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Home My WebLink AboutBLD-19-003490 Y _ t v e Use Only ��//� /1 ARO ice. EC 6 V Es 13 crmW // ' " �0 e '\ $ GEC 10 2018 Amount tt • .l ^`Permit expires 180 days from i,.' DSPAR gr$ vV issue date u EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (xT U In (508))398-22/311 Ext. 12661) /� CONSTRUCTION ADDRESS: V q 1 ^ii• a 0 i Vi I ✓ f- l A / J'' 1/M r 2"Il q(�J ASSESSOR'S INFORMATION: '' Map: yl �� Parcel: /y OWNER: f/R/A j i unen 8-/N JJ.k ')/ S yoamaik mo 0U6'/ �,, "__ PRESENT ADDRESS /� TEL #,St4,E3-343S- CONTRACTOR:r kb kit thilin ) i piano" I / Aoi 11zv t' ad f)JyC/7)al MIA t L6o6/ E vY MAILING ADDRESS TEL# f°k =7'7._(—M k— CQesidential ❑Commercial Est.Cost of Construction s 5 �,c1..) — Home Improvement Contractor Lie.N /D3-7 S') Construction Supervisor Lie.# ` S - 0 d 6 6 93 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor ❑Aave Worker's Compensation Insurance Insurance Company Name: AM Mu- PtAvt?• Worker's Comp.Policy# 1a)(eS0DSO(47t/72o/44 WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:IS q Replacement doors: # / .31&/Lt Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/HistoricnDiisst'. (,n),Replacing like 'for/like Pool fencing *The debris will be disposed of at yy/I LVti()um, WnG fCl i Location of Facility I declare under penalties of perjury that the 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 for denial or revocation of my license and for prosecution under M.G.L Ch.268,Section I. Applicant's S'.• attire: • ..tee.es.. -:rJ•g i bl4r.s.0 Date: "ire; ahli f- Ownero Si nature(or _��,��_-/_�� Date: Pp �:L�� II�� , /2 ^/P if Approved B B . -erii Date: Building i tci jj, 8l9ree) EMAIL ADDRESS: Zoning District: • Historical District: ❑ Ycs ❑ No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No :Ya K f^Issi • q}fy , �rM YFiY1„,„4474.,,k4 ' y �s2� "ey M MrtP' Ns• 'Fa A u v " .7%,..rtTnric CONTRACT PRICE *A7•71 *c cr dzbor openinas P-•'n'n!c}Q5.. ng doers and windows often reveals weathering, as well as areas that may cr ry not be previously stained or painted. As noted, Contractor will not be responsible for pthnting or staining these areas. i a Adjustments or Reattachments 11' Contractor will not assume responsibility for removal, re-attachments, or re-positioning of i` 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 maybe his main office or branch thereof, provided that the Owner notifies the Conti actor 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 I/we 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. _ r ram ner Signature Date Contractor Signa Ire Date LisaLisa a iv Ian Brad Sprinkle- Registra f n# 103757 844 R 8,Unit 7A, S.Yarmouth,MA 02664 t F 1 3 � ,z SPRIN-1 OP ID.DS ALCOR/Cr m itAwootyyry) CERTIFICATE OF LIABILITY INSURANCE °�099H/19/2001818 91 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. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies mayrequire an endorsement A statement on this certificate does not confer rights to the certMcate holder In lieu of suchp e�Tn�dorsement(s). p - - PRODUCER 508.775-6060 a' CT Kelley A.Sullivan Dryden&Sullivan Ins Agency PHONE508-775-6060 FAX 508-790-1414 88 Falmouth Road INC,No,EAB: WC,NO Hyannis,MA 02601 Mks. - Kelley A.Suilivan INSURERS/AFFORDING COVERAGE NAIC mem ERAINGMInsurance Company 14788 INSURED Sprinkle Home Improvement Rd 9arovementlnc. INSURERS:Associated Employers Insurance1 -- Hyannis,MA02601 INSURER C: INSURER D: INSURER E - INSURERF: COVERAGES CERTIFICATENIIMRFR• REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES 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.- -: INTBRR TYPE OF INSURANCE ADOL 8UBR POLICY EFF POLICY EXP I INRR RIND POLICY NUMBER IMMIMIIYYYYI IMMIDDIYYYYI um," A COMMERCIAL GENERAL LIABILITY 1000,000 EACH OCCURRENCE - $ , CLAIMS-MADE El OCCUR MPT2640X 07/01/2018 07/01/2019 FR ISFdIe:E enee: S 600,000 X Business Owners10,000 MED EXP(Any ono Berson) $ PERBOP. 4 ADV INJUP.Y - 4 1,000,000 SNL AGGREGATE LIMITAP S PER. GENERAL AGGREGATE $ 2,000,000 X POLICYL °r& Li LOC PRODUCTS-COMP/OP AGG 3 2,000,000 OTHER. r 5 A AUTOMOBILELLABMY COMBINED SINGLE LIMIT(Ea Arratentl $ 1,000,000 AONYAUra M1T2640X 07/27/2018 07/27/2019 BODILY INJURY(Per xenon) _ AUTOS�EpNLY X A��U�Nr/O�SSW�U�I�NI./E�Epp BODILY INJURY(PPeraxAdenf S A AUTOS ONLY X AIJTOSOa (PBOraE eM) GE A X UMBRELLA LPB X OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS UAB CLAIMS-MADE CUT264OX 07/01/2018 07/01/2019 AGGREGATE $ - .1,000,000 DEO I X RETENTIONS 10000 B AND WORKERSCOMPENSATIONEMPLOYERS" PER DTH- AND EMPLOYERS LIABILITY Y/N ' STATUTE ER ANY PROPRIETOR/PARTNERIEXECUTIVE � � WCC50050167472018A 01/01/2018 01/01/2019 500,000 44FFFICERM Me��qq ExcLUOEm L'J NIA ELEACH ACCIDENT $ ,alyyaqndatory In NNI E L DISEASE-EA EMPLOYEE $ 500,000 DESCRIPTION Odescribe E OPERATIONS below E.L DISEASE-POLICY LIMB $ 600,000 PROPERTY 60,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be ached lemon space Is required) Certificate Issued for Insurance verification Home Improvement Specialist CERTIFICATE HOLDER - CANCFI I ATION 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 \ �S 199 Barnstable Rd. cAta Hyannis, MA 02601 AUTHORIZED REPRESENTLit r e r 0 Kelley A.Suilivan I ' Btyden &:Sutllllivan Ins. Agency, Inc ACORD 25(2016/09) CD 1988.2015 k�1tBi.Od13rib rail rights reserved. The ACORD name and logo are registered marks of ACORD c2ie $( a/ %zoaa ecae Office of Consumer Affairs and Business Regulation One Ashburton Place- Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Le-) Registration: 1a°porra8«I 57 SPRINKLE HOME IMPROVEMENT INC `i : , ,'� Expiration: 07/08@020 199 BARNSTABLE RD. �,_ - HYANNIS,MA 02601 • { i ' - irS ry r ,r Update Address and Return Card. aLA1 O 2M40S/I7 C?2, ro itonweak.4./(t'assoeAaaits Orlin of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Caooratian before the expiration date. B found return to: EttElfailf910 Eagu_tl_a Office of Consumer Affairs and Business Regulation 103757 :!, 07/08/2020 '. One Ashburton Place•Suite SPRINKLE HOME IMPROVEMENT,INC. Boston,MA • • P � L 4r BRAD K.SPRINKLE .2`YC�--- 199 BARNSTABLE RD HYANNIS.MA 02601 UrbefBBCfehdfy Not va I: attire Construction Supervisor Commonwealth of Massachusetts Unrestricted.Buldtngs of any use group which contain ®; Division of Professional licensure less than 30,000cubic fed($31cubic meters)ofenclosed Board or Building Regulations and Standards fie, Construction'Sept rvisor CS-006640 Expires: 10/08/2019 BRAD K SPRINKLE ' .191 BARNSTABLE ROAD HYANNIS MA 02601 Failure to possess a cturent edition of the Massachusetts State Building cods is cause for revocation of this license. A Foe Infomntlon about this license (' f- Call(617)7274200 or visit www.mess.govidp1 Commissioner -- • The Commonwealth of Massachusetts `Eta,_!/ Department of Industrial Accidents raise= i; 1 Congress Street,Suite 100 - _'� =z` Boston,MA 02114-2017 —, www mass.gov/dla Workers'Compensation Insurance Affidavit:Builders/Contractors/Electr]clans/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual):SPRINKLE HOME IMPROVEMENT, INC. Address: 199 Bamstable Rd. City/State/Zip: Hyannis, MA 02601 Phone#:508 775-1778 Are you an employer?Check the appropriate box: Type of project(required): 1.17 lam a employer with 10 'employees(fon and/or pert-tine).• 7. 0 New construction 2.01 am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required] 8. Remodeling 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required. t 9. ❑Demolition 4.0l am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition ensure that all 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 • 50 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.0 We are a corporation and its officers have exercised their right of exemption per MOL a 14.❑Other 152,41(4),and we have no employees.[No workers'comp.insurance required] 'Any applicant that checks box#I 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 subcontractors have employees,they must provide their workers'comp.policy number. I am art employer that is providing workers'compensation insurance for my employees Below Is the policy and job site Information. Insurance Company Name: A.I.M.Mutual • Policy#or Self-ins.L ie.#:WCC150055016747201178A�] Expiration Date'. 1/1/2019 Job Site Address: t q 2r, (C)1 '' //r City/State/Zip:3.. /)P )l�r}4/ �Vn° Cu1O10 Attach a copy of the workers'compensation policy declaration page(showing the policy numberand 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. 11111PI do hereby cert! "'sal •: d penalties of perjury that the information provided above Is true and correct Signature: dialpte', Date: 114 Phone#: 508 775-1778 • 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#: