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Home My WebLink AboutBLD-19-003732 1 Office Use Only l•; Y *41 �ArO :Penni:# /-�. Ol -ew -y� 'Amount £0 \ ,.•%�:V (Permit expires 180 days from tssu¢date D—lq—ce373a- EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH • Yarmouth Building Department RECEIVED ' 1146 Route 28 South Yarmouth,MA 02664 DEC 19 2018 (508) 398-2231 Ext. 1261 Cf; p (4s1( BtJU N ' )F NT CONSTRUCTION ADDRESS: 02 3 Cf 1 ( lc,.t _ —"r � �. ASSESSOR'S INFORMATION: ' • •• Map: Parcel: Anna . OWNER:FiI;pj�ovA o7 ; s4: ❑ arookRX S./arA.a.,{-k i i-tA oZG6,4 Cog-2z(- t1487 NAME / PRESENT ADDRESS TEL. # Email Address: • CONTRACTOR:e 4.Mt—ay n'f Ice cit flaws ha/,' Ft4 pls�(C" Sf.�-9/oZ-�o9il7 NAME MAILING ALSDRESS TEL# Email Address k idential Commercial Est Cost of Construction$ 61 12. Co Home Improvement Contractor tic.It I M..'78 S Construction Supervisor Lia# 0 q 6 041 3 Workman's Compensation Insurance: (check one) I am the homeowner I am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: A6lco/7a 1/in;on hi'C To SvrancP Worker's Comp.Polka • . WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# 7 Replacement doors: # - Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like - � � '?hedebris will bedisposed ofat Aft Man(Sntr�-t I Location of Facility I declare under penalties of p 1statements herein contained are true and correct to the best of my knowledge and belief. Iunderstand that any false answer(s) will be just cause for denial or MMM • of my 'cense and for 3. .. •••i under MO.L Ch.268.Section 1. Applicant's Signature: IiI.EY/,. Date: 1. .- /9 - / P Owners Signature(or atta- e - cite.1 _call-- C — sate: /� Approved 8y: Date: /1 /f7$ Building O>A {ign ) Zoning District historical District Yes No Flood Plain Zone: Yes No Water Resource Protection District Within 100 ft.of Wetlands: Yes No Yes No • ' Home Improvement Agreement: Pagel Home Depot License #'s - For the most current listing www.Homedepot.corn/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. Filippova Anna New England South 1-AQANEH1 Customer Last Name Customer First Name Store #1 Branch Name Customer Lead/ PO# 123 Still Brook Rd South Yarmouth MA 02664 Customer Address City tate ip (508) 221-4987 anyaperceva@gmail.com Home Phone# Work Phone# e P one 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 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 SIGN BELOW T' CKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL AND WRITTEN NOTICE OF YOUR RIct� 0 CANCEL. Acknowledged by: ( V 11/07/2018 Customer's Sign- T& `-'` 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: $ 6126.00 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. % Deposit Amount $ 2250.00 Remaining Balance $ 3876.00 The Home Depot-2455 Paces Ferry Road,N.W.Bldg.813,Atlanta,Georgia 30339-Customer Care:1-800-466-3337 460 HDE Customer Agreement(24 JN.18) v 0.1.7 • •4.n.-._.l+u, v. 4"+1»dCnuseri5 )Nrylpn ,f ›rolessIona{-,censure Soar: zr 3uetding Regulanons and Standar? st'y it t czeri•s••:r :3-798093 z,L Un fres •.344r8,2020 THOMAS E PEAC +3t' 'r P.O.BOX SOS% `r 4 SEEKOMK MA'OV71 r • Commissioner • Jam"" The Commonwealth of Massachusetts Department of Industrial Accidents nc_•v•— Office of Investigations 4 1 Congress Street,Suite 100 % rili=SY Boston,M 02114-2017 wlt•'lvmassgov/din Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lezibly Name Btsaess/Osaanimriowlndividual): 1(�lane- pt t Address: 9oe Bos/ni '7veNpi� City'State/Zip: 54PC444 f4 . o/sys Phone:*: 725' 01TY' - c2/SC ' Are you an employer?Check the propriate box: Type of project(required): • ].�Sj I am a employer with f 4. Li am a general contactor and I 6. ❑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 1 8. 0 Demolition working for me in any capacity. employees and have workers' i 9. ❑Building addition [No workers' comp.insu aace comp.insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am homeowner doing all work officers have exercised their j 11.0 Phmibing repairs or additions I myself. [No workers' comp. right of exemption per MGL i 12.❑ f repass required.]. c.152,§1(4),and we have no insurance 13.;i Other 4/1P empiayeeS. [No worths' r�(Jja CCM e/t'f"� • comp.insurance inquired) t Ary applicant that thetics box et must also 511 out the section below showing their sorters'compensation policy information. t liomeowncs who submit this affidavit indicating they are doing as work mod then hire outside mucus must submit a new affidavit indicating such. :Contactor that check this box must attached an addinowl sheet showing the tie oft sob-cofactors sod stare whether or not those entities have employes. If the sub.comratma have employees,they must provide their workers'comp.policy mamba. I am an employer chat is providing workers'compensation insurance for my employees. Below is the policy and job she nn . -b ,mlie Company vane: (Jf /tom /Q bIVQ/ VNte / !/G ..1:41‘ . / 6. Policy#or Self-ns.Lic.#: KW& R' 1 rs-O Expiration Date: 3 -- / - f? Job Site Address: -2 c ,s+-,l[ X 1'00 K gel City/State/Zip: S' /ir,nt,Al. RA Attach a copy of the workers' compensation policy declaration page(showing the policy a r and expiration date). Failure to secure coverage us required under Section 25A of MGI,c. 152 can lead to the imposition of criminal penalties of a foe up to 51,500.00 and/or one-y imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a foe of up to$250.00 a day ,••'• later. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA ., . e coverage verification. e Ido hereby certify Sal 'i ' ' ' •- at the information provided above is true and correct �llPyl Date: /t — /c+ � I Si=sure; 1 / p Phone: J �: 6 - 9 6- Y 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/I'own Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: • • • 7 ( / n../ i' ii c'))?)EciiUiP!Y( J o/• f'caJ rc: C/Z tie : _. 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: 112785 2455 PACES FERRY RD C-11 HSC Expiration04/22/2019 ATLANTA,GA 30339 • Update Address and return card. Mark reason for change. 0 Address 0 Renevra! 0 Employment 0 Lost Card _-- Office of Consumer Affairs 8 Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE Suoolement Card before the expiration date. If found return to: •- F Registration Expiration , Office of Consumer Affairs and Business Regulation • ^.:w 112785 04/22/2019 10 Park Plaza•Suite 5170 HOME DEPOT USA INC Boston,MA 02116 if ANDREW SWEET `Lc C a I ./li./. 244555ANTCCES FERRY MO G11 HSC L ° `�A,GA 30339 �f!Tt� !thou signature Undersecretary • • OM C1mm' ACDCERTIFICATE OF LIABILITY INSURANCE 22/208 `.mm.' 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 rights to the certificate holder In lieu of such endorsement(s). CONTACT PROOU MARSH USA,INC. PHONENAOW FAX Not TWO ALLIANCE CENTER IAT No Fi 3560 LENOX ROAD,SURE 2400 EADDRESS: ATLANTA.GA 30326 NSURERIS)AFFORDING COVERAGE NAPE 0 CN1o1692069-HDDeD-GAW-Ee-19 INSURER A:OW Replolc I=ranee Co 24147 INSURED INSURER 6:NEW Hampshire IRS CO 23841 THE HOME DEPOT.INC. HOME DEPOT USA.,INC. INSURER C:HaneRisk Capeue Insurance ComrenY 2455 PACES FERRY ROAD INSURER 0: BUILDING C-20 INSURER E: ATLANTA,GA 30339 INSURER F: COVERAGES CERTIFICATE NUMBER: ATL.034353439-16 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 AU.THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ADSUB/ POLICY EFF POLICY EXP ILTADM TYPE OF INSURANCE NSD WVD POLICY NUMBER (MW'DM'YYYI fMMIDOMYYI UNITS A X CDMMRCIAt GENERALUAMLT MWZY 912717 03/01/2016 031012019 EACH OCCURRENCE IS 9,000.0X DAMAGE TOREM ED 1.000000CLAWS-MADE E OCCUR PREMISES IEE ncunenDN S LIMBS OF POLICY X$ MED QP(Arty one Penn) 5— EXCLUDED OF SIR SIM PER OCCPERSONAL a ADV INJURY ISa 9�' GEML AGGREGATE OMIT APPLIES PER: - GENERAL AGGREGATE g' '` 03 POLICY El JE PROCT- LOC PRODUCTS-COMPIOP AGG S 9.000000 OTHER: S A AUTOMOBILE LIABILITY mw T13312718 0301/2018 03,010.019 Z NEIN MDSINGLE:IMIT S 1.000.000 ANY AUTO BODILY INJURY IPdr parson) S OWNED SCHEDULED SELF INSURED AUTO PHY DING BODILY INJURY Pe aeC SM) E AUTOS ONLY _AUTOS HIRED PROPERTY DAMAGE s AUTOS ONLY AUTNON-OWNED S ONLY - IMrasodenU S UMBRELLA LMB OCCUR EACH OCCURRENCE S EXCESS LIAfi CLNMS.MADE AGGREGATE S DED REATION NE _ 5 B ANDWORKERSCOMPERSARON WC 014122577(A%,NH,W,VT) 031012018 03101/2019 x SSTTATUTE ER A( EMPLOYERS*1.11NBLm WC 014122578 WI 031012018 031012019 5,000,000 B ANI9ROPMEIBEREX LUDED'ECUTNE YIN ( ) EL EACH ACOOENT E OFFICERty N.NH) EL.O NIA 5.000.000 (Mandatory M NH) EL.DISEASE-EA EMPLOYEE S I ESyaCdescribe under RIPTION OF OPERATIONS bebw Continued on dtl0l/MalarialLIMITl Page EL DISEASE.POLICY LIMITS 5.000,000 D C Excess AND 297440011-00-2015 031012018 03/01/2019 URN: 4,000.000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD III,Adeleal Remi Shcad,M,nay be maenad N mom span Y myuhad) 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 IN BUILDING G20 ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA.GA 33339 AUTHOREEC REPRESENTATIVE of Mash USA Inc. Manashi Mukherjee .3 a+nooba .S4- ✓4eS- I ®1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo aro registered marks of ACORD r • AGENCY CUSTOMER ID: CN101642069 LOC#: Atlanta AC RO p� CO ADDITIONAL REMARKS SCHEDULE Page 2 01 3 AGENCY MARSH USA.inc. NAMED INSURED THE HOME DEPOT,INC PoucY NUMBER HOME DEPOT U.S.A..INC. 2455 PACES FERRY ROAD BUILDING 020 CARRIER ATLANTA.GA 3038 I I NAIL CODE (ADDITIONAL REMARKS EFFECTIVE DATE THIS ADDITIONAL REMARKS FORM ISA SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM Tri-LE: Certificate of Liability Insurance Workers Compensation Continued: Carne.Indemnity Insurance Company of Nath Amass Policy Hunter WLR 064783191 TALARFL1D.IA,riS.KY.LA,MS.MO.NE M.ND.OI(SC,SD,TN,WV,RT) Effective Date:01012018 • Expraion Dab:03/01/2019 (EL)Writ 51,000,000 Calmer New Hampshire Insurance Company Pricy Number WC 014122STS(DC.DEN.IN.MO.MN.MT,NY,RI) Effective Date:03/012018 Eoiratim Dare:03)01)2019 (EL)lint 51.000.000 Carver ACE American Insurance Company Pty Number WCU C134783-231(05I)(AZ CA.h,NC.OR,VA WA) Effective Dab:03/01(2018 Enxp1inlion Date:031012019 I`4 Umit:Si,000.000 SIR 51.000000 SIR for the Nola of AZ.CA.ILNC.OR,VA lNA Caner.National Union Fie Immure Company Pdicy Number XWC 1595580(OSI)ICD.CT.GA.ME.MI.NV.OH,PAAIT) Effective Data 01/012018 Evpraboo Da 03'012019 (EL)Lint 61.000.000 • 51.000.000 SIR fir Me nates of CO.MENV,ML OH.PA.UT 5750.000 SIR for Me stab of GA 535.0.000 SIR for the stab o1 CT Gamer Nabona Union Fn Imrarce Company Pdky Number XWC 4095581(051)(MA) FS an Date:0321/2018 ,■a &pi elim Dam:031012019 till (EL)Li1nit 51,000,000 "` SIR:5500000 TX EmAm/en XS Indeniy. Cadr.Dinim Union Inseams Company Poky Number TNS C4916693A(TX) Effecba Dale:03012018 • &piston Dale:03012019 (EL)Lint 510.000.000 SIR 51.000.090 ACORD 101 (2008/01) 0 2008 The ACORD name and logo are registered marks of ACORDCORD CORPORATION: All rights reserved.