The URL can be used to link to this page

Home My WebLink AboutBLD-19-001700 of•1'44. Office Use Only O Pem,it#448 C Q 41:tiv �y: l Amount D !• f,TM,•m„`'''.' Permit expires 180 days from •;. .:{ :issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 RECEIVED South Yarmouth, MA 02664 pp (508) 398-2231 Ext. 1261 SEP 20 2018 CONSTRUCTION ADDRESS: V 1 I ,igraTWALT& E. `r' ASSESSOR'S INFORMATION: n,1 Map: L{ t�/ Parcel:l(� n�,.�� r� ! OWNER:Qf el1eLJ A '',,„,, (Yawl Ott I-77i aADDRESS �,,'SI) .tyget It �iJl.on, MP TEL #&w"l am--t0.53 NCONTRACTOR{Q1y�fI Pier �l J I /1inh/ I'FI 41/4&40-Able_ iiiier1%1,MP �h) S�- ns- rI�F NpME I/ MAILING ADDRESS TEL# Pesidential 0 Commercial Est.Cost of Construction$Cl\9 S c — Home Improvement Contractor Lic.# 1p?1 S 2 Construction Supervisor Lia#S'S-1'tC0(24?, Workman's Compensation Insurance: (check one) . ❑ I am the homeowner ❑ I am the sole proprietor crave Worker's Compensation Insurance Insurance Company Name:CSt.00 recta Eno m7 en Diu li ,nce,Worker's Comp.Policy# tze.0 Sc t5So I(.7141,Qp�A (Ai H. ORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares '' II V)Replacement windows:# Replacement doors: # ;�'1 Roofing: #of Squares ( Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacingcilikeli( for like Pool fencing *The debris will be disposed of at: V ITh m \f/r vi$(.f Location of Facility I declare under penalties o ,ry at t a yi"�ts herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for den;, • voc r. e and for prosecution wider M.G.L.Ch.268,Section I. � C + Applicant's Signature: 4.14� Date. `61"n 1110 ' Owners Signature(or attachment) ja/...S.. e.,—l—ti..sk-e...dl) Date: �)/�,./QApproved By: Date: Ove /C� Bui ; Offgi. (or designee) E ADDRESS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: ' Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No NOT INCLUDED IN' CONTRACT PRICE ^:. cr. :»;mtm around window or door openings Removal of existing doors and windows often reveals weathering, as well as areas that may tt or may not be previously stained or painted. As noted, Contractor will not be responsible for painting or staining these areas. u Adjustments or Reattachments Contractor will not assume responsibility for removal, re-attachments, or re-positioning of drapery rods, window shades, blinds and/or mini blinds, and corresponding hardware. RIGHTS TO CANCEL . The Owner may cancel this Agreement if it has been signed by the Owner at a place other than the address of the Contractor, which may be his main office or branch thereof, provided that the Owner notifies the Contractor in writing at his main office, or branch by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this Agreement. HOMEOWNER: DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES I/we accept this contract in its entirety and I/we authorize Sprinkle Home Improvement to act on my behalf in all matters relative to the work to be performed on this job (i.e. permits, applicatio s etc.) if necessary. 4111101 V t,..fris) ' , geSke ich Homeowner Signature Dat Contrac'or Signator• , Date Andrew O'Malley Brad Sprinkle- Registr tion # 103757 71 South Street, S. Yarmouth,MA 02664 Homeowner Signature Date Kathleen O'Malley 71 South Street, S. Yarmouth,MA 02664 .,.,, a The Commonwealth of Massachusetts 1!l. Department of Industrial Accidents •1 Congress Street,Suite 100 Boston,MA 02114-2017 -94.04 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. • TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly Name(Business/Organization/Individual):SPRINKLE HOME IMPROVEMENT, INC. Address: 199 Bamstable Rd. City/State/Zip: Hyannis, MA 02601 Phone#:508 775-1778 Are you an employer?Check the appropriate box: Type of project(required): LQ I am a employer with 10 employees(Ml and/or part-time)." 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in S. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required]t 9. El Demolition 4❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions CI 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. oof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 132,§1(4),and we have no employees.[No workers'comp.insurance required.] *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 then hire outside contractors must submit a new affidavit indicating such. tContractors 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 and job site information. Insurance Company Name: A.I.M.Mutual Policy#or Self-ins.Lic.#:V11CC50050'l 67472018A Expiration Date: 1/1/2019 Job Site Address: '1 k So-te--‘44 444 i A CitylStatelZip:S3ACAIY101411 � atplo 4 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 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 DIA for insurance coverage verification. i.e I do hereby certify d ' r nd penalties of perjury that the information provided above is true and correct Signature: Asir ed Date: `G (5i(l r- Phone#: 508 775-177 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#: i�1 SPRIN-1 OP id.OS A OROS CERTIFICATE OF LIABILITY INSURANCE DATE(MM/ 09N 9/20182018 ' 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 pollcy(les)must have ADDITIONAL INSURED provisions or 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).I, PRODUCER 508.775-6060 11AM€GT Kelley A.Sullivan X88DryFalmouthhIR ad van Ins Agency Na :6O8-776 6060 N,1.508-780-1414 I Hyannis,MA 02601 Ulan; Kelley A.Suillvan INSURERISI AFFORDING COVERAGE NAIL e INSURERA:NGM Insurance Company 14788 INSURED Sprinkle Home Improvement Inc. INSURER s:Associated Employers Insurance 199 Barnstable Rd • Hyannis,MA 02601 INSURER C: INSURER 0: INSURER E: INSURER F t COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POUCIES 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 TYPE OF INSURANCE ADD SSU8 POl1CY NUMBER POLICY EFF POLICY EXP (MMn1JNYYYYI IMM/DD/YYYYI LIMn$ A COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE i 1,000,000 CLAIMS-MADE []OCCUR MPT2640X 07/01/2016 07/01/2019 PREMI9E3(F ix Trt nee) 1 500,000 X Business Owners 10,000 MED EXP(Any one Person) $ — PERSONAL a ADV INJURY * 1,000,000 GENA AGGREGATE LIIMITAPPQES PER: AGREGATE 2,000,000 Il POLICY U ST& LiPRODUCTS-COMPIOP S J LOC PRODUCTS-COMP/OPAGO S 2,000,000 • OTHER S A AUTOMOBILE LIABILITY (Fs BI SINGLE LIMIT $amidenD 1,000,000 — ANYAUTO M1T2640X 07/27/2018 07/27/2019 BODILY plummy Parson) S OooXSCHED�D AUTOS ONLY AUTOSBODILY INJURY(Per occident) $ As ONLY VANS G? PEERTYOAMAGE $ C0 11 S A X UMBRELLA UM X OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS UAB CLAIMS-MADE CUT2640X 07/01/2018 07/01/2019 AGGREGATE $ 1,000,000 DED X RETENTIONS 10000 1 B WORKERS COMPENSATION I STATIRE I FRTM AND EMPLOYERS'LIABILITY ANYPROPRIETORPARTNER/EXECURVEN ti WCC50050167472018A 01/01/2018 01/01/2019 EL.EACHACCIDFNT a 500,000 OFFICE IYQER EXCLUDED? N/A 600,D00 E describe under EL.DISEASE-EA EMPLO S DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY umn.S 600,000 PROPERTY 60,000 DESCRIPTOR OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Romarb Schedule,may be aeacbae Ifmon span Is ngWM) Certificate issued for Insurance verification Home Improvement Specialist • CERTIFICATE HOLDFR CANCELLATION SPRNKHO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Sprinkle Home Improvement,Inc ACCORDANCE WITH THE POLICY PROVISION �` 189 Barnstable Rd. "^-'`Q Hyannis,MA 02601 AUTHORIZED REPRESENT Kelley A.Sullivan I Btydenn,`pBC[i� t &Su�lllivan Ins. Agency, int. ACORD 25(2018103) ®1988-2015 XCORAt182'Ar1 rights reserved. . The ACORD name and logo are registered marks of ACORD mite Womniwittoectia c/cd Office of Consumer Affairs and Business Regulation One Ashburton Place- Suite 1301 Boston, Massachusetts 02108 Home improvement Contractor Registration -54.7'..n = { Type Corporation >,al �' Registration: 103757 SPRINKLE HOME IMPROVEMENT,INC. �- ., ` Expiration: 07/08/2020 199 BARNSTABLE RD. f,, ,----.;,..-�>�.--�.__ , ��. HYANNIS,MA 02601 .1�`,.=�'..r .-"9,•;.1.; 1l ---�' Update Address end Return Card. Q 20M-0rltt `lne cammdmnea/ii?0,6lorrAnaela Office of Consumer Affairs a Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corporation before the expiration date. N found return to: Aeaistratloo FxMretlon Office of Consumer Affairs and Business Regulation ,103757 =:-1 07/08/2020 One Ashburton Place-Suite SPRINKLE HOME IMPROVEMENT,INC. Boston,MA 1 It!BRAD K.SPRINKLE'; 199 BARNSTABIP HYANNIS,MA 02601 -- Undersecretary Not valid w • NJ. attire •- Consrnrction Supervisor Commonwealth of Massachusetts Unrestricted•Buildagfofanyusegroupwhicheontaln ®; Division ofPRegulations and sure Stn less than 35.000 cubic feet($11cubicmeters)ofenclosed Board of Building and Standards apace, Construction'S O pe ry i s o r CS-006641 'i expires: 1010812019 • BRAt)KSPRINKLE "'" 199 BARNSTABLE ROAD KYANNIS MA 02601 �,, FAUN to possess a current edition of the Massachusetts State Building Code is Cantor revocation of this license. Cit For information about this license Can(0177127.3200 or visit www•mass.govtdpt CitCommissioner _. _