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HomeMy WebLinkAboutBld-20-4437!" Or•Y`9R Utttce Use Only ., rt#'49` 1 rye % u. ,—i*l '. - H ;Amount LS[4. j eq,-0.....0:.„ Permit expires 180 days from i issue date EXPRESS BUILDING PERMIT APPLICAT O— —~— y-; TOWN OF YARMOUTH 1 C 1 V'_E s � Yarmouth Building Department4�`�'v572� 1 1146 Route 28 South Yarmouth, MA 02664 _ ' _ S ';�DiNO DE?P`'� (508) 398-2231 Ext. 1261 ---cd ' CONSTRUCTION ADDRESS: ASSESSOR'S INFORMATION: Map: '77 Parcel: A 7s-- OWNER: W ILL! hPt 115 CA 1 t OP),) a. 562asctOY7 NAME PRESENT ADDRESS TEL. # CONTRACTOR: PFK- A lls1 Ti ON 13AS Al(2 f f R-n• (0-4 (owJD NAME MAILING ADDRESS zi�,„/4 TEL.# Ill4dential ❑Commercial QQ p`( Est. Cost of Construction$ # 1 j 6(0( . I 1 Home Improvement Contractor Lic.# I'4"L O'1 O Construction Supervisor Lic.# 015 115 4 Workman's Compensation Insurance: (check one) � � 0 I am the homeowner ❑ I am the sole proprietor ri have Worker's Compensation Insurance {2 (t. � Insurance Company Name: �J"fp► ,{XWat'' S�(�1� Worker's Comp.Policy# 5 h lo i 40$I% WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows: # I Replacement doors: # I 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: 132 5 a(4,6 a 1213. FA&-L I2.i Val-; NI t'I 607 -6 Location of Facility I declare under penalties of perjury that the stateme�i yyy* 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 or revocation. ,y* . . or prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: A ' Date: ret3 I I 2d7,D Owners Signature(or attachment) scEit-Rife) Date: l ll ��11 Approved By: ✓...A-- Date: d.. // "" of V Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes No Flood Plain Zone: ❑ Yes E No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes 0 No El Yes No r--..... \' '�"'., The Commonwealth of Massachusetts • 08 ;- /, Department of Industrial Accidents 1 Congress Street, Suite 100 ;__ �- Boston, MA 02114-2017 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): P Fe. pdaustriw r L..-L-c. Address: I --c A (e-ed R-T (2'3 • City/State/Zip: FALL $24L/ L 1 MR Phone #: 61)g (i7( (Oga-O Are you an employer?Check the appropriate box: Type of project(required): 1.{ " am a employer with 6V 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. .emodeling 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 ❑ 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.❑ Electrical repairs or 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. 13.❑Roof repairs These sub-contractors have employees and have workers'comp. insurance.: 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑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. 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: 61-7N e•KWE ( it_ ' 5 P l Policy#or Self-ins.Lic.#: 5" 14 (p 1 140 8"1 g Expiration Date: S (. I i LC) Job Site Address: 115 eltirr. 6A0D kJ 2b` City/State/Zip: 55•Yas,Rilft Dal+t MA. et,1`JpI( 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 verification. I do hereby certify under the p#' an, :• 'of perju t r t the information provided aboveabov is true and correct. AI Date: 1 Signature: a)). I 2°2) Phone#: 5DS Vito IO$0 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#: . .9:4 r ./Rt9.4e5e7,-64i,e)ea),Office of Consumer Affairs and Business Regulation , 1000 Washington Street-Suite 710 , Boston, M,,,,„1;11,.... husetts 02118 ,i,,, Home Improve .---,.. . tractor Registration ( , Type: LLC Registration: 149840 PFR ACQUISITION,LLC ,c.. i,., --- i Expiration: 02/12/2022 1325 AIRPORT ROACi ==== cv-,,,,, FALL RIVER,MA 02720 (t74 \-....., i.. lc\ ciczi• <_?•=4,41.—civccci,,,-/ Update Address and Return Card. SCA I A 20M-05/17 .11Z W0,41406e1,404(//lieri-4,3(4444.1045 Office of Consumer Ahab*&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only 'E:LLC before the expiration date. If found return to: ,,,__ z.... 1..,,,•,1 marammign Office of Consumer Affairs and Business Regulation •-'...--;. ff- 02/12/2022 1000 Washington Street -Sults 710 te- ..t.--zi------ -- PFR ACQUISI 'it....-2.,itil."7. -- ;Y: Boston,MA 02118 .); _ e *c;• -. ,,,- 1328 AIRPORT -,J,•.t/ 44,000(4.,4010.4' FALL RIVER,MA ovin' Undersecretary Not valid without signature . .. ... ... _ _ ConvnowniNdth tb Atessewentsetts Division of Profesaketill LIceneure II) **aid a liqtafts* and Standards . -- CS4M843 AZ * Ambit*:02/08/2022 ----dp - STEPHIlit I 6 a.i2LEA . -II , 6 poimrit4 CP° . Commissioner itAft4;44,11,401.1,-- • Client#:73461 PELLAWINI ' ACORDTM CERTIFICATE OF LIABILITY INSURANCE I DATE(MMDCINT'Y) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON 04/R.THIS/201 0ERTIFICATE 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(les)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). ��•��TT PRODUCER Rae Melissa Tanguay Starkweather&Shepley raw 401 435-3600 PO Box 549 (ag,No.Extl; FAX No):401 431.9658 Providence,RI 02901-0549 Man,n, mtanguay©starshep.com 401 435.3600 INSURER(S)AFFORDING COVERAGE NAIC N INSURER A:Employers Mutual in* 21415 INSURED PFR Acquisition LLC INSURER B DBA:Pella Windows &Doors INsuRERc: 1325 Airport Rd INSURER D Fail River,MA 02720 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 ADDLSUBR LTR TYPE OF INSURANCE PMID EF POLICYy EXP JNSR WVD POLICY NUMBER MM D (p1MI0D/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY 5D67408 05/01/2019 05/01/2020 EACH OCCURRENCE $1,000,000 CLAIMS-MADE a OCCUR RREMISES(Ei HTED co $500,000 •. — MED EXP(Any one person) S 10,000 PERSONAL&ADVINJURY S1,000,000 OEM.AOGREGATEUMR APPLIES PER: GENERAL AGGREGATE s2,000,000 RPOLICY❑J CT ELOC PRODUCTS•COMP/OP AGO S2,000,000 OTHER: S A AUTOMOBILELIASIUTY 5Z67408 05/01/2019 05/01/2020.1(Eaa;B2,1eE�sl"GLELIMIT s1,000,000 _ ANY AUTO • BODILY INJURY(Per person) $ ALL _ AUTOS OWNED X AUTOSULEO BODILY INJURY(Per accident) $ X HIRED AUTOS X A O$wNED PROPERTY DAMAGE $ (Per acdden%) X Drive Oth Car _ S A X UMBRELLA LIAS i_ OCCUR 5J6740818 05/01/2019 05/01/202O EACH OCCURRENCE $10,000,000 EXCESS LIAR CLAIMS-MADE AGGREGATE $10,000,000 DED X RETENTION S10000 $ A WORKERS COMPENSATION 5H6740818 05/01/2019 05/01/2020 X sT Tum_ FOR AND EMPLOYERS'LIABILITY ANY FICRER MEMBER EXCLUDED?ECUTIVE NIA E.L.EACH ACCIDENT 81,000,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,duewbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) • • • CERTIFICATE HOLDER CANCELLATION PFR Acquisition LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPDBA:Pella Windows&Doors' ACCORDANCON E(WITHATE THE POLICYF,PROVISINOTICE N$ILI. BE DELIVERED IN 1325 Airport Road • Fall River,MA 02720 AUTHORIZED REPRESENTATIVE • 01988.2014 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 sal Office Order Copy Branch Number: 73800 Order Number: 738EHAE61 ® Window Store Name:Pella Window and Door Quote Number: 12256377 Showroom of Fall River Quote Description: Windows Project Name: Dagle,Valerie,2435243 / ��J' / Customer Information Deliver To Address Order Information William&Valerie Dagle Lot# Sales Rep Name: Harrison,Gene Gust Delivery Date: 2/26/2020 115 Captain Bacon Rd Address: Business Segment: Retail Quoted Date: 1/27/2020 115 Captain Bacon Rd Market Segment: Single Family Replacement Contract Date: 1/27/2020 Order Type: Installed Sales Booked Date: 02/03/2020 SOUTH YARMOUTH,MA 02664-2849 Effective Discount: 21.000% Earliest LRD: 2/3/2020 Contact Name: South Yarmouth, MA 02664-2849 Commission Split: Harrison,Gene-100% Primary Phone:(508)2590728 County: Barnstable Tax Code: MASS Mobile Phone: Owner Name: Tax Exempt#: Fax Number: William&Valerie Dagle Payment Terms: Greensky Financing Customer PO#: E-Mail: valdagle@hotmail.com Event#: 16399258 Great Plains#: 1005552600 Owner Phone: (508)2590728 Order Verifier Name: Cole,Russ Order Verification Date: 1/30/2020 Customer ID: 14943284 Scheduled Install Start Date: 2/26/2020 Scheduled Install End Date: 2/26/2020 Customer Number:1009057833 Install Crew: Johnson,Tim P-Timothy P Johnson Construction Customer Account: 1005552600 Install Duration: QTY Install Status: Reserved Customer Notes: Bump out window 12" Paint interior trim Bright White Custoftter: William&Valerie Dagle Quote Description: Windows Order Number: 738EHAE61 Outside View Line# Quote Qty PO Qty Description 10 1 1 Pella 250 Series, 2-Wide Double Hung, 76 X 54,White 0 0 Location: Living room Rough Opening: 76.5"X 54.5" 1:37.7554 Double Hung,Equal "' 9Frame Size:37 3/4 X 54 {h D I Frame Size: 76"X 54" General Information:Standard,Vinyl,Nail Fin,No Foam Insulated,3 1/4", J.; Final Wall Depth: 1 1/8",2 1/8" Exterior Color/Finish:White Frame Perimeter(inches): 260 Interior Color/Finish:White Assembly Type: Pella Assembled Glass:Insulated Dual Low-E NaturalSun Low-E Insulating Glass Argon Non High Altitude Last Revision Date: Hardware Options:Cam-Action Lock,White,Standard Vent Stop,No Limited Opening Hardware Screen:Half Screen,Conventional Fiberglass Performance Information:U-Factor 0.30,SHGC 0.50,VLT 0.60,CPD PEL-N-211-00056-00001,Performance Class R,PG 35,Calculated Positive DP Rating 35,Calculated Negative DP Rating 35,Year Rated 08111,Egress Does not meet typical United States egress,but may comply with local code requirements Grille:No Grille, Vertical Mull 1:FactoryMull, 1/2"Integral Mullion 2:37.7554 Double Hung,Equal Frame Size:37 3/4 X 54 General Information:Standard,Vinyl,Nail Fin,No Foam Insulated,3 1/4", 1 1/8",2 1/8" Exterior Color/Finish:White Interior Color/Finish:White Glass:Insulated Dual Low-E NaturalSun Low-E Insulating Glass Argon Non High Altitude Hardware Options:Cam-Action Lock,White,Standard Vent Stop,No Limited Opening Hardware Screen:Half Screen,Conventional Fiberglass Performance Information:U-Factor 0.30,SHGC 0.50,VLT 0.60,CPD PEL-N-211-00056-00001,Performance Class R,PG 35,Calculated Positive DP Rating 35,Calculated Negative DP Rating 35,Year Rated 08111,Egress Does not meet typical United States egress,but may comply with local code requirements Grille:No Grille, Wrapping Information:Factory Applied,Pella Recommended Clearance, Perimeter Length=260". *** 1000041-Exterior Trim PVC Qty 1 *** 1000001-Full Frame 48-96 Wide Installation Qty I *** 1000047•Lower/Build In Opening Installation Qty 2 *** 1802-Prefinish Interior Trim per Unit Qty 1 . Outside View Line# Quote Qty PO Qty Description Printed on 2/3/2020 Office Order Copy Page 2 of 4 Customer: William&Valerie Dagle Quote Description: Windows Order Number: 738EHAE61 15 1 1 Pella 250 Series, Double Sliding Door Vent Right/Fixed, Location: Dinning room 71.5 X 79.5,White Rough Opening: 72"X 80" 1:7280 Vent Right/Fixed Double Sliding Door Frame Size:71 1/2 X 79 1/2 Frame Size: 71.5"X 79.5" General Information:Factory Assembled,Standard,Vinyl,Nail Fin,Foam Final Wall Depth: Insulated,5", 1 1/8",3 7/8",No Sill Pan --� -- Exterior Color/Finish:White Frame Perimeter(inches): 302 Interior Color/Finish:White Assembly Type: Branch Finished Glass:Insulated Dual Tempered Low-E Advanced Low-E Insulating Glass Last Revision Date: Argon Non High Altitude Hardware Options:White,Keylock Included,White,White,Steel Screen:Sliding Screen,White,Premium,InViewTM' Unit Accessories: No Accessory Option Performance Information:U-Factor 0.28,SHGC 0.28,VLT 0.52,CPD PEL-N-251-00047-00001,Performance Class R,PG 40,Calculated Positive DP Rating 40,Calculated Negative DP Rating 40 Grille:No Grille, Wrapping Information:Pella Recommended Clearance,Perimeter Length =302". *** 1000041-Exterior Trim PVC Qty 1 *** 1000020-Double Door Installation Qty 1 *** 1802-Prefinish Interior Trim per Unit Qty 1 Outside View Line# Quote Qty PO Qty Description 20 0 8 Wood Products 2 1/2 Colonial 2, Length: 96, Bright Location: None Assigned White.Wood Type: Pine Rough Opening: 1: Accessory Frame Size: 0"X 0" Frame Size:-1 X-1 General Information:Pine,2 1/2 Colonial 2 Final Wall Depth: Interior Color/Finish:Bright White Paint Interior Frame Perimeter(inches): Wrapping Information:Perimeter Length=0". Assembly Type: Pella Assembled Last Revision Date: Outside ViewLine# Quote Qty PO Qty Description 25 0 1 Wood Products Stool Round 1, Length: 96, Golden Oak Location: None Assigned Stain.Wood Type: Oak Rough Opening: 1: Accessory Frame Size:-1 X-1 Frame Size: 0"X 0" General Information:Oak,Stool Round 1 • Final Wall Depth: Interior Color/Finish:Golden Oak Stain Interior Printed on 2/3/2020 Office Order Copy Page 3 of 4 Custctrier: William&Valerie Dagle Quote Description: Windows Order Number: 738EHAE61 Frame Perimeter(inches): wrapping intormation:renmeter t_engtn=u . Assembly Type: Pella Assembled Last Revision Date: • Printed on 2/3/2020 Office Order Copy Page 4 of 4 Customer:William&Valerie Dagle Project Name: Dagle,Valerie,2435243 Order Number: 7386ATOAV Quote Number: 12256377 e. This contract shall be governed by the State of Rhode Island or Massachusetts depending on the location of the work to be performed. i r , j ,., Q Order Totals Customer Name iPlease print) Pella Sales Rep Name (Please print) Taxable Subtotal $3,121.99 Sales Tax 6 6.25% $195.12 Cust nature Pella Sales Rep Signature Non-taxable Subtotal $3,744.00 j - 2 ? - 2 .% 10 Total $7,061.11 Date Date Deposit Received c'' Amount Due $7,061.11 /'n,41110 '' ' CreditCa •7 ••rovat Signature