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HomeMy WebLinkAboutBLD-19-003084 i Office Use Only ti q 0I Y9R 3} a # — d t aVg 'nt6015 u\R :n ....,„,, ,, Permit expires 180 days from if. issubdate gu)—I9-CD3ba-4 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH • Yarmouth Building Department RECEIVED 1146 Route 28 South Yarmouth,MA 02664 NOV 14 2018 (508) 398-2231 Ext. 1261 _ HU CONSTRUCTION ADDRESS: 15 Sart o Se--F (Z dl' dr `�' ASSESSOR'S INFORMATION: . Map: Parcel: / OWNER:6Iarnt I-Lnc[ar-r f7 .S,MnseI it0n • erk . Sr�J. r M & d 1464 94f-22.7- 79tie/ NAME PRESENT ADDRESS TEL. # Email Address: CONTRACTOR: Re 44'tetM, r4 908 Shrmwsbury NA orCUf Std'-962--bgyl NAME MAILING AISDRESS TEL# Email Address •esidenti.► Commercial Est.Cost of Construction$ (f514 Li � Home Improvement Contractor Lie.# 11.278 S Construction Supervisor Lim# 1)7 00 77 Workman's Compensation Insurance: (check one) I am the homeowner I amthe sole rr proprietor tk(rave Worker's Compensation Insurance Insurance Company Name: A� o/Ia /1//1;011 A ;rl Svra/icp ex Worker's Comp.Policy# % 'C ti 9 Ss 8 ' WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Z' ' Replacement doors: # - Roofing: #of Squares ( )Remove existing*(max.2 layers) Insullation Old Kings Highway/Historic Dist. ( )Replacing like for like *The debris will be disposed of at ct/t SIP Men ce i<itt I declare under penalties of.-•• it statements herein contained areLocatitrueon andofFacorrecilityct to the best of my knowledge rind belief. Iunderstand that any false answer(s)4wul be just cause for denial or of my, 'cense and for.,...:. 'in under M.G.L Ch.268,Section I. .1 /_ Applicant's Signature: Ii%.1/Y/•?� Date•. //- 1— /k Owners Signature(or at VP" See et-►• cACdr COT(- c. s ate Approved By �...�� Il!/' Date: rli/ 5"e--ti L' 7'Ming Official(or designee) Zoning District: Historical District Yes No Flood Plain Zone: Yes No Water Resource Protection District Within 100 R of Wetlands: Yes No Yes No • s° Home Improvement Agreement: Page 1 Home Depot License Number(s): Visit vwnv.homedepot.com/c/SV_HS_Contractorikense_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. Hondorf Elaine New England South I�-61CPIZZ Customer Last Name Customer First Name Store #/Branch Name Lead/Customer Order# 15 Samoset Road South Yarmouth MA 02664 Customer Address City State Zip (978) 227-7940 kelly.william14@yahoo.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. 8-3, ATLANTA, GEORGIA 30339 or EMAIL The Home Depot Cal 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 YOUIG T TO tCANCEL. Acknowledged by: l./,--0lJL . 09/06/2018 i Customer' Signature Date Contract Price and Payment Schedule : Payment of the Contract Pri is due upon signing unless a different payment schedule is required by law, specified below or in a payment addendum. Contract Price: 1344.00 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 336.00 Remaining Contract Balance 1008.00 The Home Depot-2455 Paces Ferry Road,N.W.Bldg.B-3,Atlanta,Georgia 30339-Customer Care:1-800-466-333T Customer Agreement(CAI)(31 Jan.18) v s0.1.2 • tr ii,ri us.rt.Department at Pubiid Safety- 'IttPc,,,,:risafint,oruutldinq Regulations and Stantlani. Nr "�Kiesnlnf CS.070077 x : F C on.t troop.Supervisor - ok, 9 (�/�`a�eaYH yrty�t 6 y R F t_ .. %� 5 g ry a +^tai's 01A'�'.r" .,t i •xYF t i- r:4,.: CCMNti loner : iTJ3QItU1$ �[ y � • • _ ( CI /none-e1C'c(crF � C-ad.)a cotf)CP Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 ton, Massachusetts 02116 Home Impror : ent Contractor Registration Type: Supplement Card HOME DEPOT USA INC Registration: 112785 2455 PACES FERRY RD C-11 HSC Expirat on: 04/22(2019 ATLANTA,GA 30339 • • Update Address_and return card. Mark reason Tor change. 0 Address 0 Renewal 0 Employment 0 Lost Card Office of Consumer Affairs 8 Business Regulation `z =- HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Supplement Card before the expiration date. If found return to: .zF_ jienistration Expiration, Office of Consumer Affairs and Business Regulation 112785 04/22/2019 1D Park Plaza-Suite 5170 HOME DEPOT USA INC Boston,MA 02116 ANDREW SWEET2455 PACES �ri7, ATLANTA,GA 3FERRYRD C-11 HSC L it ou signature Undersecretary I�� 1 The Commonwealth of Massachusetts T Department of Industrial Accidents 'it— '__' Office of Investigations 7.—"d1= 1 Congress Street,Suite 100 -a— Boston,M4 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / `}� Please Print Letibty Name altsinesessiOtgardzarionandiv/dual)-: ..(.70 M.- /,,f/•t t. - Address: /0 f/ BB STAN / v4Np/itQ l City'State/Zip: SAI skt M� • airy" Phone#: 7 7�/ 27 s - a ass Are you an employer?Check the propriate box: Type of project(required): 1.yi I am a employer with Ze -r 4. L. I am a general contactor and I : 6. ❑New construction / `employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet • 7. 0 Remodeling ship and have no employees These sub-enactors have I S. 0 Demolition �Y• em working for me in any cape oioyees and have workers' I e, � 9. 0 Building addition [No workers' comp. insurance comp.insurance.: ❑ 5. We are a corporation and its 10.0 Electrical repairs or additions , • , required.] 3.0 lam a homeowner doing all work omeers have exercised their j 11.0 Plumbing repots or additions i myself. [No workers' comp. right of exemption per MGL I 12.0 Roof tepzas insurance required]' c.152,§1(4),and we have no AA . . employees. [No workers' i• 13. �Other to 1enC A+.I • . comp.insurance required] t r¢Pia rein a-1..-15 • ny applicant Thar checks box e1 must also 511 out the section below showing their workers'compensation policy information. t Hommwmes who submit this affidavit indicating they are doing all wort and then hire outside contractors must submit a new affidavit indiearmg sock :Contractors that check this box mus attached an additional sheet showing the name of tie sub-comtactots and stars whether or not those entities have tployees. t the sub-conmsetots have employees,they must provide their workers'comp.policy=ober. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job she information A J / _ // �/J ]nsttraace Company Name: r/Lr Q bNcUC l/Nt vi✓ /'//'L �.tfS . ea. _ Policy#or Self-ms.Lit.it: X WC- VS 1 (- o / Expiration Date: 3 - / - 7? Job Site Address: 15 .Sa'n0 SC4 RC City/State/Zip: SSiren ou-R-•tft1A 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 MOL c. 152 can lead to the imposition of criminal penalties of a fine 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 fax of up to 5250.00 a day a•.' later. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA ' ' l ce coverage verification. Ido hereby cerun. e i ., i; •4,• i. , ,a••- at the information provided acne is true and correct en /lrPA Date: /1- 7-/ k Piton#': 571 g- ! , • - 6 I yon 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*: • DATE o 08D 'T AO CERTIFICATE OF LIABILITY INSURANCE vm1 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 tights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT MARSH USA.INC PHONE FAX TWO ALLIANCE CENTER AIC Ne Fatt INC Nal- 3550 LENOX ROAD.SUITE 2400 E-MAIL ATLANTA.GA 31126 ADDRESS: INSURERS)AFFORDING COVERAGE NAC* CN10164206941aneD-GAW-18.19 INSURER A:Old RepD1c Isuarce Co 24147 INSURED 6:New Hampshire Ins Co 23841 THE HOME DEPOT,INC. HOME DEPOT U.S.A.INC. INSURER C:HerneRisk CmMe Insurance Company 2455 PACES FERRY ROAD INSURER D: BUILDING 0-20 ATLANTA.GA 30339 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER ATL-00435343316 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. OCCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADEL SUER —POLICY Err POLICY EXP LIMITS LTR ' TYPE OF INSURANCE 015D PND POLICY NUMBER (MWODIYYYY) (MWDDIYYYYI A x COMMERCNLL GENERALWBILm MWZY 312717 03/012018 03/0112019 EACH OCCURRENCE 5 9.000000 DAMAGE TO RENTED CLAIMS-MADE E OCCUR PREMISES Ea occur2Mel 5 1.OD000D LIMITS OF POLICY XS MED EXP(Any ant person) s EXCLUDED ■ OF SIR.SIM PER OCC PERSONAL a ADV INJURY s 9,000,000 GENL AGGREGATE LMR APPLIES PER: GENERAL AGGREGATE S 9.000300 © POLICY 0 zee D LOC PRODUCTS•COMmOP AGG S 9.000.080 s OTHER: ESINGLE LIMIT A AUI16aRY AUTOMOBILE UUW78312718 031012018 03/01/2019COMBIND COMBINes 1.000000 © ANY AUTO BODILY INJURY(Par person) S OWNED SCHEDULED SELF INSURED AUTO PRY D1AG BODILY INJURY(Per cnet 15 AUTOS ONLY _AUTOS ■ HIRED NON-OWNED PROPERTY DAMAGE S AUTOS ONLY _AUTOS ONLY (Per ecoden0 5 1111 UMBRELLA LIAR OCCUR EACH OCCURRENCE s EXCESS WAS CLAMS-MADE •AGGREGATE S DED_ RETENTION S5 5 , B WORKERS COMPENSATION WC 014122577(AK,NH, T) -1YD1 1 03/012075 X I STATUTE I 77 ER AND EMPLOYERS LIABILITY YIN WC 014122578(WI) 0310172018 03/01/2019 5.000,000 B ANYPROPRIETORJPARTNERIEXECUTNE E.L.EACH ACCIDENT S OFFICERMEMBEREXCLUDEDI I� NIA 5000.000 (Mandatary MNN) EL.DISEASE•EA EMPLOYEE s DESCRIPTION war OF OPERATIONS below Continued on AOdtiS 5000.003onel Page EL DISEASE•POLICY LIMIT 5000.003 C Excess Aum 297-1-10011-00.2018 03101/201/ 031012019 Lint 4000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101.AOauo,al RIMS SCMd W,may be*bathed If mon space a nauNad) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION HOME DEPOT USA,INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANOE%I En BEFORE 2455 PACES FERRY ROAD THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN BUILDING 0-20 ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA.GA 33339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukheiee -MdL+aao'•;. �"+o"A4`aL I ®1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 pal 6/03) The ACORD name and loge are registered marks of ACORD • 1 AGENCY CUSTOMER ID: CN101642069 LOC S: Atlanta ACORp° `O ADDITIONAL REMARKS SCHEDULE Page 2 • of 3 AGENCY MARSH USA,inc. NAMED INSURED THE HOME DEPOT,INC POLICY NUMBER HOME DEPOT U.S.A.,INC. 2455 PACES FERRY ROAD CARRIER BUILDING 020 Na¢CODE ATLANTA.GA 30339 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 • Carrier Indemnity Insurance Company or North Amens a\ Policy Number WLR 064783191)AL,ARFL,I0,N,KSAY,LA.M5.M0,14EMA,ND,OILSCSD TNWV,Wy) Enactive Date:03/01/2018 a Expiration Dale:0341/2119 FL)Unit 51,000,000 Carrier New Hampshire InsuranceComparry • Pdicy Number WC014122576(DC.DEM,IN)O,MNMT,NY,RI) Effective Dale:03/0112018 1 Expiration Dee 0341/2019 IEL)lima 51.000000 Cartier ACE American Inaurance Company Policy Number WCU 064783221(051)(AZ CA.R,C,ORVA,WA) Effective Date:0341)2018 Expiration Dal:03/01/2019 (EL)Unit:$1,000,000 SIR 51.000.000 SIR for the slates of AZ.CA IL NC OR,VA,WA • Carrier National Union Fire bmurax.Company Pdicy Number XWC 4595580mi)ICO.Ct,GA,MEMI,NY,OH,PA.UT) .. Effeclive Date 031012018 Expiration Dale:03/01/2019 (EL)Limit:$1030000 51.000.00051R Mille stales ofCOME,NV,MI OH,PA.UT 5750000 SIR for the stale of GA 5352000SIR kr the stale ofCT Gamer Nabora Union Fire Insurance Company Pdicy Number XWC 4595581 IOM)IMA) ENecWe 03/01/2018 ,y EL)1/ron Dale:031012019 n�Y/,(Jlly (EL)Urml:51,000,000 J�'L SIR:5500,000 TX Employes XS Indemnily. Canierlfraos Union Mumma Company Policy Number INS C4916693A(TX) Enecbve Dalt:031012018 Expiration Data.03/012019 (EL)Lint-$10.000.000 SIR.51,00D,COD CORD 101 (2008/01) e 2008 The ACORD name and logo are registered marks of ACORDACORD ACORDCORO CDRPORATION: All rights reserved.