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Home My WebLink AboutBld-20-003832 Office Use Only ,� #53 4 i•ennui$', O �I�. y Amount �('Q)�__ < �.- ;d' Permit expires 180 days_ from r.: issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 2 ke-SS'en S t 3. Li c (5 ,n,,n ' Y ASSESSOR'S INFORMATION: Map: (di Parcel: OWNER: �l ' M V VA+2._ 02( 0 M'NAME tc)G/ IL 4 1 ',t 5•(16 t 1W 621,91H CONTRACTOR:J I/1 YnVLe b`F�f/t'Q ive 1 ft'f 1"i'1 C.��t✓4 'J`•c 12' l jL/(r) 1.j l h/J CA6 0) N„g4�V1�� EEE If #4 3 l.›J--�7 S- t- 7 S— esidenNal ❑Commercial Est.Cost of Construction.S e 1�1 4(oo Home Improvement Contractor Lic.# \ 21 J S) Construction Supervisor Lic.#C 3._'0 ‘ 0LG Workman's Compensation Insurance: (check one) ❑ I am the homeowner [C I am the sole proprietor1ttave Worker's Compensation Insurance Insurance Company Name: (V 114 M LAA) AA-Q. Worker's Comp.Policy# W CC-515as b I b7 2 v2-0/a 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. (x)Replacing like for like Pool fencing *The debris will be disposed of at: 1/ 1 1'1V V l -1-6. LfvrvkfiA.A Location of Facility I declare under penalties of perjury that the is 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 or revocation of my se and for prosecution under M.G.L.Ch.268,Section 1. t. ' (0.ia.P2.v Applicant's Signature: \ Date: Owners Signature(or attachment) i(/+'/ p L Ii`G) Date: Approved By: ..`�111111 - Date: / - /0 Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands:. Yes No Yes No I ti If contract ca 4 <<. items hanging on walls until job completion. q•,( I UNt Lt 1)11-; i'e ( ()NTR ‘t l i:i� i1 Removal of existing doors and windows often reveals weathering, as well as areas that may or may not be previously stained or painted. As noted, Contractor will not be responsible for painting or staining these areas. Contractor will not assume responsibility for removal, re-attachments, or re-positioning of drapery rods, window shades, blinds and/or mini blinds, and corresponding hardware. i i? ,'i. EEC„° e�[�` kE4.r.,L t ,.'v 1;.♦ l 4 1 E t s„ t-r h 4e -� - h Maim t �i.k ,�� t `11 E-4t t � - 1 �i ° ; Rai. :. 4.,a =.i ��d� ys C}i't_11t�_l 'v r _ 4 1 tl}1 c4; HOMEOWNER: DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Uwe accept this contract in its entirety and I/we authorize Sprinkle Home Improvement to act on my behalf in all matters relative to the work to be performed on this job (i.e. permits, applications etc.) if necessary. IW411 0€414-1... Homeowner Signatu Date Cont ctor Si. a 1 Date Diana Lantz Brad Sprinkle- Regi_tration# 103757 ,...,...,,.. Tn' bait tCW61A3. ,.i..,,....,_, SPRIN-1 OP ID:JCA ACORL7 MI DATE(MDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE� 0110312020 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 508-775-6060iACT Kelley A.Sullivan Bryden&Sullivan Ins Agency PHONE 508-775-6060 FAX 508-790-1414 88 Falmouth Road (NC,No,Ext): (NC,No): Hyannis,MA 02601 i kss: Kelley A.Sullivan INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:NGM Insurance Company 14788 fisvRED INSURER B:Associated Employers Insurance in eIhi e I provement Inc. 99 BarHyannis, 2601 INSURER C: INSURER D: INSURER E: 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 ANYREQUIREMENT,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 ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD NIVD (MM/DDIYYYYI (MM/DO/YYYYL A COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR MPT2640X 07/01/2019 07/01/2020 PRMISEs Es occurrence) $ 500,000 X Business Owners MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY I I II C I 1 LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY COMBINED $ 1,000,000 nt) ANY AUTO M1T2640X 07/27/2019 07/27/2020 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOSRE� ONLY X AUTNOSyyNEp BODILYO INJURYD (Per accident) $ X AUTOS ONLY X VMS ((Per ac dent)AMAGE $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS UAB I I CLAIMS-MADE CUT2640X 07/01/2019 07/01/2020 AGGREGATE $ 1,000,000 DED X RETENTION$ 10000 $ B WORKERS PEREH EMPLOYERS' STATUTE R WCC60050167472020A 01/01/2020 01/01/2021 500,000 AANY PROPRIIE ORR/PARTNER/E ECUTIVE NI NIA E.L.EACH ACCIDENT $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ PROPERTY 51,000 I I I I DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE IS ISSUED FOR PROOF OF COVERAGE. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Sprinkle Home Improvement Inc ACCORDANCE WITH THE POLICY PROVISIONS. 199 Barnstable Rd Hyannis, MA 02601 AUTHORIZED REPRESENTATIVE Kelley A.Sullivan ACORD 25(2016/03) 01988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD • The Commonwealth of Massachusetts ° 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):SPRINKLE HOME IMPROVEMENT, INC. Address: 199 Barnstable Rd. City/State/Zip: Hyannis, MA 02601 Phone#:508 775-1778 Are you an employer?Check the appropriate box: Type of project(required): 1.❑✓ I am a employer with 10 employees(full and/or part-time).* 7. ❑ New construction 2.0 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. 0 Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.] 10 Building addition 4.0 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. 12.0 Plumbing repairs or additions 5.1:1 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.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Ot11Er n�IMI �� 152,§1(4),and we have no employees.[No workers'comp.insurance required.] l L� *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 1 t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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.I.M.Mutual Policy#or Self-ins.Lic.#:WCC50050167472020.A . Expiration Date: 1/1/2021 Job Site Address: s(P S&3 Se_ne-Cer) SYYte.e 1— City/State/ZipS.1"taa nak ), ✓ 40t1 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 ns and penalties of perjury that the information provided above is true and correct Signature: � Date: 't I s' (21)_ Phone#: 508 775-1778 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#: Supervisor Commonwealth of M*ssiChusrtts ' Constructionf Drvrsron of Prott s¢ronii L+cemure On *IGted.Buildings Of any use/I which contain Boa'd of BuriArng RegutaUnns and Standards Construction than 3C.0fa0 cubic feet(WI Cubit means)of enclosed o e0 el sttuCtibA SUpetvtsot *pact_ CS•006643 Expires 10'0812021 BRAD K SPRINKLE 10f BARNSTABLE RD. 111/ HYANNIS MA 02001 foams to possess a current edition of the Massachusetts / Stab Building Code is cause for revocation of this license. Commissioner *!w!x( For information about this license Case(017►777.3200 or visit www C ice ("690/ire4ntrviuttecta Office of Consumer Affairs and Business Regulation One Ashburton Place-Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Type: Corporation SPRINKLE HOME IMPROVEMENT,INC. 103757 199 BARNSTABLE RD. Expiration: 07/06/2020 HYANNIS,MA 02601 Update Address and Return Card. SCA I 8 2DM-05117 r7e 09nino,,wea/JA`y`&4Ja-%uoe%/ Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation Wore the expiration date. If found return to: $ fl Office of Consumer Affairs and Business Regulation 103757 07/08/2020 One Ashburton Place-Suite SPRINKLE HOME IMPROVEMENT,INC. Boston,MA 4 BRAD K.SPRINKLE —-. 199 BARNSTABLE RD. HYANNIS.MA 02801 Und0ra0prafary Not valid at re