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HomeMy WebLinkAboutBld-20-000931 a �;'_ Office Use Only lY —w.\O. 1{K�Ju) i�I M 3I I t ertli3 �\ -ii ' .t Amount V Permit expires 180 days from ~'y'`ky issue date EXPRESS BUILDING PERMIT APPLIC t CEIVED .f t TOWN OF YARMOUTH Yarmouth Building Department AUG 20 2019 1146 Route 28 South Yarmouth, MA 02664 B U I' I P (508)398-2231 Ext. 1261 e'�� �u �., CONSTRUCTION ADDRESS: LI b /MTiLl.6S !qv 15. I 3R 1 3 1 ASSESSOR'S INi-O,mATiOC,: m I lzro Map: I Parcel: I OWNER:SIA (1uib LiD i" 7S Av JI7- ?1 1Z?ON ICI o e PRESENT TEL r CONTRACTOR: A1t-4— M •� � �OaT`- - SD 1-Z 8D •0/I4 NAME MAILING ADDRESS TEL.# p. �+� $6esidential L Commercial Est.Cost of Construction$ A i 'c v 0 o Home Improvement Contractor Lic.# I b 1 b Construction Supervisor Lic.# on 1 I7 y r Workman's Compensation Insurance: (check one) / am the homeowner I am the sole roprietor Y i have Worker's Compensation Insurance Insurance Company Name:flpfueyrvme Iort irt Itir. CD Worker's Comp.Policyg ZD 5 ppLL Zo'/i, WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# 18 Replacement doors: # Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation 'C/ Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing g *The debris will he disposed of at 61. Pi'/4K. - /(,/S ii khe 102a p114 Location of Facility I declare under penalti of p. 'u• if,' siatcme:is ilci;;:n calaainct:lc uuc and w„cci iu to;Jesi ui'uly knowledge and beilei. I understand that any false answer(s) will be just cause for denial r re ocat a .f my license and for prosecution under M.G.L.Ch.268.Section I. Applicant's Signature: Date: B-7e ' rG Owners Signature(or attachment) 5c a_.._..Gut- --_-- _ . _ __...___ -_—._-- —_--_.-__ pare: Approved By: Date: _IL' O—IC Budding Official(or desience) FMA IL ADDRESS: l Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 Ii.of Wetlands: Yes No Yes No The Commonwealth of Massachusetts I Print Form Department of Industrial Accidents Office of Investigations I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/tndividual): Power Home Remodeling Address:2501 Seaport Drive City/State/Zip:Chester PA 19013 Phone#:508-280-0156 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 30 4. 0 I am a general contractor and I employees(full and/or part-time)." have hired the sub contractors 6. ❑New construction 2.❑ i am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have R. 0 Demolition working for me in any capacity. employees and have workers' 9. �Building addition [No workers'comp.insurance comp.insurance.* required.] 5. 0 We are a corporation and its 10_0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL insurance required.] . c. 152.§1(4),and we have no 12.0 Roof repairs employees.[No workers' 13.0 Other comp.insurance required.] `Any applicant that checks box x I must also fill out the section below showing their workers'compensation policy information. I lomeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such. 1Coutractors 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. lithe sub-contractors have employees,they must provide their workers'comp.policy number. p - - I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site I i information. insurance Company Name:Harleysville Worcester Insurance Company Policy#or Self ins.Lie.#:2018006620967 Expiration Date:10/1/2019 Job Site Address: l b 1 JAcTiAl f. A V 6 City/:State/Zip: �- Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a tine up to$1.500.00 and/or one-year imprisonment,as well as civil penalties in the lbrm of a STOP WORK ORDER and a line of up to$250.00 a day against the violator. Be advised that a copy of this statement may he lbrwarded to the Office of investigations of the DIA lbr insurance coverage verification. I do hereb'certif S nd r r ains and penalties of perjury that the information provided above is true and correct p -p � Six,nature: Date 0 •/_.1! Phone#:508-280-0156 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 I lealth 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: I ' ACORU0 DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 3l20l2019 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: It 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). PRODUCER CONTACT NAME: Lacher&Associates Insurance Agency PHONE FAX (Ar Lacher Insurance Group c.No,Es)):215-723-4378 (A/c,No):215-723-5757 632 East Broad Street ADDRESS: iacher@Iacherinsurance.com Souderton PA 18964 INSURER(S)AFFORDING COVERAGE NAIC C INSURER A:Pennsylvania Manufacturers 12262 INSURED POWERCL-01 INSURER B Power Home Remodeling Group,LLC 2501 Seaport Drive,4th Floor INSURER C: Chester PA 19013 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:2008098062 REVISION NUMBER: 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 ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP W LIMITS LTR INSD VD POLICY NUMBER (MM/DO/YYYY) (MM/DD/YYYYI A X COMMERCIAL GENERAL LIABILITY 6620967 301975 4/1/2019 4/1/2020 EACH OCCURRENCE $2,000,000 GE TO CLAIMS-MADE �i X OCCUR PR/EM PREMISES(EaENTED occurrence) $1,000,000 MED EXP(Any one person) $10,000 PERSONAL 8 ADV INJURY $2,000,000 GEM.AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $4,000,000 X POLICY JECT LOC PRODUCTS-COMP/OP AGG $4,000,000 OTHER: $ A AUTOMOBILE LIABILITY 151800-66-20-96-7 10/1/2018 10/1/2019 COMBINED SINGLE LIMIT S 1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ — OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESSLWB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERSCOMPENSATION 201875-66-20-96-7 10/1/2018 10/1/2019 X AND EMPLOYERS'LIABILITY Y I N STATUTE ER ANYPROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 I describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 I I DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be aHached if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth MA 02664 AUTHORIZED REPRESENTATIVE USA •orit„.e,a‘s•c).zedrioici. ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 11, Commonwealth of Massachusetts ,j/,,, /,,,,,,,,,,,,,,,,f//. i/./7.z;,07-4/,f/t Division of Professional Licensure Board of Building Regulations and Standards Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Constructitin'StSpervisor TYPE:Supplement Card Registration Expiration CS-057645 Epires: 09/18/2019 168616 03/17/2021 POWER HOME REMODELING GROUP LLC. MARK E MORDINI 4,9 18 NEWELL DR t Y "- NORTH'ATTLEBQRO MA 02760>, MARK MORDINI • ' r ,, 2501 SEAPORT DRIVE CHESTER,PA 19013 Undersecretary CAmmissioner d 0 'I • Construction Supervisor • Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991 cubic meters)of enclosed Registration valid for Individual use only space. before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation • 1000 Was ' ton Street-Suite 710 Bosto A 118 • • Failure to possess a current edition of the Massachusetts • of vall without signature State Building Code is cause for revocation of this license. For information about this license Call(617)727-3200 or visit www.mass.gov/dpl • • National Headquarters Shelly Milano and Lisa Platanitis 2501 Seaport Drive,Chester,PA 19013 33-80246 POWER R B88-736-6335 WWW.POWERHRG.COM MA HIC#168616 PROJECT AMENDMENT Buyer(s)'Information and Description of the Property: Project Number:33-80246 April 03,2019 Shelly Milano Date of Agreement (774)836-7238(Shelly's Cell) April 20,2019 Lisa Platanitis Date of Amendment 40 Hastings Avenue SHllymilano@yahoo.com West Yarmouth,MA,02673 E-Mail Address 1 County:Barnstable Township: This Amendment("Amendment")is to the CUSTOM REMODELING AND IMPROVEMENT AGREEMENT("Agreement")by and between Power Home Remodeling Group,LLC("Contractor"),and"Buyer(s)"listed above.Contractor and Buyer(s)hereby agree to amend and modify the Agreement as Indicated below.Other than as specifically indicated below,all the terms and conditions of the Agreement will remain in full force and effect.This Amendment is subject to the terms and conditions of the Agreement.The following additions,alterations,or deletions to the products and services Buyer(s)ordered are being made: Previous Project Price: $28,748.22 New Project Price: S28,748.22 Previous Down Payments Required: $0.00 Additional Down Payment Required: $0.00 Previous Down Payments Collected: Additional Down Payment Collected: Additional Down Payment Still Due: $0.00 It is agreed and understood by and between the parties that this Amendment and the original Agreement constitute the entire understanding between the parties,and there are no verbal understandings changing or modifying any of the terms of this Amendment.Buyer(s)hereby acknowledges that Buyer(s)has read this Amendment and has received a completed, signed,and dated copy of this Amendment on the date written below. I have read and received each page of this 7 page amendment Power Home Remodeling Group Buyer(s) Buyer(s) • /04/20/19 /04/20/19 /04/20/19 Signature of PHRG Representative Signature Signature Thomas Ferry Shelly Milano Lisa Platanitis April 20,2019 09:03 111