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HomeMy WebLinkAboutBld-20-3237 . � Office Use Only O Permits• SD- �� R Amount . ThCf. Amount q ,MAT� /' 9 Permit expires I80 days from issue date 37 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department j • 1146 Route 28 South Yarmouth,MA 02664 1! C1ZA:t � 1(508) 398-2231 Ext. 1261 `G '1 CONSTRUCTION ADDRESS: 1/// _bv�l� /t��� r2� �� l�1.)) ASSESSOR'S INFORMATION: - Map: Parcel: OWNER (y ate+;(y Wei A/u�Clra le(4f-5 t0 k/ .rrrio,, 1 MAoLG 7 3 Cog-2.n-ace e N/�AME PRESENT ADD S TEL. # Email Address. CONTRACTOR: n('nfet,/ kick e~ Stc/t,LL`C` 021/Cwnetirag°�sR<i ISA 11+4 hum/1e C7 81) g 3Z-'i8D S+ NAME MAILING ADDRESS 0170I TEL.# Email Addri ideniial Commercial Est.Cost of Construction$ /2. 7 q 7 -- Home Improvement Contractor Lin# /(06 02. — Construction Supervisor Lie.# 072.772. Workman's Compensation Insurance: (check one) I am the homeowner I am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: /�ScOG ia4P GE►,Floye✓r-s Worker's Comp.Policy# G•f C--StO 5-0 1.12 Isoct-- .20 l q tk WORK TO BE PERFORMED • 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 *The debris will be disposed of at: t sle tiev41 tfM a/7"l — Lt/�J y<ll t #1 A ' Location of Facility I declare under penalties of perjury t . the ssilioq I;. are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause far denial or re • •;/, er r LavA+- M.G.L.Ch.268,Section 1. Applicant's Si• •' c• 417 4, \ Date: / 2 - - Owners Signs: (or : ent) ' / Date: Approved By (� Date: cis](or ee) Zoning District Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District Within 100 ft.of Wetlands: Yes No Yes No V ` �- 1 L)R_TiTG!! Ltt i1: 3_ :t _ 1 Corc ass S#,erg, 100 Boston, 314 021_14-2101 www,mass.S owVia ti v� 'ovic rs' Compensation InsuranceAffidavit: Builders/Contractors/Electricians/Plumbers. TO BE PLED WITH 11:1L+ PERMITTING,iL'rHORITY. Applicant Information PIease Print Legibly Name (BusinessiOrgani7ation/Individual):1 j/� }jS�on .2p(4,1:4J• )3f-f A/fi'4 ^'�r✓"r d 3 /1 Address: 15 A 6 kr r-,r-n Gt City/State/Zip: k,k1,ip n t'1_ • Phone 4: 7 X t - i s Z--t2 v c Are yo an employer?Check the appropriate box: Type of project(required): 1. I am a employer with tj (7 employees(full and/or part-time).* 7. El New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in $. Ei Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.0 I am a homeowner doing all work myself :To workers'comp.insurance required] 10 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 ao employees. 12.❑Plumbing repairs or additions 5.0 t am a 3eneral contractor and I Have hired-he sub-contractors listed an the attached sheer. 13.D of repairs These sub-contractors have employees and have workers'comp.insurance.: �`� 14. Other G(/0or 5.❑We are a corporation Ind its officers have exercised their right of exemption per IIGL o. 152,11(4),and we have no employees.[No workers'comp.insurance required.] /I Ice/a ee,t/ S ':Any applicant that checks box 41 must also all out he section below showing their workers'compensation policy information. 1.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: S3ae Gt:f C G efi,eIoye r s — Policy#or Self-ins.Lic.#: vt,'G -5 DO- co I S(, 2 t C ,a Expiration Date: y— 0 Job Site Address: 3..k City/State/Zip: t4) t stn>1r,A Attach a copy of the workers'compensation policy declaration page(showing the policy num er and expikation 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 a und'j he pa" a penalties of pedury that the information provided above is true and correct. Sipature: Date: /2- tf-/9 Phone#: i 8� ® 8— '/3 9 A Official use ' . II) 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#: st740 ;r:.,.; %Window Worldotf'Boston -' -MA•NICReglatretion ... Offic &Shotiwroolns Number. b 18A cumminga-Perk O 296•0Id.Oek-Street• D 1000 Boston llrrnplke •166025 • Woburn,MA- ;M 01801 -PembrokeA•02369-• Shrewsbury'MA 01845 Worm** . (781)932-4805 (781)826,6281 pm 845:8876 62;489043i Fly‘,, b-j www.WindowWorldof8oaton.com " Customer: Del 9 LEY PAn1 r y ,Xis it@dcCA33 4@ f(t/$7 Phone(h) MOO Address:.ISI 'i.ucK'3 sc.It p:Rd., Wirt 5,Q Phone(a). C9 a80-09?8 ' CRY: /Jost VAQ inacrfif. . . Mate:MAztr OZ617 rrs r1 rp E-Mail 151 17.@Cas,te/Ir net • WINDOW.WORLD • GLASS OPTIONS • .1000 Series Sligie-hung All-Weld $249 • 4 golar7oneElite-quMPena $1?87�Y 2000 Series OH All•Weld $269 4000 6erlea DH.AIIaNeld $tea ltlple Pane. :$299 • -6000 Series OWAfl•Wetd . _.::•'$09• "''-2[ke Sltrtet.-•. ' " ` ••$129: • WINPobtoenoNS-...... . 1_3LiteSlider " a.a8 ,,zuq gm —des breakage;Werrantr(4000/M00)•$t8MCLU�� •Pitxwe/: eed U) }: .pia,:....-. —.-g4.:8aeena,..: :,a_:::•..;_;=_:: •.9 - • foam 1nsulatlon on,leunbs attd${eal-•4.14 —.-•. :..,..., 1•:.-s>x a w,113.'' .. ' U lfko6l 1'�!�I4016660j=::..: 1 t —A DQ:•",.,..:,.,._:ix:,.(1;i v:if �p a�-•ram`... -:. �Caseriant Plus$08•(DHSeaMRatfl 9 Dou67eodrd{i -. 2 U to Casement $069 -Full Screens $26:.•'75 ,:.- ,g�+� ,• 3 tkg:Qeaarrent+: vsva_cot'Rom OO29, • :;.. Colonial (GpnlouredlFlat) ..:$65�_. 1 • r 8asenlerrhHoppetr . , $.48A-•- I_Prakta0mi. • -- '$75• ,• to' :6A)r'Yukttl.!4` eftICM6anr9 Nslek.e5.6855;, gl ad'O d't tl $162 ` } Pun .'—^'a ,btr:�7 �� c 4•��"5",` �..,/.e�df"`!R�� b4'.�Rt�'�' 7emPQJRY�� � ��1�tr.•�,Gar V _.:.'.:.ze 0':Y•i t:.Y-i/,yra .`.`..b`(R:Cbacerd t9kltta 17•.•: _.':.. - - B0 Bow,OaMon Overake (t 108 Uf)$978 _Oriel Style(4itj§0'b) 40t'' ' "05 _-BWgp1.A'tna)d •,. z $49 ,. .. .;. Wood 9MM interior Feeel,Ephe ri:ed:Fn res.:-,x. ..y.:,;Y.4536-arse •.,� A. {Serfee4nbo/�Ooon' $COD: l r I i i .4 . /l OOeld Dark OW Cherry!Fox Wood '0wa i979WILT WOMBS(1RP SAFE •N) qiima...„)..c. RI MMapla) ' "'d$GG MYHOMBWAt3-BUILTINIHEYEAR ei .0 ?. .. &orin Saner American " ""'"' ` ' " `' ''••••" _' ' , '7erra)$100 o Fi Z DedgnlityWI :.n:•;,(d/dA't •$1....-.,..„ MISCELLANEOUS �{ r ____ Window $fir. sCtatom Meador Aluminum Cladding(lwo•Benc0 . �r '�1j�`L` CPTextUred'$90 00•5 Smob91090 $ A i ' Window Color N�/�.Jr.�� / .�I�.Q�f12� Facing Color • fit/ NON rct S�•'"000sis' Install rtor'stops - : _ ._,L VIn$t Rd9rg'Patio... c S1219•-%. Inetall In N Casing Stans At'$95:-.:• �•:- Tvkt1 RdtR PaafoGoq.•;;�"�•- sis2e.- ,^_Repa'e"sW;jamb or replace sdl rwalne $75 • `"_ _Add totuehWrcetorCoW'aiifo1 gP iotloartl269 ^Full Sub-GI0(8kple).replaeement $17.5 _French ea SNang Patio Door 85 or ett. $1639 frret a Wei Boxes •:1 rbn4h Rea:9Nd Q O Do*lioP. a sr$1 •a»: .--- - ' --•-- -..Mir y a?.r1„�e,- ; ' r •i.r Mul to Ran min unit Custom •. 'Clad * 6.?.: : 7�.r•..rd:1 .. MuNtdtrit311gva1. 0 r • =6olarconeoff •. Mehl WindovwRemoval - .$i5•100."• •- 440Craeu_boor. '.>7 ;: .goo• Nee Construction Vinyl Removal $17,51i700,' - yyoa �ry ,,,, -;y, 4 4 Nei Contd.6RRetroFit $150 .OQ ^ taedorDesigner• . 4 •- •. . ease.•Ii'll'••. Radian, Windows nt••- lr19" ' • 79': if" _Removal ofEilidingBa$80w." `"t250____ r- erdiawt Am0 e4 • :-' • x- 4 BaylBowO3tnrerelon-Ext Reho Fit':.::$450• • _ jnixbr-Bflnde$Ixlsotonly)• :Ses9.: "( Sid Will NotMatotlj_' ' • .,. i��..__.. _.t -__ .�. ,3 ,-- i Door COlOtar : : v� 1:».:,17-i�3� s�?., 1:�.a,�_r-,rr• .rz �5ta c _..,. ze i.u,c ` .� 3.�' _.,.•,. '-`°'.., : 4Y, r i-!a; ..7 T.?,. ',--,,-• _„`-.Tr ••,.,••\rif1m(1,1• ,. Customer declines grids orl � - windows/�Oora(alga•i i ' m�dM81k0sttgkllf tafRte. .. :e?ellCI , P*tbad9 alW11Stllar fmsh. t Z I Customer agrees'to the terms of pelytineltt p.e.-•Ilowe:''W NO EXTRA W01 II'NOT IAtINR1TIN©1• Extra labor&Msiarlels $ _1. __ t• ' $59 set Up.Ferret. '. Fes$ Custom Order Deposlt3396.•4" • —-. is• rr`-.:,:t., r Project Start Payment 33% $ Z — : •.e ,t;:.rt,.,•.re<,•az-sp.Litt r'e:;:'- r'...e:w-5-...•••,:ltsstokyllidelttlfr.Deatty ol5fata laeon'.$- o4 .-;t . •. ;,•SNiir.4' •,,...•: 5' , r_.,t1 r.. • • ' ^,I;:cli.ri financed h$`.'- '.`. l Nal t : r.4 Wkdira Weld �n and%Tho °� Sys »0 thedePorilth $ eviodt t 1S%afaWdorgasmsMialaMMillitaltrequiprdent maga Warm custom&de **kekk athicrd1,Ndlanda digthsdate!gameteassume the oroltef'ae Mani ail mitt daMo that Pelmet matbedinundadmethaoo tr NnksotbwapNlrAtoara n el kb earths. • Rnq e,t.hgpca• • Aa wnaae earls pat egberapTradsa6.thAamIr5170Boson.8*rsators1peeweaa� dottedlaMp N CaKamet Milks sad Mesas NMdNlax Tan Park Plus.Sette 5170 Wren ell02116.Pim(617)03 . " Nowalkshies*PrfartheeOrr%atSesatinstsadtrmanittattethesouofaNAIfwe lefeed f 00I Yhdd41 ' {n"r'•i- ',1 ^I' ' a '�}. �1i .P.t' r , w111 1b .,a4 ... a0Nt0a0alrontha " ` (y •_i, t ._„ tri i Yaw Lip r auFrxl tg"htol d(s11d�d ntpa t�r q��,•dHe•otti Na{rdagcNon,: y T�4.�`P �''1I01eterihenMlldai 9116afps4ar talidlmeMoet i li• •., , rte• Wn 1 - ,1Y' MDT ;a �(( c" — 1 13 • .. : y�?ij 440.3.t� `� % ►. '"- ga t ;s/ig• 1 PltateanyMonk weft& Dab i •ea oak nla • arw sass•&. tiara Oa(ull:as liar Map eewm era par h4ak araran. nw, i i i Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards r-structIor Supery sor CS-072772 Expires: 04/07/2020 JEFF C STEELE 24 SHERWOOD AVE DANVERS MA 01923 Commissioner "L • y v Yr,.ur„rr•,ruiper&r �ln�trt�nJrJ/.: Office of Consumer Affairs&Bus wss Regulation HOME IMPROVEMENT CONTRACTOR TYPE:LLC Reoisfratlon Exuiratfon. 166025 04/11/2020 WINDOW WORLD OF BOSTON,LLC. JEFF C,STEELE �l�C --- 15A CUMMINGS PARK WOBURN,MA 01801 Undersecretary AC CERTIFICATE LIABILITY aa INSURANCE N�iJ GATEIlM/DDIY`,YY) 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: amy roberts M.P.Roberts Insurance Agency Inc. PHONE,Extl: 978.683.8073 (A/c,No): 978-683-147 1060 Osgood Street A IEss: amy@mprobertsinsurance.com North Andover, MA 01845 INSURER(S)AFFORDING COVERAGE NAIC 0 INSURERA: WESTERN WORLD INS COMPANY INSURED INSURERS: MERCHANTS INS COMPANY L Sr P BOSTON OPERATING,INC INSURER C: ASSOCIATED EMPLOYERS DBA WINDOW WORLD OF BOSTON INSURERD: 15A CUMMINGS PARK WOBURN,MA 01801 INSURERS: 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 ADDLISU It POLICY EFF POLICY EXP TYPE OF INSURANCE LTR INSR WVD POLICY NUMBER (MM/DD/YYYY) (MhVDD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO REED CLAIMS-MADE OCCUR PREMISES(Ea occc I'�i cuurrence) $ 100,000 MED EXP(Any one person) $ 5,000 A NPP8525379 04/05/19 04/05/20 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPUES PER: GENERAL AGGREGATE $ 2,000,000 POLICY n jECT 7 LOC 7 PRODUCTS-COMP/OP AGG $$ 1,000;000� OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ B AUT OWNEDOSONLY AUTOS X SCHEDULED MCAI002569 04/05/19 04/05/20 BODILY INJURY(Par accident) $ X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) . $ X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE AN065362 04/05/19 04/05/20 AGGREGATE $ 1,000,000 DED RETENTION$ $ WORKERS COMPENSATION OTH- AND EMPLOYERS'LIABILITY X PER ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 1,000,000 C OFFICER/MEMBER EXCLUDED? N/A WCC-500-5018609-2019A 04/05/19 04/05/20 (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 NTATIVE ifirott.>: ..--)L- IfYVV4006-44-- CO 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD