HomeMy WebLinkAboutBld-20-002729 v:0 u` ' Office Use Only
0 , Permit#
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`^ Permit expires 180 days from
B Lb—2,0_01 7 2,9 issue date
EXPRESS BUILDING PERMIT APPLICATIOl'I
TOWN OF YARMOUTH
Yarmouth Building Department ; �_!7
�� girl
1146 Route 28 t
South Yarmouth,MA 02664 ' , :- ; ;--ligf,92....
( 08) 398-2231 Ext. 1261 . '`3 Y
CONSTRUCTION ADDRESS: 3 I F;cti i.�� f ro t ok I
ASSESSOR'S INFORMATION: -
Map: Parcel:
OWNER: lifNAME
4n 3/ !'•rti1^3 3xo0PRESENTADDRLSS teNry ,, HAozd� Ca-f7--008S'
TEL # Email Address:
CONTRACTOR:h nd J t,.l l foc LI e•C 10 on,L LM .24Cvou►'1in S t�K Is-A LAN re) '1 i (7 g 1) 4 52-Li80 5-"
NAME MAILINGADDR SS 0l8'o i TEL.# Email Addre.
idential Commercial Est.Cost of Construction$
Home Improvement Contractor Lic.# /�o4.02S Construction Supervisor Lic.# 0 72.772-
Workman's Compensation Insurance: (check one)
I am the homeowner I am the sole proprietor Worker's Compensation Insurance
Insurance Company Name: 4353G ia4e.eQ
En y:Joyer S Worker's Comp.Policy# 0 0 --SOO 5-0 1.i_60QCt--
.2019 At
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares Replacement windows:# 5" Replacement doors: #
Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for like
*The debris will be disposed of at: t t�cle l'Ig4a SCm e, 7 — Afah veil , il A
' Location of Facility
I declare under penalties of perjury the sue _ .. . 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 rev.,4. ciiiio—,,140;,_ _ _.•. M.G.L.Ch.268,Section 1.
Applicant's Signature: k►.if-' �IL Date: //--G —I Ci
Owners Signature(or a , ,,ent) Date: // ^�
Approved By: /7 Date: 1 — /
:• cial(or .i• -*'
Zoning District:
Historical District Yes No Flood Plain Zone: Yes No
Water Resource Protection District Within 100 ft.of Wetlands:
Yes No Yes No
• Windqo� w world of Bbston MA HIGRoglelrauon
1 .. yU Offlcos&Showrooms. Number:
r r t�.i TA CUhlMblas Palk - 2a'f Old O1l Sltegt tt SQ80 609]Ott Turnpl 1000'
V + 1 40i ,0.4ii* 00Sl Ste ty. (flue. 8 di#94� . . and.,ii
. ;t78'11 4B4i .7(70113120081 i 7a
.wwW W/Iodine olidotatfsttori.0om
customer C r�`z9!2[.o?1t Ho vA•nM • Phone•(h) n
ItinallAddress: l/ �!�//�theid t9gao1( i // Phone.(d) ,1 `.51/-P°0$ + ' ( 6t1, 0
city: S;:kili i �7•S c stoarnn Stele:MA Zip p z ( •E•mad ('/�Ar4,G Merl- '7�_4 N'Q
WINDOW WORLD GLASS OPTLONS
t000 Series.3lpQle hung All-Wald $245 . A yalarZone Ellie-ouaf.Pans S148 7��
20Q(Se11es DM Al jNeld 3259 rg.
�•4000SeodesDHJUFWeId s2ee.575 Triple.Pane -vies
6000:8ktiesOH'All•Weld $309 WINDOW'OPT1ONS
$lJte Slider 3439
$689 (ilea t3re&one waa8nly.(400d/8000)'$16 INC4t1DID
_�9 L1.41eidar 1N.iq_1W pif36.m -seep lR p.
^.i*.ning cerflite(p 99 VI) $419 _,__1/2$seems 5.;.,�
PIciiKe!Fiirs¢.Lite (84:130 vq $539 _Foam InsufaiiOn on Jambs and Head Sib INCUJ020
^Avllning. . $369 Double Strength Glass(4000/6000) S15 INCLUDED
(1` tas'emem Phis s4$.(Dm 3aah RA$kim _Double Locks(>26't Sc INCLUDED
1SV' ♦t\fir 2°LTIe:lCaeeinunt $859 _Double
Screens S25
/v� 3 Lltti:S nt da-no lei OK r.:+Al, $t02$ Colonial Grids(Contoured/Nag 585
�` ` LBaaamell.Hopper $9ti1t. [+�airla(3rtQ9 373
1 _BaQ 1AA�ldobr�..o61tM0upt/1NS S-80t-285$ .SimUkted.Ordeid•ate ssag .
\ —•BO*Whdoi aoUnt/IN9•tieet$2098 )FI§ash(BSb (SO) 3 9
tt'�'V Oaz4en Vindew s2tz9 Ql. •:, otiaat... i1._. sra
�Ba� ow Camden Q�4k/atae (++11$LU)S9y9 Ot<h) �ql t�aot-ao/�o) s7a:
0 \0\& . .— vg e/.mIn iiiti &,,:-0. Fnarrl-Enhanced Frame $9§'
_WO Ciralp intarlw(sbrks ego07._aJy13100:
(Light gale/Dark t>Rid:Caary J Fwetlfood ARIi 1979 BUILT HOMPS(Blip SAFE•ASWOVA
Alcii'OM 1 MY HOME WAS:DUILr INTHE VCAH T. !nil 1
.Orromliatiet.Wabsreft:e/Americ4eTerra)s1o0 MISCELLANEOUS
Speciality Wetterior 8179
_Speciality Window S h Custom Exleno►Aluminum Cladding(Twoa8ond
J Textured 5 j 90 rliJ.¢:8moolit390 S O.
6\0c41 )
. WindoswCo(ot. W / ti ca-r
Arras oatras Facing Cole: 1k/A Ps'
Muft4Bend Cladding Si*
NON WM/4 DOORS ~rinsleli mien r/Elderiar,Stops $50
WnytRoUtng Patio Door'Sit.ai en. St219 Install Interior.casing Stpns At.s9S
l-Vinyl Roiling Fano Door 05. St Repair SUL Jamb or rep(aceal8 nosing S75-
_fiddle baselsiettfOt momRoeagPaao0oor __FuilSub-Stll(Singielreplacement. Sin-French Rail s1k11ng Ps1lO Doe Sit.or BIL 51539 _Insulate Weight Sexes S2 .
en ROO 5tl kg Pado Door Mt • Mull to Form Misll tmk 530
Fieltenflail-iiiiin:PedaDoprna si749 �MullionRemoval S50
_-c911 oe1E>tlertoigaddk+p
-• ;Saran,Snit 53to Metal WlndoW Reono al S75
btie$padd00dr • sale-. •NewConatn�FonVtnyl.Removal. 917S:
,_._Woodgtatiiti�l do 535g�_ 'I4oW Const:E1rt.9elrn FIt $15;
_ •diesikdeet . .•• •S = _•: ftpottor Bay/0w. lndowa• StOd' —
esegor. VS 3vr $zee Removal.of;Hi tsllntlay/Bow '$250`
Handlega s B eneinvGoneeitienitie:R9Ito FM- 4.450 ,
_(edoi... tabctootPlI1)� 5+354• .(New Siding Will Wallah). •s - .-
- HOUND.UP FOR-WNINDOW-.WORL;D:CARES
' gpgc-001o(. . I • $I.hih OhlNalri Ringo'Swim- S 414
alien .Oatifde F®,.. .
•G ornet Oeo6ties 0).1e11df.41fs11 acid Lind$$laltdspe(nling.ariWor tep*N.may Ge Ihitlet
Oti terii0•daeilnee:midi-,4n £ M!WitlPNr/dogre tgltl C I
1010WWINIIIRTitil t NeriBttb*salitaMdmc6xlNiitdiiese ep POil ti Nano tYsitet rnoaa;•04NiPpmt iNAis I
e ORROMAIIInettnti#11810004011%Mkil MONAieslale.OfndOSIS iitlt.DWI li(W6aOuMk2'3ildtr»SPiaaR(NltslyEth
(�oiliCrgAWCRK(F•NOTIN.witinu I .Custo(ner•agreesto:tfi,temis.O(paYm t•t18-r,DI)otee:
le
rr __ Ex4ia Lab.:&Material $ t4. -7•
itio QYU 0 OJT l eea ' Ma Sal Up.Perms,asposal&Delivery Fees$ O0
t-„ias r', Al` AlTotal Amount S �Q y •`• �
K����"�� Custom Order Aeposlt 33% S/' 7' .Ckl As
• Pro)e.t Steen Payment 33% S 7
Balance Due Day of lnstNtallon $f
. • Amount Rn/ulced v • • ice
wieste*deet%weosal yiinie eptitvtetkyry *MiL.NWs92ntla1 etwi?! 10 days SttlaiAl. s as V
h10. 114.'dhadthhoaal:Mw ikwo(M•11 Nitit �-TfiF0NaH( algrwis eRlaew -w ote. 6
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IkjauWft91Nl.Is ixililied 1 kl blo ivanl of a durp$i(agsa m sntirOOVaymotn.aia.p IHIA$tin net i»Wilted least.a 015$St i
.d • finellia0.netti a(10 b0034tdia!(ra42t4`etat,. ft
t iebe r�iaY a geii }trr4essitUlinip INIy litill p1t0,Jrla'Wh1 141Wifi tdbukkiOn.da�1 entrdbad461 at ld[s:lnewebftoa.
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aoawof•n Yatb Copy•OprKw1 *sow Copy•Pio PIA Cop►'•Cdlant&r own e.r«..%tot t.y
am-
Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Construction Supervisor
CS-072772 Expires: 04/07/2020
JEFF C STEELE ' •
24 SHERWOOD AVE
DANVERS MA 01923 •
Commissioner CAL
^f;4,'(r.Nr MP aWP(ild
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
TYPE:LLC
Be9La !
1®Bon 04/1112020
WINDOW WORLD OF BOSTON,LLC.
JEFF C.STEELE 4.Cl ---^
15A CUMMINGS PARK
WOBURN,MA 01801 undersecretary
e Co intro nwear t or' Iassacri rserrs
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 0211=14017
www.mass.s ov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED Mitt IRE PERMITTING G AUTHORITY.
Applicant Information Please Print Legibly
Name (Business%Organivation/Individual):Lij-, js-10n QJP/m-T,qj.L/1('. .d8 4 t,7,-;('a,Aid dot d- a 44
Address: 15 A Cum r-%
City/State/Zip: In/ohvr'n FM D t k o) Phone#: 7 'I - S Z-L/ p 5
Are yoq an employer?Check the appropriate boa: Type of project(required):
1. I am a employer with (7 employees(full and/or part-time).* 7. ❑New construction
2.❑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 Q 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
10 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ,
These sub-contractors have employees and have workers'comp.insurance.« l�.❑Roof repairs A '
o.❑We are a corporation and its officers have exercised their right of exemption per MGL a. 1 1.L J Otiller wl
152,31(4),and we have no employees.[No workers'comp.insurance required.] .n 43
"Any applicant that checks box#1 must also all 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 ssoc i o f e d ei Phu ye r S
Policy#or Self-ins.Lic.#: C. -5-DC)- cc /gto O cl- 2011,0k Expiration Date: L/- '- 2 0
Job Site Address: 3 ( (-i c , 1,trok City/State/Zip: s /',r/o 4
Attach a copy of the workers'compensation policy declaration page(showing the policy num er 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 'olator.A co o this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verific 'on.
I do hereby certi undr he pa' a enalties of perjury that the information provided above is true and correct.
Signature: I Date: /t'- — �9
Phone#: g ' 8- y 3 9 S
Official use 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#:
Accal? CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNYYY)o3rzsr19
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 NAME CT amy roberts
M.P.Roberts Insurance Agency Inc. (PAHoo,NNo.Exn: 978-683.8073 FAX No: 978-683.3147
1060 Osgood Street E-MAIL m r
North Andover, MA 01845 ADDRESS: amyl p oberts(nsurance.com
INSURER(S)AFFORDING COVERAGE NAIC#
INSURER A: WESTERN WORLD INS COMPANY
INSURED INSURER B: MERCHANTS INS COMPANY
L&P BOSTON OPERATING,INC INSURER C: ASSOCIATED EMPLOYERS
DBA WINDOW WORLD OF BOSTON INSURER 0:
15A CUMMINGS PARK
WOBURN,MA 01801 INSURERE:
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,
L EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR RUM MUSH' POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSD VyyD POLICY NUMBER (MM/DD/VYYY) (MMIDD/YYYY) LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE TO D
CLAIMS-MADE 1"1 OCCUR PREMISES(Ea ocr currence) $ 100,000
MED EXP(Any one person) $ 5,000
A NPP8525379 04/05/19 04/05/20 PERSONAL S ADV INJURY $ 1,000,000
GENt AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000
1 POLICY 7 78r n LOC PRODUCTS-COMP/OP AGO $ 1,000,000.
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
_ (Ea accident)
ANY AUTO BODILY INJURY(Per person) $
B OVtRJEO X SCHEDULED MCA1002589 04/05/19 04/05/20 BODILY INJURY(Per accident) $
AUT0.4 ONLY AUTOS
X
HIRED X NON-OWNED PROPERTY DAMAGE $
_ AUTOS ONLY _ AUTOS ONLY (Per accident)
$
X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,000
EXCESS UAB CLAIMS-MADE AN065362 04/05/19 04/05/20 AGGREGATE $ 1,000,000
DED RETENTION$ $
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY X STATUTE ER
C OOF'FICER/MEMBER EXCLUDED?/ XECUTIVE —i N/A WCC-500-5018609-2019A 04/05/19 04/05/20 EL EACH ACCIDENT $ 1,000,000
(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 I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it 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
EVIDENCE OF INSURANCE ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REP ENTATIVE
I /C1t )rLItYVV4.416.42--
O 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD