HomeMy WebLinkAboutBLD-19-001654 'Office Use Only :;
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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH 15C6-I f -o Licitc '
Yarmouth Building Department RECEIVED
1146 Route 28
South Yarmouth,MA 02664
(508) 398-2231 Ext. 1261 SEP 13 2018
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CONSTRUCTION ADDRESS: /2 rly gull B - 0"ENT
ASSESSOR'S INFORMATION: ' -•
Map: Parcel:
OWNER:47ne(arve7 /2 Rrit Run �L r,,ovIi /1.4 0.2..4/.:d6/7-1P77- r/oL7.—
NAME ADDRESS/ TEL # Email Address:
CONTRACTOR:7t e Oen Then-F etos S1trewshury HA °Car s0?-962--69q2-
, • NAME MAILING ADDRESS TBL# Email Address
Commercial u Est.Cost of Construction$ /S/OA
Home Improvement Contractor Lie.# //oZ it S Construction Supervisor Lia# /0/3/S
Workman's Compensation Insurance: (check one)
I am the homeowner I am/the sole proprietor I have Worker's Compensation Insurance
Insurance Company Name: A/a orta /II/1;04 h%
iO4 'e .T Svran �
ev �i) Worker's Comp.Policy H_ _ 9 CC? ,
' WORK TO BE PERFORMED
Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares 6 Replacement windows:# Replacement doors: # -
Roofing: it of Squares ( )Remove existing*(max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for like
The debris will be disposed of at tt i lle Math co("'it-
Location of Facility . .
I declare under penalties of perju' 4. i statements herein contained are true and correct to the best of my knowledge and belle!. I understand that any false answer(s)
•
will be just cause for denial or of my 'cense and for to.-. .•. under MG.L Ch.268.Section 1.
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Applicant's Signemre: iii.Irstir, A /� Date: / -/2- '/
Owners Signature(or atta' ”' See � „ edC Cori-- C — u ate:
Approved By: c Date: ei 45 "l6r
Building Offici: (or 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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Home Improvement Agreement: Page 1
Home Depot License Number(s): Visit www.homedepot.com/c/SV_HS_Contractor_License_Numbers for latest license into
MA: 107774, 112785
Salesperson Name: Christopher Read Registration No. (if applicable):
Home Depot U.S.A., Inc. ("Home Depot") or service provider named below ("Service Provider") will
furnish, install or service the equipment listed below at the price, terms and conditions as outlined on
this form.
GARVEY ANNE New England South 1-635BX2H
Customer Last Name Customer First Name Store#/ Branch Name Lead/Customer Order #
12 port run South Yarmouth MA 02664
Customer Address City State Zip
508-588-6225 617-877-4022 lindamariet@verizon.net
Home Phone# Work Phone# Cell Phone# Customer Email Address
NOTICE OF RIGHT TO CANCEL: YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR
OBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT HOME DEPOT USA INC.,
2455 PACES FERRY ROAD, BLDG. B-3, ATLANTA, GEORGIA 30339 or EMAIL
The Home Depot @ customercancellationnortheast@homedepot.com
BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE
SUPPLEMENT PROVIDES A DIFFERENT CANCELLATION PERIOD. THE STATE SUPPLEMENT
CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE.
YOUR PAYMENTS WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME
DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME
DEPOT OR SERVICE PROVIDER, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE
SAME CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED
TO YOU. OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN
SHIPMENT AT HOME DEPOT'S EXPENSE.
THE LAW REQUIRES THAT HOME DEPOT GIVE YOU A NOTICE EXPLAINING YOUR RIGHT TO
CANCEL. PLEASE SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL AND
WRITTEN NOTICE OF YOUR RIGHT T CANCEL.
Acknowledged by: ariluei 06/30/2018
Customer's Signature Date
Contract Price and Payment Schedule : Payment of the Contract Price is due upon signing unless a
different payment schedule is required by law, specified below or in a payment addendum.
Contract Price: 13019.45 Includes all applicable taxes. Excludes finance charges.*
Sales Tax: o.00 (If applicable)
*Maximum deposit ONLY applicable in MD, MA, ME(33%), NJ, WI(99%)
•
Dep. 25.0 % Deposit Amount 3254.86 Remaining Contract Balance 9764.59
The Home Depot-2455 Paces Ferry Road,N.W. Bldg.8-3,Atlanta,Georgia 30339-Customer Care: 1-800-466-3337
Customer Agreement(C,E,I)(31 Jan.1B) v 501.2
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, Commonwealth of Massachusetts .
iliDivision of Professional Licensure
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- Board of Building Regulations and Standards -
Construction Supervisor Specialty ; •
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CSSL-101315 Expires_ : 1.0,2912019
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.< L WALDEMAR PARAFINOWICZ ., kt°,•
. 246 MILLBURY STREET •
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AUBURN MA 01501 ' :;;rY t:° x'`,
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The Commonwealth of Massachusetts
Department of Industrial Accidents
st-'e _a= Office of Investigations
.el ) 1 Congress Street,Suite 100
-
-- Boston,M4 02114-2017
ww'wmass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information U Please Print Legibly
Name (Bus pess/Grganimmdo&Individual): ..I. Ofil _ ert I -
•Address: / B e/ go 5 1 l viQNp/a I �/
City'State/Zip: $Arags 47t t.4 • oiCYC Phone#: 7 7 /" 0175" - a /Sr
' .Ars von an employer?Check the propnate bot: Type of project(required):
• I. I am a employer with 209t 4. L I am a genera]contactor and I 6. 0 New construction
/ `employees(full and/or part-time).* have hired the sub-contractors
listed on the attached sheet : 7. 0 Remodeling
2.0 J am a sole proprietor or partner- i
These sub-contractors have ! g• Demolition I
ship and have no employees 0
working forme in any empioyees and have workers' I '
capacity. I 9. 0 Building addition I
• .1-No workers' comp.insurance comp.insurance.:
required] 5. 0 We are a corporation and its 10.0 Electrical repairs Cr additions
3.IT I am a homeowner doing all work officers have exercised their j 11.0 Plumbing repots or additions
right of exemption per MGL
I myself. No workers' comp. l 12.0 R f repairs
l insurance required.]t c.152,§I(4),and we have no ! ``//
q ) employees. [No workers' II 13. Or3er SQivt�
CO .mpinsurance required.] i
•.v:y applicant that checks box et must also 511 out the section below showing their workers'compensation policy mfonnatioo.
t Homcowoas who submit this affidavit indicating they are doing as work and then hire outside contractors must submit a new affidavit mdscatmg such
:Contactors that check this box must attached m additional sheer showing the name oft sub-contactors and state whether or not those taint have
=players. a the sub-cosmaaem have employees,they must provide their workers'comp.policy number.
I am an employer that is providotg workers'compensation insurance for my employees. Below is the policy and job she
fnfararice C eater
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lystrance Company Name: r/t/ 2 et/QJO VNio/✓ net, ,�.t/+� . eB.
Policy#or Self-ms.Lit.#: K /W�t // 6 tCt.( l Expiration Date: 3 - / - i?
Job She Address: /1- 5"/e✓t i 1✓ll City/State/Zip: s. yw ar ✓I&l tm-
Attach a copy of the workers'compensation policy declaration page(showing the policy num r and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of et iaal penalties of a
fine up to$1,500.00 and/or one-y a imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day a• "st Eir•later. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DLAJrace coverage verification.
Ido hereby certify un': e ' • ' aida . '." - hat the information provided above is true and correct.
6
//'g�� Date: 9, /Z •- /i
Sisnattae: 1,p.� ,
pJ�7
Phone#: 5-v-
. ! � - - 6 1 J o'- .. -.
Official use only. Do not write in this area,to be completed by city or town officiaL
On 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*:
/11 01(2)1?IIX/1?evert c. e C2 (Th .1? .i
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
• Home Improvement Contractor Registration
Type Supplement Card
HOME DEPOT USA INC Registration: 112785
•
2455 PACES FERRY RD C-11 HSC Expiration: 04/22/2019
ATLANTA,GA 30339 • '
Update Address and return card. Mark reason for change.
0 Address 0 Renews! 0 Employment 0 Lost Card
Office of Consumer Affairs&Business Regulation
-- HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE Supplement Card before the expiration date. if found return to:
F flenist ation Expiration, Office of Consumer Affairs and Business Regulation
r 112785 042212019 10 Park Plaza-Suite 5170
I-TOME DEPOT USA INC Boston,MA 02116
ANDREW SWEET `,Q.C; �a ����j7
APACE RRD 71 HSC u
TIAAGA O G ithou signature
Undersecretary
•
DATE
DMAIDOWYY
ACO0
CERTIFICATE OF LIABILITY INSURANCE ID )
64,........--
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(les)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,subject to the tonne 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 endorsements}
PRODUCER CONTACT
MARSH USA,INC FAX
TWO ALLIANCE CENTERINCCNo Fxtt INC.Nor
356DLENOX ROAD.SUITE 2400 LULL
ATLANTA.GA 30326
INSURER(S)AFFORDING COVERAGE NAIC e
C14101642069HnneD-GAW-1519 INSURER A:010 Republic Irslfarlre Co 24147
INSUREDINSURER a:Nevi Hampshire ITIS Co 23841
THE HOME DEPOT,INC
HOME DEPOT U.S.A.,INC wsuRER C:HaneRlsk Capme Insurance Comm
2455 PACES FERRY ROAD INSURER D:
BUILDING 0.20
ATLANTA.CA 30339 INSURER E,
INSURER F:
COVERAGE CERTIFICATE NUMBER: ATL-004353439-16 REVISION NUMBER:3
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.
/NSR E
INSURANCE ADDLSUBR POLICY EFF - POLICY EXLIMR6
LTYPE OF VI
TRDIED VO POLICY NUMBER IMWDDIYYYYI (MWDONYVYI
A X COMMERCIAL GENERALUANLMI MWZY 312717 0301(2015 03/01/2019 EACH OCCURRENCE S 9,900,0E0
DAMAGE 10 RENTED I ggp 000
CLAIMS-MADE OOCCUR PREMISES lEa secunente I 5
LIMITS OF POLICY XS • MED EXP(Any one person) ,S EXCLUDED
OF SIR SIM PEROCCPERSONAL A ADV INJURY IE 9,W0'000
GENt AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 3 9.000.300
) POLICY0
PR0.JECT DLOC PRODUCTS•COMPIOP AGO 3 9.000 OLD
OTHER
A AUTOMOBILE LIABILRY
ANY AUTO
MWT6312716 03/01/2018 0310112019 CEOs�BIWED SINGLE LIMIT E 1000.000
BODILY INJURY/Par person) 3
OWNED —
SCHEDULED SELF INSURED AUTO PHY DING BODILY INJURY/Per accident) 3
AUTOS ONLY _AUTOS PROPERTY DAMAGE
HIRED NON-OWNED 5
AUTOS ONLY _ AUTOS ONLY
UMBRELLA (Pare dentl
S
—
LINT OCCUR EACH OCCURRENCE E
EXCESS LAECLAIMS-MADEAGGREGATE 3
S
OED RETENTIONS PER OTH-
B WORKERS COMPENSATION WC 014122577(AN,NH,NJ,VT) 038h/2018 03101/2019 x STATUTE ER
AND EMPLOYERS' YIN WC 014122578(WI) 03/01RD11 03/01/2019 EL EACH ACCIDENT S 5000.0%
B ANYPROPRIETORPARTNEFUWECUTNE
OFFICERMEMBEREXCIUDED' NIA EL DISEASE.EA EMPLOYEE 3 5.000.000
II
(Mandatory M NH) 5000,000
!DESCRIPTION
oonON OFunder CmDRUeO on godnmal Page EL DISEASE•POLICY LIMIT S
Dxc ssIAuto OF OPERATIONS bebP
C Excess MAO 2971-10011-05201e 03m11201e 03/01R019 Unit 4.000.003
DESCRIPTOR IPTN OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,AOGtlanal Rowans Schedule,may be attached R "e
mon SOON reyuIted)
EVIDENCE OF INSURANCE
CERTIFICATE HOLDER CANCELLATION
HOME DEPOT USA.INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
2455 PACES FERRY ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED M
BULGING C-20 ACCORDANCE WITH THE POLICY PROVISIONS.
ATLANTA.GA 30339
AUTHORIZED REPRESENTATIVE
o1 Marsh USA Inc.
Manashi Mukherjee ,Itaa%^ssat'Z ^"O LAjC&-
C 7988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo aro registered marks of ACORD
•
AGENCY CUSTOMER ID: CN101642069
LOC#: Atlanta
ACOROS
la`s ADDITIONAL REMARKS SCHEDULE Page 2 of 3
AGENCY __ —
MARSH USA.INC. NAMED W THE HOME HOME DEPOT,INC
POLICY NUMBER HOME DEPOT U.SA..INC,
2155 PACES FERRY ROAD
BUILDING C-20
CARRIER ATLANTA,GA 30339
NAIC CODE
ADDITIONAL REMARKS EFFECTIVE DATE:
THIS ADDITIONAL REMARKS FORM ISA SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance
Workers Compensation Continued'
Cerner Indemnity Insurance Company of NMh Amen
Pdicy Number WLR C6471)3191(ALAR FL ID,W,KS,KY,LA,MS MO.NE1112.,NDOK,SCSDTN,WV,WY)
Efleceve Date 03012018
Expiration Dam 03101/2019
FL)Lunt 512000,000
Corner New Hampshire Iniwance Company
Pdmy Number WC 014122576(DC.DE,HLIN.MD,MN.MT,NY,RI)
Erfectva Date'03/01/2018
Expiration Date 03/012019
(EL)Lmt 81.000.000
Carrier ACE Anencen Insurance Company
Policy Number WCU C91783221(051)(A2,CA,4NC.OR.VA.WA)
Eflacave Date 03/01/2018
Expiation Dae 03/01/2019
(EL)Limit.51,000,000
SIR 51.000:00 SIR for the stoles of AZ.CA.I,NC.OR VA WA
Corner.Bawd Union Fee Insurance Company
Ad ley Number XWC 1595580(0SO(CO3C1,GA,ME,MI,NV,OH,PA UT)
Efface)*Data 0301/2018
Expiration Dae 031012019
(EL)Uncut 51.000000
51.000.000 SIR for the rotes of CCMENV,MI,OH,PA,UT
5750.000 SIR for the stele of GA
5304000 SIR For the slate of CT
Center Nabonat Union Foe Insurance Company
Pdmy Number XWC 4595581(OSI((MA)
\ E2F
/4aV�t1 ,y I'`YKe3Il/
SIR 5500000
TX Emdayers XS Indemnity.
Camerpuuos Orion Insurance Company
Pdmy Numbr TNS C4916893A(TX)
Effective Date.0.1012018
Expiration Date.03/012019
(EL)Lent SIO ODD ODD
SIR SI,00D,rC
CORD 101 (2008)01)
C 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD