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EXPRESS BUILDING PERMIT APPLICAT STC E I V E D
{ TOWN OF YARMOUTH
Yarmouth Building Department OCT 02 2018
1146 Route 28
South Yarmouth,MA 02664 BUI gib,ttr, m vs,,R
(508)398-2231 Ext. 1261 By — J/
CONSTRUCTION ADDRESS: Z y Gn-OPulp 71_ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: IflAttIQAI i-G`K� f Q f3T epAID Pn. let 01•oo8I
NAME I'1RLSLNI DRLSS. IEL #
CONTRACTOR: 1'lAttK I r tpn0lefa is til tc.�n. N/.ATi6CBerse sj SpJ•alp •e/I6
NAME MAILING ADDRESS TEL.It
t`Residential 0 Commercial EsL Cost of Construction$ 2 0, 'Y> 3
Home Improvement Contractor Lie.# I b 8 6!6 Construction Supervisor Lie.# Of 7 b V r
Workman's Compensation Insurance: (check one)
u I am the homeowner L I am the sole VI Proprietor have Worker's Compensation Insurance n
Insurance Company Name: I :it - I .. do ( bu i. Worker's Comp.Policy# Ze 19IvI b ZQ9(r7
WORK TO BE PERFORMED
Tent — Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares Replacement windows:# Replacement doors: #
Roofing: #of Squares q 1 (X)Remove existing*(max.2 layers) Insulation
Old Kings Highway/Historic dD.isst. ( )Replacing like for like �Poo'lrfencing
'The debris will be disposed of at: 6t. t' ktvcry f f.(f k &J Dila pl KI
/ Location of 2614 „,111
I declare under penalties of p i th : statements herein contained are true and correct to the best of my Ltonledge and belief. I understand that any false answer(s)
xi II be just cause for denial r ocat on f my license and for prosecution under M.t1L Ch.268.Section I.
Applicant's Signature: Date: /D '2i8
Owners Signature(or attachment) (f7 Cp r Date: /-�
Approved By:
....0".......-y
/. / Date: /V °-2---ie
Dui ng t ' ml(or iesigncc) EM. .11 WDRESS:
Zoning District:
Historical District: T. Yes No Flood Plain Zone: Yes : No
Water Resource Protection District: Within 1001E of Wetlands:
Yes No ” Yes No
The Commonwealth of Massachusetts Print Form
t Department of Industrial Accidents
Office of Investigations
- ;._, 1 Congress Street,Suite 100
•
Boston,MA 02114-2017
• www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le&ibly
Name(Business/Organization/Individual):Power Home Remodeling
Address:2501 Seaport Drive
City/State/Zip:Chester PA 19013 Phone#:508.280-0156
Are you an employer?Check the appropriate hoc Type of project(required):
1.0 1 am a employer with 30 4. 0 I am a general contractor and I
employees(full and/or part-time).
have hired the sub-contractors 6. ❑New constmdion
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
shipand have no employees These sub-contractors have
R. ❑Demolition
working for me in any capacity. employees and have workers' 9. 0 Building addition
[No workers'comp.insurance comp.insurance.:
required.] 5. ❑ We arc a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself.[No workers'comp. right of exemption per MGL
12.0 Roof repairs
insurance required.]t c. 152.§1(4),and we have no
employees.[No workers' 13.0 Other
comp.insurance required.]
'Any applicant that checks box tl l much also fill out the section below showing their workers'compensation policy information.
t I It-meow/sere who submit this amdavit indicating they arc doing at work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of de sui*emnractoss and state whether or not those entities have
employees. lithe subcontractors have employee,,they must provide their worker,comp.polity 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:Harleysville Worcester Insurance Company
Policy#or Self-ins.Lie.#:2018006620967 Expiration Date:10/1/2019
Job Site Address: Z q &'moi P0AI0 )N. City/State/Zip:VAtCMourW Di II-
Attach a copy of the workers'compensation policy declaration page(showing the policy n mber 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-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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cereffy{,��'Jryj�,r t gins and penalties of perjury that the information provided above is true and correct.
Sinnature- t/hnl lil� Date 0'Z'' (
Phone 4.508-280-0156
Official use only. Do not write in this area,to he completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone It:
1 •
...---stM
A R O CERTIFICATE OF LIABILITY INSURANCE DATEYYY)92�OIM6
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
I REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IIMPORTANT: If 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 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 endorsemengs).
PRODUCER CONTACT
Lacher&Associates Insurance Agency PHOOI a FAX
Lacher Insurance Group WC_NwEFa21S723.43T8 ue):215-723-5757
632 East Broad Street ADAIN`
E-MAILDDRESS/ lacher@lacherinsurance_com
Souderton PA 16964 INSURERLSIAFFORDING COVERAGE NAIC0
INSURER A:Harleysville Preferred Ins.Co 35696
INSURED POWERCw1 INSURER e:ARCO Insurance Company 19100
Power Home Remodeling Group,LLC
2501 Seaport Drive INSURER c:Depositors Insurance Company_ _
42587 _
Suite BH400 INSURER o:Pennsylvania Manufacturers 12262
Chester PA 19013 INSURER E:
INSURER E:
COVERAGES CERTIFICATE NUMBER:236892370 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED 70 THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM CR 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 PAD CLAIMS.
INER AUU SUER POLICY EFF I POLLCY EXP
I TR TYPE OF INSURANCE MYQRD I WPOLICY NUMBER (MM/DO/YYYI (MMIDDNYYYI LISIRS
A X COMMERCIAL GENERAL LIABILITY CL0000005039AG 101/2018 411/2019 EACH OCCURRENCE St 000.000
MS-MADE [ J OCCUR $AMAGEAORENTED
PREMIXES jEa occur/jewel 2300.000
MED EXP(Any one pmwr) S15 MO
PERSONAL B ADV INJURY $2000000
GEM AGGREATE LINT APPLIES PER GELERAL AGGREGATE $4000.000
POLICY 1-1 JEGT I I LOC PRODUCTS-COAPAP ACG 51.000.000 —
OTHER $
0 AUTOMOBILE LIABILITY 15180040-2086/7 10.1/2015 10/1/2019 COMBINED SINGLE LIMIT $1000000
X ANY AUTO _LasaYenD
BODILY INJURY(Per pawn) s
OWNED SCHEDULED BODILY INJURY
AUTOS MAY AUTOS (Px86MMd) S
HIRED NONOWNED PROPERTY DAMAGE
AUTOS
AUTOS ONLY _AUTOS ONLY LPw ecctlwl 5
$
UMBRELLA LAB _ OCCUR EACH OCCURRENCE S _
EXCESS 13A6 CLAIMS-MADE AGGREGATE _f —
DFD RETENTIONS S
p WORKERS COMPENSATION 2018754020-967 1011/2018 10/1/2019 X Ir2euTE I._IER __—
AND EMPLOYERS'LIABXJTT Y/II
AKKPROPRIETOIPARTNERLEXECUTIVE EL EACH ACCIDENT $1,000000
OWFICERMEMBER EXCLUDED? ❑IN IA
Mandatory in NN) EL DISEASE-EA EMPLOYEE $1.000.000 _______
DFSCRIPTIOONN or OPERATIONS below EL DISEASE•POLICY LIMIT 51,000,000
B GENERAL LIABILITY-CO BTX ACPGLA03047208912 10/1/2018 1011/2019 EACH OCCURRENCE 2.030.00D
C GENERAL LIABILITY-FL ACPCLD03O4T208812 101/2018 1011/2019 GENERAL AGGREGATE 40000W
MED EXPENSE 10.000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,AddIonal Reny**Schedule,ray be MMched It more ewe Is merited)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Town of Yarmouth ACCORDANCE WITH THE POUCY PROVISIONS.
1146 Route 28
South Yarmouth MA 02664 AUTHORIZED REPRESENTATIVE
USA
®1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
n.
Commonweahh of Massachusetts
Division of Professional Licensure = Office of Consumer Affairs BBuslnesa Regulation,
Be••d of gumming a.qulanons and Standards HOME IMPROVEMENT CONTRACTOR
Construction Supervisor TYPE:Supplement Cad
Registration FeMrattoq
CS-057665 Expires:39118:201; 168616 03!17/2019
eh.
POWER HOME REMODELING GROUP LLC. '
MARK E MORDINI • MARK MORDINI
18 NEWELL OR •
NORTH ATTLEBORO MA 02760 W.H 2501 Seaport Drive Ste B110
Chester,PA 19013 Undersecretary
C,1.-Commissioner
/
Construction Supervisor ---_— --.�— .
Unrestricted-Buildings of any use group which contain
less than 35,000 cubic feet(991 cubic meters)of enclosed
space. Registration valid for Individual use only
_ before theration d It found return to:
Office ons mer a and Business Regulation
10 P Plaza Suit 517
en,MA A2116i
Failure to possess a current edition of the Massachusetts 74/'J /1
State Building Code Is cause for revocation of this license. `I got valid without signature
For Information about this license
Call(617)727-3200 or visit wwwma ss.govfdpl
National Headquarters Marion Ferro
2501 Seaport Drive,Chester,PA 19013 33-43915
POR WWWPOWERHRG.COM September 29, 2018
CUSTOM REMODELING AND IMPROVEMENT AGREEMENT MA Fl ICI 168616
Buyer(sy Information and Description of the Property: Project Number:33-43915 September 29,2018
Marion Ferro Date aIAgreement
(617)777-4662(Marion S Cell) trrymaz®msn.eom
24 Great Pond Dr
South Yarmouth,MA,02664 (508)633-0081 (Other) E-Mat Address I
County:Barnstable
Township:
Buyer(s)listed above hereby Jointly and severally agrees to purchase the goods and/or services of Power Home Remodeling Group
and its vendors("Contractor')in accordance with the prices and terms described in this 5 page document and the Product
Specifications,which are incorporated as part of the Agreement(collectively,this'Agreement). This Agreement represents a cash
sale of goods and services. Buyer(s)agrees to pay the cost of the goods and services purchased as described herein, regardless of
timing or approval of any financing Buyer(s)may seek for their purchase.
Purchase Price: $28,333.14 Pre Installation Inspection Dates:
Down Payment: $0.00 Estimated Project Start:3 to 4 weeks
Balance Due on $28,333.14 Estimated Project Completion:1 to 2 days
Substantial Completion:
Buyer(s)acknowledge that a definite start and completion dates are NOT of the essence. Delays beyo
Method of Payment: Credit Card Contractor's control not Included in calculating time frames. See Delayflnlmown Conditions
Buyer(s) hereby acknowledges receipt of a copy of the pamphlet, "The Lead-Safe Certified Guide to Renovate Right', Informing
Buyer(s)of the potential risk of lead hazard exposure from renovation activity to be performed in or at Buyer(s)' Property, at the
address written above. Buyer(s)received this pamphlet on the date of this Agreement, before commencement of work.
27 3' Buyer(s)'Initials.
This Agreement constitutes the entire agreement and understanding between the parties, and this Agreement replaces any and all
prior negotiations, representations, or agreements, either written or oral. No amendment, modification or waiver of this Agreement
shall be valid or effective unless in writing and signed by both parties. Buyer(s)hereby acknowledges that Buyer(s) 1)has read the
entire Agreement and has received a completed, signed, and dated copy of this Agreement, Including the two accompanying Notice
of Cancellation forms,on the date first written above and 2)was orally informed of his/her right to cancel this transaction.
Buyer(s) also agrees and understands that if Buyer(s)finances the work with a third-party,the terms of that financing will be
contained on separate documents, including any finance charge.
Future promotions not applicable.
DO NOT SIGN THIS AGREEMENT IF THERE ARE ANY BLANK SPACES.
I have read and received each page of this 5 page agreement.
Poweriome Rem. 'eling Group Buyer(s)
a es /09/29/18 '1 "`�' /09/29/18
Signature of Remo.eling Consultant Signature
Derrik Lofgren-Thatcher Marion Ferro
YOU,THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY
AFTER THE DATE OF THIS TRANSACTION. SEE THE ATTACHED N&'IICE OF CANCELLATION FORM FOR AN EXPLANATION OF
THIS RIGHT.
September 29, 2018 18:12 IJlpp I I IffIOHllIIIIII Page 1 of 5
National Headquarters Marion Ferro
2501 Seaport Drive,Chester,PA 19013 33-43915
September
p 888.7366335 29,2018
.00 ER WWW.POWERHRO.COM
MA HId 168616
PRODUCT SPECIFICATIONS
Buyer(s)'Information and Description of the Property: Project Number:33-43915 September 29,2018
Marion FerroDate aAgreement
24 Great Pond Dr
(617)777-4682(Martin's Cell) nymaz@msn.com
South Yarmouth,MA,02664 (508)633-0081 (Other) EaMagAddess I
County:Barnstable
Township:
Buyer(s)listed above hereby jointly and severally agrees to purchase the goods and/or services listed on the accompanying specification
sheets,in accordance with the prices and terms described in the Custom Remodeling and Improvement and the Product Specifications
(collectively,this"Agreement").
Pre Installation Inspection Date:Your pre Installation Inspection is tentatively scheduled for TBD.
Roofing-GAF Inclusions:For steep slope roofs,the application includes Fortitude Lifetime Shingles with 50-year non prorated labor
warranty.Also includes removal of existing shingles,installation of F-style drip edge,Weather Watch Ice and water shield,Deck Armor
breathable roof deck protection,Pro Starter starter strip,Snow Country ridge vent exhaust,Timbertex premium ridge cap shingles,
PowerVent intake ventilation,all flashing and chimney crickets where needed and 6 nails per full shingle.All applications used only where
applicable.Clean up and haul away of all job related debris.
To protect our clients,Power HRG includes,at no additional cost,the removal and replacement of up to 320 square feet of soft or rotted roof
decking if needed on steep slope applications. My additional wood replacement needed,over and above the 320 square feet we provide
will be done at a cost to the homeowner of$3.57 per square foot.For Example:Atter the shingles have been removed,if we find there is a
need to replace 345 square feet of wood,Power HRG will pay for the first 320 square feet. It is the responsibility of the homeowner to pay for
the cost of 25 square feet of replacement at$3.57 per square foot,which In this example Is$89.25.
For low slope roofs,which are roofs with a pitch below 2/12,the application includes a 15-year non prorated labor and material warranty,
removal of all existing roofing materials,new decking,TriBuilt base and cap sheet,drip edge and flashing,where applicable. Roofs with
cedar shingle removal will Include all new decking as part of the installation. Clean up and haul away of all job related debris.
It Is agreed and understood by and between the parties that the Product Specifications,along with the Custom Remodeling and
Improvement Agreement,constitutes the entire understanding between the parties,and replace any and all prior negotiations,
representations,or agreements,either written or oral. The Product Specifications may not be changed,modified,or varied In any way unless
such changes are In writing and signed by both Buyer(s)and Contractor. Buyer(s)hereby acknowledge that Buyer(s)has read the Product
Specifications.
I have read and received each page of this 2 page agreement
Power Home Remodeling Group Buyer(s)
/0929/18 /09/29/18
Signature of Remodeling Consultant Signature
Derrik Lofgren-Thatcher Marlon Ferro
YOU,THE BUYER(S),MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY
AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF
THIS RIGHT.
September 29,2018 18:13 IIIIIII�I�I IIII UHp (11
1p
Page 1 of 2
National Headquarters Marlon Ferro
2501 Drive,Chester,PA 19013 33-43915
888-Pp�yER: WWW.POWERHRG.COM September 29,2018
war MA HIC7 168616
Project Specifications
Roofing: Whole House less Low Slope 1 2925.0'x1.0'
ROOFING: Models GAF Styles Fortitude Types None Configs None
t::: ::9
OPTIONS: Cola Sapphire I Removal Standard Shingle I Installation Details None
GAF as
CORPORATION
Sapphire
Roofing: Low slope 1 800.0'x1.0'
ROOFING: Models GAF Styles TriBUiti Low Slope Types None Configs None Options Color: Black/
Installation Details None L aW
OAF MATERIALS
CORPORATION
Roofing: Low slope decking 1 800.05c1.0'
ROOFING: Models GAF Styles Replace Wood Types Plywood Configs None Options None i Installation
Details None t !!
OAF MATERIALS
CORPORATION
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