v` Signature of Sales Person Signature Signature Paul Conboy Robert Sergio Print Name of Sales Person Print Name Print Name UPDATED: 08/23/18 Page 2 / 11 Commonwealth of Massachusetts 79' Division of Professional Licensure Board of Building Regulations and Standards Constnj.Ctri IS`iSpervisor CS-095707 E',pires: 09/08/2020 BRIAN D DENNISON '^:# / : 8 BLACKWEL4PRIVE ,. V " CHARLTON MA41150T ♦ , 4t4c :1JOly .,.. y.- .. Commissioner Letwe 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 = . 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 ` -•a--g 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: 9/19/2018 Supplement Card Boston,MA 02116 ILITHERN NEW ENGLAND WINDOWS LLC. :NEWAL BY ANDERSON f/ IIAN DENNISON j / ALBION RD �.EF..c7C.C.�.g JCOLN.RI 02865 LS:ndersecreiary Not valid without signature • , 3JIIal." :_Sc?:., D.pars en. 'JI ab:;C S07E' / U _ oard of Building Regulations and Standards ,_t. CS-095707 e �� e �r � .Rz : -- rf dr BRIAN D DENNISON ,a, L,5- h; _ t LAMBS POND CIRCLE r'•" « - t CHARLTON MA 01507 Oo -nissioner 09;08:2018 The Commonwealth o fMassachtvetts Department of Industrial Accidents _=it1= � $ 1 Congress Street,Suite 100 I y Boston,MA 02114-2017 • %;;:var www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information ( j Please Print Leeiblr • NameoansinesstOrganmaxionanditidnal): SuTH-`1a2A� e V e R.ii (A fp ciows Address: 26, 4L,]Sice City/State/Zip: _ , • • Phone 4: tj[.2 It— ?Pro Are you an employer?Check ibe appropriate bot Type of project(required): 1%am a employer with 20 temployees(full and/or part-time), • 7. ❑New construction 2.01 am a sole proprietor or partnership and have no employees working for Inc in any rapacity.[No workkvss'comp..msmance required.) g• Remodeling 3.0I em a homeowner doing all work myself INo imprimis'comp.insurance requi edj t 9• ❑Demolition imprimis' 4.01 am a homeowner and will be biting contractors to conduct all work on my property. 1 will 1 Building addition • ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 50 I am a general cantre for and I have hired the sub-contractors listed on the attached sheet 12-0 Pl robing repairs or additions These sub-contractors have employees and have workers'romp.insurance? LJ. RRoofrepairs 6.00.'e are a rmporation and its officers have exercised the?right exemption,pvMGL a 14.EOtber 4 f,it O 152, 1(4),and we haven employees.fNo workers'comp.insurance required] re pl ei cent en 1-5 `Any applicant that clerks box tl must also fill out the section below showing their workers'compensation policy infmmarioa t Homeowners who submit this affidavit indicating they are doing all work and then him outside contactor 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 nor those entities have employees. If the sub-contractors ben employees,they must provide their workers'comp.policy number. /am an employer that is providing workers'compensation insurance for my employees. Below is the policy afrd)ob site information. Insurance Company Name:fire me s Ii- s, ('t[ - /.J Policy#or Self-ins.Lie.*: Ll/GA 3/.5-t7 Z 4 •- Z 0Expiration Date: I// //7 Job Site Address: Li lle of LQ/J e City/State/Zip: S. twrro.•F( 114 Attach a copy of the workers'compensation policy declaration page(showing the policy num er and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to 51,500.00 and/or one-yet imprisonment,as well as civil penalties in the form of a STOP WORE 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 ofthe DIA for insurance coverage verification. 1 do hereby certify under th airs and penalties ofperjury the the information provided above is true and correct Sic:nature: �,. D21e: / — s'v Phone t': SID i-2Z t T ceT, 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*: • '`liCOR CERTIFICATE OF LIABILITY INSURANCE I DA'E'"M)DWYYTT `r•••---% 1212912017 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(les)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 CoBiz Insurance,Inc.-CO NAME- PHONE 1401 Lawrence St,Ste. 1200 Ric Na Fad.303-988-0448 IIFAX Denver CO 80202 STRATI 1 odeNat 303988-0804 ADDREss- COMMI(Bcob¢insurence.com INSURER(S)AFFORDING COVERAGE MAIC e INSURER A:Acadia Insurance Company 31325 NSURED ESLERCO01 • INSURER e:Rremens Insurance Company of WA,D.C. 21784 Southern New England Wndows, LLC. dba Renewal by Andersen of Southern New England INSURER C:Homeland Insurance Company of New York 34452 10 Reservior Rd INSURER D: Smithfield RI 02917 RIMER 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. NOTNTTHSTANDING ANY REQUIREMENT,TERM OR CONDmON 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. ISR 400E SUER TR TYPE OF INSURANCE MSD amPOLICY NURSER NWWDDIWYIT MWDDNWYI LThfl A X COMMERCIAL GENERAL WHET CP/4115872B 1112018 111)2015 EACH OCCURRENCE 51.000,000 dWMS-MADE E OCCUR DNAAGETO RENTED PREMISES(Ea occurrence) 3 500000 MED EXP(My One person) 310.000 PERSONALS ADV NARK'_ 51400,000 GC-NL AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S 2.000,000 X POLICY 0�JECTT 'O LOC • PRODUCTS.COUP/OP AGG 32.0°0.000 OTHER 3 A AUTOMOBILE Linen N CPA315872a 1/12018 1/1)2015 (Ee emeen0 INGLE LIMIT 31 000 Ono X— ANY AUTO BODILY INJURY(Pa person) 5 AU.OWNED —SCHEDULED BODILY MMIIRY AUTOS AUTOS (Per accident) S X HIRED AUros X APJTIOrED I PROPERTY DAMAGE (Per acodeM1 3 'X 3 A X UMBRELLA LIAR X occur(h LPA315672E 1112016 1/1201F EACH OCCURRENCE _ 310.000,000 EXCESS LIAB CLAIM$44ADE AGGREGATE $10.000000 DED X rtEfEMIONID gm- AMO 5 e WORKERS COMPENSATION YIN VVCA315672S21) 111201! 1/1)2015 X EATUrE I ERK AMD EMPLOYERS LIAPILRY ANY PROPRIETOR/PARTNER/DECUTIVE OFFICERR. InNER EXCLUDED? ❑NIA EL EACH ACCIDENT $1 DOD= yaRREyMasIC�EEM.Idatary NH) EL DISEASE•EA EMPLD 51,000,000 DDESCRIPTIONt.OOPE(ATONS below • EL DISEASE-POLICY LIMIT 31,000.000 C y 71)300735440D0 1112011 111)2015 Each Occurrence 51.000000 Aggregateade 0,,000edurnMRes-omen Dm 06202013 IESCRIPTON OF OPERATORS I LOCATORS/VEHICLES(ACORD 101,Adel anal Remarks Solreeule,may be attached If mare space 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 POUCY PROVISIONS. For Informational Purposes AUTHORIZED RBRFSENTATNE C 1985-2014 ACORD CORPORATION. All rights reserved. CORD 25(2014/01) The ACORD name and logo are registered marks of ACORD