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HomeMy WebLinkAboutBld-20-002031 Office Ilsa Only o ' ,Z `� 0 Pemtttt l �� o Amount Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 i i i,! ,T L South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 4/q3 CONSTRUCTION-ADDRESS: g 1 Kerr( non Se 4-4 c r ASSESSOR'S INFORMATION: • • / ` Map: Parcel;C'A,•-r-4),A per' * OWNER: '66rr 4.4v/ 3I I440-1r1St' --f('r cry � 1M4 a267C sod- 737-`1ls14 NAME a Ake �ci- .. # Erne Addre: CONTRACTOR:,±67 ft N A W1POtPWP se' Q ADDRESS R.r 0 i 7 (y i)22�# -7 Email Ad( Residential. Commercial Est Cost of Construction$ / / 7 7 g Home Improvement Contractor Lie.# (7 3 2.'13 Construction Supervisor Lie.# 0 767$7 Workman's Compensation Insurance: (chk one) I am the homeowner I am the sole proprietor have Worker's Compensation Insurance A ./ Insurance Company Name:$,�SEA). I JS. OA Worker's Comp.Policy# 14 4Itr72 F 2- WQlK TO BE PEflPORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares - Replacement windows:# I 0 Replacement doors: # Roo : #of Squares ( )Remove existing*(max.2 layers) Insulation �vI 10'10 I_q �— Id Kings Highway/Historic Dist. ( ),Replacing like for like *The debris will be disposed of an 61 de ems,.►s te.'.o ff_ .i4C.e(c 2X iebsattion of Tacliit:► I declare under penalties.of perjury that the, , :: , herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer( will be just cause for denial of"" ,, and for prosecution under M.O.L.0 h.268,Section 1. Applicant's Signature: ] Date: 7—/(7)- /C( Owners Signature(or attachment) 'C S� '" s;r `I -- ' Dent Approved By; c - Date 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 6/->wno_zemeallo-/,_,,,,a_ cle-/„Iazi, Office of Consumer Affairs and Business Regulation 1000 Washington 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 1 Cr 20M-05/17 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 ALCG •--- 10 RESERVOIR ROAD SMITHFIELD,RI 02917 Undersecretary without signature Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constructs n `Supervisor CS-095707 E p i res: 03/08/2020 BRIAN D DENNISON 8 BLACKWELL-DRIVE f , ` CHARLTON MA.Q 1507 ff , -sk _ _ Commissioner The Commonwealth of Massachuseii s = —r' Department of lnduslrial Accidents ' —_ie= ' 1 Congress Stree4 Suite 100 _' Boston,MA 02114-2017 �'',. wWw.Rfass.gov/din Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNUTTLYG AUTHORITY. Apollo at Information Please Print Leeibly Name(Bush s/Organization/inividualy S b0►-th e f A.- ke to Lnq'G r)r/ //1 dailS Address: w Se r UDt r 4 . �.1 City/State/Zip:S tr1 t'1k.4 a el t ! O L9 /7 Phone#: 4O/-2.-2,ir- ? g-0 vz. Are you as employer?Check the appropriate box: p wttlt f Type of project(required): ` t. 1 am a I employees(full and/or part time).• g7. New construction am a sole proprietor or partnership and have no employees working forme in any capacity.[No workers'comp.insurance required.] 8: Remodeling 301 am a homeowner doing all work myself[No workers'csmp insurance required.]t 9• ❑Demolition 4.0 1 ant a homeowner and will be:tiring contractors to conduct all work on my property. t will 10 El Budding 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 50 I am a general contractor and I have hired the subcontractors listed on the attached sheet 13.QRoofrepairs These sub-contractors have employees and have workers'comp.insurance.: / � / 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.(►�ottler G�i i�-G�/ 152,*1(4),and we have no employees.[No workers'coop.insurance required.] (`eg1a .e-- 'Any applicant that checks box#1 must also fill cut the section below showing their workers'compensation policy information. • t Homeowners who submit this affidavit indicating they are doing all wale and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box mast attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. Ifthe sub—contractors have employees,they must provide their workers'comp.policy number. I am an employer that Is providing workers'compensation insurance formy employees Below is the policy sad job site information. c ',r Insurance Company Name: 'ri reienn In , a . OF W I4 I b.C , Policy#or Self-ins.Lic.if: LOCri 3ls8"7e 707 . Expiration Date: /- / Lo Z.O lob Site Address: "1:J Keil co M Se-f'i" a r• City/State/Ziikn.,,,..r(yh 4 r-A Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§2SA is a criminal violation punishable by a fine up to S 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 venifu at ion. I do hereby c 4 , i under the • -, penalties ofpajnry that the information provided above is true and correct ''r'''c: i ` — D._: 7- O- Phone#: 1 o1 -7-2-r— 9 0 Official use only. Do not write in thit area,to be completed by city or town Vidal City or Town: Permit/License# Lulling Authority(circle one): 1.Board of Health 2.Building Department 3.City/fown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: L Ac RE) CERTIFICATE OF LIABILITY INSURANCE DATE A tizeno°°`�'$Y' 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 NHONE S` 1401 Lawrence St., Ste. 1200 ( .Extk 303-988-0446 (*FAX Nog 303-988-0804 Denver CO 80202 ADDRESS: COMaii©cobi2;nsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Acadia Insurance Company 31325 INSURED ESLERCO-01 INSURER s: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 TYPE OF INSURANCE .Irlso „w,o POLICY NUMBER JMMIDDIY POLICY YYYUM IDDO/YYYTY, UMRS A X COMMERCIAL GENERAL LIABILITY CPA3158728 1/1/2019 1/1/2020 EACH OCCURRENCE $1,000,000 X DAMAGE TO RENTED PREMISES(Ea occurrence) $300,000 MED EXP(Any one parson) $10,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE UNIT APPLIES PER: GENERAL AGGREGATE $2,000,000 _ X POUCY JJEC LOC PRODUCTS-COMP/OP AGG $2,000,000 ^ _ OTHER: _ $ A AUTOMOBILE LIABILITY CPA3150728 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 NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS X AUTOS (Per accident' $ A X UMBRELLA UAB X accuR CPA3158728 1/1/2019 1/1/2020 EACH DC('1JRRENCE $15,000,000 EXCESS UAB CLAIMS-MADE AGGREGATE $15,000,000 DED I X RETENTION to $ B WORKERS COMP 4SATION WCA315872824 1/1/2018 1/1/2020 X TATurE OTH- ER AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE E. EACH ACCIDENT $1,000,000 OFFICEWMEMBER EXCLUDED? n L.N/A (yewyess �in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 Ifescribe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY UMIT 81,000,000 C Liability 7830073940000 1/1/2019 1/1/2020 EachOccurence $2,000,000�lms-MsPolicy gelgruep 000Retroactive Dab 08I20/2013 $ DESCRIPTION OF OPERATIONS/LOCATIONS J VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. FOR INFORMATIONAL PURPOSES ONLY AUTHORIZED REPRESENTATIVE I @ 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 46 f Renewal Agreement Document and Payment Terms byAndersen. dba:Renewal ByAndersen of Southern New England g Debra Keavy 1 Legal Name:Southern New England Windows,LLC 31 Kencomsett-:111 Cir w�sooTw,\•ucEME:-NT Rol R 360oir9RdMASmithfield,#1 R 0291745,CT 634555, Lead Firm#1237 YHa(508)737 9154rmouth Port, A 02675 Phone:866-563-2235 I Fax:401-633-6602 I sales@renewalsne corn C:(508)737-8330 Buyer(s) Name: Debra Keavy Contract Date: 06/28/19 Buyer(s)Street Address: 31 Kencomsett Cir, Yarmouth Port, MA 02675 Primary Telephone Number: (508)737-9154 Secondary Telephone Number: (508)737-8330 Primary Email: ckeavy31@gmail.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: S17,778 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: $8,889 Balance Due: 58,889 Estimated Start: Estimated Completion: Amount Financed: 12-16 weeks 12-16 weeks 517,778 Method of Payment: Financing 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: 50% has been paid by GS, 50% paid by GS at compl. Taxes paid 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 07/02/2019 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:Renewal By An n of uthern New England Buyer(s) 06-AAj Signature of Sales Person Signature Signature Kevin Desmarais Debra Keavy Print Name of Sales Person Print Name Print Name UPDATED: 06/28/19 Page 2 / 15