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HomeMy WebLinkAboutBLD-19-002775 Office Use Only j '_ - 0 (Femur# r_. O— Our -y 'Lint ` MINT/. t1 A A t.,-.,,.•r :`Permit expires 180 days from n. issue;date B U -1°1- -1E- • EXPRESS BUILDING PERMIT APPLIC £ E UEIV . TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 OCT 31 2016 South Yarmouth,MA 02664 Burt' T (1508) 398-2231 Ext. 1261 Br S.., s� CONSTRUCTION ADDRESS: 51 WC", b ltdorl -> ASSESSOR'S INFORMATION: ' • •• Map: Parcel: OWNER'`d ell 5: a):,H N6,i'nv, r. :Ail%r,-t actin 111 41 Oda*7 S 4,40-d a 9-,5 68 3 NAME PRESENT ADDRESS TEL # Email Address: croNTRAcroRI e 4'ne t'', eo4 log Slt sborr t-PA �y<— s`fg'-962--69,49 , NAME MAILING ADDRESS 'EL# Email Addres CRCommercial r Est.Cost of Construction$ ?j Rot Home Improvement Contractor Lin# HA..i S Construction Supervisor Lie.# 0 7 DO 77 Workman's Compensation Insurance. (check one) � � I am the homeowner I am the sole proprietor Y'havv//e Worker's Compensation Insurance p Insurance Company Name: Aar; /I111;0 4 hre .Th Sy r"ailce V) Worker's Comp.Policy# XWC l/S 1 cc 1 I ' WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# .c Replacement doors: # Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Sings Highway/Historic Dist. ( )Replacing like for like •'Ihe debris will be disposed of at AAS P /fact cut(/t t Location of Facility . I declare under penalties of perk',• ' statements herein contained are true and correct to the best of my knowledge end belief. Iundersrand that any false answer(s) will be just cause for denial or • of my 'cense and for v, -• ••n under M.G.L at.268.Section I. -griApplicant's Signature: ist-ILS/ DDam: /0- 3/- i k Owners Signature(or alta SIEME �Apr� tx�Tlzt C�IL — Date c Approved By. h/ Date /D- 3 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 N4 Yes No Home Improvement Agreement: Pagel Home Depot License Number(s): Visit www.homedepot.com/c/SV_HS_Contractor_License_Numbers for latest license info MA: 107774, 112785 Salesperson Name: Robert Delisle 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. Powell Richard New England South 1-6KSIO3T Customer Last Name Customer First Name Store #/ Branch Name Lead/Customer Order# 51 Wimbledon Dr West Yarmouth MA 02673 Customer Address City State Zip (440) 227-5683 bprp73@icloud.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 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-R}GHT T CA EL. Acknowledged by: 09/21/2018 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: 3808.00 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 952.00 Remaining Contract Balance 2856.00 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 !w.4;e $, y < �2o«« 2. w . : #\ : : $ : ��\ ! "d 2 ��, . f § ° • fag \ ,$ ; 2 : , .{ � � ���� ; I2 _ r . t>« c!lo. • 1 a " ( _ { {f } } \ ;iU\ f « } • . tilt . ° �� 3 \ 4 /kms: » . dye \ �\.f%« � \ ?2«r The Commonwealth of Massachusetts Department of Industrial Accidents 'V=T, ' ffg Office of Investigations "teit— 11 1 Congress Street,Suite 100 1 1 Boston,M4 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information J Please Print Letibly Name (Btsigessrotganimtiotvindividual): ...Wont- `7�of /' - Address: /e f/ BB sioxi / ;RNpfit- City I City'State/Zip: SApCwrkt Atilt • oirys Phone#: 77`/- 02 75- - a/SS ' An you an employer?Check the fropropriate box: Type of project(required): I.!ly I am a employer with ,$ 4. I am a general conractor and I . 6. ❑New construction / `employees(full and/or pmt-time).' have hired the sub-contractors 2.0 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 8. 0 Demolition for me in any capacity. employees and have workers' I o �Y• 9. ❑Building addition o workers' co insurance comp.insurance 3.[ I am a ho Ne am a homeowner doing all work offices have exercised their 5. We are a corporation and its 10.0 Electrical repairs or additions • I ❑ ! 11.0Plumbing repair or additions I I myself. [No workers' comp. right of exemption per MGL ! 12.0 Roof repcfrs c.152,§1(4),and we have no A � insurance required.] ]3. Other Mill�9+s/ employees. [No workers' comp.insurance required] ! reela+.9"`�4 •Ary applicant tial checks box el must also fill out the section below showing their workers'compensation policy mronnation. t Homeowncs who submit This affidavit indicating they are doing all work and tom hire outside contracto s must submit a new affidavit indicating sock :Contractors that check this box mum attached an additional sheet showing the name cite sub-contacmts and stars whether or not those entities have employees. S the sub-con ractom have employees,they must provide their warren'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information L-stt�ceCompany Name: A r/tr A/474 ;pa/ VJ66,,,,;"/ Fitt �A/S . eB. Policy#or Self-ins.Lin.#: X W c..... qS p c 8 II Expiration Date: 3 - / - i 9 Job Site Address: S[ W i. , lecr♦On c �f. City/Satetip:W/rme..4L.1 i-iA 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 e fine up to 51,500.00 and/or one-ye.. imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to M50.00 a day a•.• 41.latm. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DL t ce coverage verification I do hereby certify un•, e; •i; , • i- . •- %•- at the information provided above is true and correct silt 04',1 Date: /0 - 3/—/g phone#: VI - / 1 - 6 / %01- • Official use only. Do not write in this area,to be completed by city or town official • City or Town: Permit/Llcense# 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#: • • r,: i.,. rt onzNeeyrea '/i 0/ _• GaJJcic oel'J 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 Expirat on: 04/22/2013 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 8 Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE Supplement Card before the expiration date. M found return to: flenistratlon Expiration, Office of Consumer Affairs and Business Regulation a 112765 04/22/2019 10 Park Plaza-Suite 5170 HOME DEPOT USA INC Boston,MA 02116 ANDREW SWEET - L c t'+�-- 2455 PACES FERRY RD C-11 HSC L G41 ATLANTA GA 30339 Undersecretary ;11 ithou signature ACORD CERTIFICATE OF LIABILITY INSURANCE DATE RAI ems ) L 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. M 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 (AtCPHNFie Fin, I INC Not 3560 LENOX ROAD.SUITE 2400 E-MAILSs ATLANTA.GA 30326 INSURER(S)AFFORDING COVERAGE RAC• 0N101642069-HmMD.GAW-1619 INSURER A:OIG RepCAt Insurance Co 24147 INSUREDINSURER B:New Hampshire Ins Co 23841 THE HOME DEPOT,INC. HOME DEPOT US.A.,INC. INSURER C:HaneRisk Cwtie Insurance Careen/ 2455 PACES FERRY ROAD INSURER D: BUILDING C-20 ATLANTA.GA 30339 INSURER E, INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-0435343616 REVISION NUMBER:3 THIS 15 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 SUER POLICY EFF POLICY UP UNITS MSD MVO POLICY NUMBER Jtemmor YYYI (MMTOIYYYYI A X COMMERCIAL GENERAL LIABILITY MWZY 312717 03/0112018 031012079 EACH OCCURRENCES 9.000_1%10 DAMAGE TO RENTED 1000000 CLAIMS-MADE OCCUR PREMISES IEA occurrence! 5 LIMITS OF POLICY%5MED EXP(Any ore person) ,S EXCLUDED ■ OF SIR.SIM PER OCC PERSONAL&ADV INJURY 5 9000.000 GEM.AGGREGATE Lam APPLIES PER: . GENERAL AGGREGATE S 9000.300 © POLICY O PRO- ❑LOC PRODUCTS-COMPIOP AGG S 9.000.0[0 • JECT a OTHER: SINGLE LIMIT A AUTOMOBILE umuuTT MWTB312718 031012019 03/01/2019 IEA LOMBIN(:D codenINNEDI $ 1.000.040 a© ANY AUTO BODILY INJURY pot person) 5 OWNED SCHEDULED SELF INSURED AUTO PITY DAG BODILY INJURY(her acegetd) 5 1 AUTOS ONLY _AUTOS HIRED NON-OWNED PROPERTY DAMAGE 5 AUTOS ONLY _AUTOS ONLY (Per aco•entl 5 ill UMBRELLA DAB _ OCCUR EACH OCCURRENCE S EXCESS LW CLAIMS-MADE AGGREGATE S DED RETENTIONS 5 B WORKERS COMPENSATION WC 014172577 (AN,NH,NJ,VT) 1/5712018 031012019 X PER STATUTE ER AND EMPLOYERSUASR.m WC 014122578 WI 031012018 03772019 R B ANYPROPRIETORNARTNERIIXECUTME YIN I ) E.L.EACH ACCIDENT 5 9000809 OFFICERIMEMBEREXCLUDEDY NIA (Med aalery le NH) LI-DISEASE•EA EMPLOYEE S 5.000.000 SDESCyrs RIPTaibe O nunF OPERATIONS below dnn er Caed on ADmilnal Page EL DISEASE•POLICY LIMIT 5 5.000.000 ION O C Excess Auto 297-1-10011-00-2018 03712018 03/012019 Unit 4.000.000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (AGGRO 101,Additional Remarks Schedule,may be attached II mon span a required) 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 020 ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA.GA 30339 • AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee . ,a%A.`2 �^"4t"A44- I C1956-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The AC ORD name and logo are registered marks of ACORD s AGENCY CUSTOMER ID: CN101642069 LOC it: Atlanta ACORO® ADDITIONAL REMARKS SCHEDULE Page 2 of 3 Aoe`�yer MARSH USA,INC. • NAMED INSURED THE HOME DEPOT,INC POLICY NUMBER HOME DEPOT U.SA.,INC. 2455 PACES FERRY ROAD BUILDING G20 CARRIER ATLANTA.GA 30319 • NAIL CODE ADDITIONAL REMARKS EFFECTIVE DATE THIS ADDITIONAL REMARKS FORM ISA SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liabili Insurance WoAnrs Compensation Continued Carrier.Indemnity Insurance Company or North Ammo* Pdicy Number WLR C64783191(ALAR,FL,ID,IA,KS.KY,L&MS.MO,NENM,ND,OK,SC.5D.1N,WV,WY) EBecave Dalt 03/012018 Expiration Dale:0301/2019 IEL)Lint 51,000,000 Cerner Now Hampslre Insurance Company Pdicy Number WC 014122576 (DC.DEHLIN,MD,MN.MT,NY,RI) Effective Date:03012018 • Expiration Dale 0301/2019 (El)Lint.51.00E00D ' • • Cartier ACE Amman Insurance Company Pdcy Number WCU C64783221(051)(AZ C&LLNC.ORVA.WA) Efleceve Dale:03/012019 • Expiration Dal:031012019 (ELI Lind:S1,000,00D SIR 51,000000 SIR for the stales of AZ,CA.,ILNC,OR,VA,WA Carrier.Naaora Edon Fee Imurarce Company Policy Number XWC 4595580(OSO(CO,CT,GA,ME,MI.NV,OH,PA.UI) Effective Dale 03012018 Expuahoo Dale.03012019 (EL)Una:$1,000,000 51,000,000SIR la the states reCO,MENV,MI,OH,PA,UT S750,000 SIR Ir Mexate of GA 5350.000 SIR Ice the stale ofCT Caner:Nabona Union Ftre Insurance Company Pdicy Number XWC 459558110511(MA) EffectiveiDatto/0 (/201 ,y 2018 Expasfion Dal:01012019 M (EL)Lint S1,1300,000 SIR:5500.000 TX Emdoyers 145 Indent CanierEmios Union Insurance Company Policy Number.INS C4916693A(TX) Mane Dale:011012018 &piston Data.03/01/2019 (ELI Lint 510.000000 SIR.$1.000,300 CORD 101 (2008/01) C 2008 The ACORD name and logo are registered marks of ACOROCORD CORPORATION: All rights reserved.