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HomeMy WebLinkAboutBld-20-001181 Office Use Only t O 4,'' _'Permit# i' +�c �'� Qqq ' � tr ,. lid',► r Amount Mwrrwen w '' ...u�;:d% `Permit expires 180 days from 1 -'1:. ( �� 'issue date J3�.1D-,,.. . //g EXPRESS BUILDING PERMIT APPLICAIIO E ! V E D TOWN OF YARMOUTH f..A_Ur Yarmouth Building Department 2019 1146 Route 28 _ _ Gry South Yarmouth,MA 02664 BUILDING DEPART N. (508)398-2231 Ext. 1261 BY --- --" CONSTRUCTION ADDRESS: I,'1 IV n r-('1-‘ Mai,- \ S-r' ASSESSOR'S INFORMATION: Map: Parcel: OWNER:St/ 'n f In c Ado y i t 1 /1•Mu:w.. ,S r. ' S 1 yat(eh). . ti A 02.444 5 b8-39 4'S 88 I NAME PRESENT ADDRESS / TEL # Email Address: coNTRACTOR � .j�co G .��A P .24 Pe�uc Sf./� , A o'er o I '-800-341-2.2!1 NAM/ / MAILING ADDRESS `/ T L# Email Addre esidential Commercial/ Est Cost of Construction$ 3) S - — Home Improvement Contractor Lie.# /Y t c/I Construction Supervisor Lie.# //0 7 6,.3 Workman's Compensation Insurance: (check one) I am the homeowner I am the sole proprietor Illuive Worker's Compensation Insurance Insurance Company Name: 6aeri"U i-el S.- Worker's Comp.Policy# Al Ea,ve, pi$ 7 7 g' WORK TO BE PERFORMED , Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares • Replacement windows:# 2- Replacement doors: # Roofing: #of Squares ( )Remove exjsting*(max.2 layers) Insulation Old Kings Highway/Historic Dist. .(- )Replacing like for like ok *The debris will be disposed of at: AA S 4.rlai►.c y.#ri-Pell G dp4.i r.0t .IA Location of Facility I declare under penalties of 4011 the statements 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. i,:I .of my license and for prosecution under M.G.L Ch.268,Section 1. Applicant's Signatniet_- I Date: g'2'& Owners Signatoye(or + . ,, ,) Se a et.-f'1'a-C Ca—,.-teat cal" Date: Q /��" Approved By- A Date: 6 Owl / / Building ( ) Zoning District: Historical District Yes No Flood Plain Zone: Yes No Water Resource Protection District Within 100 ft.of Wetlands: Yes No Yes No Page 1 of 11 MA Reg 4146589 CT Reg S0605216 Federal ID#20-2625129 Window / Door Contract l)J (S Customer Information susan mcavoy (508) 394-5881 () Date: 07/22/2019 139 North Main Street Suemcavoy68@gmail.com Rep: Leo Duplessis South Yarmouth MA 02664 Office# 800-242-9974 Location Agreement NEWPRO hereby agrees that;it will,for the:consideration hereinafter mentioned, furnish all:labor and material necessary to install the goods purchased by Owner in accordance with the terms described Ph the following pages of this agreement (collectively,this "Agreement")at the premises located at: 139 North Main Street South Yarmouth MA 02664 Windows Being Installed. . 2 Doors Being Installed. 0 Window Details Location: Bedroom 1 Series: Enviro XR5 Deluxe 2 Lite Slider Interior Color: White Screen Type: Full Exterior Color: White Grid Pattern: None Hardware Finish: White Grid Type: None Additional Labor: (Conversion) Glass Options: None Location Bedroom 2 Series. st. Interior Color: White Enviro XR5 Deluxe 3 Lite Slider 1/4 x 1/2 x 1/4 Exterior Color White Screen Type Full Hardware Finish: White Grid::Pattern. None Additional Labor: (Conversion) - Grid;°Type_ None Glass Options _ None window Capping Colored Capping Capping Texture PVC Capping Color Clay 42637 Additional Details Newpro will remove any demoed or installation debris from the property in relation to this contract. All promotions were applied at the time of:purchase and:can not be combined:with any future offers. Discounts Senior Discount Applied Payment Total Price: $3,528 Deposit $0 Due Upon Completion $3,528 This space intentionally left blank e uT:>G gitai r.;m 1.s.2-) Page10of11 Terms and Conditions Owner has read and agrees to the terms and conditions of this Agreement. Owner specifically agrees to the (1) Total Cash Price; (2) work being performed; and (3) work not being performed. Owner understands that this Agreement and any attachments contain all of the promises made by NEWPRO. Owner has been orally advised of his right to cancel this transaction at any time prior to midnight of the third business day after the date of this transaction and Owner was provided with two (2) copies of a cancellation form explaining this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. YOU THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY OF THIS TRANSACTION. SEE THE ACCOMPANYING NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS RIGHT. The undersigned gives NEWPRO permission to debit their checking/savings account, or process a credit card transaction, for the deposit amount indicated on or after the contract date. Subsequent payments, such as start payments, or completion payments will remain in effect until I cancel it in writing, and agree to notify NEWPRO of alternate payment intentions. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that NEWPRO may at its discretion attempt to process the charge again within 30 days. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and will not dispute the scheduled transactions with my bank or credit card company; provided the transactions correspond to the terms indicated in this authorization form. iws/y6,-:\•\.'CA/Y171{ susan mcavoy 07/22/2019 Date Leo Duplessis 07/22/2019 Date This space intentionally left blank ',Dina nrn`.1.'29 j'. i i :e�^ t O R r r r ! i i !lice� . � gr; ;./�f� :� ..;f :' �.S�tS�.i3. on T/pe: 3l:ccier^sr. �3r= gIstrgticn: l 4,3589 ,'IC'I'f?RC;CAR - f I1`IG =x EFifadon: -n4•7' ;� ' - '�71v 25 CEDAR S IT ilr°BURN, .'L, 0'301 Update Address Ind Return Carl. !%I 1, �.•/////•/)//,/•//.'/// :%7./%.s-1 Office of Consumer Affairs 3 dustiness Regulation I-ICME IMPROVEMENT CONTRACTOR Registration iaiid for individual use only TYPE;Stipolement Card before the expiration date. If found return to: Roaistratio R Exairadon Office of onsumer Affairs and Business Regulation f-4B58g- 05434/2021 1000 ington Street • Suite 7111 'IE'll!'o 3'ERATIN( t_LC. 3bstort,• A 02113 ;E FREY 0OriNO'RS 26 r JAr? �T �,/Nrac-s✓:G; ,I� • N^,91�RN. 'I.- 3'30 `.-tfiot valid Without 3ignat'ur9 Undersecretary • !.Uissichusetts Department of Puolic Safer; 3oard of Buildrng Regulations and Standards • License: CS-110763 S..)cr.J! �, t. JEFFREY CONNORS 64 OLD FIELDS ROAD _ SOUTH BERWICK ME O3900 r/... r,. =ipir.ation o� ,ms ,oncr 05105/2020 , . , .,...,,...• ..., r".. '''-• - ''-'— ,-.•;,... ', 1=1,• . • i ,',,s T,,-,, • _ . . i ,_,.,o, „...:-.---,.! AN&,•,4 9-,:.-PoZ,,, :,,-4. r',.y. `,, ' . , I _ iff'"- A- -,,•As.:;_,,-',--•" - --' . t!",_'`. , , -,, ',-,,..1;.,..-,,,,,..eit-4-:-,- • '...-.,41'',1.,. ,-,,,, l'sNa'0. , . I ,e ' -t4-4,W,i~-• • ' , _2:. m 7f;J:,:t:i.,-:, ' `'114!•-.4--A Cle -',')--.':t i ',, •L'.4ktqi:::_ -:- . --:-. '"....-:'w& -:,Ns,-:^,ii,t.i - ' • -IT !..,14 . 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'' '''' '. ,--7.-7, The Commonwealth of Massachusetts ° Department of Industrial Accidents 1 Congress Street,Suite 100 = Boston,MA 02114-2017 aT� z+ • www.massgov/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): ero (Dp e G.-fv lt) L(, C Address: 2 6, Ct"Aa r City/State/Zip: W p L v t-,n(j- A 01 g(i [ Phone#: /-goo -3 1-1 2_ - 2 2- I Are you n employer?Check the appropriate box: Type of project(required): 1. I am a employer with 2.0 -employees(Cull and/or part-time).* 7. D New construction 2.0 I am a sole proprietor or partnership and have no employees working*for me in aci 8. Remodeling any capacity.ty.[No workers'comp.insurance required.] 3. I am a homeowner doingall work myself. 9. ❑Demolition ❑ y [No workers'comp.insurance required.]` 4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. I wilt 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole l 1.0 Electrical repairs ar additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 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. 13. 13sof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14,j�rf Other (.J 152,$1(4),and we have no employees.[No workers'comp.insurance required.] /et:*/4t Gi/n1-'1.9 *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I.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'col nation insurance for my employees. Below is the policy and job site information. L Insurance Company Name: A324.113 Policy#or Self-ins. Lic.#: Eiv6,02 ?D Expiration Dater //2 Job Site Address: 139 ill. Ma;/► St. City/State/Zip: S.)an.,, 4€ PI A Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration'date). Failure to secure coverage as required wider MGL a. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year impriso i ent,as well as civil penalties:in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the viol. .r.A %.y of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verificatio . I do hereby certlJ'i nth pains and penalties of perjury that the information provided above is true and correct. Sianature: Date: P Phone#: • ` —$u L(-g Z 9 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#: IR r--1-) 'III I�,. . I = w LIABILITY j I '�—J_Ah1 _ 1 oa luiow, ..) 0'L,0lZO t THIS CERTIFICATE IS ISSUED AS A,L'LATTER OF INFORMATION ONLY AND CONFERS/1O RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED 3Y THE POLICIES 3ELOti11. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT SETWEEN 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 andorsement(s). PRODUCER CONTACT Melissa Pflug NAME: Mackintire Insurance Agency Inc IA/C. E E): (508)366-816'1 jq/C,No): (508)366-5202 11 West Main Street E-MAIL melissap@mackintire.com INSURERS)AFFORDING COVERAGE NAIC II Westborough MA 01581-1931 INSURER A: Sentry Insurance INSURED INSURER B: Middlesex Insurance Co Hewpro Operating LLC INSURER C: Guard Insurance Group 26 Cedar St. INSURER D: Colony Insurance Co INSURER C: Woburn MA 01801 INSURER F: COVERAGES CERTIFICATE NUMBER: 19-20 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 TYPE OF INSURANCE SUBi� POLICY NUMBER MMMIIDDDIYYYY IMMIDD/YYYY LIMITS F POLICY EXP LTR INSD INVD l ) , 1 X COMMERCIAL GENERAL UABILITY EACH OCCURRENCE ; 1,000.000 DAMAGE TO REN I tD 500,000 I CLAIMS.MADE 1 7‹ OCCUR PREMISES(Ea occurrence) > 15 000 MED EXP(Any one person) S A A0092403003 12/31/2018 12/31/2019 PERSONALSAOV INJURY 1,000,000 GEN'LAGGREGATE UMIT APPLIES PER: I I GENERALAGGREGATE ; 3,000,000 POLICY j CT LOC I PRODUCTS-COMP/OP AGG ; 2,000,000 OTHER: I 3 AUTOMOBILE UABILITY I I COMBINED SINGLE UMIT 3 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) S B OWNED X SCHEDULED A0092403004 12/31/2018 12/31/2019 BODILY INJURY(Per sccidenq S AUTOS ONLY AUTOS /� HIRED NON-OWNED PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY (Per accident) ' Uninsured motorist BI s 250,000 X UMBRELLA UAB I OCCUR FACH OCCURRENCE ; 5,000,000 A EXCESS LIAB CLAIMS-MADE A0092403006 12/31/2018 12/31/2019 AGGREGATE 5 5,000.000 DED X RETENTION 3 0 _ 5 WORKERS COMPENSATION PER OTH- AND 6MPLOVBRS'LIABILITY STATUTE ER C ANY PROPRIETORIPARTNER/EXECUTIVE YIN EL EACH ACCIDENT S 500,000 OFFICER/MEMBEREXCLUDED? n N/A NEWCO28778 05/01/2019 05/01/2020 )Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 500,000 It yes.descnbe under 500,000 DESCRIPTION OF OPERATIONS below _ _ E.L.DISEASE-POLICY UNIT 5 Limit $1,000,000 Pollution Liability D CSP304242 12/31/2018 12/31/2019 Aggregate $2,000,000 DED $5,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 3EFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE MA 01504 ! ,/”.;c1 I , ©1988-2013 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD