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Home My WebLink AboutBLD-19-003730 • "Office Use Only g•YAC • 4 gyp; ;Pemdttl r l� Oi •_ •' -y� ii?Amount ..5 V nwi iw n o h t \.t,,,tu„/,d +Pemut expires 180 days from ...- i issti;date %`issrie;date . f3U)-fG—Ob373o EXPRESS BUILDING PERMIT APPLIG TIO 1 E I Z«t irj TOWN OF YARMOUTH Yarmouth Building Department DEC 19 2018 1146 Route 28 ' South Yarmouth,MA 02664 ciu( E' _--ra DU(;T (508) 398-2231 Ext. 1261 nY "�, ___ CONSTRUCTION ADDRESS: So 3 Ro ie 2.8 Un:f 5 ASSESSOR'S INFORMATION: ' •' Map: Parcel: owNER:?'trla 1'1al'er 6032te22d-5 n/. n-+•..66. rtA 02-6713 ?&0- Cot-LAI la" NAME PRES //ADDRESS / TEL # Email Address: CONTRACTOR:Te 443,,PleThn-F 908 clire, sbury HA ornir 5-19?-962.-661447 NAME MAILING Al5DRESS TEL# Email Addres! Residential Commercial t Est.Cost of Construction$ Zir5S O Home Improvement Contractor Lia# //Alt S Construction Supervisor Lieif 0700 7 7 Workman's Compensation Insurance: (check one) I am the homeowner I am the sole proprietor I have Worker's Compensation Insurance nn %We ys'955 8 Insurance Company Name: A�a�n-ra �l�ii On hi-e Ta Svra/tfP 4� Worker's Comp.Policytl ' 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 Kings Highway/Historic Dist. ( )Replacing like for like 'The debris will be disposed of at 443le_ Plate cot-Xt Location on Facility I declare under penalties of p- statements herein contained are true end correct to the best of my knowledge end belief. I understand that any false answer(s) will be Jost cause for denial or . • Iof my 'cense and for ta. .'•.under MillsCa 268.Section I. :... ' / 2 — /9 — iFr Applicant's Signet= icitgi a.: Date ri .- a c/i f Caine'. c. aah• Owners Signature(or attac.., GG//' Approved By /_ w./Z ar.s Date: /2—g 71; Building Official fC :.") / Zoning District Historical District Yes No Flood Plain Zone: Yes No Water Resource Protection District Within 100 ft.of Wetlands: • Yes No Yes No QHome Improvement Agreement: Pagel Home Depot License#'s - For the most current listing www.Homedspot.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. Imaher pamela 1New England South 1-APQZLDR Customer Last Name Customer First Name Store#/Branch Name Customer Lead/PO# 1503 route 28 unit 5 West Yarmouth MA 02673 Customer Address City tate ip (860) 502-4418l 1(860) 502-4418 breaker20@netzero.net 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: 1908 Boston Turnpike Unit 1 Shrewsbury MA 01545 Address City tate Ip 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 DEPOTS EXPENSE. THE LAW REQUIRES THAT THE HOME DEPOT GIVE YOU A NOTICE EXPLAINING YOUR RIGHT TO CANCEL PLEASE SIGI�SECOW TO CKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL AND WRITTEN NOTICE OF YOUR RI TO CANCEL. Acknowledged by: C 1 111124/2018 Customers igna ure 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: $ 3350.70 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 $ 837.68 Remaining Balance $ 2513.02 The Home Depot-2455 Paces Ferry Road,N.W.Bldg.B-3,Atlanta,Georgia 30339-Customer Care:1-800-466-3337 460 EIDE Customer Agreement(24 ad.18) v 0.1.7 • * '. J f i ,.- wrt+ s `, I, $ti � + k 'tcc `- 'G! �" a :' ' I.19 t tr, i E3 AM = 1 t ry ', mt , �-"I 'k$J.iHTI � a: • --- The Commonwealth of Massachusetts Department of Industrial Accidents r- � "en Office of Investigations -wl— -4 1 Congress Street,Suite 100 Via— 9' Boston,.114 02114-2017 www massgov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name iBtssessKltganiatiowIndividud): Ho int- Der t, l address: /6 f BO s IM° 7' iN®n4Z Citv'State/Zip: 5ArCc's4f v, MA • days- Phone#: 7 7i/— 02 TS - 02/SC ' Are� you an employer?Check the kripropriate box: Type of project(required): 1. / I am a employer with 2091- 4. L. I am a genera]contactor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contactors • listed on the attached7. 0 Remodeling 2.❑ I am a sole proprietor or partner- sheet i I ship and have no employees These sub-contractors have I 8. 0 Demolition waking for me in any capacity. employees and have workers' + 9 ❑Building addition No workers' comp.insurance camp.insurance.: . required.) 5. ❑ We are a corporation and its I 100 Electrical repairs or additions • 3.C I am a homeowner doing all work officers have exercised their j 11.0 P1>mmbing repeis or additions right of exemption per MGL f.repairs j myself No workers' comp. 12❑ • ♦ c.152,§1(4),and we have no I/ ins noncerequired.] 13. Orher WnnOR.,/ empioycey [tip wa ions' � comp.iasra• nnce required.] I re1elwe.e A'tenfS *tut).applicant that ehectr box el rat also 511 out the section below showing Thea workers'compensation policy information. t Bomeownes who submit this affidavit indicating they are doing all work and then hits outside coaoacton must submit a new affidavit indicating such. :Con acton that checkthis box must attached an additional sheer showing the name oft sub-comactors and stem whether or not those entities have employee. 1 the sub-coraramors have employees,they mast provide their workers'comp.policy number. I am an employer the is providing workers'compensation insurance for my employees Below is the policy and job she Lzstsanr_Company Name: r/ter' Hei.i4 et/ VNlO/✓ A//'e+ y.Vs . (•a Policy#or Self-ms.Lic.it: K W Ci VS 1 1.11:1- 'S/ Expiration Date:lar", - / - / f Job Site Address: ei O 3 (2..r•i("e 2? 5 city/state/zip:W Yellow e ft+t /I A Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to stars coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-y a imprisonment,es well as civil penalties in the form of a STOP WORK ORDER and a ire of up to 5250.00 a day .•:' •lator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DL . e coverage verification I do hereby certify ran,: - r ,'k; , i... , , •-, at the information provided above Is true and correct Si l��eyi Date: /Z — /9 —/� Siiaure: 1 a p phone t: Jt/ - 9 _ - 6 I y2- .- - --- - Official use only. Do not write in this area,to be completed by city or town ofjtrlaL • 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#: • • • • 0)1?]fl0.7111teU'(cfl t t fef. C/IGCJeM Office of Consumer Affairs and Business Regulation 10 Park Plaza - Sufte 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Type Supplement Card Registration: 112785 HOME DEPOT USA INC Expiration 04/2212019 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 a1 Consumer Affairs 8 Business Regulation • �"_�- HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE Supplement Card before the expiration date. It found return to: ;�=F=. Registration Expiration , Office of Consumer Affairs and Business Regulation 112785 04/22/2019 10 Park Plaza-Suite 5170 HOME DEPOT USA INC Boston,MA 02116 ANDREW SWEET R..4 'x? 2455 PACES FERRY RD G71 HSC L+ - u-, ithou signature ATLANTA.GA 30339 Undersecretary • m DATE R CERTIFICATE OF LIABILITY INSURANCE ii.......---- 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 teams and conditions of the policy,certain policies may require an endorsement. A statement an this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). cortACT PRODUCER NAME MARSH USA,INC. I FAXor X TWO ALLIANCE CENTER JIc PHONEo En? INCX - 3560 LENOX ROAD.SUITE 2400 ADDRESS: ATUNTA,GA 30326 INSURER(S)AFFORDING COVERAGE AMCa CN101642064hnTMDCGAW-1619 INSURER A:OIW Remelt Insane Co 24147 INSURED INSURER B:New Ham,sNre Ina Co 23841 THE HOME DEPOT.INC. • HOME DEPOT U.S.A.,INC. INSURER C:HDmeRisk Crew Insurance CGnmI 2055 PACES FERRY ROAD -MSURER D: BALDING C-20 INSURER E: ATLANTA.GA 30339 INSURER F: COVERAGES CERTIFICATE NUMBER ATL-034353439-I6 REVISION NUMBER: 3 THISURED NAMED ABOVE INDICATED.CNO ITWATHSTANDING POLICIES REQUIREMENT.TERM OR CONDITIONVE OFBEEN ISSUED TO THE ANY CONTRACT OR OTHER DOCUMENT WITH RESP CT TO ( PERIODR THE POLCY IS 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. (NSRADDL :R POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE IVSD MND POLICY NURSER IMMmWWW YV) INDWYYYYI A X COMMEACUL GENERAL LABILITY MWZY 312717 031012018 03/012019 EACHOCCURRENCE S 9.000.000 DAMAGE TO RENTED 1.000.000 I CXm IMS-MADE �OCCUR PREMISES fEa CCGnral a LIMITS OF POLICY XS MED EXP Any On person) S EXCLUDED OF SIR SIM PER DCC PERSONAISAOV INJURY IS 4�' 00 GEN.AGGREGATE LAST APPLIES PER: GENERAL AGGREGATE a 9.000.003 n 'POLICY❑jEc ❑LOC PRODUCTS-COMPIOP AGG S 9.0000911 a OTHER: COMBINED SINGLE LIMIT A aro MOBILE LIABILT- NNfiB312718 031012018 031012019 (Ea eflenD S 1.000.000 X ANY AUTO eaWLY INJURY(Per Demon) a • OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per=Cent) 9 • AUTOS ONLY _AUTOS DAMAGE Y RT - T HIRED NON-OWNED IF.PROPEOPEns AUTOS ONLY AUTOS ONLY S UMBRELLA LW OCCUREACH OCCURRENCE S — DICERS L1AB CLMMS-MADE AGGREGATE a DED I RETENTIONS _ S B ISOMERS COMPENSATION WC 014122577(AX,NH,W.VT) 06112018 03/012019 x STATUTE Ea AND EMPLOYERS'UASRnY Y I N WC 014122578(WI) 031012018 0310112019 E.I.EACH ACCIDENT a 5600= B ANYPROPRIETORWARTNERIFXECUTIVE OFFICERIMBABERENCLUDEDT O NIA (Mandatary In NH) EL.DISEASE-EA EMPLOYEE S 5.000.000 ■Yn describe under Continued on AR:tonal Page EL DISEASE-POLICY LIMIT S 5000000 DESCRIPTION OF OPERATIONS below C I Excess Aub 297-1-10011100-2018 03/012018 031012019 UM 4.000.000 I DESCRIPTION DF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be aeacMd I mom span's 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 N BUILDING C. ACCORDANCE WITH THE POUCT PROVISIONS. ATLANTA.GA 30339 • AUTHORIZED REPRESENTATIVE N Mash USA le. Manashi Mukheljee 245auao1.-%. .Ie,' I IS 1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN101642069 ------ThLOC#: Atlanta Ami O ADDITIONAL REMARKS SCHEDULE Page 2 of 3 AGENCY MARSH USA.INC. NAMED W TUE H THE HOWDEPOT.INC Poucr NUMBER HOME DEPOT U.SA,INC. 2455 PACES FERRY ROAD BUILDING C-20 CARRIER ATLANTA,GA 30339 NAIL CODE EFFECTIVE DATE; ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM ISA SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance • Workers Conpenmion Connect Carrie Indanmity Inman Cornany of North America Pxicy Hunter WLR C6:7831911ALARFLID.IA.RS.KY,LA.MS,ND.NEM.I,ND.OI(SCSD.TN,WV,WY) Effective Our 031012016 Expiration Dale:03)01/2019 IEL)Unit 51.000800 Comer New Hampah re Insurance Compery • Him/Nunber WC 014122576(DC,DEHLIN,MO,MN,MT,NY,RI) Effective Dale:03/012018 Expiration Dale:031012019 IEL)Lim!:$1800,000 Carrier ACE American Insurance Company Pdcy Number WCU C6a783711(051)(AZ.CA,ILNC.OR VA,WA) EfbcWe Date:03/012018 Expiration Oats.0/1012019 (FL)Lr it:$1,000,000 SIR 51.000,000 SIR rorwe Pates of AZ.CA.X,NC.ORVA,WA Camer.Nato*Udon Fire Samara Corner, Ploy Number XWC 4595580 rose(CO,CT.GA.MEMI,NV,OH,PA.UT) Entice Date 03101!2918 Exaraeos Date:031012019 1E14 Unit 51,000800 51.000.000 SIR for the rotes of CO,MENV,MI,OH.PA.UT 5750.000 SIR for Me stab of GA 5350.000 SIR for the slab of CT Came Non Udon For Insurance Company Policy Number.XWC 9595581(0511 IMA) Expinio Dele:03/01/2018 3/01201 ,L FxpiMon Date:03)012019 Y/,(/�6Y ' (EL)Limit 51800,000 SIN 5500,000 TX Ennoyes XS Indemnity. Cwiertnia Orion Insurance Caryery Polity Nunbr.7145 Ca916593A(TX) Effective Dale:03101/2058 Expiration Data.03/01!2019 (EU Lint 510.000.000 SIR 5!.000,000 ACORD 101 (2008101) C 2008 The ACORD name and logo are registered marks of ACORD CORPORATION.. All rights reserved.