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HomeMy WebLinkAboutBLD-19-001490 .OPermifliicotUe Only ' �`.a_ eN ` i? . t^ r41 . _ pamitexpires180daysfom issue date1 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 SEP - 6 2018 (508)398-2231 Ext 1261 CONSTRUCTION ADDRESS: 20 ayridSt ---- r. By. ASSESSOR'S INFORMATION: . Map: Parcel: • ->et- I OWNER: t9 A efzz; 10 f3%rrtd3a "b(. n D t.1 VIA os674 TEL #C1'41-.2171 NAMmartAddress CONTRACTOR• . . t a IU. • to- otos A -P Tel one( 4 2 8--7t00 AME MAiLING ADDRESS TEL# Email Addr Residential Cor»merchd Est.Cost of Conviction$ 13 7 C-4 —Home Improvement Contractor Lie.# (7a2-45 Construction Supervisor Lte.# 046787 Workman's Compensation Insurance: (check one) . I am the homeowner I am the sole proprietor A have Worker's Compensation Insurance iPS. ea'S1HF-/ Worker's Com lidy# w CA-11682 9-2 0 Insurance Company Name:�aurl�A�s P-Fo WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# C, Replacement doors: # Roofing: #of Squares ( )Removeveexisting*(max.2 layers) Insulation 9 /8" Old Sings Highway/fllstork Dist. (t4 ileplacing like for like ' ^ *The debris will be disposed of ac hh le "Li£ ``Qi"01 c— L:n Lein " amain of Faellitly r I declare under peaaldea of paiury tbst the a eats herein contained ere true and correct to the best of my knowledge and belief. I understand that any false answer(s) WIU be Just cause Im denial ratlon of m and for prosrudon under M.OL Cli.268,SectiOn 1. Applicant's Signature: Date: 9- C"--- iS- k r Damt Owners Signature(or attachment) �� � Pr/ ��� Approved Br Date Bulli (or designee) . Zoning District Historical District Yes No • Flood Plain Zone: Yes No Water Resource Protection District Within 100 f.of Wed Ndds: Yes No Renewal Agreement Document and Payment Terms brAndersen. dba:Renewal By Andersen of Southern New England John&Dianna Adelizzl "e�` Legal Name:Southern New England Windows,1.1.0 20 Bayridge Drive 11. to% RI#36079,MA#173245,Cr#0634555,Lead Firm#1237 Yarmouth Port,MA 02675 WINDOW\uo 10 Reservoir Rd I Smithfield,RI 02917 H:(774)994-2879 Phone:866-563-2235 I Fax:401-633-66021 sales@renewalsne.com C:(508)362-6957 Buyers)Name: John &Dianne Adelizzl Contract Date: 08/21/18 Buyer(s)Street Address: 20 Bayridge Drive,Yarmouth Port, MA 02675 Primary Telephone Number: (774)994-2879 Secondary Telephone Number: (508)362-6957 Primary Email: adellzzi0716@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 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: 513,754 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: $4,584 Balance Due: 59,170 Estimated Start Estimated Completion: Amount Financed: 50 8 to 10 weeks 8 to 10 weeks Method of Payment Cash/Check We schedule installations based on the date of the signed contract and secondarily on the date in which we complete the technical measurements.The installation date that we are providing at this time is only an estimate.We will communicate an official date and rime at a later date.Rain and extreme weather are the most common causes for delay. Notes: Deposit paid via check 107;;Taxes paid in Yarmouth MA Buyer(s)agrees and understands that this Agreement constitutes the entire understandings between the parties and that there are no verbal understandings changing or modifying any of the terms of this Agreement.No alterations to or deviations from this Agreement will be valid without the signed,written consent of both the Buyer(s)and Contractor.Buyer(s)hereby acknowledges that Buyer(s) 1)has read this Agreement,understands the terms of this Agreement,and has received a completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first written above and 2)was orally informed of Buyer's right to cancel this Agreement. NOTICE TO BUYER:Do not sign this contract if blank.You are entitled to a copy of the contract at the time you sign. YOU,THE BUYER,MAY CANCEL THIS TRANSACTION AT ANYTIME NOT LATER THAN MIDNIGHT OF 08/24/2018 OR THE THIRD BUSINESS DAY AFTERTHE DATE OF THIS TRANSACTION, WHICHEVER DATE IS LATER.SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. Legal Names Southern New England Windows,LLC dba:Eenew jE ,denen of So rn New England Buyer(s) ^ /1 /t� Signature of Sales Person Signature Signature Josh Ocharsky John Adelizzl Dianne Adelizzi Print Name of Sales Person Print Name Print Name UPDATED: 08/21/18 Page 2 / 12 Commonwealth of Massachusetts r ®� Division of Professional Licensure Board of Building Regulations and Standards ConstrgCthrti I$ pervisor iJ CS-095707 I E"�ires: 09/O8/2020 BRIAN D DENNISON '..' % 8 BLACKWEL1 DRIVE CHARLTON MA:91507 - 11.0/.CSi:101\ Commissioner v"" 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 once 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: 178245 Type: 10 Park Plan-Suite 5170 Expiration: 9/19/2018 Supplement Card Boston,MA 02116 )UTHERN NEW ENGLAND WINDOWS LLC. :IAN DL Y DEP.SON IIAN DENNISON ALBION RDf�— JCOLN,RI 02865 lyndefsecreiary Not valid without signature ',4:cc :e ar.me`I. Vi ; ..i:, SC?E77 fi .Board of Buildinc Regulations and Star dards • CS-095707 rRf , h 4V h BRIAN D DENNISON 7 LAMBS POND CIRCLE CHARLTON MA 01507 NAL-7-7. C c_ =xc rp.:C" Commissioner 09:08:2018 The Commonwealth of Massachusetts 111471 ---gt =;;If_- Department of lndustrialAeeidenis F =p1 y 1 Congress Street,Suite 100 • - l= g Boston,MA 02114-2017 www.mass.gov/alta Workers'Compensatiba Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FRED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly • Name (Business/Organization/Individual): •,�rjr }(- Id e .q.11 1/(It.�G1dws Address: 2 t 4usio0 City/State/Zip: _ ,.4,., p • Phone##: ick)( . 2 Q eto Are you an employer?Check the appropriate bot Type of project(required): I. I am a employer with 20 temployees(full and/or part-time)• 7. Q New construction 201 am a sole proprietor or partnership and have no employees working forme in any capacity.[No workers'comp.irsurance required.] 8. ❑Remodeling 3.01 am a homeowner doing all work myself[No workers'comp.insurance required]' 9. 0 Demolition 0 4.0 I am a homeowner end will be hiring contractors to conduct all work on m y property. I wil l ❑Building addition ensure that all contractors either haveworkers'compensation insurance or me sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 501 am a general contractor and I havehired the sub-contracmrs listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance? 13.❑Roof repairs 6. Weare acorporation and its officers have exercised their rigM�exemption per MGL e. 14' er Win 152,¢1(4),and we have no employees.[No workers'comp.insurance required] C,(0(4 ec-'e n r S 'Any applicant that checks box#1 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 their 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-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 dndjob site information f Insurance Company Name:Fire men$ 1 pg. l./� D rtibil Policy*or Self-ins.Lie.;k: (.4)( A3/S$'72.9 - 2.0 Expiration Date: I// / i Job Site Address: 20 g4yri c City/State/Zip:*J.t,✓K R<ft A Attach a copy of the workers'cotn/pensa n policy declaration page(sbowing 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 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 of the MA for insurance coverage verification. I do hereby certify under 1h acrd penalties of perjury that the information provided above is true and correct Sienature: Date: f'— C—• / Sr ?hone** czID I- Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License 1r ' Issuing Authority(circle one): • 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector. S.Plumbing Inspector . 6.Other Contact Person: Phone t?: CP A�� ® ' CERTIFICATE OF LIABILITY INSURANCE OAre(MawOmm) 7 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.11THIS 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 policypes)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 endorsemen(s). 'RODUCER CONTACT CoBi2 Insurance,Inc.-CO NAME* 1401 Lawrence St,Ste. 1200 PHONE _ Inc Nn Fro-303-988-0446 i(NCC.Not 303.9880804 Denver CO 80202 ADoaess• COMailecoblzinsurance,com INSURER(S)AFFORDING COVERAGE NAIC I (CURED ESIFJRCO-01 INSURER A:Acadia Insurance Company 31325 insurance e:Firemens Insunce Company ofWA D.C. 21784 Southern New England Windows,LLC. dba Renewal by Andersen of Southern New England INSURER C:Homeland Insurance Company of New York 34452 10 Reservior Rd INSURER o: 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 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 CONDrnONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TRTYPETYPE OF INSURANCE ADOL SUER POLICY EFF POLICY EXP ` MSD YWD POLICY NUMBER (MMIODIYYYYI INMIODIYYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY CPA315E72B 1/12018 Minn EACH C` MS•MADE E OCCUR DAAwGETOE Et.000.00E WRENTED PREMISES(Ea occurrence) S 300.000 MED EXP(Ary one person) 110,D00 PERSONAL S ADV INJURY _ S 1.000,000 — GENT AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S 2.000.000 _ © POLICY JPEa LDC I PRODUCTS•COuP/OP AGO (2.000.000 OTHER' S • A AuTOMOBRE LIABILITY N CPA315E728 I 1/12015 I 1,12015 .BIINED SINGLE LIMIT $ (Es000 coo © ANY BODILY INJURY(Par penin) S O . ALL OWNED —SCHEDULED BODILY INJURY CPM elD sopdI AUTOS AUTOS © HIRED AUTOS X NON-VARED PROPERTY DAMAGE (Per inner) 5 S A X UMBRELLA UAB X OCCUR CPA315872E 1/12015 1/12015 EACH OCCURRENCE 510000,000 EXCESS LIAB CLAIMS-MADE I AGGREGATE 110,000,000 DED X RETENTION50 $ B AND EMWORKEPL S COYERS LIABILITY YIN OLIPENSATiON 15E126-20 111f2012 tn2ots X PEAR TUfE EqN ANY PROPWETORNARTNERIEXECVnVE li OFFICER/EMBER EXCLUDED? NIA EI EACH ACCIDENT 11.000.000 M NH) EL DISEASE•EA EMPLOYEE 11.000,000 r�yu dasalbe un)M If ssRIPTION un OPERATONS below EL DISEASE-POLICY DMR I 11,000,000 C RIE 7930073340000 1/1)2015 1/1/2019 Er Omrmle 91.0(0.00Aggregate 0 DeductMe 1000Re00rte DM!05202013 PSCRIPT1ON OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Addivonal Re.arts Schedule,may be attached R mare apace R raceme) :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 AUTHORED REPRESENTATIVE ®1988-2014 ACORD CORPORATION. All rights reserved. ‘CORD 25(2014/01) The ACORD name and logo are registered marks of ACORD