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Home My WebLink AboutBld-20-2030 L' Ontj Ot .rYT7 Amount f�a Permit expires 180 days from • ,\ l r'[2 issue date '. BLV-o�O-d D EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH - • Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 tit! ; ! a(508)398-2231 Ext 1261 3367 °1 )( ) CONSTRUCTION ADDRESS: 9 J'vfry .0 n. ASSESSOR'S INFORMATION: Map: Parcel: • OWNER CAcs/PGt q cJ'i/ry ,C/,. !./•yk/'�"4�✓f'L1 #'i A D1.6 7 3 1a 3—� 7 5-q gal 7 NAME ff� I.-1 /off D d• TEL. # E mart Addres CONTRACTOR: 1ler'A l Wii0k(P `Si�MAt<at6 ADDRESS 0437 ( i) a2 ��t Email Add Residential Commercial Est.Cost of Construction$ 9r I R c Home Improvement Contractor Lic.# 17 3 2.'13— Construction Supervisor Lie.# 04678 7 Workman's Compensation Insurance: (check one) I am the homeowner I am the sole proprietor have Worker's Compensation Insurance,�� Insurance Company Name: /�f LJUS IPS•. CADP Worker's Comp.Policy# CA'$t6r?2 6,2" , WQJK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares • Replacement windows:# S Replacement doors: # Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Sistoric Dist. ( ),$epiacing like for like *The debris will be disposed of at Ish de e/lAtet s tt.P,r►off"k— S " '"e(" i 3boetian of Pacill I declare under penalties of perjury that the 0, • herein contained are true and correct to the best of my knowledge and belies. I understand that any false answers, will be just cause for denial . ocadoa of•• and for prosecution under M.O.L.Ch.268,Section 1. Applicant's SimmomeT .r Date: /0 — 9 " r G7� Date: Owners Signature(or attachment) 'IC `,r �" Approved By: -. : I U `10'/y 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. " "rn' dba:Renewal B Andersen of Southern New England Y S Katherine Choma Legal Name:Southern New England Windows,LLC 9 Surry Ln • � * _ RI #36079,MA#173245,CT#0634555, Lead Firm#1237 West Yarmouth,MA 02673 WINDOW RELACENIENT 10 Reservoir Rd I Smithfield,RI 02917 H:(203)273-9397 Phone:401-349-1384 I Fax:401-633-6602 I sales@renewalsne.com Buyer(s) Name: Katherine Choma Contract Date: 09/23/19 Buyer(s)Street Address: 9 Surry Ln, West Yarmouth, MA 02673 Primary Telephone Number: (203)273-9397 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: 59,185 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: $3,061 Balance Due: $6,124 Estimated Start: Estimated Completion: Amount Financed: s0 8 to 10 weeks 8 to 10 weeks Method of Payment: Credit Card We schedule installations based on the date of the signed contract and secondarily on Cash/Check 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: Taxes paid in Yarmouth, Ma. 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 09/26/2019 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:Ren Andersen o uthern New England Buyer(s).7_77 Ats lor Signature of Sales Person Signature Signature Gino Montesi Katherine Choma Print Name of Sales Person Print Name Print Name UPDATED: 09/23/19 Page 2 / 12 r>7 G % // {'1'`/_1(: r '(ice; f/77.�•)7'(''/i;.)r?/ ° 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 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: Reaistratioq_ 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 10 RESERVOIR ROAD SMITHFIELD,RI 02917 Undersecretary Nr without signature r , Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construtt 'on Supervisor CS-f 9 70 Expires: 09/08/2020 BRIAN D DENNISON Y_ 8 BLACKWELLDRIVE . / CHARLTON MA-01507 :1 tea , Commissioner CAL _ The Commonwealth'of Piassachusetts ,� Jr_ Department of industrial A ccidenis ,- = 1 Congress Stree4 Suite 100 . :_;=' Boston,MA 02114-2017 < r' www mass.gov/dia J• Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plambers. TO BE FILED WITH THE PEILWWiT4YG AUTHORITY. Applicant information Please Print Legibly Name(Business/Organiration/[ndividual): Sher iv 'Ve tnn/G it/ /n 4,J,Lis Address: / ) ?e.s&uDir 1 -C.L City/State/Zip:S tq i th4 del Pt't C 9 /7 Phone#: �/O/—ZZ r- 6 Are you an employer?Check the appropriate box: Type of project(required): 1. lam a employer with 20femployees(full and/or part-time).° g 7. New construction am a sole proprietor or partnership and have no employees working for me in 8: Remodeling any capacity.[No workers'comp.insurance required] 3. I am a homeowner doingall work myself 9. ❑Demolition Y (No workers'comp.insurance required.] 4.2 I an a homeowner and will be hiring contractors to conduct all woricon mY P��Y• L will 10 Q 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.C1Plumbing repairs or additions 5.0[am a general contractor and I have hired the subcontractors listed art the attached sheet These sub-contractors have employees and have workers'camp.insurance.: 13.Q Roof repairs ,I s.a We are a corporation and its officers have exercised their right of ncemption per MGL a 14.0Other IN id. / 132,¢l(4).and we have no employees.(No workers'comp_insurance required.] r eptor ten 1u-1 "Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy intbnnation. • t Homeowners who submit this affidavit indicatinng 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. iftle sttb.contractots have employees,they must provide their workers'..,, policy number. /am an employer that Zr providing workers'compensation insurance for my employees. Below Zr the policy andJob site information. Insurance Company Name: T!rtallen1 J j0ra/we_ `p - Or 'W 4, b. C . policy#or Self-ins.Lic. #: (A/CA�3i, 872 7p?V . Expiration Date: /" /'-2.0 LO Job Site Address: q Cvcry fin. City/Stateflip: Ai.yar„„,44., 4 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$1,500.00 and/or one-year imprssnment,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 verification. 1 do hereby ce ' under the p penalties o/penury that the information provided above is true and correct I Signature: Date: /0—4.—t'} Phone#: 4101 %-_2.2,-fr--- ! .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 l#: O AC'ORE? CERTIFICATE OF LIABILITY INSURANCE OATS(MMID0I YYY) I/080013 I i THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 1 I CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES 1 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 NAME: 1401 Lawrence St., Ste. 1200 la°c.No.an. 303-988-0446 FAX Nol:303-988-0804 IL Denver CO 80202 ADORES&: COM ail i cobizinsurance.com INSURERS)AFFORDING COVERAGE NAIC e INSURER A:Acadia Insurance Company 31325 INSURED ESLERCD 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 0: 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 AWL SUER . POLICY EFF POLICY EXP LTR TYPE OF INSURANCE 1NSD,WVG POLICY NUMBER IMM/DD/YYYY) (MM/DD/YYYYL LIMITS A X COMMERCIAL GENERAL LIABILITY CPA3158728 1/1/2019 1/1/2020 EACH OCCURRENCE 3 1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $300,000 MED EXP(Any one person) S t0.000 PERSONAL S AOV INJURY $1,0011000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 X POLICY JET LOC PRODUCTS.COMP/OP AGG S 2.000.000 ' OTHER: , $ A AUTOMOBILE LIABILITY CPA3158728 1/1/2019 t/112020 COMBINED SINGLE LIMIT S (Ea accident) 1.009.000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) 3 AUTOS NOON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS (Per eecidenq_ $ — $ A X UMBRELLA LIRE X OCC(� CPA3158728 1/1/2019 1/1/2020 EACH OCCURRENCE $15,008,000 EXCESS LIAR CLAIMS-MADE AGGREGATE $15,000.000 DED X RETENTIONS 0 ER $ B WORKERS COMPENSATION WCA315872924 -- 1/1/2019 1/1/2020 X STATUTE ER AND EMPLOYERS'LIABILITY YIN ' ANY PROPRIETOR/PARTNERE INXECUTIVE El..EACH ACCIDENT 11,000,000 OFFICERS/EMBER EXCLUDED? N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S t,0o0.000 It yes.describe under 1 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POUCY LIMIT,$1,000.000 C Pollution UabiMy 7930073340000. 1/112019 1/1/2020 Each Occurrence $2,000,000 Claims-Made Policy Aggregate S2,000.000 Retroactive Date 06/20/2013 Deductible $25,000 DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if 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 AUtt''T(iOR12EDREPRESENTATIVE N I @ 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD