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bld-20-000507 F.YRR i Office Use Only :, • `� r,Permit# Q1��` y Amount ` MATTACM F. 44, �, �.o..r�o"°�;d Permit expires 180 days from issue date E Lb a-50-7 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department J� L. . ' 1146 Route 28 Ciri;:frSouth Yarmouth, MA 02664 (508) 398-2231�✓Ext. 1261 CONSTRUCTION ADDRESS: y� , 1 U �� Q 49 w, y:::�. ASSESSOR'S INFORMATION: Map: Parcel: • OWNER:/? r J Jf.:02,i L Lis k i SGt✓vlA. 7 7.2 S y oZ 2,J 3 NAME PRESENT ADDRESS TEL. # CONTRACTORP`fir i` A q,).5 I d. . i 3:2-c Ai 2.r47-t l�r,,)/ i a,.t.. // Co 8 6-7C, L2v�Q. NAME '�i MAIL G ADDRESS TEL.# / r esidential ❑Commercial Est.Cost of Construction$ 7 o i(1i Home Improvement Contractor Lic.# I V ?II() Construction Supervisor Lic.# be/893 -- V Workman's Compensation Insurance: (check one) �v` ❑ I am the homeowner ❑ I am the sole proprietor 0 I have Worker's Compensation Insurance -Li Insurance Company Name:S't,,(k t1- , z. ,Ch f) 14� Worker's Comp.Policy# 67(5A i S '`.... Q WORK TO BE PERFORMED G,) Tent Duration (Fire Retardant Certificate attached?) Wood Stove ), Siding: #of Squares Replacement windows:# Replacement doors: # / ' Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation , Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing : ('� *The debris will be disposed of at: 1 J�0 RJ � I / �y� 1 Location of Facility \�l I declare under penalties erjury that the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) Ali will be just cause for denial or v ation of license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signatu ` Date: 7/� ! 1/ �J :::se::tzatrac_ q m Date: 2/ ,ry`�J Building Official(or d e E ADDRESS: A Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No The Commonwealth of Massachusetts i2 Department oflndustrialAccidents 1 Congress Street, Suite 100 • Boston, MA 02114-2017 IMP s.• 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): Frp A 1 Address: 13.2 �`i 1 1),-)r, 12-i City/State/Zip:r�J V c)-7,x, Phone #: /sr (,(9 6 Are you an ployer?Check the appropriate box: Type of project(required): l. I am a employer with employees(full and/or part-time).* 7. ❑Ney!„cerfstruction 2.E I am a sole proprietor or partnership and have no employees working for me in 8. emodeling any capacity.[No workers'comp.insurance required.] 9. ❑ Demolition 3.E I am a homeowner doing,all work myself. [No workers'comp.insurance required.]t 10 E Building addition 4.E 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.E Electrical repairs or additions proprietors with no employees. 12.E Plumbing repairs or additions 6.E 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.= 6.E We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E Other 152,§1(4),and we have no employees. [No workers'comp. insurance required.] *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: •-'trAt. Policy#or Self-ins. Lic.#: j HC j(108 i _ Expiration Date: 5/ Job Site Address: ~�� sd— /� City/State/Zip: teed 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 yation. I do hereby certi y nder e p ins an enalti s o erjurythat the information provided above is true and correct. Sianat a Date: ! •Z--� J c Phone#: Saa (,, 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#: pJlefolyviitoz,beelea,/z4 ,52/ 0///4140,cleyk,,Jey6, Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 Boston, Massachusetts 02108 Home Improvemen , orttractor Registration Type: LLC Registration: 149840 PFR ACQUISITION,LLC 1325 AIRPORT ROAD Expiration: 02/12/2020 FALL RIVER,MA 02720 Update Address and Return Card. SCA 1 0 20M-05/17 2 e t 4,142wouue oyeldP/itadaaciumea Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:LLC before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 149840 02/12/2020 10 Park Plaza-Suite 5170 PFR ACQUISITION,LLC Boston,MA 02116 CHARLES MILOT JA 1325 AIRPORT ROAD"• YYr"`mmm "11 FALL RIVER,MA 02720 Undersecretary Not valid without signature c. Commonwealth of Massachusetts Division of Professional Licensure Board of Building Re ulations and Standards Const4pfrvisor CS-081843 •`a f ,pi• res 02/06/2020 STEPHEN T I KID a \\a 5 AZALEA LA g PLYMOUTH M 4,2364 �` 4 Commissioner Client#:73461 PELLAWINI ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 04/26/2019 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 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 N2MEACT Melissa Tanguay Starkweather&Shepley PHONE 401 435-3600 FAX 401 431-9658 (A/C,No,Ext): (A/C,No): PO Box 549 E-MAILDE ADDRESS: mtanguay@starshep.com Providence,RI 02901-0549 INSURER(S)AFFORDING COVERAGE NAIC M 401 435-3600 INSURER A:Employer$Mutual Ins 21415 INSURED INSURER B: PFR Acquisition LLC INSURER C: DBA:Pella Windows&Doors INSURER D: 1325 Airport Rd INSURER E Fall River,MA 02720 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. LTR TYPE OF INSURANCE ADDLSUBR POLICY EFF POLICY EXP JNSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) UMITS A X COMMERCIAL GENERAL LIABILITY 5D67408 05/01/2019 05/01/2020 EACH �ES(EOCCURRENCE $1,000,000 E CLUMS-MADE X OCCUR PREMISa occurrence) $500,000 • MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 RO- POLICY JET LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY 5Z67408 05/01/2019 05/01/2020 Fen,Ma ccideBINED nt)SI s1,000,000 NGLE LIMIT (E ANY AUTO BODILY INJURY(Per person) $ ALL AUTOS OWNED X AUTOSULED BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS (Per accident) X Drive Oth Car $ A x UMBRELLA LIAR X OCCUR 5J6740818 05/01/2019 05/01/2020 EACH OCCURRENCE $10,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $10,000,000 DED X RETENTION$10000 $ A WORKERS COMPENSATION 5H6740818 05/01/2019 05/01/2020 X A UTE 0TH AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y I N 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 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE.HOLDER CANCELLATION PFR Acquisition LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN DBA: Pella Windows&Doors ACCORDANCE WITH THE POLICY PROVISIONS. 1325 Airport Road Fall River,MA 02720 AUTHORIZED REPRESENTATIVE I ©1988.2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) 1 of 1 The ACORD name and logo are registered marks of ACORD #S1305339/M1305328 PRMBT