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HomeMy WebLinkAboutBLD-19-001650 ••^" Office Use Only _ 01-Y2.4\4_ '• � ! C Petmit# of jL .—y 'Amount s� {' t ce :14, n cs ti "`° �•``;�`' •Permit expires 180 days from t. -Issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 SEP 13 2018 (508) 398-2231 Ext. 1261 / BUILCNN �ptNT CONSTRUCTION ADDRESS: z I�/I P aY L/ t'o Cyit���./IInU ASSESSOR'S INFORMATION: Map: Parcel: OWNER:SofieMoran o4 eOna`/ewood in. Attu,rl'h / 14 026 73 6/7-P41- 117 NAME ADDRESS TEL # Email Address: CONTRACTOR:"Tye .(- rte ` 'e°4 cos c na+Mbu (ADDRESS�SL.(S y e *26gy? NAME Email Addre es n Commercial Est.Cost of Construction$ /t7 P// Home Improvement Contractor Lie.# II et i S Construction Supervisor Lie./ eq 5-6 0 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: 14417a /(/Aon hiY lnsvrancp a Worker's Comp.Policy# xt.✓e 46-9 s -oi WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares ./6 ( t/)Remove existing*(max.2 layers) 9 Insulation Old Rings Highway/Historic Dist. ( )Replacing like for like 'The debris will be disposed of at kitS/t_ ML!//£ fist ext- -' Location of Facility I declare under penalties of pert . statements herein contained are true end correct to the best of my knowledge and belief. Iunderstand that any false answer(s) will be just cause for denial or ,l.••.of my license and for Ns. • r•n under M.GL Ch.268,Section 1. q Applicant's Signahue: IiI�1/.f 1 Date: /--/2—/8 Owners Signature(or atm ' � -r�5 e� I4 C artery t ec+ — Date: Approved By. [/ j Date: q `'Cl '' )Y. Building Official(or designee) Zoning Distrito Historical District Yes No Flood Plain Zone: Yes No Water Resource Protection District Within 100 ft.of Wetlands: Yes No Yes No r . • Home Improvement Agreement: Page 1 Home Depot License Number(s): Visit www.homedepot.com/c/SV_HS_Contractor_License_Numbers for latest license Info 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. MORAN JULIE New England South 1-6EZCDT5 Customer Last Name Customer First Name Store #/ Branch Name Lead/Customer Order# 26 Candlewood Lane West Yarmouth MA 02673 Customer Address City State Zip (617) 699-4927 wulrmor@gmail.com 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 Q 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 DEPOTS 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 TO CANCEL. Acknowledged by: 08/22/2018 Cm uster'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: 10141.78 Includes all applicable taxes. Excludes finance charges.* Sales Tax: 0.00 (If applicable) *Maximum deposit ONLY applicable in MD, MA, ME(33%), NJ, WI(99%) Dep. 25.0 % Deposit Amount 2535.44 Remaining Contract Balance 7606.34 The Home Depot-2455 Paces Ferry Road,N.W.Bldg.B-3,Atlanta,Georgia 30339-Customer Care:1-800-466-3337 Customer Agreement)C,E,I)(31 Jan.18) v 60.1.2 i • �- . Massachusetts Dep : _> Teti p , � ands B=oard pi But ding Re kens e: CS-0956&E • t'SgsL4� �"T10 ell Su pen; ahg�, JON L3 +,��d A LS H '4i43-,,e, Yfy':a-''Cd I WASHBURN AVENUE.:- . r, .y ° y ,l+ rvl L?fiery'?,�''`ti 0S%•1{Yd„V. KINGSTON MA 02364 :.._. 747- �W., ssir "•`�.a Fir1w1"S'n s"��a�4+F+' �'"s ..x4r>•�''�+� �4. r •,_a.-rm s�:h. 1 i a i o i1 : Co-/i t1 —2c7Z./o/ r�.t i 4j's«Z"y=`9mc{•;�-y:p�.?Fiic»c- of?k .r ck�, Y-;`,{'/`*v�.'r.�`'°r `:''."i, - - } See "� 1 14 cke CX 7118/2018 . Details • • ensee Details Demographic Information Full Name:-.-e— —1- - Jon D Walsh wiser Name: !cense Address Information 'City: Kingston State: MA 1pcode: 02364 ountry: U 'ted tates !cense `Information License No: - . CS-095605 License Type: - - - Construction Supervisor Profession: Building Licenses Date of Last Renewal: 7/16/2018 Issue Date: Expiration Date: 6/14/2020 License Status: Active Today's Date: 7/18/2018 Secondary License Type: Doing Business As: _} Status Change Rpas.n: License Renewal Prerequisite Information I No Prerequisite Information Close Window , Site Policies I Contact Us©2011 Commonwealth of Massachusetts • 1/1 https:l/ericense.chs.stale.ma.usNerificationhDetails.aspx?agency_id=181icense id=2845568 -- - -- --- . --"--- ---- a The Commonwealth of Massachusetts �- m Department of Industrial Accidents gr.Nt:v. " —.as;lid_ e Office of Investigations t,i�l- Ttl 1 Congress Street,Suite 100 ,,a= Boston,M4 02114-2017 n'ww.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information `� /' Please Print Leuibly Name (Busneesseorgeeintioo/idiviees0: yWom.e_ /-f epo*-/- , Address: /o :/ 8O S/ViV `/ ORNpb&- l �/ City'State/Zip: SAPRAC4611 t Mj4 . 4/sYf Phone#: 7 7// e2 15- - .2/3-s- ' S - a-/.-s-' Are you an employer?Check the k, propriate box: . L am• 1. 1 am a mrioyer with 2.450-t- 4. of Typeroject(required): 1 a g eneral contactor and I employees(hill and/or part-time). have hired the sub-contactors •. 6. 0 New construction I am a sole proprietor or partner- listed on the attached sheet • 7. 0 Remodeling ship and have no employees These sub-contractors have ii B. ❑Demolition working for me in any capacity. employees and have workers' iI .-, • .[No workers' comp.insurance comp.insurance; 9. V Building addition I required] 5. ❑ We area corporation and its 1 10.0 Electrical repairs or additions • 3.❑ I am a homeowner doing all work officers have exercised their I 11.❑P bing repairs or additions I myself. [No workers' comp. right of exemption per MGL 12. Roof repeirs 1 insurance required.]' c.152,§1(4),and we have no ; employees. [No worths' ! 13.0 Other • • . comp.insurance required] I, •.Vy applicant that checks box el mat also 511 out the section below showing their workers'compensanon pohcy information. ,Homeowner who submit this affidavit indicating they art doing an wort eat=hire outride eoapaemrs must submit anew affidavit Indianan sock :Contactors that check this box must attached an addinooal sheet snowing the name of the sub-contactors and stare whether or not those entities have xpioyea. 1 the sub-connectors have employees,they mast provide their workers'comp.policy amnber. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job she L-vstt*anc: Company Name: /LkJc"(-r/L>' vs-7 /N2p egQ,/C (lN�vi✓ ///'t „�-il/S . (.s• / 9 .- Policy d or Self-ins.Lic.#t: X //W�� t- ys 7 e/ Expiration Date: 3 – / - r 9 Job Site Address: I & C €(/e r✓oud Lt7, City/State/Zip:l✓. //:-.0..44./f'(A Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required ander Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or one-y ., imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day ::r:'r' 41.lator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA. h .ce coverage verification. I do hereby certify Ult. e,L. •i; ,4 • 1 .4•. - at the information provided above s true and correct � '�/eta i arae: �yI�1 / a ,ate: - Phone#: Sag'- 9, - t� 1 y� • Official use only. Do not write in this area,to be completed by city or town official. • City or Town: Permit/License h Issuing Authority(circle one): 1.Board of Heath 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Ptnmbing Inspector 6.Other Contact Person: Phone#: • 7.R-744.7 . '^�/rt 0ll?7.?? ietoealrll r t 1L1;aCArti ' .1 •: 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 ❑Renevra! ❑Employment.❑ Lost Card _ r ,.,,...7.,,,.// ' :r.,,..,. -.,, • _ Office of Consumer Affairs 8 Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only '-'-'- TYPE Supplement Card before the expiration date. If found return to: T=, Registration Expiration, Office of Consumer Affairs and Business Regulation te=a 112785 04/22/2019 10 Park Plaza-Suite 5170 I-tOME DEPOT USA INC Bostori,MA 02116 ANDREW SWEET 'Lc-{1. -- OF z 2455 PACES FERRY RD C-11 HSC 6 s (4 , ATLANTA,GA 30339 undersecretary ' ' ithou signature • A----N 0" CERTIFICATE OF LIABILITY INSURANCE DATE lino"BD ' 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 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). PRODUCER CONTACT • MARSH USA.INC PHONE I FAX TWO ALLIANCE CENTER RAA:Na EMTIAN:.Nat 3560 LENOX ROAD,SURE 2400 E-MAIL ATLANTA.GA 30326 ADDRESS' INSURER(S)AFFORDING COVERAGE NAIL t CN101642069.HornD-GAW-11319 INSURER A:OIDRBDti tWIDMER CO 24147 INSURED INSURER 6:New Hampshire Ins Ca 23841 THE HOME DEPOT.INC. HOME DEPOT U.S.A.,INC INSURER C:HaneRNk Cann Insurance Company 2455 PACES FERRY ROAD MsuRER D: BUILDING C-20 ATLANTA,GA 30339 INSURER E, INSURER F: COVERAGES 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 AU.THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ,NSR DL ADSLIER POLICY ERR POLICY EXP LIMITSLTYPE OF INSURANCE (MWYF TRMSD WVD POLICY NUMBER DDYYI (MW�pDIYWYI A X COMMERCIAL GENERAL ummrrr MWZY312717 031012018 03/01/2019 EACH OCCURRENCE S 9.000.000 DAMAGE TO RENTED 1ppp 000 CLAWS-MADE OCCUR PREMISES!Ea oecumno l 1 LIMBS OF POLICY XS MED EXP(Any one person) .1 EXCLUDED ■ OF SIR.SIM PER OCC PERSONAL a ADV INJURY I S 9,000.000 GENt AGGREGATE La11T APPLIES PER: GENERAL AGGREGATE S 9.000.000 © POLICY O JPECT 0 LOC PRODUCTS•COMPIOP AGG S 9.000 DLO OTHER: S A AUTOMOBILE LIABILITY MWT8312718 031012018 03101/2019 tEs.ctNNene SINGLE LIMIT $ 1,000,000 © ANY AUTO _ BODILY INJURY(Pomown)n) S OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY IPeI=Nea) S AUTOS ONLY _AUTOS HIRED NON-OWNED I PROPERTY DAMAGE 5 AUTOS ONLY AUTOS ONLY IPM acedenn 5 UMBRELLA LIA9 OCCUR EACH OCCURRENCE S EXCESS UM CLAIMS-MADE AGGREGATE S DEO RETENTION SS B WORKERS COMPENSATION WC 014122577 (A(,NH,NJ,VT) •03762018 '03101/2019 X SEPA OR_ AND EMPLOYERS LIABILITY YIN WC 014122578(WI) 03/012018 03/012019 E.L EACH ACCIDENT S 5000.000 B ANYPROPIUETORMARTNERIIXECUTNE ❑ OFFICERMBABEREXCLUDEDT N NIA WanSMpry b NW) EA DISEASE-EA EMPLOYEE 5 5000'000 am, Continued on Adteanat Page EL DISEASE•POLICY LIMn S 5.000000 Desroeno OF OPERATIONS balm C Excess Aldo 297-1-10011-062018 03/012018 03101/2019 Unit, 4.000.000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Add anal Remarks Saimaa*may be seaeSSU ll mete Spate a mune) 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 IN BUILDING C-20 ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA.GA 30339 ' AUTHORED REPRESENTATIVE al Marsh USA Inc. Manashi Mukheryee -�1'ta.%..aok•- ..141-•-•-94-4•44)-4-4- I S&..e2o 'R'I ©19884016 ACORD CORPORATION. All fights reserved. ACORD 25(20 18/03) The ACORD name and logo aro registered marks of ACORD • • AGENCY CUSTOMER ID: CN101642069 LOC#: Atlanta ACORO® `O ADDITIONAL REMARKS SCHEDULE Page 2 of 3 AGENCY _ MARSH USA.IHC. NAMED INSURED THE HOME DEPOT,INC POLICY NUMBER HOME DEPOT USA.INC. 2455 PACES FERRY ROAD BUILDING 020 CARRIER ATLANTA.GA 30339 NAIL 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 Carrier Indemnity Insurance Company of North Annum* Pdicy Number WLR C64757191(AL,AR,FL,ID.U,KS.KY.LA,MS.MO.NENIAND,01(SCSIXTN,WV,WY) EBeche Dale 03/012018 Expralion Dale-03/012018 (EL)Unit 51,000.000 timer New Hampshre Insurance Company Pricy Number WC 014122575 (DC.DE.M:N.MO.MN MT,NY,RI) Effective Dale 03/01/2018 Expralion Dale 03/01/2019 (EL)Unit 51 ODD 000 Carrier ACE American Insurance Company Pricy Number WCU C64783221(051)(AZ.CA.L.NC.ORVA.WA) Effective Dale.03/01/2018 Expralion Date 031012019 (EL)Unit:S1.099000 SIR$1,000030 SIR for the stales of AZ.CA.E.NC.OR,VA.WA Lamer National Union Fire Insurance Company Pricy Number XWC 4595580(057(CO.CT.GA.ME,MI.NV.OH,PA.UT) Effective Date 031D1201$ Erprohoo Dale 03/012019 (EL)Unit 51,000,000 51.000,000 SIR lor Ikestales oICO,MENV,MI,OH.PA.UT 5759000 SIR M testers al GA 5350,000SIR kr'hostels of CT GmerShona/Union Fee Insurance Company pa/y Polity Number XWC 4595581(051)(MA) Eecae Data 03912018 Lon Dain 03/012019 t L)Ent 51,000,000 SIR 5500,0L9 TX Employers XS Indemny. tamer:Er nos than Insurance Company Pdicy Number TNS 049166934(TX) Efucave Dale.03912018 Exp rebon Data.03012019 (EL)Liner 510.000 OW SIR 51.000.00 /CORD 101 (2008101) e 2008 The ACORD name and logo are registered marks of ACORDACORD ACORDCORD CORPORATION. All rights reserved. Details Page 1 of 1 Licensee Details Demographic Information pull Name: Jon D Walsh caner Name: License Address Information ity: Kingston tate: MA ipcode: 02364 ountry: United States License Information _icense No: CS-095605 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 7/16/2018 Issue Date: Expiration Date: 6/14/2020 License Status: Active Today's Date: 9/19/2018 Secondary License Type: • Doing Business As: Status Change Reason: License Renewal • Prerequisite Information No Prerequisite Information • • http://elicense.chs.state.ma.usNerification/Details.aspx?agency_id=1&license_id=284556& 9/19/2018