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HomeMy WebLinkAboutBld-20-000958 �: = (� o�71:-= ' C `Amount (� Ts4, 1� 4 „Arr sp a =-permit expires 120 days from (1 _20-�tc r date • EXPRESS BUILDING PERMIT APPLICATION . TOWN OF YARMOUTH ' RECEIVED Yarmouth Building Department 1146 Route 28 ` AUG > 1 2019 South Yarmouth,MA 02664 + (508)398-2231 Ext 1261 i a u 1 74T 1 CONSTRUCTION ADDRESS: /3.?.... l rpaf Lik sJerr, S ASSESSOR'S INFORMATION: ' Map: Parcel: / / OWNER�/ ,4/�SacK /1i 2 Gre.C/t.APr/0rr) Al . .S•�ar.►uv i'l A 0 2(.G`1 86 3.2S'611 NAME • PRESENT ADDRESS Email Addri CONTRACTOR:? { frle .D.6004, gag Shfewsburr tiA 013-4S- sce-g(aZ-64LI/ _ NAME MAILING1A15DREss TEi..# Email Ac 'dniial Commercial Est.Cost of Construction$ 76.Co S some Improvement Contractor Lie.# l/01.7e S Construction Supervisor Lic.# 100 S9 Workman's Compensation Insurance (rhPrk one) I am the homeowner , I am the sole proprietor vI have Worker's Compensation Insurance Insurance Company Name: A7Ti1f / nrla l (1II;on f7!`e Liz Su rp/1CP a. Worker's Comp.Policy# %We 5.5 6 53 el 1 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove - Siding: #of Squares Replacement windows:# S 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 at kk Ste. Ma/k n . Location of Facility . 'declare under penalties-of.•-' .4,. -statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer will be jest cause for denial or ... ..., of my -..- and for up.,.... n under M.G.L Ch.268.Section 1. Applicant's Signalurm 1iIrl* Date: Owners Siguature(or atta• ,ee a ' fa. Chia Gri-- -- Rate: Approved By: �� Date: i8 -d.1-6 Building Official(or designee) 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.com/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. KNAPSACK MOLLY New England South 1-MBS76LA Customer Last Name Customer First Name Store #/ Branch Name Customer Lead/ PO# 132 Great Western Road South Yarmouth MA 02664 Customer Address City State Zip (860) 828-6114 learnedm@gmail.com Home Phone# Work Phone# Cell Phone# 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 State Zip 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 DEPOT'S 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 DEPOT'S EXPENSE. THE LAW REQUIRES THAT THE HOME DEPOT GIVE YOU A NOTICE EXPLAINING YOUR RIGHT TO CANCEL. PLEASE SIGN BELOW TO ACKNOWLEDGE���� THAT YOU HAVE BEEN GIVEN ORAL TOUR AND WRITTEN NOTICE OF RIGHT' .-ANCEL. Acknowledged by: \\- ��;; N� 07/12/2019 Customer's Signature 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: $ 3665.00 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. 25.0 % Deposit Amount $ 916.25 Remaining Balance $ 2748.75 The Home Depot-2455 Paces Ferry Road,N.W.Bldg.B-3,Atlanta,Georgia 30339-Customer Care: 1-800-466-3337 460FI HDE Customer Agreement(24 Jul.18) v 0 1.8 Home Improvement Agreement: Page2 >, Finance Charges: *Any interest payments or other finance charges will be determined by Customer's separate cardholder or loan agreement, to which The Home Depot is NOT a party, and will be in addition to Customer's payment under this Agreement. Customer is subject to the terms and conditions of the cardholder or loan agreement, as applicable. No funds should be made payable to Service Provider; however, Service Provider may collect Customer's payment(s) made payable to The Home Depot. Insurance proceeds will will not v be used to pay some or all of the total amount of sale. Description of Work to be Performed: Installation of windows A more detailed description of the work to be performed is included in the section entitled Scope of Work which appears on page 3 of this Agreement. Anticipated Delivery Date/Installation Schedule Approximate Start Date: 09/06/2019 Approximate Finish Date: 10/04/2019 All dates are approximate and subject to change based on unforeseen events including inclement weather, permitting delays, and delays in confirming insurance coverage of Your claim for any repair, if applicable. Electronic Records Authorization: You are entitled to a paper copy of this Agreement if you choose. If you consent to an e-mailed copy, your consent applies to this Agreement and all subsequent documents and written communications related to this agreement. By contacting your Service Provider, you may update your email address, withdraw your consent, or obtain a paper copy of the Agreement or related documents at no charge. By providing your consent and verifying your email address above, you confirm that you have access to a computer that can receive and open emails and PDF documents. 'oni 'aling this paragraph, I consent to receive only electronic records related to this transaction. B Initial Acceptance and Authorization: By signing below, you authorize Home Depot to (a) arrange for Service Provider to perform Installation and/or (b) order and arrange for the delivery of special order merchandise, including special order merchandise that may be custom made, as specified in this Agreement. Do not sign if blank or incomplete. (Service Provider's/permitting information may need to be provided to You later.) By signing, you acknowledge that you have read, understand, and accept this Agreement in its entirety, including the General Terms and Conditions and State Supplement, if any. You further acknowledge receiving a complete copy of this Agreement. Keep it to protect your legal rights. X 07/12/2019 The Home Depot Customer's Signature Date Service Provider Name X 110' 07/12/2019 908 Boston Turnpike Unit 1 o- igner R app icab e) Date Service Provider Address 07/12/2019 Shrewsbury MA 01545 i•natur:<4 n Beh • e De•of Date City tate Zip �.� M IIIIIIIII R-I-073-13-00016 ervice `rovi—:' o Nu ber Service Provider License Number The Home Depot-2455 Paces Ferry Road, N.W.Bldg.B-3,Atlanta,Georgia 30339-Customer Care:1-800-466-3337 460FI HOE Customer Agreement(24 Jul.18) v 0.1.8 poi Commonwealth of Massachusetts 7-07 Division of Professional Licensure Board of Budding Regulations and Standards Construction Supervisor Speciait,• CSSL-100546 Expires; 06118/2020 ERICSSON TORRES P.O.BOX 673 SOUTH YARMOUTH MA 02664 ` C/1... /1-.A.-°°- . Commissioner The Commonwealth of Massachusetts Department of Industrial Accidents ra, it 1 Congress Street,Suite 100 _a y_.= Boston,MA 02114-2017 = www.massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/PIumbers. TO BE FILED WITH 1'HE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organi7ation/individual): Hon— e t (p-' Address: q OS +�oS-1.-Dr) Tu rt"pi K e. City/State/Zip: re c l v r yt 1`1 A of s i-t S Phone#: -7 Li -2.-7 5 - L i 5.S Are yo an employer?Check the appropriate box: Type of project(required): l.Iaam a employer with 20O+employees(full and/or part-time).* 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling any capacity.[No workers'comp.insurance required] 3.0I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. 0 Demolition 10 0 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 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.®I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.❑We are a corporation and its officers have exercised their right of exemption per MGL a. 14.121. flier r r 152,§1(4),and we have no employees.[No workers'comp.insurance required.] rep l4 ce--+e-,143 *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I 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-contractors 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 is the policy and job site information. _ Insurance Company Name:. Nafbl7Gtl al►01 'A t,te I-4.cur4/1P# an--only Policy#or Self-ins.Lic.#: X/VC 5 S ('53 °1 7 - Expiration Date: 3 — I '-2 C) Job Site Address: /a)2 6fe.r.7f-t„ .Siii.r/, S J- City/State/Zip: S.(r,' ..44L, h A Attach a copy of the workers'compensation policy declaration page(showing the policy num er and expirfitioa 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 imprisonm:.. as ' ell as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. ' py• this statement may be,forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify un, ' =,, an,in ,enalties o , - , - ' information provided above is true and correct • .Extr/fm- 1 Signature: %of / / Date: '1-/— / Phone#:, 116/ ' .- .3 1 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#: !mil'/l>d%>/'7///=L'(//f (/. /�/�111 // Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvemea .Contractor Registration Type: Supplement Card Registration: 112785 HOME DEPOT USA INC Expiration: 04/22/2021 PO BOX 105451 ---- `=i ATTN: LICENSE MGMT TEAM ATLANTA,GA 30348 - Update Address and Return Card. SCA I C+ 20M-05/17 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPEKAupolement Card before the expiration date. If found return to: Reaistlien Expiration Office of Consumer Affairs and Business Regulation 04/22/2021 1000 Washington Street Su' 10 HOME DEPOT 0 _ Boston,MA 02118 ANDREW SWEET ;%' 2455 PACES FERRY f c-t1 HSC % •�� / �•'` - ATLANTA,GA 30339 No alid1 •ut SI•nature Undersecretary ACO O® CERTIFICATE OF LIABILITY INSURANCE D02/06/2019DmrYY) 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). PRODUCER CONTACT MARSH USA,INC. NAME: • TWO ALLIANCE CENTER PHONE I FAX 3560 LENOX ROAD,SUITE 2400 EMAIL Eat): IA/C,No): ATLANTA,GA 30326 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# CN101642069-HomeD-GAW-19-20 INSURER A:Old Republic Insurance Co 124147 INSURED INSURER B:New Hampshire Ins Co 123841 THE HOME DEPOT,INC. HOME DEPOT U.S.A.,INC. INSURER C:HomeRisk Captive Insurance Company . 2455 PACES FERRY ROAD BUILDING C-20 INSURER D ATLANTA,GA 30339 INSURER E: • • INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-004353439-28 REVISION NUMBER: 21 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 IADDLISUBR I POUCY EFF ' POUCY EXP LTR; I INSD'WVD POLICY NUMBER i IMM/DD/YYYYI I IMMIDDIYYYY)I UMITS A 1 X !COMMERCIAL GENERAL LIABILITY 'MWZY 314574 '.03/01/2019 i 03/01/2022 EACH OCCURRENCE 1 S 1.000,000 CLAIMS-MADE i X ! OCCUR DAMAGE TO RENTED ; 1,000,000 PREMISES(Ea occurrence) X SIR:$1,000.000 MED EXP(Any one person) $ EXCLUDED PERSONAL&ADV INJURY 1 s 1.000,000 GEN'L AGGREGATE LIMIT APPLIES PER !GENERAL AGGREGATE i 3 1,000.000 X !POLICY PRO- LOC JECT PRODUCTS-COMP/OP AGG 3 1.000.000 OTHER: 5 A AUTOMOBILE LIABILITY ! MWTB314573 1 03/01/2019 03/01/2022 COMBINED SINGLE LIMIT 's 1.000.000 (Ea acraden0 X :.ANY AUTO _ •• BODILY INJURY(Per person) '$ 7-1 OWNED SCHEDULED SELF INSURED AUTO PHY DMG • _ AUTOS ONLY AUTOS BODILY INJURY(Per accident)!3 HIRED —7 NON-OWNED PROPERTY DAMAGE AUTOS ONLY ,_AUTOS ONLY i(Per accident) $ $ UMBRELLA LIAB _ OCCUR 'EACH OCCURRENCE $ ! i EXCESS LIAB i !CLAIMS-MADE; AGGREGATE $ • DED RETENTION$ $ B I WORKERS COMPENSATION WC 012717099(AK,NH.NJ,VT) ;03701/2019 ;03/01/2020 1 X , - I •AND EMPLOYERS'UABILITY P STAER TUTE O ERTH B I YIN ; ANYPROPRIETORlPARTNERJEXECUTIVE ' WC012717100(WI) 03/01/2019 `03/01/2020 5.000,000 '.OFFICER/MEMBER EXCLUDED? N :IN/A: E.L.EACH ACCIDENT $ (Mandatory In NH) ; E.L.DISEASE-EA EMPLOYEE 3 5.000,000 If yes,describe under • Continued on Additional Page • I DESCRIPTION OF OPERATIONS below 9 E.L.DISEASE-POLICY LIMIT I$ 5,000,000 C Excess Auto 1 I 1297110011002019 03/01/2019 03/01/2020 !Limit: i 4,000,000 A I Excess General Liability i 1 I MWZX 314580 i 03/01/2019 03/01/2022 1 Limit: 8,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD lot,Additional Remarks Schedule,may be attached if more space Is required) 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 C-20 ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee -IvCoLuaok.z. ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN101642069 _ LOC#: Atlanta A`OR 0 ADDITIONAL REMARKS SCHEDULE Page 2 of _ 3 AGENCY NAMED INSURED MARSH USA.INC. THE HOME DEPOT.INC. HOME DEPOT U.S.A..INC. POLICY NUMBER 2455 PACES FERRY ROAD BUILDING C-20 ATLANTA,GA 30339 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Workers Compensation Continued: Carrier:Indemnity Insurance Company of North America Policy Number:WLR C65890549(AL.AR,FL.ID.IA.KS.KY.LA,MS.MO,NE,NM.ND.OK,SC.SO.TN,WV.WY) Effective Date:03/01/2019 Expiration Date:03/01/2020 • (EL)Limit:S5,000,000 Carrier:New Hampshire Insurance Company Policy Number'NC 012717098 (DC.DE,HLIN.MD.MN.MT,NY.RII Effective Date:03/01/2019 Expiration Date:03/01/2020 (EL)Limit:35.000,000 Carrier.ACE American Insurance Company Policy Number WCU C65890586(OSI) (AZ.CA.ILNC.OR'/A,'NA) Effective Date:03/01/2019 Expiration Date:03/01/2020 (EL)Unlit:$4,000.000 SIR:S1.000.000 SIR for the states of AZ,CA,IL,NC.OR.'/A.WA Carrier National Union Fire Insurance Company Policy Number.XWC 5565596 PSI)(CO.CT,GA,ME,MI.NV.OH,PA.UT) Effective Date:03/01/2019 ExOration Dale:03/01/2020 (EL)Limit:14,000,000 31.000,000 SIR for the stales of CO.ME,NV,MI,OH,PA.UT 3750.000 SIR for the stale of GA 8350,000 SIR for the state of CT Canner:National Union Fire Insurance Company Policy Number.XWC 5565597(OSI)(MA) Effective Date:03/01/2019 Expiration Data:03/01/2020 (EL)Limit:34,500.000 SIR:3500,000 TX Employers XS Indemnity: CanierttHnios Union Insurance Company Policy Number.TNS C65221019 iTX) Effective Date:03/01/2019 Expiration Date:03101/2020 (EL)Limit:310,000,000 SIR:S1.000,000 ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD