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HomeMy WebLinkAboutBld-20-000968 Office Use Only (lCtle)'1 Permit# \t t ,, t3 4 �,€ C= Amount Permit expires 180 days from ''^^ issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department R- Esc _ �$ 1146 Route 28 1 South Yarmouth,MA 02664 4 AUG 21. 2019 li (508)398-2231 Ext 1261 i __ _.. __. _-_i. CONSTRUCTION ADDRESS: LL ttkel f fir 1._.a`. _._ ASSESSOR'S INFORMATION: Map: Parcel: ' OWNER: .THE, i3e4rA c ti:r c_ct. Q/>ftw. 12dr¢-- M A 6.16 7�' Sul--362-2-D S'( NAME /0 nr�ci• -( 1TE"'it Emait Addre CONTRACTOR'� fl fn N~ Onlotow` SMII- sI-li! . v )22� �NAME ADDRESS .' Email Ad( Residential.) Commercial ESL Cost of Conenction$ /''/ /'/ 2 Home Improvement Contractor Lic.# 173 2.'/3 Construction Supervisor Lie.# 0%6-7O 7 Workman's Compensation Insurance: (rhnr_k one) I am the homeowner I am the sole proprietor have Worker's Compensation Insurance Insurance Company Name: 6REireLeA..4 t PS. t .0 Worker's Comp.Policy# CA.t68'7a$)_L/ WORK TQ BE PERFORMED Tent Duration (lore Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# 5 cohl. Replacement doors: # Roofing:, #of Squares ( )Remove vee existing*(max.2 layers) Insulation tN Old Kings H'ighway/Historic Dist. ( y epladng like for like . *The debris will be disposed of at: tth de 11AA A ((.9"off._ S "�(cl 91" liberation of Feat I declare under penalties of perjury that the:,. ,,,-:,t herein contained are tine and correct to the best of my knowledge and belief. Iunderstand that any false answer( wiUbe just cause for denial. ..... .1 of m! i s• , -and for prosecution'Bader M.O.L Ch.268,Section 1. U. . hate -7 — 31 — r9 Applicant's Signanue: 4C Owners Signature(or attachment) See- 00Anagiter Data Approved By: �' Building Official(or designee) Zoning District Historical District Yes No Flood Plain Zone: Yes No Water Resource Pao District: Within 100 it.of Wetlands: Yes No Yes No 7 6/?2/22CR/Wl ead l 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 0 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 Exoiration 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 A 10 RESERVOIR ROAD SMITHFIELD,RI 02917 Undersecretary without signature Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards ConstructCon Supervisor CS-095707 F= p i res: 09/08i2020 BRIAN D DENNISON / 8 BLACK WELL'-DRIVE CHARLTON MA:01507 4� Commissioner C,4" ‘41 The Commonwealth of Massachusetts � ;�,L- Department of IndustrialAcddents 1 Congress Stree4 Suite 100 _ _ "' Boston,MA.02114-2017 Workers'Compensation Insurance Affidivit:Builders/Contractors/Electricians/P►umbers, TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): S V(,L`f'her". 'Veto tnll/ 4 o/n d,D Address: I C) ?e.Se_r UDl r ?4 . Ci /State/Zi : opt' -4 del T( OZ l ° ty P S / � 7 Phone#: �/Ol-ZZ�- 9 Are you au employer?Check the appropriate box: Type of project(required): I. I am a employer with �"O'�employees(full and/or part-time).* I. Cl New construction ` am a solo proprietor or partnership and have no employees working for me in 8: Remodeling any capacity.[No workers'comp.insurance required] ❑ 3.0I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. ❑Demolition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. [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.QPltunbing repairs or additions 5.Q I am a general contractor and I have hired the sub•contractars listed on the attached sheet These sub-contractors have employees and have workers'camp.insurance.: 13. - [;oof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c 14. Other r n rio o i4./ 132,¢l(4),and we have no employees.[No workers'comp_insurance required.] re•I4 re-.7 Pet-1 'Any applicant that checks box lt1 must also fill out the section below showing their workers'compensation policy information f" t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submits new affidavit indicating stint. Contractors that check this box must attached an additional sheet showing the name of the cob-cantcactoa and state whether or not throne entities have employees. If the 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 andfob site information. Insurance Company Name: Tt esfli1en.5_ 7;itsufame_. a . OF Wig, Cb. C . Policy#or Self-ins.Lic.#: W c it c( !c2 7 p?y • Expiration Date: /- /—2 O LO Job Site Address: ZZ -(--c r S-f-• City/State/Zip:/1 iu.)-«N avt r`l A Attach a copy of the workers'compensation policy declaration page(showing the policy number and ex iration date). Failure to secure coverage as required under MOL c. 152,§25A 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 veri li att'on. I do hereby ce under the p penalties ofperm9 that the information provided above is true and correct • • Signature: Date: ?-3 i- / q Phone#: lol -2:Zr— Official use only. Do not write in this area,to be completed by city or town o,Q3cial City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: J DATE(MM/DONYYY) A CCPRE, CERTIFICATE OF LIABILITY INSURANCE 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 IA/C.No.Ext1: 303-988-0446 (A/c,Not:303-988-0804 IL Denver CO 80202 Aooss: COMaiI©cobizinsurance.com INSURER(S)AFFORDING COVERAGE NAIC k 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 ADDL SUER . POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDD/YYYY) (MMIDDIYYYY) UMITS A X COMMERCIAL GENERAL LIABILITY CPA3158728 1/1/2019 1/1/2020 EACH OCCURRENCE $1,000,000 CLAIMS-MADE n OCCUR PR S l RENTED PREMISES(Ea occurrence) $300,000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GENL AGGREGATE UMIT APPLES PER GENERAL AGGREGATE $2,090,000 POUCY PRO- n 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 X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS (Per accident) $ A X UMBRELLA LIAB X OCCUR CPA3158728 1/1/2019 1/1/2020 EACH OCCURRENCE $15,000,000 EXCESS LIAR CLAIMS-MADE AGGREGATE $15,000,000 QED X RETENTION$o $ B WORKERS COMPENSATION WCA315872924 1/1/2019 1/1/2020 X STATUTE ER AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? n N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 Ir yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POUCY UMIT $1,000,000 C Pollution Liabtiky 7930073340000. 1/1/2019 1/1/2020 Each Occurrence $2,000,000 Claims-Made Policy Aggregate 52,000,000 Retroactive Date 06/20/2013 Deductible 525,000 DESCRIPTION OF OPERATIONS I 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 REPRESENTATIVEy /v � 1;111y, — I 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Renewal Agreement.Document and Payment Terms Andersen' dba:Renewal ByAndersen of Southern New England gl John&Mary Jane Beach ► 4 Legal Name:Southern New England Windows,LLC 22 Winter St — -�'0.� ._ RI#36079,MA#173245,CT#0634555, Lead Firm#1237 Yarmouth Port,MA 02675 WINDOW RE LACEMENT 10 Reservoir Rd I Smithfield,RI 02917 H:5083622054 Phone:866-563-2235 I Fax:401-633-6602 I sales®renewalsne.com Buyer(s)Name: John & Mary Jane Beach Contract Date: 07/15/19 Buyer(s)Street Address: 22 Winter St,Yarmouth Port, MA 02675 Primary Telephone Number: 5083622054 Secondary Telephone Number: Primary Email: john.a.beachecomcast.net 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: $12,192 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: $4,063 Balance Due: 58,129 Estimated Start: Estimated Completion: Amount Financed: $0 6 to 8(historic) 6 to 8 (historic) 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: Depo paid check/bal 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 07/18/2019 OR THE THIRD BUSINESS DAY AITER 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 Andersen of Southern New England Buyer(s) C-Ach. Signature of Sales Person Signature Signature Cory Scanlon John Beach Mary Jane Beach Print Name of Sales Person Print Name Print Name UPDATED: 07/15/19 Page 2 / 14