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HomeMy WebLinkAboutBLD-19-002777 4.•Y ' Office Use Only h Zo _"i01 Pemd[il Oi . 5 tAmount \MTT/. I• Ct s \`sv...o:# Permit expires 160 days from ; • EXPRESS BUILDING PERMIT APPLIC • I; E I V E D TOWN OF YARMOUTH Yarmouth Building Department OCT 31 2018 • 1146 Route 28 South Yarmouth,MA 02664 sui r eft (508)398-2231 Ext. 1261 "' t CONSTRUCTION ADDRESS: 671" #14 en g .1A ASSESSOR'S INFORMATION: ' • .. /� /� / Map: Parcel: OWNER of( il7e/ �OL/-•A14,, c RJ a/yvn. M, ,'iA 016 1 21 SOIL— 77 c— 5-0 q 7 NA PRESENT ADD ESS TEL # Email Address: coNTRAcroR:TiZe ¢10,/rte ion-F 908 RItr&,asborr HA erSyS Sri'-962--60g7 , NAME MAILING'ADDRESS TEL# Email Address Reside ' Commercial Est.Cost of Construction$ t/f 2-25 — Home Improvement Contractor Lie.# not 19 S Construction Supervisor Lic.# ii 70 e) 7 7 Workman's Compensation Insurance: (check one) � I am the homeowner I am the sole proprietor Yhave Worker's Compensation Insurance Insurance Company Name:�1(o/la //Ill;04 ,41-c ).%'C Tn Svranee 4Worker's Comp.Policy# )(WC)(WC1/5-1/5-p 1 SS I ' WORK TO BE PERFORMED Tent _ Duration (Eire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# I Replacement doors: # Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like — Me debris will be disposed of at A(l S P MLA(At a RI— ' Location of Facility . I declare under penalties of• statements herein contained are no and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial orof my 'cense and for w,. ••n under MG.L Ch.268,Section 1. •, /_ Applicant's Signature: O f ftri ra n/ Dare: /b - ?i—/ Owners Signature(or atter . - Sae 4+ Ce . C s,"C ra G.. — Date: .------ 1V 3)q1 Approved Br Date: 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 • Zwai 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. COLLYER PAT New England South 1-61(10067 Customer Last Name Customer First Name Store #/ Branch Name Lead/Customer Order # 64 Adams Road West Yarmouth MA 02673 Customer Address City State Zip (508) 775-5047 yarmouth236@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 DEPOT'S 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 ACKNOWLE HAT U HAVE BEEN GIVEN ORAL AND WRITTEN NOTICE OF YOUR RIGHT TO CANCEL Acknowledged by: 09/19/2018 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: 4283.10 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 1070.78 Remaining Contract Balance 3212.32 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 m ., 2 ar @0: | {k ,\ / ƒ ? f . ! |! : % © c e f �l \ iC e 114 % \ { |f ( I ° ? 2a . ! {2212 ice. { f : « #\ } : 2 ,& !/! / a• . _y ! \ 7 hi �4 / \ �� \ . . � � �� y:«. w. y . « ^ ^', ', * .. _. e • The Commonwealth of Massachusetts r=_ T Department of Industrial Accidents far Office of Investigations �e'— �� i 1 CosgressI Street,Sute 100 Boston,.lL9 02114-2017 4 y ww'w mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ( J `� /' Please Print Legibly Name (Busapess/Orgardationilndividual): ..il D/n ei J✓t e>' Address: /Bt/ Be$1750-N / I/RNf/k l Citv'State/Zip: SAtros6lnft/LAM . on-yr Phone#: 7 Vic 02 7S - c2/3—s— I /3-S Are you an employer?Check the stdpropriate box: Type of (required): • ' I.:�Sj I am a employer with ZA0'r 4• t_ I am a general ccmcecmr and I 6. New project ctial / `employees(full and/or part-time).* have hired the sub-contractors 2.0 lam a sole proprietor or porter- listed on the attached sheet 7. 0 Remodeling ship and have no employees These sub-contractors have 1 8. 0 Demolition working for me in any capacity. employees and have workers' I j or)�o 9. 0 Building addition • No workers' comp.insurance comp.insurance.: I nutted) 5. 0 We are a corporation and its I 10.0 Electrical repairs or additions • 3.0 I am a homeowner doing all work officers have exercised their j 11.0 Plumbing repots or additions I myself. No workers' comp. right of exemption per MGL i 12.0 Roof reprits . irstrance required]' c.152,§1(4),and we bave no : � employees. [No workers' • 13.i Other CO s1:-)clue i/ / comp.insurance required] I, r e(a'r•e... •.ary applicant that checks box 41 must also Ell out the section below showing their workers'compensator policy mrormation. t Homeowae:s who submit this affidavit indieaing they are doing all work and thm hire outside cor nsetors must submit a new affidavit iodianngsuch. :Contactors that check this box mus attached an additional sheet showing the name tithe sub-mmumta and state whether or not those entities have xpioyees. a the sub-contactors have employees,they most provide their workers'comp.policy number. am an employer that is providing workers'compensation Insurance for my employees. Below is the policy and job site information. �t / / - C1 Instranc:Company Name: /L"jJ"4-J�/ter �/ 2p�t[/•etl4.� VHF on/ /!/'t �s . C.6. / Policy ti or Self-ins.Licc./t: K W t- I- - 1 I 8/ Expiration Date: 3 - / - [ 9 Job Site Address: 4 LI -Ada An S r20 e City/State/Zip: lnJ./s n.A I t e'-t-4 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 MGL c. 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or one-y a imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fete of up to •='50.00 a day :• 4.lator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA . ;ce coverage verification ./de hereby certify tet', e, • a- •- at the information provided above is true and correct i• ..,, . I ileA.a a Q .l Date: Phone n: a 6 p - / / - a l e2- . Official use only. Do not 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/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone*: ! {1ofilvzoJe(elect Z :ficeiJacireeie-Th uuf` F= 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 04/22(2019 ATLANTA,GA 30339 Update Address and return card. Mark reason for change. ❑ Address 0 Renewal 0 Employment 0 Lost Card Office of Consumer Affairs&Business Regulation -- ' HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE Suoolement Card before the expiration date. It found return to: L�-a Fleaistration 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 ,47 2455 PACES FERRY RD C-11 HSC ATLANTA u GA 30339 Undersecretary ' ' (thosignature ACORD CERTIFICATE OF LIABILITY INSURANCE °cma2nDN°° I 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: If 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. NAME fAX TWO ALLIANCE CENTER PNCxM Fee INC.NoT- . 3560 LENOX ROAD.SUITE 2400 EMAIL D R°ESs: ATLANTA.GA 30326 INSURERS)AFFORDING COVERAGE MAIC* CN101642069-HoneD-GAW-1619 INSURER A:CID Republic Insurance Co 24147 INSURED B:Npx HalpsNr!IRS Co 23841 THE HOME DEPOT,INC HOME DEPOT U.S.A.,INC. INSURER e:HaneRi9k Carew Insurance CanRJnr - 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 ADOL SUBR -POLICY EFF POLICY EXP LIMITS LTRNMWVD POLICY NUMBER IMWDDIYYYY1 IMIUDD?YYYYI A X COMMERCIAL GENERAL LIABILITY MWZY 312717 0301201e 0310112019 EACHOCCURRENCE $ 9000.000 DAMAGE TO RENTED 11ND 000 CLAIMS-MADE OCCUR PREMISES Ma occurrent.: 5 LIMITS OF POLICY XSMED EXP IAny one person) $ EXCLUDED OF SIR.SIM PER OCCI 9.000.000 PERSONAL a ADV INJURY S GENT.AGGREGATE LMR APPLIES PER: . GENERAL AGGREGATE S 9000.300 /• 'POLICY❑JER T El LOC PRODUCTS.COMPIOP AGG S 9.000,000 �ll OTHER: 5 A LE usCOMBINED SINGLE UNIT AUTOMOBILE MWTB312718 01012018 031012019 (Ea awdenti 5 I,000,OOC X ANY AUTO BODILY INJURY(Por person) $ OWNED —SCHEDULED SELF INSURED AUTO PRY DRAG BODILY INJURY(Pr eccaenI) 5 AUTOS ONLY _AUTOS • HIRED NON-OWNED PROPERTY DAMAGE 5 AUTOS ONLY _AUTOS ONLY 'Per att+MnII 5 UMBRELLALIAB OCCUR EACH OCCURRENCE S EXCESS UM CLAMS-MADE AGGREGATE S DEC: RETENTION5 5 B WORKERS COMPENSATION WC014122577 (AK,NH,NJ,VT) 031012018 01012019 X PEERT11fE EN P AND EMPLOYERSWABILm YIN WC 014122578(WI) 03012016 031072019 5.000,000 6 ANYPROPRIETORIPARTNERID(ECUTWE E.L.EACH ACODENT S OFFICEWMEMBEREXCUAEDY Q NIA 5•5.000.000 (Ma1aensdatory M YNI EL.DISEASE•EAEMPLOYEE 5 DESCOnset user RIPTION OF OPERATIONS below Continued on Artifice]Pag! EL.DISEASE•POLICY LIMIT 5,000.000 C Eras Ale 297.1-10011-°62016 030112018 0310112019 Unit 4.000000 • DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD M.Mations:RMnarks Schedule,my be MOM R mon Spam a reeubed) 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 AUTHOREED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee ."La..Lsro .Z J'A^^Lc—Kr4cA- I C 1958-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN101642069 ORp® AC LOC#: Atlanta `O ADDITIONAL REMARKS SCHEDULE Page 2 of 3 AGENCY MARSH USA,INC. NAMED INSURED THE HOME DEPOT,INC POLICY NUMBER HOME DEPOT U.SA„INC, 2455 PACES FERRY ROAD BUILDING 0-20 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 Liabili Insurance Workers Compensation Continued Grrier.Indemnity Insurance Company of North Amens Pdicy Number WLR C64783191(ALAR FL ID.I&KS.KY,LAMS.MO.NE,MA ND,OR,SC,SOTI{WV,WY) Effective Data.03/01/2018 Expiration Date:031012019 (EMU*51.000,000 Comer New Hemp:Owe Insurance Company Pdicy Number.WC 0111225Th(OC,DE,HUN,MD MN,MT,NY,RI) Effecfive Dale:03012018 Expiration Dale 030112019 IEL)Linn:51,000.000 Cartier ACE Amerman Issuance Company Pdicy Number WCU 061783221(0S1)(AZ.CA,L,NC,OR,VA,WA) Effective Dale:03012318 Expiration Dap.03/01/2019 IEL)Unit:$1,000,000 SIR 51.000000 SIR kr the slates of AZ,CA,IL,NC,ORVA,WA Caner National Union Fire Insurance COMSAT Polity Number.XWC 4595580(OSI)(CO,CT.GA,ME,MI,NV,OH,PA,UT) Effective Dale 03012018 Expiration Dale 03/01/2019 IEL)Unil:81.000.000 51,000,000 SIR for he slates of CO,ME,NV,IAI,ORPA,UT $750,000 SIR brine stele of GA 53:9,000 SIR for!he stale of CT Samar National Urion Fire Insurance Company Pdicy Number XWC 1595581(OSII(MA) CEBecav,o Date:0000200/ M A apl�ulpl Doh:03/01/2019 Ill by (EL)Limit 51,000,000 SIR:55500.000 TX Emdq'ws XS Indem iy. Camar.Ilmios Union Insurance Company Policy Numbs TNS C4916693A(TX) • Effeclve Dale:03912018 Expiration Data.03/01/2019 (EL)Lint 510.000.000 SIR.51.000,909 CORD 101 (2008/01) ®2008 ACORD CORPORATION: All rights reserved. The ACORD name and logo are registered marks of ACORD