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HomeMy WebLinkAboutBld-20-002521 • Office Use Only .4,114 O fir! . H Amount :6:), o*'�E�$ Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 f� I^ L CONSTRUCTION ADDRESS: \ J e Cinne S `�G.`-k , �Gt(Yn i-f 7 ASSESSOR'S INFORMATION: Map: \ t 5 Parcel: tv. OWNER:Pf 1 '(A lb.e15 / 14-1C E 1/ 1(e UeGnY J4 63147 i 1 LiNYn JkpA'-,AP, £ ? S NAMEp PRESENT ADDRESS ttJJ TEL. # 3 "5 , 6145 CONTRACTOR:] �ir7 k�.t�641 e I-- )�5 i x94. Q . iy) 4 ( (2.(p at N I �k^L� MAILING ADDRESS TEL.# - "y7 S-t1`1 iditesidential 0 Commercial Est.Cost of Construction$ C i t �nn 51 sV — � Home Improvement Contractor Lic.# \(]3� J _ Construction Supervisor Lic.#_`3 -_D_C>(o U,Lt Workman's Compensation Insurance: (check one) ❑ I am the homeowner E I am the sole proprietor `have Worker's Compensation Insurance Insurance Company Name: P (v-k. Worker's Comp.Policy#IACL 5 X)S v 1 b74 1�141� WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replace ent windows:# I Li Replacement doors: # Roofing: of Squares '20> ( Remove xisting*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( Replacing like for like Pool fencing *The debris will be disposed of at: ,.J cA'a"L - `�► "�" Location of Facility I declare under penalties of perjury that the nts herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or revocation my 1 nse and for prosecution under M.G.L.Ch.268,Section I. Applicant's Signature: Date: lb\mil _o Owners Signature(or attachment) (5-ek Q i e �e.ls� Date: Approved By: Dom: Buildin c' r d rgnee) EM DRESS: Zoning District: Historical District: Yes No Flood Plain Zone: Yes . No Water Resource Protection District: Within 100 ft.of Wetlands: -- Yes No I Yes No 'u Ed zoo ssawj P �tljqgluetloaauz tin k. 6 asodmd setnatu 4: �� G �u .off n :.... F^- '. NTRACT xt .`" ,`, breakable or roofing; we recommend you remove any 's v' and trim� :--on walls until job completion. NOT INCLUDED IN CONTRACT PRICE J Paintin or stainin around window or d Removal of existing doors and windowsoften reveals weathering, as Well as areas that may ainted. As noted, Contractor will not be responsible for or may not be previously stained or p painting or staining these areas. J Ad'ustments or Reattachments for removal, re-attachments, or re-positioning of Contractor will not assume responsibility . w shades,blinds and/or mini blinds, and corresponding hardware. drapery rods, window RIGHTS TO CANCEL this Agreement if it has been signed by the Owner ata place other The Owner may cancel gmail than theOwner address of the Contractor, which may be his main officein branch thereof,odinary tha t the Owner notifies the Contractor in writing at hisidni midnight of the third business day posted, by telegram sent or by delivery, not later thang following the signing of this Agreement. HOMEOWNER: HIS CONTRACT IF THERE ARE ANY BLANK SPACES DO NOT SIGN T Improvement to this contract in its entirety and I/we authorize Sprinkle Home Imp Uwe acceptperformed on this job (i.e. act on my behalf in all matters relative to the work to be permits, applications etc.) if necessary. illPiewi Di // IMAtillini........_ 8 i 'i? ��1 ' og Homeowner R n. Date r ate Contractor Signature Brad Sprinkle- Rcgistr tion#103757 Erika Berg The Commonwealth of Massachusetts Ii. .../11 i r ° I Department of Industrial Accidents �!= 1'� ., 1 Congress Street,Suite 100 ,,1� Boston,MA 02114-2017 Viiir, w.ww nrass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leiibly Name(Flu siness/Organization/Indivi dual):SPRINKLE HOME IMPROVEMENT, INC. Address: 199 Barnstable Rd. City/State/Zip: Hyannis,MA 02601 Phone#:508 775'1778 Are you an employer?Check the appropriate box: Type of project(required): 1.0I am a employer with 1 0 employees(full and/or part-time).* 7. 0 New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] r—,_ 9. ❑Demolition s.(J 1 am a homeowner doing all work myself.[No workers'comp.insurance required.]1 4.0 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. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance.t . 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other (il„N c� I"'`'� 152,§1(4),and we have no employees.[No workers'comp.insurance required.] J 1 I ' *Any applicant that checks box#1 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-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: A.I.M.Mutual Policy#or Self-ins.Lic.#:WCC50050167472019A Expiration Date: 1/1/2020 Job Site Address: \ to 3e CACa/l-e 5 PG.. 4,1 City/State/Zip: g061 ,,. i ?v' - l'►P dZip J N 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,§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$250.00 a day against then violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage vVri cation. I do hereby certify under thep s }nd penalties of perjury that the information provided above is true and correct Si ture - Date: �,)—GI 1 20I 5 Phone#: 508 775-1778 Official use only. Do not write in this area,to be completed by city or town official I 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#: _.—•' SPRIN-1 OP ID: DS ACORU' CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 411em.....%- 07/03/2019 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. .n 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 508-775-6060 ACT Kelley A.Sullivan Bryden&Sullivan Ins Agency PHONE 508_775-6060 1 FAX 508-790-1414 88 Falmouth Road (NC,No,ea): (NC,No): Hyannis,MA 02601 -/ASS: Kelley A.Sullivan INSURER(S)AFFORDING COVERAGE NAIC U INSURER A:NGM insurance Company 14788 INS�R) e'm� INSURER B:Associated Employers Insurance I ( e e R rovement Inc. Hyannis, 2601 INSURER C INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 !Q ANY REQ1 IIREMENT TERM (1R C(1Nr1ITNI (1F ANY C ONTR_ACT OR OTHER DOCUMENT WITH RESPECT TO I IHI(_J-1 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 I TYPE OF INSURANCE ADDL ISUBR POLICY NUMBER I POLICY EFF POLICY EXP I LIMITS LTR INSD NND (MM/DD/YYYYI IMMIDDIYYYYI A COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR MPT2640X 07/01/2019 07/01/2020 PPREMISES EaoTuEence) $ 500,000 X Business Owners MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY I I`JE6 I I LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ ANY AUTO M1T2640X 07/27/2019 07/27/2020 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOSI ONLY X AUTOS ED BODILY INJURY(Per accident) $ X AUR�OS ONLY X AUTOS ONLY (Peeaacdent)AMAGE $ $ A X UMBRELLA(JAB X OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS UAB I I CLAIMS-MADE CUT2643X 07101i20 -9 07/01/2020 AGGREGATE $ 1,000,000 DED X RETENTION$ 10000 $ B WORKERS COMPENSATION STAR I Br - AND EMPLOYERS'LIABILITY Y WCC50050167472019A 01/01/2019 01/01/2020 500,000 AANY PR PRIIMB�PARTNE /E ECUTIVE N N 1A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE$ 500,000 It yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if mom space is required) Home Improvement Contractor CERTIFICATE HOLDER CANCELLATION SPRNKHO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES Be CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Sprinkle Home Improvement,Inc ACCORDANCE WITH THE POLICY PROVISIONS. 199 Barnstable Rd. Hyannis, MA 02601 AUTHORIZED REPRESENTATIVE Kelley A.Sullivan I ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD n 4,, O a �s5t 3 .8 ii iF w O` W c o[� id - s o m i i . - 1 mf,E o-a"9. wiii 1 pa« • li $ 4n; I it11111.° PY---- > 0///eo. . Office of Consumer Affairs and Business Regulation One Ashburton Place-Suite 1301 Boston, Massachusetts 02108 Home improvement Contractor Registration . _ Type: Corporation SPRINKLE HOME IMPROVEMENT,INC. Registration:• 178757 199 BARNSTABLE RD. � 07J08/2020 HYANNIS,MA 02601 • Update Address and Return Card. SCA 1 0 20M-005/17 /� / J?e ornm io ([ea(/or:''fCfzwarAu ells Office of Consumer Attain a Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Car:oration before the n date. If found return to: HL91aratlon Exaltation Office of Consumer Affairs and Business Regulation 109757 07/08/2020 One Ashburton Place-Suite SPRINKLE HOME IMPROVEMENT,INC. . Boston,MA BRAD K.SPRINKLE 4Q1----. 199 BARNSTABLE RD. HYANNIS.MA 02001 undefaacratary Not valid 4itUr. o� TOWN OF YARMOUTH iRCFtVFD 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451 . a Telephone(508) 398-2231 Ext. 1292-Fax(508)398-0836 i ( 1 i .QL KING'S HIGHWAY HISTORIC DISTRICT COM ITT - -0 _. i 1 7.019 APPLICATION FOR - _`,-,,.SIN CLERK CERTIFICATE OF APPROPRIATENESS SCdkl tI4idriVAgYlVm for issuance of a Certificate of Appropriateness under Section 6 of Chapter 470, Acts of 1973 as amended, for proposed work as described below&on plans, drawings, photographs, &other supplemental info accompanying this application. PLEASE SUBMIT 4 copies OF SPEC SHEET(S), ELEVATIONS, PHOTOS,&SUPPLEMENTAL INFORMATION. Check All Categories That Apply: Indicate type of Building: Commercial V. Residential 1) Exterior Building Construction: New Building Addition _Alterations V.Reroof Garage Shed _Solar Panels ✓Other: 3 is � 5 ' T(,•%v1 2) Exterior Painting: Siding Shutters Doors Trim Other: 3)Signs/Billboards: New Sign Change to Existing Sign 4) Miscellaneous Structures: Fence Wall Flagpole Pool Other: Please type or print legibly: ,, ,) Address of proposed work: I 3 J r C PNTvi I( Map/Lot# Its /6„5 �c u� Owner(s): EMC-C te 0-3 / ( LCVO Phone* �&" /S c 7- 3-+�'7 All applications must be submitted by owner or acccompanie by letter from owner approving submittal of application. Mailing address: C •0 • is, (.., g t C71 A �IA �k- t m L� S7 Year built 11 62. Email: e`I.k'.b'Z( 2 5 t`.4c. i 1 ' /Preferred notification method: Phone ✓ Email Agent/contractor: S Q rl r)iCt e &Om< ffl Yvt 1e n"1e/1'-t- Phone*SO 1S•--17 S -I-)- MailingAddress: PtS - cArnS er-c• N cien Cry o(C'o% Email: g Q r in,c a' C'' &s A-' 'nG-1— Preferred notification method: Phone Email Description of Proposed Work: r - Cke.p Vi c2 t�1.vY►GI.• A l.,;► Inc .e 0 yk-�Gt �\�' S`m 1e. P_z�c s� '' • 3>ep(cam t,.a S h.r*er-j`c-3 CaM FiVir Ca te-0 10,1S if-- arc U t4-ti e - s-ci t, ,9 Gra -_lop�d c,t,l .� w,•1-4 is ltw n�n "1 im, wpm p . Signed(Owner or agent): 1 Date: b 1 1�l t > Owner/contractor/agent is aware that a permit is required fr•,, the Building Department.(Check other departments,also.) ➢ If application is approved,approval is subject to a 10-day ap•-al period required by the Act. • This certificate is good for one year from approval date or upon date of expiration of Building Permit,whichever date shall be later. ➢ All new construction will be subject to inspection by OKH.OKH-approved plans MUST be available on-site for framing&final inspections. For Committee use only: Approved with Modifications Denied Rcvd Date: c1 Reason for Denial: Amount li Cas CK# 3 . b - g ': tp^i i' ,-. , .. Signed: Rcvd by: 45 Days: le'y--J g //(//� / Date Signed: C �f /( riL_YIA 1 APPLICATION 19 - AO68 #: