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Home My WebLink AboutBLD-19-001655 Office Use OnlI y . of'Yektit cart-1"D 4/Cc. Oi ,5 4Amount nwr•rn n 'n' 1 +.,,...•�S, i Permit expires 180 days from re t issuq)date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH - Yarmouth Building Department 1146 Route 28 RECEIVE D South Yarmouth,MA 02664 / `` (508)398-2231 Ext. 1261 S P 33 2��018// CONSTRUCTION ADDRESS: .5-0 A/0 bb/ L0, BUiL I G DEpARTnne ASSESSOR'S INFORMATION: ' Map: Parcel: OWNER: 4ene ScP rt(4# SOA ,y 4/ Al yrrru.-14,7 MA 02673 °203-!,2 -oRRo NAME PRESENT ADDRESS TEL # Email Address: CONTRACTOR:The AA ✓t-le en4 et D8 ,k ILw G y'ADDRKg ESS 01_51-(r Ste- 6a --69'12 TEL Email Address • '.ential Commercial r Est.Cost of Construction$ q 21 I Home Improvement Contractor Lie.# /l oZ.71 S Construction Supervisor Lie.# 0 7007 7 Workman's Compensation Insurance: (check one) I am the homeowner I am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: Aoela. /lin bn hre Zi Svra/iCP �l Worker's Comp.Policy# Xy✓C `/5 9 ri 5 ' I ' WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# 7 Replacement doors: # - Roofing: #of Squares ( )Remove existing'(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like *The debris will be disposed of at lift 3/e- /7142/k C/rr PX t J Location of Facility . I declare under penalties of perj :.. ,• statementsherein eontsinnd 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 of my 'cense and for to.-• ..n under MILL Ch.268,Section 1. 1. Applicant's Signet= 405,,,,.e., i ,,j.. Date: 9—l2 —/ Owners Signature(or atta , gee toe_ C'AC(�G 1 Date: Q �` Approved By -."--4:: Date: 7 'i�l O -i Building Official(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 bY"OA 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: Janice Campbell 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. Schmidt Gene New England South 1-6FBHDSX Customer Last Name Customer First Name Store #/ Branch Name Lead/Customer Order# 50 Nobby Ln West Yarmouth MA 02673 Customer Address City State Zip (203) 912-0890 (203) 329-8849 gene640@hotmail.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 DEPOTS 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 CAN Acknowledged by: 08/18/2018 Gust �—'�� Date Contract Price and PayM�ft 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: 4281.45 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 1070.36 Remaining Contract Balance 3211.09 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,p(31 Jan.18) v 5012 • o ,47 �t at rWIMItN itYM • ; aa xa'.tarr� "7iarrwwdaro -, ar it d : ' ' aoIUnaanb Poti•7n531404 , nootcrs3 '; • aWePuV$S Pug suoµginBaid buiPPng{o peas ; j I%a 4vC aggnd/o waw e..dep s3NartyilsAyY • _.7±---"t „77 %i e E%olllMO/I iear<<�l? 0/ 1` f'l,:�if1dtte.ien E6 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 Registrations 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 Renewal 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: peoistration Expiration, Office of Consumer Affairs and Business Regulation _ 112755 04/22/2019 10 Park Plaza-Suite 5170 HOME DEPOT USA INC Boston,MA 02116 ANDREW SWEET ` -4 a-- �rli 2455 PACES FERRY RD C-11 HSC U 0 (AI i ATLANTA,GA 90339 Undersecretary ithou signature • The Commonwealth of Massachusetts �. T Department of Industrial Accidents 1.1 Office of Investigations _d,1 1 1 Congress Street,Suite 100 Boston,.314 02114-2017 `� www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information `� Please Print Legibly us Name(Biess/Organimoon/lndlvidual): Home- per e t. I/y _ Address: 90 0p// 8 s/,iv 1lIRNpi42. l City'State/ '.: S{IrCtasb ' . o/rya' Phone#: 7 7/1- ell 5- - a/S-S ' Are you an employer?Check the : .propriate box: ! Type of project(required): 1.!>V I am a employer with Ziff 'r 4. I_ I am a general contactor and I / ` 6. 0 New construction employees(full and/orpart-lite).r have hired the sub-contractors • listed on the attached sheet 7. 0 Remodeling 2. ]am a sole proprietor or partner- i These sub-contactors have i 8, Demolition ship and have no employees 0 wedging for me in any capacity. employees and have waiters' ! I 9. 0 Binding addition [No workers' comp.insurance comp.issuance.: I required.] 5. 0 We are a corporation and its ! 10.0 Electrical repairs or additions , 3.[ I am homeowner doing all work ofcers have exercised their ! 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL ! 12.0 insurance required.) Roof repass t c.152,§1(4),and we have no ,�,// / / employees. [No workers' 13. t)�. Other t✓r�4/0-4 • • comp.insurance required) I, reek eem en r"...5 •.v:y applicant that checks hos el must also fill out the section below showing their workers'compensanon policy mformation. t Homonym=who submrtthis affidavit indicating they vu doing all wort and then hire outside roaoactors must submit a new affidavit mdicaonginch :Contractors that check this box must attached an additional sheet showing the mac scribe sob-contractors sod suite whether or not those entities have employees. f the sub-cowactom have employees,they must provide their workers'comp policy number. I urn an employer that is providing workers'compensation insurance for my employees. Below is the policy and job she information � �/ lama=Compare Name: Carr I Lr AZv74-Iva VNi et.pi ///'G S L< . e9. Policy*or Self-ins.Lie.#: X W�/Ci/ L7 J t J C 8/ Expiration Date://.. //3 - /////- i�t9/� Job Site Address: 'CO /vD4by 1n. City�lSmte2ip:k/ tr�no✓1 A i!"/A Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of VJGL c. 152 can lead to the imposition of criminal penalties of a fore up to$1,500.00 and/or one-y imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fore of up to$250.00 a day a• •It 4{•lator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DLA i o ce coverage verification. I do hereby terrify un• e + •••�• the information provided above i true and correct af le Date:Date: 9- /L - /d Sia to tae: p141.2- Phone#: SV"8- ! '- 6 _ 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 Aeahh 2.Building Department 3.CityrTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: • ACOROa CERTIFICATE OF LIABILITY INSURANCE Do"sn2aoois 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: M the certificate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If 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 PHONE I FAX TWO ALLIANCE CENTER WC Na Erik INC Not - 3560LENOXROAD,SURE 2400 E-MAL ATLANTA.GA 30326 ADDRESS: INSURER(S)AFFORDING COVERAGE SAC* CN101642069-HomeD-GAW-1&19 INSURER A:Old Reptile Irsuance Co 24147 INSURED a:New Hampshre ins Co 23261 THE HOME DEPOT,INC HOME DEPOT U.S.A.,INC INSURER C:HBneRIs*Caney!Insurance Cornrow 2455 PACES FERRY ROAD INSURER 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 ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSR TYPE OF INSURANCE ADDL SUER POLICY EFT POLICY EXP LIMITSLTRNYY) SD WVD POLICY NUMBER 1MINDOPI JIAMIDWYI YYY A X COMMERCIAL GENERAL LIABILITY MWZY 912717 031012018 03/012019 EACH OCCURRENCE s 9.000000 DAMAGE TO RENT ED CLAIMS-MADE E OCCUR PREMISES(Ea occurrence( 1000000 rence( 3 LIMBS OF POLICY XSMED EXP(Any one person) S EXCLUDED OF SIR 51M PER OCCPERSONAL S ADV INJURY 5 9000000 GEM.AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE S SACC 303 POLICY❑JET [J LOC PRODUCTS-COMP/OP AGG S 9.000.0(0 OTHER . 5 A MWTB312718 03012018 031012019 COMBINED SINGLE LIMIT s I00000C II AUTOMOBILE WBIUTY (Ea stades% IA ANY AUTO BODILY INJURY per person) S OWNED SCHEDULED SELF INSURED AUTO PHY DMC BODILY INJURY(Per accident) 3 AUTOS ONLY _AUTOS F HIRED NON-OWNED PROPERTY DAMAGE 5 AUTOS ONLY —AUTOS ONLY (Per acoden0 S UMBRELLA LAS OCCUR _ EACH OCCURRENCE S EXCESS IJ CLAIMS.MADE AGGREGATE S DED I RETENTION S S B WORKERS COMPENSATION WC 014122577(AK.NH,NJ,VT) -03/012018 03(012019 X I PE13 _ STATUTE ER AND EMRDYEASLMBeJTf YIN WC 014122578(WI) 03012015 03/01/2019 E.L EACH ACCIDENT S 5000.000 B MSYPROPRIETORPARTNER/E(ECUTNE OFACERMEMBEREXCLUDED+ NIA (Mandatory M NH) EL.DISEASE-EAEMPLOYEE S 5.000,000 000 'DESCRIPTION deSORM under Coninued on National Page _ E L DISEASE-POLICY LIMIT S 5,000. DESCRIPTION OF OPERATIONS hub./ C Excess Aub 297-1-10011-062018 031012018 031012019 LJnrt 4.000.000 DESCR IPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,say M Necked R mow Spa N iyuked) 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 POUCY PROVISIONS. ATLANTA.GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee ivtoL+asc''a �y&.a-cca&a}— 1 G1988-2016 ACORD CORPORATION. All rights reserved- ACORO 25(2016103) The ACORD name and lege are registered marks of ACORD AGENCY CUSTOMER ID: CN1D1642069 LOC It: Atlanta ACORp® AGENCY ADDITIONAL REMARKS SCHEDULE Page 2 of 3 MARSH USA,INC. NAMED INSURED _— THE HOME DEPOT,INC POLICY NUMBER HOME DEPOT GSA.INC. 2955 PACES FERRY ROAD CARRIER BUILDING C-20 ATLANTA.GA X1339 NAIL CODE ADDITIONAL EFFECTIVE DATE REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: Z5 FORM TITLE: Certificate of LiabilityInsurance Waken Conpensabon Continued Carrier Indemnity Insurance Company of North America Poky Number WIR C64783191(AL,AR FL ID IA ys.KY.LAMS MO.NENt1.ND,OK.SCSD,TN,WV,WY) Effective Dale 03012018 Expiration Date 03101/2019 IEL)Lint 51,000,000 Comer New Hampahre Insurance Company Rimy Number WC 0141225713(DC DE.KIN MD MN MT WY RI) Effective Dale'03101/2018 Expiration Dale 03/012019 (EL)Lunt 57000.000 Carrier ACE American Insurance Company Pony Number WCU C64783221(051)(AZ.CAIL,NC.ORVAWA) EOecbvo Date 03012018 Expiratien Dan 03012019 (EL)Uri*51,000,000 SIR 5100E800 SIR for the stales of AZ.CAIL,NC,OR,VAWA Carver Nabont9 Wort Fre Imurame Company Policy Number XWC 9595580(OSIJ(CO,CT.GA,ME.MI.NV.OH,PA.UT) Effective Date 03/01/2018 • Exprshoo Dela 03912019 (EL)Urdl 51E00.000 51000,000 SIR or Me awes of CO,MENV,MI.OVA,UT 5750.000 SIR for the stale of GA 5350.000 SIR for the sale ofCT Carver Nabonal Union Fre Immense Company Policy Number XWC 9595581(050(MA) Swindon Bean Dale'0000200/ ,T ,k Gyvalion Dale'93101/2019 �II Yh({I6y (EL)Limit 51,000,000 '�'l SIRS500,000 TX Emdvyer,XS Indemnity. Canu remios Urion Insurance Company %icy Number INS C4916693A(TX) Eaeebve Dale 031012018 Ecprehon Data.03012019 (EL.)lint 510000000 SIR 51.000.000 iCORD 101 (2009/01) 02 2008 The ACORD name and logo are registered marks of ACORD CORPORATION. All rights reserved.