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HomeMy WebLinkAboutBld-20-001763 .Office L'sa Only • S :` Petmic • ` try O;� ClQi_ � ',--. ►'s Amotmt " "'"`" ¢ a'4 Permit expires 180 days from • �'` issue date EXPRESS BUILDING PERMIT APPLICATION , :K TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 p k. ' `2.( d l 9f South Yarmouth,MA 02664 44 /q - 454,OP (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: -Z C. t 5 Se_n c+ efl 54. • ASSESSOR'S INFORMATION: Map: Parcel: ' OWNER: u2✓\4 Larifr.— a26 FPsso„,1„,-, Sf. S• /�snetau/II , ' A d2 SD 4c4 $-3ei2-DSr37 NAME /OI�REsDBSS�ci TEL # Erne Addres CONTRACTOR: 1fA IJ 1%, W►AatPWs J#'i -)-er/ -r r,Ai7 (rid) 22 � ��tt Email Add Residential Co:mnercial Est.Cost of Construction$ 15 8 5' 'Z — Home Improvement Contractor Lic.# 17 3 2.45- Construction Supervisor Llc.# 0?67e 7 Worl®an's Compensation Insurance: (check one) I am the homeowner I am the sole proprietor have Worker's Compensation Insurance Insurance Company Name: .pIp WS 'Ps. 1.D Worker's Comp.Policy# tO CA 't6r72 b.21-1 W91 K TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares - Replacement windows:# I Replacement doors: # Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings hiighway/Historic Dist. ( ),I►eplacing like for like ' *The debris will be disposed of an Wh 3.7e �sn a (49eft B^ k 3)1;4 ( lI r isb utlun of%willt( I I declare under penalties of perjury that the. A;,;-, herein contained are true and correct to the best of my knowledge and belief. I understand that any false answers! will be just cause for denial ar�epocation of„ •a,, and far prosecution under MQ.L Ch.268,Section 1. \(yl��'._. Date: C— z — ( 9 Applicant's Signature: 1 Date: Owners Signature(or attachment) Sew 7_�Date ��� Approved By: Building Official ) Zoning District: Historical District Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: IYes No Yes No Renewal Agreement Document and Payment Terms byAndersen. dba:Renewal ByAndersen of Southern New England gl Diana Lantz Legal Name:Southern New England Windows,LLC 26 Fessenden St �� 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)398-0537 Phone:401-349-1384I Fax:401-633-6602 I salesarenewalsne.com C:7603332652 Buyer(s) Name: Diana Lantz Contract Date: 09/12/19 Buyer(s)Street Address: 26 Fessenden St, South Yarmouth , MA 02664 Primary Telephone Number: (508)398-0537 Secondary Telephone Number: 7603332652 Primary Email: revslantzegmail.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: $15,832 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: $5,276 Balance Due: $10,556 Estimated Start: Estimated Completion: Amount Financed: 6 to 8 weeks 6 to 8 weeks So Method of Payment: Credit Card We schedule installations based on the date of the signed contract and secondarily on Cash/Check 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: Depo paid CC Bal to be paid by check tax 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 09/16/2019 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 Namn Southern New England Windows,LLC dba:Renewal By Andersen of Southern New England Buyer(s) Cyan_ Signature of Sales Person Signature Signature Cory Scanlon Diana Lantz Print Name of Sales Person Print Name Print Name UPDATED: 09/12/19 Page 2 / 13 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 I 0 20M-M--05//1�7- ii ,y fe 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: Registration Expiration Office of Consumer Affairs and Business Regulation 17aa4s- _ 09/18/2020 1000 Washington Street-Suite 710 SOUTHERN NEW ENGLAND WINDOWS,LLC Boston,MA 0211 I BRIAN DENNISON l2-- 10 RESERVOIR ROAD U SMITHFIELD,RI 02917 Undersecretary it without signature Commonwealth of Massachusetts IFDivision of Professional Licensure Board of Building Regulations and Standards Constrw_Ct ornSupervisor CS-095707 Epp i res: 09/08/2020 BRIAN D DENNISON -- 'a 8 BLACKWELL-DRIVE ; / -; -,1 CHARLTON MA /01507 , Y1• ) r-- •;, }ti`N 1 r 1• Z� Commissioner The Commonwealth of Massachusetts A '' - i'- Department of Industrial Accidents + ',L - = 1 Congress Stree4 Suite 100 7......7. �� Boston,MA 02114-2017 N www mass gov/dia ''-- Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Aopliclnt Information Please Print Legibly Name(Business/prganization/Individual): S V Uth a/' lee u) tnc IG firi 1A)I/i d/ILLS Address: /O e Sep r UDt r .c..1 . Ci /State/Zi : p,t ty p S -til-e el ,7?t 0z9 /7 Phone#: 4 Dl-22,r- `3 to 6 Are you an employer?Cheek the appropriate box: Type of project(required): I. l am a employer with F0f-employees(full and/or part-time).* g 7. 0 New construction rum a solo proprietor or partnership and have no employees working forme in 8: 0 Remodeling any capacity.[No workers'comp.insurance required] 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.] 9. ❑Demolition 0 4.01 am a homeowner and will be hiring contractors to conduct all work on my property- I will 1 D 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 _ 5.01 am a general contractor and 1 have hired the sub-contractors listed on the attached sheet j 3. Roof repairs These sub-contractors have employees and have workers'comp.insurance.t p 6. we ace a 14.�ter c.,r i)L g,./ corporation and its officers have exercised their right of exemption per MGI,c. 15.,¢l(4),and we have no employees.[No workers'comp insurance required.] rep4cp -.e tS 'Any applicant that checks box 01 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. tContractors that check this box must attached an additional sheet showing the name of the sub-conhactor and state whether or not those entities have employees. Iftlte sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees: Below is the policy andjob site information: Insurance Company Name: T'I re/ 1;6(..4ra/tt_ (•O . pF W,4/ b.c . Policy#or Self-ins.Lic.#: U)CA 3f 5 8 c ?p7 7 • Expiration Date: /- /-2 D LO Job Site Address: -(v lc'S S Pr,ere eN .5 4•. City/State/Zip: S. ‘7,.+, L. M \ Attach a copy of the workers'compensation policy declaration page(showing the policy numb r and expiration►date). Failure to secure coverage as required under MGL c. 152,125A is a criminal violation pnniQhnI le by a fine up to$1,500.00 and/or one-year imprisonrnent,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby c under the p penalties of perjury that the information provided above is true and correct Signature: _ Date: 9—.2. 5- 1 `i Phone#: 1491 Z< 9 r Official use only. Do not write in dais area,to be completed by city or town of icia[ 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#• AC CERTIFICATE OF LIABILITY INSURANCE I J DATE(MMIDD/YYYY) •�'' I 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 PHONE FAX 1401 Lawrence St., Ste. 1200 (A/c.No.ExtI:303-988-0446 (ac,Nol:303-988-0804 Denver CO 80202 E-MAIL a IESS: COMail©cobizinsurance.com INSURER(S)AFFORDING COVERAGE NAIC N INSURER A:Acadia Insurance Company 31325 INSURED ESLERCO 01 • INSURERS: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 D: 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. INSR ADDL SUER. POLICY EFF POLICY EXP LTR TYPE OF INSURANCE iNSD wVD POUCY NUMBER INRWDDIYYYY) IIVAIO /YYYYI, LIMITS A X COMMERCIAL GENERAL UABIUTY 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 GENT.AGGREGATE UMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 • POUCY JFEC LOC _ PRODUCTS-COMP/OP AGG $2,000,000 ' OTHER: _ $ A AUTOMOBILE LIABILITY CPA3158728 1/1/2019 1/1/2020 COMBINED SINGLE LIMIT $ (Ea accident) 1.000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED tt PROPERTY DAMAGE X HIRED AUTOS X AUTOS (Per acciden $ $ A X UMBRELLA LIAB )( OCCUR CPA3158728 1/1/2019 1/1/2020 EACH OCCURRENCE $15,000,000 EXCESS LL48 CLAIMS-MADE AGGREGATE $15,000,000 DED X RETENTION$0_ _ $ B WORKERS COMPENSATION WCA315872924 1/1/2019 1/1/2020 X ST TUTS ER AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOWPARTNERIEXECUTIVE E.L.EACH ACCIDENT 81,000,000 OFFICER/MEMBER EXCLUDED? N❑N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POUCY UMIT $1,000,000 C Poluton Uablty 7930073340000 1/1/2019 1/1/2020 Each Occurrence $2,000,000 ate $2,000,000 Retroactive Date 0O8/20/2013 DDsduct ble $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 NWk- 5A�/ 1 ®1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD