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HomeMy WebLinkAboutBld-20-001765 .Office Ilse Only , Permit* O Amount •°_c' Permit expires 180 days from R I '�ZO J 7(4— issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department arel 1146 Route 28 South Yarmouth,MA 02664 SEP 2 6 20j9 ( 08)398-2231 Ext. 1261 "40, CONSTRUCTION.ADDRESS: J '1 t? S e - ASSESSOR'S INFORMATION: Map: Parcel: OWNER: licA of C7rcJf4 i9 Rosy Ri cgr1.1 , L 6P-a Ste- aZ94 NAME Is JrCesorifor p4; V TEL # EmaTtAddre CONTRACTOR 5m tern &LP% (�rnovtvs Srr IN / 7?i r 29/77 . CPS) 224 ZVO 3�t Email Ads Residential Commercial Est.Cost of Construction 2-2,01(' —Home Improvement Contractor Lic.# 113 Z.' c Construction Supervisor Lic.# 0 76-78 7 Workman's Compensation Insurance: (check one)I am the homeowner I am the sole proprietor )4 have Worker's Compensation Insurance 1 4)CA -3I6 72 8�/ Insurance Company Name: �paf4t� �S. ?0f f� �1r°z'cer's Comp.Policy# WOJK TO BE PEiFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# l l 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 ac a(de /• ter a ,,...o Sin— `' e tmtiun of Facilit I declare under penalties of perjury that the ,: herein contained Bream and comet to the best of my knowledge and belief. Iunderstand that any false answers will be just cause for denial ocrition ofm7r •a, and for prosecntion under NMI-Cb.268,Section 1. Applicant's Sigaatme: Date: Owners Signature(or attachment) at See- Ate" Date' Approved By: � Dam: Building�cial ) • Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 it.of Wetlands: Yes No Yes No Renewal Agreement Document and Payment Terms byAndersen. dba:Renewal By Andersen of Southern New England Michael Grella 4;4iei Legal Name:Southern New England Windows,LLC 19 Rose Road 4 RI #36079, MA#173245,CT#0634555, Lead Firm#1237 South Yarmouth,MA 02664 WINDOW NE LACEMENT 10 Reservoir Rd I Smithfield,RI 02917 H:(508)258-0294 Phone:401-349-1384 I Fax:401-633-6602 I saleserenewalsne.com C:(508)394-0045 Buyer(s)Name: Michael Grella Contract Date: 09/09/19 Buyer(s)Street Address: 19 Rose Road, South Yarmouth, MA 02664 Primary Telephone Number: (508)258-0294 Secondary Telephone Number: (508)394-0045 Primary Email: migrella@msn.com Secondary Email: Buyer(s) hereby jointly and severally agrees to purchase the products and/or services of Southern New England Windows,LLC d/b/a Renewal By Andersen of Southern New England("Contractor"),in accordance with the terms and conditions described in this Agreement Document and Payment Terms,any documents listed in the Table of Contents,and any other document attached to this Agreement Document, the terms of which are all agreed to by the parties and incorporated herein by reference(collectively,this "Agreement"). Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. Total Job Amount: S22,096 By signing this Agreement,you acknowledge that the Balance Due,and the Amount Financed must be made by personal check,bank check,credit card,or cash. Deposit Received: SO Balance Due: S22,096 Estimated Start: Estimated Completion: Amount Financed: 6-8 weeks 6-8 weeks SO Method of Payment: Credit Card We schedule installations based on the date of the signed contract and secondarily on the date in which we complete the technical measurements.The installation date that we are providing at this time is only an estimate.We will communicate an official date and time at a later date. Rain and extreme weather are the most common causes for delay. Notes: $7,364 cc dep. 1/3 at start, 1/3 at comp, permit/taxes PD in Yarmouth Buyer(s)agrees and understands that this Agreement constitutes the entire understandings between the parties and that there are no verbal understandings changing or modifying any of the terms of this Agreement.No alterations to or deviations from this Agreement will be valid without the signed,written consent of both the Buyer(s) and Contractor.Buyer(s)hereby acknowledges that Buyer(s) 1)has read this Agreement, understands the terms of this Agreement,and has received a completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first written above and 2)was orally informed of Buyer's right to cancel this Agreement. NOTICE TO BUYER: Do not sign this contract if blank.You are entitled to a copy of the contract at the time you sign. YOU,THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME NOT LATER THAN MIDNIGHT OF 09/12/2019 OR THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION, WHICHEVER DATE IS LATER.SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. Legal Namr.Southern New England Windows,LLC dba:Renewal ndersen of Southern New England Buyer(s) Signature of Sales Person Signature Signature Seth Grizey Michael Grella Print Name of Sales Person Print Name Print Name UPDATED: 09/09/19 Page 2 / 13 E _/'ice,122 r" ?/_'-Pf� f ! Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Supplement Card SOUTHERN NEW ENGLAND WINDOWS.LLC Registration: 9 3245 10 RESERVOIR ROAD Expiration: 0 09/118/28/2 020 SMITHFIELD, RI 02917 Update Address and Return Card. SCA 1 20M-05/17 Fcvrrin..sqccear&i> 7lia.,,zeviebieli, Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Supplement Card before the expiration date. If found return to: Reaisttation Exairation Office of Consumer Affairs and Business Regulation 1Z324S-__ . 09/18/2020 1000 Washington Street-Suite 710 SOUTHERN NEW ENGLAND WINDOWS,LLC Boston,MA 0211 BRIAN DENNISON 10 RESERVOIR ROAD SMITHFIELD,RI 02917 Undersecretaryv without signature Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constru t on- Supervisor CS-095707 Epp i res: 09/08/2020 • J BRIAN D DENNISON `"�a 8 BLACKWELl DRIVE ; CHARLTON MA-01507 T, 1 1.L, CL. Comrriissioner The Commonwealth of Massachusetts ME i."" Department of IndustrialAccidents —w+l. 1 Congress Stree4 Suite 100 • T "' Boston,MA 02114-2017 �,.;r` www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Annlicant Information Please Print Legibly Name(Business/organization/Individual): S oc h ern, Je u) till G 1 n(1t]L1 S Address: /C) kcer uD,r c/ . City/State/Zip:Sol t -6ele ,Rt 0Z9 /7 Phone#: 4O/-22 r— , See Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with �+-employees(full and/or part-time).• 7. New construction ` 2 am a sole proprietor or partnership and have no employees working for me in 8: 0 Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myseU:[No workers'comp,insurance required.]t 9. 0 Demolition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 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 5.Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13. 'of repairs These sub-contractors have employees and have workers'comp.insurance.t / 6.0We ace a 14. Other ink A fin,/ corporation and its officers have exercised their right of exemption per MGL c. 152,11(4),and we have no employees.[No workers'comp.insurance required.] ler Pee re/net',"-5 'Any applicant that checks box 51 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. tContracoers 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 sub-contractors have employees,they must provide their workers'camp.policy number. I am an employer that is providing workers'compensation insurance for my employees: Below it the policy and job site information. Insurance Company Name: 'Fl rep, 1acs ce °( a . Of WA, b. C . Policy#or Self-ins.Lic.#: LIZA\.345-3 /oZ ?O?y • Expiration Date: I' /—2.0 ZO Job Site Address: 1 Rose_ at' / City/State/Zip: S.,i-, o,jL. ei A Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiradon 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 verillation. t do hereby c under the • penalties of pe#ury that the information provided above is true and correct . Signature: Date: '9�Z S Phone#: 101 *—Z'T-f / 00 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#: 1 ` ACC CERTIFICATE OF LIABILITY INSURANCE ,I DATE(MM/DD/YYYY) �..�.�' 12/28/2018 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 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 CoBiz Insurance, Inc.-CO PHA` 1401 Lawrence St., Ste. 1200 ac No.an;303-986-0446 C.No):303-988-0804 Denver CO 80202 ADDDREEss: COMaiI©cobizinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Acadia Insurance Company 31325 INSURED ESLERCO-01 INSURER a:Firemens Insurance Company of WA,D.C. 21784 Southern New England Windows, LLC. INSURER C:Homeland Insurance Company of New York 34452 dba Renewal by Andersen of Southern New England 10 Reservior Rd INSURER 0: Smithfield RI 02917 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:787175890 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. LTRI POUCY EXP LTR TYPE OF INSURANCE Jd8 LD_WV� POLICY NUMBER (MM�YWY)JIAMIDONyyn, LIMITS A X COMMERCIAL GENERAL LIABILITY CPA3158728 1/1/2019 1/1/2020 EACH OCCURRENCE $1,000,000 CLAIMS-MADE n OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $300,000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY ECT n LOC PRODUCTS-COMP/OP AGG $2,000,000 - OTHER: , $ A AUTOMOBILE LIABILITY CPA3158728 1/1/2019 1/1/2020 COMBINED SINGLE UMIT $ (Ea accident) 1,000.000 X ANY AUTO BODILY INJURY(Per person) $ — ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X AUTOS NON-OWNED (PerPR accideY nt) $ $ A X UMBRELLA LIAR X OCCUR CPA3158728 1/1/2019 1/1/2020 EACH OCCURRENCE $15,000,000 EXCESS LIAR CLAIMS-MADE AGGREGATE $15,000,000 DED X RETENTION$0 $ B WORKERS COMPENSATION WCA315872924 1/1/2019 1/1/2020 X STATUTE EOTH- R AND EMPLOYERS LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N❑N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes descrbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POUCY UNIT $1,000,000 C Polution Liability 7930073340000 1/1/2019 1/1/2020 Each Occurrence $2,000,000 Claims-Mada Policy Aggregate $2,000,000 Retroactive Date 08/20/2013 DeductIbk $25,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it 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 ACCORDANCE WITH THE POLICY PROVISIONS. FOR INFORMATIONAL PURPOSES ONLY AUTHORIZED REPRESENTATIVE Nam 5 ✓ I ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD