HomeMy WebLinkAboutbld-20-002980 o`' ` 40 3W `p 'f?t 0Vgb
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etivr pp s.'�'+ =.P�mit expires 180 days fro!
isstitdate
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH •
Yarmouth Building Department -
1146 Route 28 ',.,
South Yarmouth,MA 02664 ��rO
(508)398-2231 Ext. 1261 5'
� � fl
CONSTRUCTION ADDRESS: /6 c qir -Nb yls R.P.
ASSESSOR'S INFORMATION: ' •
IMap: 4 7 Parcel: 7,2/
OWNER: a !� es / A 41' 7 S sic riA ozcf S c 2i l-B)I
N ADDRESS TEL # Email Addh
CONTRACTOR:Tie. Atone it-P "08 SIi n rskurry, t w 015 5 cam'-et 62 -lam I2
NAME MAILING(ADDRESS TEL•* Email A
Resider Commercial Est.Cost of Construction$ -/ S SO
Home Improvement Contractor Lic.# //o1.7e S Construction Supervisor Lk.# /OD S V C
Workman's Compensation Insurance: (rherir one)
I am the homeowner I am the sole proprietor VI have Worker's Compensation Insurance
(in;nn re 1.ASv r Wkke PoaltCp ( . orr's Comp. licy# X WC _`i.5 6 J..5 9 t
Insurance Company Name:A���e h
• WORK TO BE PERFORMED -
Tent Duration (Fire Retardant Certificate attached?) Wood Stove -
Siding: #of Squares Replacement windows:# 3 Replacement doors: # -
Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation
Old Kings]Sighway/Historic Dist. ( )Replacing Like for like ,.
*The debris will be disposed of at kf-S e. Mali JfX7'
Location of Facility
I declare umderpenal' , •starts herein contained are true and correct to the best of my knowledge and belief. fund:wand that any false anew
penalties-of.
will to just cause for denial Or'- ` , of my r _,,, and for!it!,,_ ..•I,tntderALC L Ch.268,Section 1. Q
�.� Dart~ //-2 p —/
Applicant'sSignawre: iiiil 1
Owners S gaature(or '•SW 7« 4ci C.L.Wra.G+" f"' Pate;
Approved By:
.t Date: //2 'f
Building O d )
Zoning District:
Historical Di t Yes No Flood Plain Zone: Yes No
Water Resource Protection District Within 100 ft.of Wetbuids:
Yes No Yes No
AV Home Improvement Agreement: Page2
Finance Charges:
*Any interest payments or other finance charges will be determined by Customer's separate cardholder
or loan agreement, to which The Home Depot is NOT a party, and will be in addition to Customer's
payment under this Agreement. Customer is subject to the terms and conditions of the cardholder or
loan agreement, as applicable. No funds should be made payable to Service Provider; however, Service
Provider may collect Customer's payment(s) made payable to The Home Depot.
Insurance proceeds will will not v be used to pay some or all of the total amount of sale.
Description of Work to be Performed:
Installation of Windows
A more detailed description of the work to be performed is included in the section entitled Scope of
Work which appears on page 3 of this Agreement.
Anticipated Delivery Date/Installation Schedule
Approximate Start Date: 11/26/2019 Approximate Finish Date: 12/24/2019
All dates are approximate and subject to change based on unforeseen events including inclement
weather, permitting delays, and delays in confirming insurance coverage of Your claim for any repair, if
applicable.
Electronic Records Authorization:
You are entitled to a paper copy of this Agreement if you choose. If you consent to an e-mailed copy, your
consent applies to this Agreement and all subsequent documents and written communications related to
this agreement. By contacting your Service Provider, you may update your email address, withdraw your
consent, or obtain a paper copy of the Agreement or related documents at no charge. By providing your
consent and verifying your email address above, you confirm that you have access to a computer that can
receive and open emails and PDF documents.
y i it ling this paragraph, I consent to receive only electronic records related to this transaction.
Initial
Acceptance and Authorization:
By signing below, you authorize Home Depot to (a) arrange for Service Provider to perform Installation
and/or (b) order and arrange for the delivery of special order merchandise, including special order
merchandise that may be custom made, as specified in this Agreement. Do not sign if blank or
incomplete. (Service Provider's/permitting information may need to be provided to You later.) By signing,
you acknowledge that you have read, understand, and accept this Agreement in its entirety, including
t e General Terms and Conditions and State Supplement, if any. You further acknowledge receiving a
c• • • e copy of thi greement. Keep it to protect your legal rights.
X r -.._ 10/01/2019 The Home Depot
' ustomer's Signature Date Service Provider Name
X 10/01/2019 908 Boston Turnpike Unit 1
Co-Signer (if applicable) Date Service Provider Address
X 10/01/2019 Shrewsbury MA 01545
Si.‘O half f e Depot Date City State Zip
) R-I-073-13-00016
Service Provider Pflo Nu ber Service Provider License Number
The Home Depot-2455 Paces Ferry Road,N.W.Bldg.B-3,Atlanta,Georgia 30339-Customer Care:1-800-466-3337
460FI HDE Customer Agreement(24 Jul.18) v 0.1.8
~` ' Home Improvement Agreement: Pagel
N 11
Home Depot License#'s - For the most current listing www.Homedepot.com/LicenseNumbers
MA: 107774, 112785
Janice Campbell
Salesperson Name: Registration No. (if applicable):
Home Depot U.S.A., Inc. ("Home Depot") or Service Provider named below will furnish, install and/
or service the equipment listed below at the price, terms and conditions as outlined on this form.
Hayes Gina New England South 1-MRGRORW
Customer Last Name Customer First Name Store #/ Branch Name Customer Lead! PO#
168 Captain Noyes Road South Yarmouth MA 02664
Customer Address City State Zip
gina@justdogstraining.com
Home Phone# Work Phone# Cell Phone# Customer Email Address
NOTICE OF RIGHT TO CANCEL: YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY
OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT:
908 Boston Turnpike Unit 1 Shrewsbury MA 01545
Address City State Zip
Or Email: customercancellationnortheast@homedepot.com
Service Provider Email Address
BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE
SUPPLEMENT PROVIDES A DIFFERENT CANCELLATION PERIOD. THE STATE SUPPLEMENT
CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE.
YOUR PAYMENT(S) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME
DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME
DEPOT OR SERVICE PROVIDER, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE
SAME CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED
TO YOU. OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN
SHIPMENT AT HOME DEPOT'S EXPENSE.
THE LAW REQUIRES THAT THE HOME DEPOT GIVE YOU A NOTICE EXPLAINING YOUR RIGHT
TO CANCEL. PLEASE SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL
AND WRITTEN NOTICE F YOUR RIGHT TO CANCEL.
Acknowledged by: 10/01/2019
C Signature Date
Contract Price and Payment Schedule : Payment of the Contract Pri s due upon signing unless a
different payment schedule is required by law, specified below or in a payment addendum.
Contract Price: $ 2550.00 Includes all applicable taxes. Excludes finance charges.*
Sales Tax: $ o.00 (If applicable)
*Maximum deposit ONLY applicable in MD, MA, ME(33%), NJ, WI(99%)
Dep. 25.0 % Deposit Amount $ 637.5 Remaining Balance $ 1912.50
The Home Depot-2455 Paces Ferry Road, N.W.Bldg.B-3,Atlanta,Georgia 30339-Customer Care: 1-800-466-3337
460F1 FIDE Customer Agreement(24 Jul.18) v 0.1.8
Commonwealth of Massachusetts
i, 7.1Division of Professional Licensure
Board of Building Regulations and Standards
I Construction-Supervisor Specialty
. CSSL-100546 pires: 0611812020
{
ERICSSON TOiRES k - r,w.
P.O.BOX 673 - '
SOUTH YARMOTH MAr� :664 `'.-
4 yN.,)
rG is' ,. -i S.
C,L, 44* ° '''''''
Commissioner
• f/4 [jai>?/no rtuc lf o�diet&tie z-:el1
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
TY- . • ooration
it -„ ,� Expirati9n
3 .06/.0/2021
ERICSSON He q," ;E„,g' :',�7,-. INC41
J 3
1 I. ...;,...
ERKCSSON TO
t
REVERE, MA 02.1E
The Commonwealth of i1Iassachusetts
Department of I,ndustrial:Accidents
- 1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.aov/dia
''''.1.,
b
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED W1TH 11:11 PERMITTING AUTHORITY.
Applicant Information Please Print Leaibly
Name(Business/Organization/Individual): 1--I p M e t� O p--('
Address: a0S'S ►moos--nn Turnpi Ke l
City/State/Zip: Bre w c Lv c y/ ilk Oi S 4 S Phone#: 7 7 Li -2_'1 5 - Z. 15 5
Are yo an employer?Check the appropriate box:
Type of project(required):
1. I am a employer with.20 0+employees(full and/or part-time).* 7. 0 New construction
2.0 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.]
3.01 am a homeowner doing all work myself[No workers'comp.insurance required.]t
9. ❑Demolition
10 0 Building addition
4.❑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 11.0 Electrical repairs or additions
proprietors with no employees. 12.❑,Plumbing repairs or additions
3.E1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0Roof repairs
These sub-contractors have employees and have workers'comp.insurance.:
6.❑We are a corporation and its officers have exercised their right of exemption per MGL a 1 [ ther /�/i jt (,.3
152,§1(4),and we have no employees.[No workers'comp.insurance required.] r,et4 t-!zer 4.--L5
*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'cottipensation insurance for my employees. Below is the policy and job site
information. _ _
Na
Insurance Company Name:. //6.f7atl (/I1tQ1 ./tie L77.cura-1(P_ ai,..%„, /7,/
Policy#or Self-ins.Lic.#: MAI ' 5560. 5 1 7 Expiration Date: 3 - I -2 Q
Job Site Address: //A' 6/ 7Q7/-, A/,Ves ,` ..i City/State/Zip: S. er t`7A
i
Attach a copy of the workers'compensation policy declaration page(showing the policy nu 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 imprisonm-.• . ' ell as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a
day against the violator. ' • • this statement may be.forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify an - r,, an i'enalties o r a • •• . information provided above is true and correct
Aidi in
Signature: ' '• A I r/l I Date: //'.2 O/C/
Phone#: 2/0/ - 3`l,
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#:
/722I' r:7-'7217 -7i'7i/7"7'7////2 i ter-Atli'77/7.-1<'f/r
Office of Consumer Affairs and Business Regulation
1000 Washington Street - Suite 710
Boston, Massachusetts 02118
Home Improvement-Contractor Registration
= Type: Supplement Card
Registration: 112785
HOME DEPOT USA INC Expiration: 04/22/2021
P O BOX 105451
ATTN: LICENSE MGMT TEAM cs
ATLANTA, GA 30348
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:Stioolement Card before the expiration date. If found return to:
Reaistratien Expiration Office of Consumer Affairs and Business Regulation
04/22/2021 1000 Washington Street Su' - 10
HOME DEPOT t Boston,MA 02118
ANDREW SWEET ,i /
%lug
2455 PACES FERRY RUC-11 HSC ,'oGlis�d `-
ATLANTA,GA 30339 - No> ad!' •ut si•nature
Undersecretary
•
ACO 7ATE(MMIDDIYY'�'!)
CERTIFICATE OF LIABILITY INSURANCE )2106/2C 1
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 CONTACT
MARSH JSA,'NC. /JAME:
PHOE FAX
TWO ALLIANCE CENTER A/C.NNo.Eat): A/C,Not:
3560 LENOX ROAD,SUITE 2400 E-MAIL
ATLANTA,GA 30326 ADDRESS:
INSURER(S)AFFORDING COVERAGE NAIC
CN101642069-HomeO-GAW-19-20 INSURER A:Old Republic Insurance Co 24147
INSURED INSURER a:Hew Hampshire'!ns Co 23841
THE HOME DEPOT,INC.
HOME DEPOT U.S.A..INC. INSURER C:HomeRisk Captive Insurance Company
2455?ACES FERRY ROAD INSURER D
BUILDING 0-20
A TLANTA.GA 30339 INSURER S.:
INSURER F
COVERAGES CERTIFICATE NUMBER: ATL-004353439-28 REVISION NUMBER: 21
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 'NHICH 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 'ADDL,SUBR( POLICY EFF POLICY EXP LIMITS
L TR INS()I'WVD POLICY NUMBER '(MM Y)/DDIYYYYI immiooYYY
A ! X COMMERCIAL GENERAL LIABILITY MWZY 314574 03/01/2019 03/01/2022 EACH OCCURRENCE : 5 1.300000
CLAIMS-MACE . < JCCUR , DAMAGETO RENTED
PREMISES;Ea occurrence) 3 1300,000
< SIR:51.000.000 I MED EXP,Any one person) 5 EXCLUDED
PERSONAL 3 ADV INJURY : 3 1,309,009
CENt AGGREGATE LIMIT APPLIES'ER: GENERAL A AGGREGATE : 3 1.J00,300
X POLICY 1E '_OG ' PRODUCTS-COMPIOP AGG 5 I000.000
OTHER: 5
A AUTOMOBILE LIABILITY MWT8314573 03/01/2019 )3101i2022 'OMBINED 3INGLELIMIT 5 1.300.000
iEa 3cctdeLn
< : ANY AUTO - ' 3001LY INJURY(Per person) ! 5
OWNED SCHEDULED - SELF INSURED AUTO?HY DMG 3001LY INJURY(Per accident( S
;AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE -
_� AUTOS ONLY AUTOS JNLI : (Per occident).
• i
• UMBRELLA LIAR ' OCCUR EACH OCCURRENCE ! S
EXCESS LIAR CLAIMS-MADE 'AGGREGATE 5
OED : RETENTION 5 : 3
B !WORKERS COMPENSATION 'NC 012717099(AK,NH.NJ.'/T) •03/01/2019 :03/01/2020 : x PE.RTUTE j . ERH•
B AND EMPLOYERS'LIABILITY Y N 'WC 012717100 WI 03/01/2019 03/01/2020
'ANYPROPRIETOR/PARTNER/EXECUTIVE - ( ) E.L.EACH ACCIDENT S 5.000,000
:OFFICER/MEMBER EXCLUDED') N N/A _
(Mandatory in NH) - `E.L.DISEASE-EA EMPLOYEE) 5 5.000,000
If/es.describe under Continued on Additional'age 5,000,000
DESCRIPTION OF OPERATIONS oeiow E.L.DISEASE-POLICY LIMIT 5
C Excess Auto 297110011002019 03/01/2019 03/01/2020 Limit: 4,000,000
A Excess General Liability MWZX 314580 I03/01/2019 03/01/2022 Limit 9,000,300
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more apace is required)
EVIDENCE OF INSURANCE
CERTIFICATE HOLDER CANCELLATION
HOME DEPOT USA,INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
2455?ACES PERRY ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
BUILDING C-20 ACCORDANCE WITH THE POLICY PROVISIONS.
ATLANTA,GA 30339
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Manashi Mukherjee _1K41.1suat4k:
1988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: ON'3 I342069
LOC : ,Aianta
ACOR El ADDITIONAL REMARKS SCHEDULE Page 2 of 3
AGENCY NAMED INSURED
MARSH SSA.INC. 7HE HOME DEPOT 'NC.
— — - --- -- HCMECEPOTJ.3.•A..INC.
POLICY NUMBER 3455 PACES FERRY ROAD
3WLDING -20
-- — a r LANT.a•3A 30339
CARRIER NAIL CODE
EFFECTIVE DATE:
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: Certificate or Liability Insurance —
Workers Compensation Continued:
Carrier:Indemnity'nsurance Company of North amenca
Policy Number:NLR 065890549(AL.ARFL.ID.iA.XS.KY.0.MS..NO.NE.NM.ND.OK.SC.30.7N•NV.NY)
Effective Date:03/012019
Expiration Date:03/01/2020
(EL)Limit:;5,000,000
Corner:New Hampsnrte Insurance'Company
Policy Number NC)12717098 'DC.0E.HI.iN.,MD.•NN.MT,NY,RI)
Effective Date:03/01/2019
Expiration Date:03101i2020
(EL;Limit:;5.000.000
Comer:ACE American Insurance Company
Policy Number WCU C55890586(OSI) !AZ.CA.IL.NC.JR.'/A.NA)
Effective Date:03/01/2019
Expiration Date:03/01/2020
(EL)Limit:334.000.000
SIR:11.000.000 SIR for the states al AZ.OA.IL•NC.JR.YA.NA
Carrier:National Union Fire Insurance Company
Policy Number XWC 3565596((QSI) CO.CT.GA„ME..MI.NV.OH•PA.JT)
Effective Date:03101/2019
Expiration Date:03/01/2020
(EL)Limit:14,000,000
31.000000 SIR for,he states 3f CO.ME,NV..NI.JH,PA.UT
1750.000 SIR for the state af'3A
1350,000 SIR for he date of CT
Carrier National Union Fire Insurance Company
Policy Number:XWC 5565597(OSI)(MA)
Effective Date:03/01/2019
Expiration Date:03/01/2020
(EL)Limit:34,500.000
SIR:i500,000
IX Employers XS Indemnity:
Carrier:116mos Union Insurance Company
Policy Number INS 065221019;TX)
Effective Dale:03/012019
Expiration Date:03/012020
(EL)Limit:310.000,000
SIR:11.000,000
ACORD 101 (2008/01) g 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD