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HomeMy WebLinkAboutBLD-19-001649 ' i'.a 1't dCk rOffceUseOnly {', :Permit# piFAmount SD , • i <..,,,%. ,' ;Permit expires 180 days from :-.--,#5,;} Issu 4ate . 15ub- lei - p01cot/q EXPRESS BUILDING PERMIT APPLICATION • TOWN OF YARMOUTH • Yarmouth Building Department R E C E 0 �/ E D 1146 Route 28 South Yarmouth,MA 02664 SEP 13 2018 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 0 ze /'s kG ey . ' rNT ASSESSOR'S INFORMATION: ' Map: Parcel: oWNERTD/awr&4 !(e Sc Vo S1airra..) Na/S Kn.004- A- rid 6,‘.4 S7$-391-o371 NAME PRESENT ADDRESS I TEL # Email Address: CONTRACTORRe Horne ono los Cltrewsberr PA mar std'-962--6eiy2_ , NAME MABdNGADDRESS TEL# Email Addres Resident: Commercial Est.Cost of Construction$ /O 0 L Home Improvement Contractor Lic.# //et ie S Construction Supervisor Lie.# 0 9 S--6 0 5— Workman's Compensation Insurance: (check one) I am the homeowner I am the sole proprietor I havelWorker's Compensation Insurance Insurance Company Name: aloe; /di;04 hire f SvrancP 4) Worker's Comp.Policy# )(Pie9 t 95. I 8 - - WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # - Roofing: #of Squares /7 ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like v Me debris will be disposed of at (4 Se. Mencmen" Location of Facility .. I declare under penalties of perju statements 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 denial or - ofmy 'censeand for to..• '•n under M.OYCb.268,Section 1. ii ••OFl r Applicant's Signature: Aird&.<i" //�� Date: e)--/2 —'L P Owners Signature(or atts• "" See art Co'` C x'C((tt CL � Date: ----` 9 +I—I1 Approved By' ./l Building Official(or designee) Date Zoning District: Historical District Yes No Flood Plain Zone: Yes No Water Resource Protection District Within 100 ft.of Wetlands: Yes No Yes No • 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. ROSE DEBORAH New England South 1-6DDF4AV Customer Last Name Customer First Name Store #/ Branch Name Lead/Customer Order# 40 Sparrow Way South Yarmouth MA 02664 Customer Address City State Zip (508) 398-0379 deerose49@aol.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 @ 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: QdA/t--. --P Crt_t 08/12/2018 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: 10023.75 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 2505.94 Remaining Contract Balance 7517.81 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 50.1.2 .4 --,. .„-,--• lassachusetts Dec. : . • - :,arcis "d •,-„ ,_.. ...,,,,....„, Nitr Roaro: of But,' iiin N.- g 'cense: CS-09560-5 •,-,.. . ,iminqn..,t,!,-,,,, - , ,,,,r," , .-, -4. f• (-II 0 n :Dz.* ,,,,,-- - • :-.." — . 1 ..... .......„,.. , ..... . ,.....„,r,...,,., 4,..,..:115,34,-..,;,,,,,:t5; . .;:...z: y414^;,c7,;:kk sr•c. .:!f .ii. attcH;Virem.grtik4o,btryri:Pti,ts.,j. = ''•‘1-Stt-tlf.ti-37: .6t,i..t ?Ns' ,,,rCbilt,3'.4 JON D WALSH : .r." .,./ .5-45,4124t.fekil ...A. , . > •,-:- - Irtoi' Iti-fri •;•;,:?,:l. ii4442.1, n:Fi,±4 c9trtfk I WASHBURN AVEN"P: ., , „.. KINGSTON MA 0z364. -- . . Se - A4sc-( c-t4. on e ..... (....), ,..... 1 m;p0.0"" .......0.0..087' 4, „, esia. s..., .."‘antisioner 06- lil -Jc2 ° 5,r-r ,E4-firrviinr.iserstitan,e.:„;--4,--:::.:- : —,J.,-...r...reqr /21,..,,,,,,,2.,,,,,f.•. v 17:: ,IA , 12,4 ,".trit :::,*.tinj -; ' - '7k,. ;7-', ,.........,:A t,•..-. ., I . _ " ' . 1 ' I."`:%. •• ' .•:-. 'f'L` ‘: ',. ,..... :-'.1:' ..-. - 711 812 01 8 s Details ensee Details Demographic Information Jon D Walsh wrier Name: License Address Information /City: Kingston State: MA Zipcode: 02364 ountry: U 'ted tates • License 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: _J atus Chan a Ras n: License Re ewal rerequisi e n orma ion No Prerequisite Information Close Window ©2011 Commonwealth of Massachusetts Site Policies I Contact Us 1/1 https:l/elicense.chs.stale.ma.usNerirication/Dela ils.aspaagency_id=1&license_id=2845568 • • ._....- ...__— 1 • The Commonwealth of Massachusetts Department of Industrial Accidents -1' Office of Investigations "/1_tsy 1 Congress Street,Suite 100 t�— Boston,M4 02114-2017 `� - www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information `� Please Print Legibly Name (Busbzgess/Orgmdmdo&Individual): ...WomPi /_{✓te'- - Address: el 865/7t/ / t/RNp/4Q- l City'State/Zip: s/IKWt41,7: M/ • oiry. Phone it: 774/- s2 7S - a'/SS'-- ' Are you an employer?Check the propriate box: Type of project(required): • 1./ j I am a employer with 2f�3i 1- 4. , I am a general contractor and I 6. ❑New construction `employees(full and/or part-time).* have hired the sub-contactors . 2.❑ I am a sole proprietor or partner- listed on the attached sheet • 7. 0 Remodeling ship and have no employees These sub-contractors have i S. 0 Demolition working for me in anycity• employees and have workers' i I 9. 0 Building addition [No workers' co insurance comp.insurance ed) 5. ❑ We are a corporation and its 1 10.0 Electrical repairs or additions • 3.C I am a homeowner doing all work officers have exercised their 1 n.0 Pl bing repairs or additions I myself. [No workers' comp. right of exemption per MGL I1?. Roof rep-' urrs i insurance required.]t c. 152,§1(4),and we have no � employees. [No workers' i 13.❑ Other comp. insurance required.] I i 'Any applicant that checks box e!must also 511 out the section below showing their workers'compensation policy mformatoa. t Homeowners who submit this affidavit indicator they as doing ea work and thea bite outside contract r must submit a new affidavit mdmatmg such. :Contactors lbs check this box mus inched an addinaoal sheer showing the one of the rubtwnacton and sue whether or not those entities have aployees. f the sub-maroons have employees,they most provide their workers'camp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job she information '`.4f A14,74 , /. / ��// - /� L-rstt�ce Company Name: T/Ll Q opt/ / VN!or/ ///'t� ,�.tlS . `B Policy b or Self-ins.Licit: KW Ci '/S 1 �21 Expiration Date: 3 - / - /9 Job Site Address: 'YO 9alvb l.✓ 1.41 City/State/zip: S$x/ria .l /"1 A Attach a copy of the workers' compensation polity declaration page(showing the polity number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-ye:. imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a foe of up to 5250.00 a day a••', Egg•Iain. Be advised that a copy of this statement may be forwarded to the Office of . Investigations of the DLce coverage verification. Ido hereby certify un•, e 'i; •a • ti.. • at the information provided above is true and correct vitt I:I Si�ature: 1 Date: 9-/2 '/f" phone 0: �e— q% - - a /tot_ Official use only. Donor 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?own Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: • • • :'If fl ol1Z1TZC;1111)er �'��i t/n/ t r'JJaCl7llJeT 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. -, .. :�.....r-. ❑ Address 0 Renevra! 0 Employment 0 Lost Card .,n-.,,:';r, • ;r',,..,.t,:,, Office of Consumer Affairs I Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only • TYPE Suoulement Card before the expiration date. If found return to: _— _— Registration Expiration, Office of Consumer Affairs and Business Regulation 112785 04/22/2019 10 Park Plaza-Suite 5170 HOME DEPOT USA INC Boston,MA 02116 ANDREW SWEET 2455 PACES FERRY RD G71 HSC � � (A-; I ATLANTA,GA 30339Undersecretary ' ' ithou signature • OM DATE ACCERTIFICATE OF LIABILITY INSURANCE 2Z201 `...-/ 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. M SUBROGATION IS WANED,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 NAME PHONE FAX TWO ALLIANCE CENTER WC No FttY WC-Not 3560 LENOX ROAD.SURE 2400 E-MAIL ATLANTA.GA 30326 ADORES& INSURER(S)AFFORDING COVERAGE AMC* CN101642069.NnmD-GAW-1&19NEURER A:Old Republic II6Man Cc 24147 INSUREDINSURER e:Nov.Hangshre Ire CO 23E41 THE HOME DEPOT,INC HOME DEPOT USA.,INC INSURER e:Hari€ Ca mym Insurance Company . 2455 PACES FERRY ROAD INSURER D: BUILDING C-20 INSURER E: ATLANTA.GA 30339 INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-00435343918 REVISION NUMBER:3 THIS IS TO SURED NAMED ABE FOR THE INDICATED.CNOTWITHSTANDINGTALNY REQUIREMENT.ICIES OF TERCE M OR CONDITION OFTED BELOW HAVE BANY CONTRACT OR OEEN ISSUED TO THETHER DOCUMENT WITH RESPECT TO POLICY PERIOD 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 TYPE OF NSUMNCE ADOL SUER -POLICY EF POLICY EXP LIMITS LTR Ra PND POLICY NUMBER (MMIDDIYYYY1 JMM•PMYYYYI, A X COMMERCIAL GENERAL LIABILITY MWZY 312717 031012010 03/012019 EACH OCCURRENCE s 9,000.000 CLAIMS-MADENTED OCCUR vPRREEMIISESGEOfEa octants) 3 1 000000 LIMITS OF POLICY XS • MED EXP(Any one person) S EXCLUDED . OF SIR SIM PER OCC PERSONAL a ADV INJURY S 9',000 GENT.AGGREGATE LIMIT APPLIES PER' GENERAL AGGREGATE S 9.000`OW © POLICY D PRO. ❑LOC PRODUCTS-COMP/OP AGO S 9.000.000 •(ECT S OTHER A AUTOMOBILEUABILITY MW1TB312718 03N72018 031012019 COMBINED SINGLE LIMIT S 1.000.000 Me eccelenh © ANY AUTO BODILY INJURY(Pot person) S OWNED SCHEDULED SELF INSURED AUTO PHY OMG BODILY INJURY(Per accident) 3 • AUTOS ONLY _AUTOS DAMAGE HIRED NON-OWNED PROPERTY PD 3 AUTOS ONLY AUTOS ONLY ls IUMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LNB CLAIMS-MADE AGGREGATE S OED RETENTION 3 B WORKERS COMPENSATION WC 014122577(AK.NH,NJ.VT) 03'012018 031012019 % ST TUTE ER e AND EMPLOYERS'LIABILITY YIN WC 014122578(WI) 03101/2015 031012019 EL EACH ACCIDENT E 5.000,000 ANYPROPRIETORJPARTNERIOIECUTIVE NIA OFFICEra/SABEREXCLUDEME.L.DISEASE•EA EMPLOYE E 5,000.000 M NH) 5,000.000 I dlscnbe'itt Continued m Acetone!Page EL DISEASE-POLICY Lett S DESCRIPTION OF OPERATIONS below 000 Om C Excess Auto 297410011-00-2018 03/012010 031012019 Unit I I DESCRIPTION OF OPERATIONS'LOCATIONS I VEHICLES (ACORD 101.Adbtenal Remarks Schedule,may be attached N more mom Y rpuNM) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION HOME DEPOT USA.INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED A ED BEFORE 2455 PACES FERRY ROAD THE EX RA ON DATE THETHE EOF, NOTICE WILL BE DELIVERED m BUILDING G21 NS. ATLANTA.GA 30339 - AUTHORIZED REPRESENTATIVE cd Mata USA Inc. Manashi Mukherjee J1ita%^oo'- S _.Las^d-e'r" i CI 1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN101642069 LOC 18: Atlanta ACOROS COADDITIONAL REMARKS SCHEDULE Page 2 of 3 AGENCY _ MARSH USA,INC. NAMED INSURED HEH THE HOME DEPOT,INC POLICY NUMBER HOME DEPOT U.SA.INC. 2455 PACES FERRY ROAD BUILDING C-20 CARRIE0. ATLANTA.GA 30339 MAIC CODE ADDITIONAL REMARKS EFFECTIVE DATE; THIS ADDITIONAL REMARKS FORM ISA SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Workers Conpensalion Continued Carver Indemnify Insurance Company of North Amerce Pdicy Number WLR C64783191(AL AR.FL,ID,IA.KS,KY,LA,MS MO.NEaOA.ND,OASCSO TN,INV,WY) Effective Date-03/012018 Exprabon Dab 031012019 FL)Lint 51.000000 Lamer New Mampabn Insurance Company Pdlry Number WC014122576(DC.DEHUN.ND.MN.MT,hIY,RI) Effective Dale 03212018 Expiration Dale 031012019 (EL)Limit SI 000 000 Carrier ACE Amerman Insurance Company Petty Number WCU C64783221102)(AZ CA,IL,NC.OR.VA.WA) Effective Date 03/012018 Expiration Dale 031012019 (EL)Lunt 51,000,000 SIR SI,000 000 SIR kr 1M slates of AZ.CA,E,NC,OR,VA,WA Camer.Nam*Union Fire Insurance Company Policy Number XWC 4595580(050(CO.CLGA.ME,MI,aN,OH,PA UT) Elfeeave Date 03/012018 £xprahoa Dale 031012019 (EL]Unit 51,000000 51.000000 SIR for the slates of CO,MENV,MI.OH,PA,UT 5750,000 SIR for diastole of GA 5350,000 SIR 1m IM stale of CT tamer Naomi Union Fre LsuranceCompary Poky Number XWC 45_'5581(OSI)(MA) EOecave Dale'00101220/ WPnrmn S1.0 00012019 n� (EL)burl s1,OW,000 r�'l SIR 5500,000 TX DO oyen XS Indemnify Cam r.Rmios Union Insurance Connally Policy Number TNS C4916693A(TX) EBaceve Dale.03/012018 Espnehon Data.0301/2019 (EL)Lime$1/0400000 SIR SI.000.000 ,CORD 101 (2008/01) 02008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Details Page 1 of 1 Licensee Details Demographic Information (Full Name: Jon D Walsh wner 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 I No Prerequisite Information http://elicense.chs.state.ma.usNerification/Details.aspx?agency_id=1&license_id=284556& 9/19/2018