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HomeMy WebLinkAboutBld-20-002164 Y i%ce Use Only y ,ir.,,,r'e 0 * •� I\,`� $ Amount E..ss ; Permit expires 180 days from .---:""I':- .:"... issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (� (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: k 1 S Q.J 01- .' ( s •.C(t .A nelo-L4fV1 YIN) C/n L/ _` (,/ 4 ASSESSOR'S INFORMATION: Map: (00 Parcel: """7 0 OWNER: l CSC\ 0°CCO/14(.31A- NAME `, PRESENT ADDRESS TEL. # CONTRACTOR: 3 Jr 3*Y�Jg t(..) �Q 0 NAME ING ADDRESS TEL.# t ' "a'')S ....1....1,)1 ,4r m O Residential pomercial Est.Cost of Construction$ `'I pL.(X Home Improvement Contractor Lic.# \031 S1 Construction Supervisor Lic.# ( S C C ((o 3 Workman's Compensation Insurance: (check one) E I am the homeowner C I am the sole proprietor G I have Worker's Compensation Insurance Insurance Company Name: P \ +`'vw Worker's Comp.Policy#W(-C- 031)l c,,-)(-(--)p > 9A WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replac ent windows:# Replacement doors: # Roofing: #of Squares —77 ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: td4-1MCta-141L. /.0-RLI Location of Facility I declare under penalties of perjury that the e! ents 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' license and for prosecution under M.G.L.Ch.268,Section 1. I'� l.lt , x , Applicant's Signature ,I Date: lb T)')-�S I C[ Owners Signature(or attachment Date: Approved By: Date: )/i 57/, Building ci (or designee) EMAIL ADDRESS: Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No .1. Yes No All warranties for product supplied by the Contractor under this Agreement shall be those given by the manufacturers of such product,which shall be and hereby passed directly to the Client. Such manufacturer's warranties,the Client may be required to register or mail in a warranty card or other evidence of ownership and use of such product in order to activate such warranties. The Client's failure to send in or register such documentation,which failure voids that manufacturer's warranty,shall not create any responsibility for the Contractor to warranty such product. Note: Any changes in the contract during the duration of the project which results in additional monies due will be paid in full to the contractor at the time of the change. I authorize Sprinkle Home Improvement to act on my behalf in all matters relative to the work to be performed on this job(i.e.permits,applications etc.)if necessary. Authorized ignature Date Contractor Signature Date Brad Sprinkle-Registration number. 103757 *Tobe- f t_ bitm . The Commonwealth of Massachusetts G Department of Industrial Accidents _;,�]� 1 Congress Street, Suite 100 'Witty Boston,MA 02114-2017w www.mass.gov/dia .. Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual):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): 1.0 I am a employer with 10 employees(full and/or part-time).* 7. ❑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.] 9. ❑Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t ` 10 El Building addition 4.0 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.Q 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. :2''oof repairs These sub-contractors have employees and have workers'comp.insurance.X p 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. •Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *My 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. tContractors 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. lam 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: 11 S 9)4--,I's- City/State/Zip:SMarMo-*/'m°'(5-2"`'I 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 the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify un r the pains and penalties of perjury that the information provided above is true and correct Signa • Date: l D l f t t l 9 Phone#: 508 775-1778 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#: All . W'. 11 11 a elrs� . !i " a i - « x u I., a till 2 z•t f1 o mo3 pi . 11 t 5 I: U5-1 +v ail; III z "s; 1 II I as/ /z 1,1s 1- 3 fs a « II O O N Q 2 (6262-9wir?,G4uvec&&A fi�".���E� acAt mP al, Office of Consumer Affairs and Business Regulation One Ashburton Place-Suite 1301 Boston,Massachusetts 02108 Home ImprovementContractor Registration . . Type: Corporation SPRINKLE HOME IMPROVEMENT,INC. Registration: 173757 199 BARNSTABLE RD. Expiration: 07/06/2020 HYANNIS,MA 02601 • Update Address and Return Card SCA 1 0 20M-05/17 r e mmor4nu'eallAr 7 1atta1A cello' Office of Consumer Maim&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPO Corporates before the expiration date. If found return to: aMilitindite WOMB Office of Consumer Affairs and Business Regulation 10375T 07i08/2020 One Ashburton Place-Suite SPRINKLE HOME 0.4PROVEAENT,INC. Boston,MA BRAD K.SPRINKLE 199 BARNSTABLE RD' Not valid w alature HYANNIS,MA 02601 Undersecretary __,...1 SPRIN-1 OP ID: DS ACOREY DATE(MMIDD/YYYY) ,1, CERTIFICATE OF LIABILITY INSURANCE 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. 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 PHC/+E 508-775-6060 I FAX 508-790-1414 88 Falmouth Road (Arc,No,Ext): (Arc,No): Hyannis,MA 02601 iIiss: Kelley A.Sullivan INSURER(S)AFFORDING COVERAGE NAIC X INSURER A:NGM Insurance Company 14788 NSVR INSURER B:Associated Employers Insurance fill rn tAb a Rdrovement Inc. INSURER C. Hyannis,MA 02601 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 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 I TYPE OF INSURANCE IADt1L SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD (MMIDDIYYYYI (MMIDDIYYYYI A COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR MPT2640X 07/01/2019 07/01/2020 PREMSEs°(EaEoNccTurrencee $ 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 j ef LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY (Ea COMBINED SINGLE LIMIT $ 1,000,000 ANY AUTO M1T2640X 07/27/2019 07/27/2020 BODILY INJURY(Per person) $ OWNED X SCHEDULED AUTOSRE� ONLY AUTOS Ep BODILY INJURY(Per accident) $ X AUTOS ONLY X AUTOS ONLY (Per acc dent)AMAGE $ $ A X UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS UAB CLAIMS-MADE CUT264OX 07/01/2019 07/01/2020 AGGREGATE $ 1,000,000 DED X RETENTION$ 10000 $ B AND EMPLOYERS'ERS�UABI TY STATUTE ERH- ANYPROPRIETOR/PARTNER/EXECUTIVE YIN WCC50050167472019A 01I01/2018 01/01/2020 E.L.EACH ACCIDENT $ 500,000 QFFICER/MEMSEPEXCLUDED? N N/A SOO,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Home Improvement Contractor CERTIFICATE HOLDER CANCELLATION SPRNKHO SHOULb ANY OP 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 1 ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD