HomeMy WebLinkAboutBLD-19-003729 Office Use Only--- —
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EXPRESS BUILDING PERMIT APPLICfl ON E I V E 0
TOWN OF YARMOUTH
Yarmouth Building Department 1 DEC 19 2018 j
1146 Route 28 _ ,J
South Yarmouth,MA 02664 ERM l - r t' i
(508) 398-2231 Ext. 1261 By: —
CONSTRUCTION ADDRESS: Co C(Ow e_I I i<cl. •
ASSESSOR'S INFORMATION: -'
Map: Parcel:
owNER:%bat/tr( Korn cc (tn.JcII M. t.J.'ar w..4N-. MA 03.67 2, 5'60-YO7 —46 `�Z
NAME ADDRESS TEL. # Email Address:
CONTRACTOR:rke 4n'te en-F 'tog Clln2friE.eirr Diz�ess" scz1r 519?-9 L 2--6q�f7
. NAME Email Addre:
Residential Commercial Est Cost of Construction$ C.o 6, 4 S —
Rome Improvement Contractor Lie.# l 101..78 S Construction Supervisor Lia# 0960 GI 3
Workman's Compensation Insurance•. (check one)
I am the homeowner I am the sole proprietor have Worker's Compensation Insurance
Insurance Company Name: Add/1 /(hi an ArC XI Svrantp a Worker's Comp.Policy# %WC tic 9'5.5—?
WORK TO BE PERFORMED
Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares _ Replacement windows:# CI Replacement doors: # -
Roofmg: #of Squares ( )Remove existing*(max.2 layers) Insulation
Old Kings Ilighway/fiistoric Dist. ( )Replacing like for like
�
*The debris will be disposed of at LiI3ie Mar'ptce t
Location of Facility
I declare under penalties of perj n statements herein contained axe true and correct to the best of my knowledge and belief. I understand that any false answer(s) .
will be just atm far denial or of my cense and for au•..• •••,under MO.L Ch.268.Section 1.
Applicant's Signature: .41yJ;r,94 L Darn: 12 - Pi i - /I<
Owners Signature(or atac• t - See cr eh Ct Q"�'L C(•(tt d-'( — Date. �.�
Approved 8y �-Li � Date: / I�/,
Building OGgn )
• Zoning District
Historical District Yes No Flood Plain Zone: Yes No
Water Resource Protection District Within 100 ft.of Wetlands: ,
• Yes No Yes No
tr%
Home Improvement Agreement: Pagel
16,
Home Depot License#'s - For the most current listing www.Homedepot.com/LicenseNumbers
MA: 107774, 112785
Janice Campbell
Salesperson Name: Registration No. (if applicable):
Home Depot U.S.A., Inc. ("Home Depot") or Service Provider named below will furnish, install and/
or service the equipment listed below at the price, terms and conditions as outlined on this form.
KORN DAVID New England South 1-APNOOBT
ustomer Last Name Customer First Name Store #/ Branch Name Customer Lead/ PO#
50 Crowell Road West Yarmouth MA 02673
Customer Address City tate Zip
(860) 202-9692colonelk50@hotmail.com
colonelk50@hotmail.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:
908 Boston Turnpike Unit 1 Shrewsbury MA 01545
Address City tate Zip
Or Email: customercancellationnortheast@homedepot.com
Service Provider Email Address
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 PAYMENT(S) 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 DEPOT'S EXPENSE.
THE LAW REQUIRES THAT THE HOME DEPOT GIVE YOU A NOTICE EXPLAINING YOUR RIGHT
TO CANCEL. PLEASE SIGN BELOW TO CKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL
AND WRITTEN NOTICE OF Y RI HT 0 CCEL.
Acknowledged by: lA` 'JJ 11/10/2018
C tom r' Si na re 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: $ 6643.60 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 $ 1660.91 Remaining Balance $ 4982.69
The Home Depot-2455 Paces Ferry Road,N.W.Bldg.B-3,Atlanta,Georgia 30339-Customer Care:1-800-466-3337
460 HOE Customer Agreement(24 Jul.16) Y 0.1.7
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The Commonwealth of Massachusetts
Department of Industrial Accidents
1 t'.'
__ ---ls Office of Investigations
I_feta:, d 1 Congress Street,Suite 100
' '— Boston,M4 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information `� Phase Print Lesribly
ts
Name (Bapess/UganiatiowTndividual): WO file, Y�D
Address: /B e/ &O$7/ l vRNe/� �
Citv'State/Zi.: sIl/'fµ'.� 1 n't' . aiPhone 4: 7 Ili—✓ 01 7 - .2./.5-5—
i
2/.55—
Are you an employer?Check the propriate box: •
Type of project(required):
• ].V I am a employer with 4. ` I am a general cone actor and I 6. 0 New construction
/ `employees(full and/or part-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 g, 0 Demolition
work' Mg for me in any capacity. employees and have workers' ' 0
1 9. Building addition
(No workers' comp.insurance comp.insurance.:
�7 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.r I am a homeowner doing all work officers have exercised their j 11.0 Plumbing repairs or additions
right of aemption per MGL
myself No workers' comp. 12.❑Roof repairs
t c.152,§1(4),and we have no /I
insurance required] 13Z-other W,1Ydo't-;
employees. [No workers'
comp.insurance required] i t re pi rem fit/-S
'Any applicant that chs13 box at must also fill out the section below showing their workers'compensation policy mfoanatioo.
t Aomcowncs who submit this affidavit mdieatmg they are damg all work and than hire outside conn a must submit a new affidavit indicating such
:Contactors that check this box mut attached an additional sheet showing the mine ofthe rub-contactors and sate whether or not those=ties have
employta. 1the sub-comaetou have=players,they meat provide their workers'comp.policy ameba.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job she
information. CarrEsmanceCompany Name: /ts h4;N4i VNioa Fitt.
AC, y�vS
. C9
Polio#or Self-ins.Lit.#: X W Ci L/5-
/ Cge 2/ Expiration Date: 3 - / - /9
Job Site Address: 50 CI-Oc)e I I (ZS City/State/Zip:���,'iA
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
• Failure to secure coverage as required ander Section 214 of MGL c. 152 can lead to the imposition of criminal penalties of a
Erne to to$1,500.00 and/or one-y .. imprisomnent, es well as civil penalties in the form of a STOP WORK ORDER and a foie
of up to S250.00 a day a• later. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the MA ice coverage verification
at the information provided above is true and correct
IdoherebyeerIIfyun•� a: • ,:1i ,• ' ,• ,•. f
♦1 ift,F% /2 -- / g — / S
�y
Sismaeae: �/ Date:
Phone#: 57 a — 94 - 6 1 qe2- .
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): •
I.Buard of Ankh 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone*:
•
•
' lie `l.01Jt 71l %421(ye!2 c /z (,i O I Cal.)addz(Jeff
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:Expiration: 0427172/2019
2455 PACES FERRY RD C-11 HSC
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. H found return to:
=1 Registration Expiration , Office of Consumer Affairs and Business Regulation
:.. . 112765 04'22/2019 10 Park Plaza-Sutte 5170
I-fOME DEPOT USA INC Boston,MA 02:16
ANDREW SWEET2455 PACES FERRY S
94 1
ATLANTA,GA 0339RD G11 HSC L o u: i0 ithou signature
Undersecretary
•
r
DATE '
ACORD CERTIFICATE OF LIABILITY INSURANCE v2
`4-----
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 WANED,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).
CONTACT
PRODUCERMARSH USA,INC. PHONE ac Not
TWO ALLIANCE CENTER IAIC No FOh
3560 LENOX ROAD.SUITE 2400 E-MAL
ADDRESS:
ATLANTA,GA 30326
INSURER(S)AFFORDING COVERAGE MACS
CN101642069-/MReD•GAW18-19 NEURER A:ON Replatc Instance Co 24147
INSURED INSURER a:New Hampshire Ins Co 23841
THE HOME DEPOT,INC
HOME DEPOT USA,INC. INSURER C:HDmeRisk Craw Insurance Cornrow •
2455 PACES FERRY ROAD INSURER O:
BUILDING C-20 INSURER E+
ATLANTA.GA 30339
INSURER F:
COVERAGES CERTIFICATE NUMBER: AIL-304353439-16 REVISION NUMBER:3
THIS IS TO INDICATED.CNOTIFY TWIT THAT
POLICIES
REQUIREMENT,TERM OR CCE LISTED ONNDITIONLOW VE BEEN ISSUED OF ANY CONTRACTT THE OR OTHER DOCUMENT WITH FOR
TO WHICH RIOD
TH S
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.
INSRADDLSUBR POLICY EFF POLICY EXP LIMITS
LTM TYPE OF INSURANCE ,N NIY
D ANA POLICY NUMBER IMDDYYf YI
IMWEDI YY
A X COMMQMLGENERAL UA LMI MWZY 312717 031012018 031012019 EACHOCCIIRRENCE 4 9,000,000
DAMAGE TO RENTED S 1000000
1 CLAIMS-MADE 0 OCCUR PREMISES IEE occurrence:
LIMITS OF POLICY XS MED EXP(Any on person) S EXCLUDED
OF SIR:SIM PER OCC PERSONAL d.AOV,JURY S 9. '030
X AGGREGATE LIMIT APPLIES PER: -
GENERAL AGGREGATE S 9.000.000
�1 POLICY❑JEPRCT O• 0 LOC PRODUCTS-COMP/OP AGO S 9.000.000
S
OTHER: COMBINED SINGLE LIMIT S 1,000,000
A AUTOMOBILE WBILRT MWTB312718 031012018 03,12
019 (Ea amda�
X ANY AUTO BODILY INJURY per penonh 5
OvmED SCHEWLED SELF INSURED AUTO PHY DMG BODILY INJURY IPM accderel S
H
AUTOS ONLY _AUTOS PROPERTY DAMAGE
HIRED NON-OWNED
E
AUTOS ONLY AUTOS ONLY IPM modenll
S
I UMBRELLA LIAR OCCUR EACH OCCURRENCE S
EXCESS LIAR CLAIMS-MADE AGGREGATE S
S
OFD RETENTION S PER 1 OTi-�
B WORKERS COMPENSATION WC 014122577(A%,NM,W,YT) 031012018 03$12019 X STATUTE ER
AND jypq p I TOR/PART ITTEFV YIN WC 014122578(WI) 031012018 031012019 EL EADI ACODENT 4 5.000,00C
B CR9CE AErBERENZ.UDEDUECUTNE O MIA
Mandatory
EL DISEASE•EA EMPLOYEE S 5.000000
L n.d ey M NH) 5,000.000
Tame�under
OF PATIOS�w Continued on Atldadlel Paye E.L.DISEASE•POLICY LIMIT S
C OEESrcess Auto 297.1.10011-00.2018 031012018 03012019 Unit 4.000.000
DESCRIPTOR OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 1S1,Addeural Ramat, nay be arched R more spec.M repuind)
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 EXPIRATNOt4 DATE THEREOF, NOTICE WILL BE OEUVERED IN
BUILDING C-20 ACCORDANCE WITH THE POLICY PROVISIONS.
ATLANTA.GA 30339
AUTHORED REPRESENTATIVE
of Marsh USA Inc.
Manashi Mukherjee .,Ya%A4osa• ^"w"Ad.4-4-
1
®1988-2098 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
.1 .
AGENCY CUSTOMER ID: CN101642069
.---� LOC#: Atlanta
AI O pati ADDITIONAL REMARKS SCHEDULE Page 2 of 3
AGENCY
MARSH USA.INC. - NAMED INSURED
THE HOMEDEPOT,INC
POLICY NUMBER HOME DEPOT U.SA.,INC.
2955 PACES FERRY ROAD
BUILDING 620
CARRIER ATLANTA.GA 30339
NAIC CODE
EFFECTIVE DATE
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance
Women Conlpenralion Conbnuet
Carrie.lndamlity Insur noe Company or Norm Amen
Pdicy Number WLR 064783191 IALARFL.ID,IA,KS.HY,IAMS.MO,NENIA.ND,OICSC.SO.TN,WV,WY)
EBacave Deer:0313112016
•
Expiration Oahe 03/01/2019
(EL)Unit 51.000.000
Camer New Hampshire Insurance Company
Pdicy Number WC 014122576(DC.OEHLIN,MD.MN.MT,NY,R0
Effective Date:03012018
•
Expiration Celt 0301(2019
(EL)Lime:51.000.000
Choir ACE Amerman Insurance Company
Pdmy Numbr.WCU C64783221(051)(AZ.CA.L.NC.ORVAWA)
Recta Data:03012018
Expiration Dal'031012019
(EL)Um:51,000.00D
SIR 51.000,000 SIR for the Paton of AZ.CA,ILNC.OR VA,WA
Lamer.Naaor Urion Fire Imuraree Company
Pdicy Number XWC 9595580(0S8(CO.CT,GAME MLNV.OH,PA.UI)
Effecave Dan 031012018
Expiration Daly:03012019
(EL)Lint 51.000.000
51.000,000 SIR for Ne mates of CO,MENIIMI,OH,PA UT
5750.000 SIR krteall ofGA
S3:A,000 SIR kr the sal of CT
{..
amer Named Union Fin InsuranceConpany
atel Number XWC 9595581(051)(MA)
ffective Dau:031012018 ,a ,y
1pinlionDal:030@019 nllY/,({I6YL)Limt 51.000,000 '�'lR:5500.000
TX Emldeyee XS Indemnity
Canie.Oodot Union ksulnce Compnry
Policy Number.INS C9916693A I1X)
Effective Data:03/01/2018
ExpumOan Dale:03)012019
(EL)Unit 510.000.000
51R S1.000.600
ACORD 101 (2008/01)
08 2008
The ACORD name and logo are registered marks of ACORDCORD CORPORATION: All rights reserved.