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HomeMy WebLinkAboutBLD-19-002545 'S Office Use Only 01'YAR v,_* 4o. Permit# O H • Amount u ._Nc'tn"„'S,s:? ,Permit expires 180 days from --h•' .::::.: - issue date EXPRESS BUILDING PERMIT APPLICA .: C E I V E D TOWN OF YARMOUTH OCT 2 9 2018 Yarmouth Building Department 1146 Route 28 BUIL. ,r e -• fr ,, .0 South Yarmouth,MA 02664 By: _ i (508)398-2231 Ext 1261 9 CONSTRUCTION ADDRESS: c� vflOW Q1/vDit t CtfirAN S'61 Ir r r3 C52-61). ASSESSOR'S INFORMATION: �//�^ ' Map: /sem ( Parcel: �1 a,,(P 1 (�[� ^� OWNER: YOii-k. V ICU CS a )c re I D II t-o pA .rn0 21 NAME 1 PRES ADDRESS / TEL #S70 r?U4— 4'le)-c CONTRACTOR �� A • . .1 it Oenr-4- Cl/dim IL/A 624 ,..vis Cf2_all N E t MALLIN ADDRESS TEL#Sok"'u_I 21 , 1ttesidential ❑Commercial Est.Cost of Construction S O ,pc(_. Home Improvement Contractor Lie.# 103' S") Construction Supervisor Lie.#CS — 0 O(o(04 3 Workman's Compensation Insurance: (check one) 0 I ant the homeowner 0 I am the sole proprietorG have Worker's Compensation Insurance vCj Insurance Company Name: 1 �S(�lin t a Worker's Comp.Policy# LOCC.SC�D SI Con 4Th2c P WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 1-1 Replacement windows:# q Replacement doors: # Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/HistoricstDist.�(, 1)/Repllacinng like for/� like Pool fencing 'The debris will be disposed of at 1-#.3 arm tsw-ti ltie_rA1 Location of Facility - I declare under penalties . r� . 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 ford ,ir of m license and for prosecution under M.G.L Ch.268,Section 1. ``�� Applicant's Signature: a4 S. / . DDate: \o\ -.ct \Fr Owners Signature(o attacbme i) • Date: Approved By: �d- kg i Date: tO' ii Building Official(or design EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 3 No Flood Plain Zone: C Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes U No If contract calls for siding and trim,or roofing; we recommend you remove any breakable items hanging on walls until job completion. NOT INCLUDED IN CONTRACT PRICE Painting or staining around window or door openings Removal of existing doors and windows often reveals weathering, as well as areas that may or may not be previously stained or painted. As noted, Contractor will not be responsible for painting or staining these areas. Adjustments or Reattachments Contractor will not assume responsibility for removal, re-attachments, or re-positioning of drapery rods, window shades, blinds and/or mini blinds, and corresponding hardware. RIGHTS TO CANCEL The Owner may cancel this Agreement if it has been signed by the Owner at a place other than the address of the Contractor, which may be his main office or branch thereof, provided that the Owner notifies the Contractor in writing at his main office, or branch by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this Agreement. HOMEOWNER: DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Uwe accept this contract in its entirety and Uwe authorize Sprinkle Home Improvement to act on my behalf in all matters relative to the work to be performed on this job (i.e. permits, applications etc.) if necessary. 140,l riciA24-lea fie 'Homeowner Signatur a Contract a r Signature ' Date Paula Noll Brad Sprinkle- Regis tion#103757 2 Snow Brook Road,W.Yarmouth,MA 02673 • The Commonwealth of Massachusetts =->11�P= Department of7ndustriaTAccidents Congress Suite 1.1 _ 1! 1 Boston,MA 02114- 2017 100 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant InformationQQ Please Print Legibiv Name (Business/Organization/Individual): Jp/ \CL(' �.Q �( cemfr.-A R Address: \ 11I n gS376le 1 City/State/Zip: 1N(AC/Y4 , PPP APO Phone 14: C$C "I)S- 177 An you an employer?Check the appropriate box: Type of project(required): VI am a employer with i 1-') employees(Ml and/orpart-time).' 7. 0 New construction 10 I am a sole proprietor or partnership and have no employees working forme in any capacity.(No workers'comp.insurance required.) 8. ORemodeling 3. I am a homeowner doingall work 9. ❑Demolition' . ❑ myself(No workers'comp.insurance requited.)t 4.0lam a homeowner and will be hiringcontractors to conduct all work on10 ❑Building addition my property. I w71 ensure that ell contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am agenetal contractor and I have hired the sub-contactors listed on the attached sheet 13.0 Roof repairs These sub.comracton have employees and have workers'comp.insurance: p 6.0 We area corporation and its officers have exercised their right of exemption per MGL c. 14. Other 1 WALE lOvl c45txi t 152,11(4),and we have no employees.(No workers'camp.insurance required.] 3S Ain 'Any applicant that checks box e 1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tContracton that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that Is providing workers'compensation insurance for my employees. Below is the policy and job site informatlon Insurance Company Name: 1U Ltf?>1 to Policy#or Self-ins.Lic.#:Lo CC S'ouS (...71/4-r)_ 1r�\ A Expiration Date: \ ) t Lao\g Job Site Address: cSY1(51J (Y YDtC U t DA.� City/State/Zip: LA A-tetrAx.x4-4.0notI2c 3 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cent er e ' and penalties of perjury that the Information provided above is true and correct Signature: Date: , b\dctI k k" phone#: Official use only. Do not write in this area,to be completed by dry or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ��. SPRIN•1 OP II) fl$ ACORUe DATE(MMIDWYYYY) CERTIFICATE OF LIABILITY INSURANCE 09r19r2013 THIS CERTIFICATE 13 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 1NSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. H 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 p ep�npdorsement(s NAME' ). PRODUCER r 508-775-6060 CT KelleyA.SuiiIvan Dryden&Sullivan Ins Agency PSE 88 Falmouth Road Nye SOB•775 6060 t N,p508-790-1414 Hyannis,MA 02601 's iDnakss: KelleyA.Sullivan INSURERISI AFFORDING COVERAGE - NAIC C INSURER A:NGM Insurance Company 14788 INsuREO Sprinkle Home Improvement Inc. AISURER 9;Associated Employers Insurance 199 Damnable Rd Hyannis,MA 02601 INSURER C: - NSURER 0 7 INSURER l INSURER F! COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 CLAMS. I TR NS TYPE OF INSURANCEADDLSUBR POLICY EFF POLICY EXP INen YNn POLICY NUMBER rMMI11n/YYYY1 Iuwnn,YYYYI LIMITS A COMMERCIALGENERAL UABILRY r EACH OCCURRENCE $ 11000,000 CLAIMS-MADE [j OCCUR MPT2640X 07101/2018 07/01/2019 P°R ISFa IF„ °w,n l $ 500,000 X Business Owners MED EXP IAmOwe nereonl • 10,000 PERSONAL a ADV INJURY 1 1,000,000 SfelAGGREMZE LIMITAPPUES PER: GENERAI AGGREGATE $ 2,000,000 X POLICY !pa u LOC PRODUCTS•COMP/OP AGG $ 2,000,000 S A AUTOMOBILE WBMY . COMBIN SINGLE LIMIT S 1,000,000 (Fa Aroeftn — Ateaut0 M1T2640X 07/27/2018 07/27/2019 BODILY INJURY(Per uereaM S _ AWNEDTEDULEO AU AUTOS ONLY TOS BODILY INJURY(PerecSMenl) $ X AU X HIRED X NfN.nwNFn PROPERT7Yy p.MAGE — AUTOS ONLY — AUTOSONLY F (Per ecSWenO _ S A X UMBRELLA LNB X OCCUR EACH OCCURRENCE S 1,000,000 EXCESS LIAR ` CLAIMS-MADE CUT2640X 07/0112018 07/01/2019 AGGREGATE. $ 1,000,000 DEO X RETENTIONS 10000 S B WORKERS COMPENSATION ' PER 0TH- AND EMPLOYERS'LVUIILITY STATIrTF ER ANY PROPRIETOR/PARTNER/EXECUTIVEWCC50050187472018A 01/01/2018 01/01/2019 - 600,000 OFFICERAIEMBER EXCLUDED? N NIA E EACH ACCIDENT $ 600,000 (Myannnd,ktory In NH) E L DISEASE-EA EMPLOYEE f DESORPTION O1eF describe der 36ebw EL DISEASE-POI ICV LIMITf 500,000 PROPERTY 60,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remedm Schedule,may he attached If more space Is required) Certificate Issued for Insurance verification Home Improvement Specialist CERTIFICATE HOLDFR - - - CANCELLATION SPRNKHO _ - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Sprinkle Home Improvement Inc ACCORDANCE WITH THE POLICY PROVISION 199 Barnstable Rd. AtITHOraD nerncccn Q A� J Hyannis,MA V2Sii1 Kelley A.Sullivan Styden&Sullllivvan Ins.Agency, Inc. ACORD 25(2016/03) ©1988.2015I(%pl!tidowai8 'AO rights reserved. The ACORD name and logo are registered marks of ACORD Q92€ (69ncy9cAlasiaciteedeit: Office of Consumer Affairs and Business Regulation One Ashburton Place-Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration r Type corporation SPRINKLE103757 HOME IMPROVEMENT INC I — Registra0on. . OZVS/2 199 BARNSTABLE RD. ,� ° w,sr j 't Expiration: 07/08/2020 HYANNIS,MA 02601 =- ' I`-\\ j„ Y ,__. Update Addreasand Return Card. SCAI 0 20M 007 s'o,nmonmena�oltivu /lsnrkme Offlen of Consumer Affairs B Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Coroaration before the expiration date. If found return to: grin]] LERILI 20 Office of Consumer Affairs end Business Regulation 103757 07)082020 One Ashburton Place-Suite SPRINKLE HOMEIMPROVEMENT,INC. Boston,MA ry � BRAD K SPRINKLE _ , 199 BARNSTABLE RD HYANNIS.MA 02601 Not valid w-777r si attire Construction Supervisor Commonwealthot Massachusetts Unrestricted•Buildppsof any use group which contain 111,, DivitiOn 01 Professional Licensureless than 35.000cubic feet(981cubic meters)ofenclosed Board or Building Regulations and Standards space. Co nstruction tOper/ISOr CS-006643 Expires: 10108/2019 BRADKSPRINKLE "' aL .199 BARNSTA8LE ROAD HYANNIS MA 02601 "' Falture to possess a current edition of the Massachusetts �. .. State Building Code Is cause for revocation of this license. - n For Information about this Dense /' L Call(61T)T2T4200 or Nett www.mass.govldpl Commissioner llV//^^^""` .__.___. _._._....___ _—.--..