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Home My WebLink AboutBld-20-000967 .Office Ilse Only • ': V r _ 4 11 Permit* 4 Amount T ii �.�_,31 Permit expires 180 days from eigt; issue date EXPRESS BUILDING PERMIT APPLICA -----�_�� TOWN OF YARMOUTH E• $ V E Lbw f...0),__, Yarmouth Building Department 1146 Route 28 ! I AUG 21 2019 I South Yarmouth,MA 02664 t _�_ .._, (508) 398-2231 Ext. 1261 _�; CONSTRUCTION-ADDRESS: 34 ei.S to S ;A ASSESSOR'S INFORMATION: Map: Parcel: OWNER:SY.', O%CrErl 34 i4a s%t s%A (7J MI. .re.no��S i'^,4 D 2G 7 5 c -2 I-70 i 4 NAME D TEL # EmailAddres ivese or c�• ZZ 8�-9�a CONTRACTOR:Smitht A IA. tOgn o PCPs Sri• �e%_1l_NZ" ad/7 - CPI) NAME MAILING ADDRESS TEL Email Add Residential Commercial Est.Cost of Construction$ Sig 7$ -- Home Improvement Contractor Lie.# I7 3 2.'/.5 Construction Supervisor Lie.# O 76-7D 7 Workman's Compensation Insurance: (check one) I am the homeowner I am the sole proprietor T have Worker's Compensation Insurance Insurance Company Name: r/�fireLekis IDS. C'31n f Worker's Comp.Policy# CA 8/68'72 S.2'/ WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares - Replacement windows:# Replacement doors: # L Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings HighwaylHistoric Dist. ( ).Replacing like for like write debris will be disposed of at h/de ,✓l L.r` ``Q."0 ._ S`' ' •Q41 9_1: La:cutiun of Faca I declare under penaldes.of perjury that the -,• ,••-•• :herein contained are true and correct to the best of my knowledge and belief. Iunderstand that any false answers; will be just cause for denial or�wyocation of,• • •-• and for prosecution under M.G.L.Ch.268.Section 1. Applicant's Signature: �(y��•+'� Date: 1/—I �l t = Owners Signature(or attachment) 44C Sag- /fir COARVer Date: Approved By: _....f.odL ./ Dam ?.-4•1 `C Building Official(or designee) • 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 by Andersen. dba:Renewal By Andersen of Southern New England Kevin O'Brien .�� Legal Name:Southern New England Windows,LLC 34 Anastasia Road Alit RI#36079, MA#173245,CT#0634555, Lead Firm#1237 West Yarmouth,MA 02673 WINDOW RE LACEMENT 10 Reservoir Rd I Smithfield,RI 02917 H.(508)221-7084 Phone:401-349-1384 I Fax:401-633-6602 I salesOrenewalsne.com Buyer(s) Name: Kevin O'Brien Contract Date: 08/06/19 Buyer(s)Street Address: 34 Anastasia Road,West Yarmouth, MA 02673 Primary Telephone Number: (508)221-7084 Secondary Telephone Number: Primary Email: 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: 58,878 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: $2,959 Balance Due: S5,919 Estimated Start: Estimated Completion: 8 weeks 8 weeks Amount Financed: S2,959 Method of Payment: Cash/Check 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: 1/3 DEP 1/3 ON START 1/3 ON COMP 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 08/09/2019 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 Name:Southern New England Windows,LLC dba:Renew nn rsen of S thern New England Buyer(s) Signature of Sales Person Signature Signature Eric Woods Kevin O'Brien Print Name of Sales Person Print Name Print Name UPDATED: 08/06/19 Page 2 / 10 Office of Consumer Affairs and Business Regulation 1000 VVashington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Supplement Card Registration: 173245 SOUTHERN NEW ENGLAND WINDOWS. LLC Expiration: 09/18/2020 10 RESERVOIR ROAD SMITHFIELD, RI 02917 Update Address and Return Card. SCA I 20M-05/17 .Te Feev»irefrecee¢dii 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 173245 09/18/2020 1000 Washington Street-Suite 710 SOUTHERN NEW ENGLAND WINDOWS,LLC Boston,MA 0211 BRIAN DENNISON 12-C --- 10 RESERVOIR ROAD u SMITHFIELD,RI 02917 Undersecretary id' without signature Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constru t' n Supervisor CS-095707 = E p i res: 09/08/2020 BRIAN D DENNISON -' ylit 8 BLACKWELL�DRIVE 11 CHARLTON MA.=01507 i rl Commissioner The Commonwealth of Massachusetts �� —�,L- Department of Industria1Accidents LI _Fey= 1 Congress Streets Suite 100 -j J "4 Boston,MA 02114-2017 ..' www mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTLYG AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): S(.3ti..lh e le/1,- /Je(d,) to /G4 W i/)4LILLIS Address: /U Se.r up'r tit i . J ty p S -e del,RI OZ l v Ci /State/Zi : �t �e( q 7 Phone#: 5/D/-ZZ�— g Are you en employer?Check the appropriate box: Type of project(required): I. I am a employer with 20�employees(full and/or part-time).* 7. CI New construction 2 am a sole proprietor or partnership and have no employees working for me in $: Remodeling any capacity.[No workers'comp.insurance required.] ❑ 3.01 am a homeowner doing all work myself[No workers'comp.insurance required]• 9. ❑Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on mY property. I will 10❑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.❑Plumbing repairs or additions _ 5.CI I am a general contractor and I have hired the subcontractors listed an die attached sheet 13. airs These sub-contractors have employees and have workers'comp.insurance.: ❑ oof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL a 14. Other c��J 3o vr 152,11(4),and we have no employees.[No workers'comp-insurance required] r eP(a e&et.e Al that applicantat checks box tt l 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. :Contractors that check this box must attached an additional sheet showing the name of the sub-concactms and state whether or not those entities have employees. If the 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 Ls the policy and job site information. T'I Insurance Company Name: re�er�,� 7;j(,(,4'Q/( e_ a . OF WA. b. C C . I Porky#or Self-ins.Lic.#: ())CA 3f59 7a ip?r . Expiration Date: /' / 2 0 2-O Job Site Address: '34 Avla S-tq S;6 City/State/Zip: LI. �rrfrw.. it-,A Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiredn 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 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 verifi'iation. I do hereby c ' under the p penalties of perjury that the information provided above is hue and correct • • D - - ?bone#: 101 `Vac' 9 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#: Ac CERTIFICATE OF LIABILITY INSURANCE I DATE(MM/DDNYYY) �'r 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 Ni ON 1401 Lawrence St., Ste. 1200 Arc.i o.Exti: 303-988-0446 C.No):303-988-0804 E-MAIL Denver CO 80202 ADDRESS: COMail@cobizinsurance.com INSURERS)AFFORDING COVERAGE NAIC# INSURER A:Acadia Insurance Company 31325 INSURED ESLERCO-01 INSURER B:Firemens Insurance Company of WA,D.C. 21784 Southern New England Windows, LLC. dba Renewal by Andersen of Southern New England INSURER C:Homeland Insurance Company of New York 34452 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 TYPE INSURANCE ADOL SUBR , POLICY EFF POLICY EXP LTR JNSD$VQ POLICY NUMBER (bMAIDD/YYYY) IMWDONYYY) UMITS A X COMMERCIAL GENERAL UABILITY CPA3158728 1/1/2019 1/1/2020 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X 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 UMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 • X POUCY JERC LOC PRODUCTS-COMP/OP AGG $2,000,000 - OTHER: , $ A AUTOMOBILE LIABILITY CPA3158728 1/1/2019 1/1/2020 COMBINED SINGLE OMIT (Ea accident) $1.000.000 X ANY AUTO BODILY INJURY(Per person) $ — ALL OWNED —SCHEDULED _ AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUT03 X NON-OWNED PROPERTY DAMAGE — AUTOS (Per accideMl $ $ A X UMBRELLA LIAB X OCCUR CPA3158728 1/1/2019 1/1/2020 EACH OCCURRENCE $15,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $15,000,000 DED X RETENTION$_g_ $ B WORKERS COMPENSATION WCA315872924 1/1/2019 1/1/2020 X AND EMPLOYERS'LIABILITY Y/N ST TUTE OTH- ER - ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? a N/A E.L.EACH ACCIDENT $1,000,000 (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 Pollution Liability 7930073340000 1/1/2019 1/1/2020 Each Occurrence $2,000,000 Claims-Made Policy Aggregate $2,000,000 Retroactive Date 06/20/2013 Deductible $25,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) 1 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 / CO 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD