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Home My WebLink AboutBLD-19-003392 r Office Use Only OF.Y,9k i Sk. �. Permit)/ > '11 C 'AmoeM 1rJ-�' .H �nh x ;�'•+..no• e.d.' `Permit expires 180 days from ; issue date B( 1S-19-> -3?a-- EXPRESS BUILDING PERMIT APPLICAT ¶E C E I V E U TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28C"f�1"2U1 t South Yarmouth, MA 02664 'Bt a , s T 4 Q p ' (508)398--2231 Ext. 12612By r CONSTRUCTION ADDRESS: l N . t al h_541%eP I `J . Limy-10A ASSESSOR'S INFORMATION: Map: "70 Parcel: a OWNER nYvIe Pcotita.e e2so (rm oilb I'm ,fl.LhAlvvcrt Pilo 1 ivr NAjM^ �,�// ,�1,. ,,.�' ///��PRESENT ADDRESS 1 (� 1,�,, /tom( , Ia # qn-s)a--36 -70 3)- CONTRACTOR:3VINd Q 4k/ A DD / �'� l i� I xdrisizb ,'*", 14 c(an✓2 U`4�l NAAIMNE 1 MAILING ADDRESS TEL#Sod__ en c_17)k. sidential 0 Commercial Est.Cost of Construction$. jDUD ---' p Home Improvement Contractor Lia# ! 03/ Si Construction Supervisor Lie.# t('S -0O 4 to VS, Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I amthesole proprietor 4Aave Worker's Compensation Insurance A Insurance Company Name: n 1144 'v t ul-1,t a Worker's Comp.Policy# U(C So(350 I Li Li")P‘St kiA WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Rep acement windows:# Replacement doors: # Roofing: #of Squares ' ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic(yDiisstt. �( ))/Repl�aciinng likepforlikePool fencing *The debris will be disposed of at t f t i(Jvo V 1 t.Lii' !/il..rl t-L Location of Facility I declare under penalties of perjury a stat n '_1 .irkd tryq and const to the best of my hiowledge and belief. I understand that any false answers) will be just cause for denial or motet ,eT, tion i' M�A\er M.G.!.Ch.268,Section I. Applicant's Signature: - Date-. '1 \t{b D�/ Ownersrgnature(or ettachme Date: Approved By. ;Id nee G Date: �- �� dd' � raI(or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 3 No Flood Plain Zone: C Yes C No . Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No The Commonwealth of Massachusetts Department of Industrial Accidents 5inl_ y1 Congress Street,Suite 100 a^ Boston,MA 02114-2017 t1/47-709 www.mass.gov/dla Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organizationffndividual):SPRINKLE HOME IMPROVEMENT, INC. Address: 199 Barnstable Rd. City/State/Zip: Hyannis, MA 02601 Phone#:508 775-1778 Are you an employer?Check the appropriate box: Type of project(required): 1.0 l am a employer with 10 employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.0f am a homeowner doingall work myself. t 9. El Demolition y [No workers'wrap.insurance required.] 4. I am a homeowner and will be hiringcontractors to conduct all work on myproperty. 10❑Building addition ❑ I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions S.Q 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet 13. OOfrepairs These sub-contractors have employees and have workers'comp.insurance.: 6.0We are a corporation and its officers have exercised their right of exemption 14. Other Ro g p per MGL c. 152,§I(4),and we have no employees.[No workers'comp.insurance required] *Any applicant that checks box NI 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. :Contractors 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 fob site information. Insurance Company Name: A.I.M.Mutual Policy#or Self-ins.L� el ic..#:WCC50050167472018A Expiration Date: 1/1/2019 �/ Job Site Address: "1 f' I r IL11) Sktte City/State/Zip:3• /1J4 V-T✓), t143 dad V 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 certify u l i7, ,enaities of perjury that the information provided above is true and correct. Signature: I x,51 Date: GI'1 it k' Phone#; 508 775-1778 Official use only. Do not write in this area,to b- completed by city or town official City or Town: Permlt/LIcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/ own Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: a. • WOieWgildiCtritittla Office of Consumer Affairs and Business Regulation One Ashburton Place-Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Type: Corporation SPRINKLE HOME IMPROVEMENT INC ! : - • Registrat 103757 • .I E�iraadl: 07/08/2020 199 BARNSTABLE RD. '.�If_ 1 _ HYANNIS,MA 02601 .":t i ' ry • a —�'.. update Address and Return Card. scat O xoumn _ Oflice of Consumer Maks 6 Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for indIvIdual use onfy TYPE:Camaetian before the expiration date. R found return to: BSol91lallo., E iAndlffi Office of Consumer Affairs and Business Reguation... 103757 07/08,2020 One Ashburton Place•Suite • SPRINKLE HOME IMPROVEMENT,INC. Boston,MA • • BRAD K SPRINIQE ,`U'-,.c�x�_ M' 199 BARNSTABLE RD. HYANNIS,MA 02001V Not valid v-/I-77:Si ature Construction Supervisor • Commonwealth lProtbfional Massachusetts Unrestricted-Buidigsof any use group whichcortain ®' Division 01 Proteulatiosanc sure Issthan 35,000cubic feet(fit cubic meters)ofenclosed Board of Building Regulations and Standards space. Construction t)peNl50r CS-006643 Expires: 1010612019 . S BRAD K SPRINKLE 199 BARNSTABLE ROAD a3 HYANMS MA 02601 • Failure to possess a current edition of the Massachusetts • State Building Code Is cause for revocation of this license. V _information license _ _ _. �1 SPRIN•1 OP ID•DI A�ORO• CERTIFICATE OF LIABILITY INSURANCE °09/19/20189` 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(les)must have ADDITIONAL INSURED provisions or be endorsed. N 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 508-775-8060 Ar ACT Kelley A.Suilivan Dryden 6 Sullivan Ins Agency PHONE508-775 6060 FAX 508-790.1414 88 Falmouth Road 1,010,No,Ern, WC,Nor Hyannis,MA 02601 it" ies: Kelley A.Sullivan INSURERISI AFFORDING COVERAGE NAIL e weu!ERA;NGM Insurance Company 14788 INSURED Sprinkle Home Improvement Inc. al5URER s:Associated Employers Insurance 199 Barnstable Rd Hyannis,MA02601 INSURER C: 'INSURER D: INSURER e: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE USTED 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 - I TR TYPE OF INSURANCE _ ADOSNnR POUCYNUMBER IMPOLCWFYFYIMOILrICnY/ X I LIMITS A . COMMERCIAL GENERAL LIABILITY1,000,000 EACH OCCURRENCE $ CLAIMS-MADE a OCCUR MPT2640X 07/01/2018 07/01/2019 ptrAIBEB fEiENmuSencel * 600,000 X Business Owners 10,000 MFD EXP lAm ons omen, $ — PERSONAL S ADV INJURY $ 1,000,000 OOE�LAOORgOATE LIMIT APPLIES PER - GENERAL AGGREGATE i 2,000,000 ^l POLICY ILII last 11 LOCPRODUCTS-COMP/OPAGG E 2,000,000 OTHER f A AUTOMOBILl LIABILITY - CEOAMBIN SINGLE LIMIT acadanoE 1,000,000 '.. ApNYAUro MIT2640X 0717/2016 07/27/2019 BODILY INJURY(Per dsreonl $ _ AUTOS ONLY X SCHEDULED �R� AUTOS BODILY INJURY(Per accident) $ A AUTOS ONLY X AU70 ate (PINei tlenil E E f A X US!RELLA LUe X OCCUR EACH OCCURRENCE E 1,000,000 E%CESS urn CLAIMS-WEE CUT2640X 07/01/2018 07/01/2019 AGGREGATE $ 1,000,000 DED X RETENTION i 10000 f B WORKERS COMPENSATION PER . ETH- AND EMPLOYERS'UABILITY STATURE ER ANYPROPRIETORIPARTNERIEXECUTNEWCC50050167472018A 01/01/2018 01/01/2019 EL.EACH ACCIDENT f 500,000 QpFFFcE gM EXCLUDED? N NIA `Mylwfl - E DISEASE-EA EMPLOYEE $ 500,000 DESCRIPTIO OF OPERATIONS belay E DISEASE-POLICY LIMIT f 600,000 PROPERTY . 60,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks SoMdub,may be attached R more space Is required) Certificate Issued for insurance verification • Home Improvement Specialist CERTIFICATE HOLDER 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 I .�1.1 (n� 199 Barnstable Rd. AvmowZED REPRESENT -�`�A 1 8 . Hyannis,MA 02601 Kelley A,Sullivan Bryden&Sullivan Iris.Agency, Inc. ACORD 25(2016/03) ID 1988.2016/85R8CO14135MiI tPt rights reserved. The ACORD name and logo are registered marks of ACORD S� aji , r.1 .. 'V ^M'�?%J. u. ,,,,„,,,,,,;v:„ k'S 5 Av kr s Gfw.• t, t �5,',. Y - iu� { 7:iHv ,vd i` Any changes in the contract during the duration of the project which results in additional monies due will , be paid in full to the contractor at the time of the change.4. orize 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. -ccei. VISTLviLe. ?owner Signature Date F Contractor Signature Date 'aradise Brad Sprinkle- Registration number. 103757 Hari Street, S. Yarmouth, MA 02664 14 i t gr 333 ir f Y es 4A� -C { { t All Mp :i tip 6li ` 1,'14 3"