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Permit expires 180 days from
issue date
EXPRESS BUILDING PERMIT APPLIC " • ' �
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28 cF % 10
South Yarmouth,MA 02664 _
(508) 398-2231 Ext. 1261 3 "'r
t 6Y
CONSTRUCTION ADDRESS: / it //p h (A
ASSESSOR'S INFORMATION: _
Map: Parcel:
OWNER: �/Ky I4 It 43 /, ,t ado/1oh ,,cv14 rtA a�675 .a8- 4/30-Oi o3
NAME FRES ADDRESS I TEL # Email Address.
CONTRACTOR:W nfbathe(I a.0-god- cn,LLC oZ�Cwnr�tings tK ISA tie.hu rra/'1/t' (7 8 I) '32-'4D S+
NAME MAILING ADDRESS 01701 TEL.# Email Addrs
idential Commercial Est.Cost of Construction S 8811''7/
Home Improvement Contractor Lic.# /(rh O2 Construction Supervisor Lic.# 0 72 77L.
Workman's Compensation Insurance: (check one)
I am the homeowner I am the sole proprietor I have Worker's Compensation Insurance
Insurance Company Name: 4 C ia►4 eJ &d Oy t?r'S Worker's Comp.Policy# !� C C--St)O 6-0 1 �Q�--
11 .20 t9 Or
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
( ) ))'Yl'9'°'.}9
Old Sings Highway/Historic Dist. (placing like for like
'The debris will be disposed of at: t 4'ch 4044 L1l )4 v[/1 , /1 A
Location of Facility
I declare under penalties of perjury I : the s a�,a, ,�� are true and correct to the best of my knowledge and belief. I understand that any false answers)
will be just cause for denial or re . o •;� � 1' � : ••;: -::• M.G.L.Ch.268,Section I.
Applicant's Signature: �• �`-1 Date: �2 1( -1 C.
Owners Signature(or: . eat) A ce c ac �6c 1 Date:
Approved By -Li-• Date: a. - 4-6 '' �6
dal(or designee)
Zoning District
Historical District Yes No Flood Plain Zone: Yes No
Water Resource Protection District Within 100 ft.of Wetlands:
Yes No Yes No
•u„/_... Window World of Boston MA HIC RegistratIon
Offices&Showrooms Number. .
sj'a .(i 01SA Cummings Park 0 295 Old Oak Street 0 1000 Boston Turnpike 166026
Woburn,MA 01801 Pembroke.MA 02359 Shrewsbury,MA 01545 Federal ID Or
(781)932-4805 (781)826-6281 (508)845.8876 82-4898432
-
www.WindowWoridolloston.com
Customer. /1/A NC y Mqry{C/NS Phone th($-0t)Y.2o-oQf '
Install Address: Ri/ , iik.1I)0[�:f Al Phone(c)GCd)2Y(ZY9 r �i<. '
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City' earia'e-07if- ,ri-4.7 State:MA ZI Qtf 95 E-mailf_ !loom,:
Pg msn.Go"
WINDOW WORLD GLASS OPTIONS
2000 Series NI-Weld
5259 Single-hungAli-Weld $249
2000 WOO DHHAIFW /,SolarZone Re-Dual Pane 5129 499
fo 4000 Series OH AB-Weld $289 Mr° -Mple Pane $299
8000 Series DH All-Weld $309
_2 Ute Slider E429 WINDOW OPTIONS
3 Ute Slider nor.hA ran MI.ran ua Sees) Glass Breakage Warranty(4000/6000) $15 INCLUDED
Picture/Fixed Lite (0-83 Ut) $419 1/2 Screens S9 INCLUDED
/Elated Lite (84-130 Ury 5539 Foam Insulation on Jambs and Head $11 INCLUDED
•
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S35e 3.5y Double Strength Glass(4000/8000) 315 INCLUDED
_Casement Plus$49(OH Sash Rah)$379 Double Locks(>28") as INCLUDED
/ 2 Lite Casement $659 45 tf /0 Full Screens $25 Zfo
__3 Lite Casement a.s.rn to av h.t Wh S1029 /0 Colonial Grids I) $65 GSO -
•
Basement Hopper S469 _Prairie Grids $75
Bay Window-Soffit Mount/INS Seat$2859 Simulated Divided UM $182
• _Bow Window••Soli!Mount/INS Seat$2999 �—Tempered OH Sash(8S0)(TSO) $75 7r_Garden Window $2179 / Obscure Glass(88O)(TSO) $75 7-r
Bay.Bow.Garden Oversize (+109 UI) S979 Oriel Style 4
Beige I Almond S49 Y 10/60 or tI0/40) f75
__Wood Grain Interior Mews 4000 1 6000 only)S100 _Foam Enhanced Frame $35
(Light Oak!bait Oak!Cherry!Fox wood PRE 1978 BUILT HOMES(RRP SAFE RENOVATI '
Rich Maple) MY HOME WAS BUILT IN THE YEAR an Initial
Brown Exterior(Arch.home/Amman Tena)S I on
Designer Color Exterior S179 MISCELLANEOUS
—Spedallty Window 'h $ �I'.0uatom Exterior AlurnittiM gadding
Window Color (,(f�_ , f_ J Textured$90 •8 Smooth$90 g i'49 0
/ - Facing Color
inside Owrlde
2.-• Multi-Bend Cladding $20 O.'
NON CUSTOM DOORS • /l4 Install Interior/Exterior Stops S50 70a,—
Vinyl Rolling Pam Door 5R Or ea. $12 . 1113181 Interior Casing Starts Al S9$
Wtyl Roiling Palo Door 8k. S '•'' _Repair Sill,Jamb or replace sill nosing S75
Add to bass pace for Custom Roang Patio Door•1259 Full Sub-Sill
French Rad Sliding Patio Door 5ft or:, $1539 (Single)reP�eement $175
Freneth Rai Sliding Patio Door eft. S1639 —Renal Weight Boxes $20
French Rod Shang Patio Door• $1749 —_MUD to Form Multi Unit $30
custom Exterior Cladding $300 _Mullion Removal $�
SolarZarw Else $309 Metal Window Removal S75
Grids Patio Door $210 New Construction Vinyl Removal $175
Woodgraft intim. $399 New Coast.Ext.Retro Fit $150
• _ExtenOr Design• .ors 5599 Roof for Bay/Bow Windows $500
_wiener Cast . 2,7 3,2
5279 —Removal of Existing Say/Bow $250
_Randrose •.•.• S _Bay/Bow Conversion Ext.Retro FB $450
_interior: •3(six fool only} saga
3 (New Siding Will Not Matoh)
® ROUND•UP FOR WINDOW WORLD CARES
Door Color
Muds ! dish* SL Jade CRdrm's RamaReveal S
Customer declines exterior wrap and understa .a painting and/or repair may be required Initial r
I 1 Customer declines grids on 2 windows/doors 1rtIUac
t1 r=M C stamnlsrmpembbkrMel lgncowtcare ithads comet OMAN.SlIimo./dannSysWltObreoR arml bonPe l dten
excess aSTS•9LlkanaatMraldof CON Assabeamdorsal,lasarecDi aielAlPe++tlRrofematapad*AsidewiaxPensiN/S4CammdlaowithiMWaaen
NO EXTRA WORK IF NOT IN WRITING! Customer agrees to the terms of payment as follows:
�u' J4— S m'- Q Extra Labor&Materials $ SS.
/� p f, Site Set Up.Permit,Disposal&Delivery Fees$ ?NAM
�"` y ` � - Ol Total Amount f QV 7. t70
�'2 o f H�TG � Custom Order Deposit air i ?,3Yy cis
/NgJf ERNE Proms Stan Paymeoil. $ 325O
,..,fGS B ce Due Day of Installation $ 52.50C•thif
Mader World of Barton radklpgas u Amount Financed $
adla,OM wish a and befog substantially Oxrlpkled h days Saran nu.Ws No
My deposit regxdmd In advance of Us shill ell the wed SHALL HOT exceed 31 1/3%ci Me total contact poke or rim au e a1 Cost of 4rry astute or eVemem of a
marls*alai orderer oaten:
Mal be demanded anti Oho cMwact Is aunalaid as Um saltshak x of boat paths
of rim work In amnia Cal am propel9sW ludcatnl an SCxbddA.INlira p1ygMM
Mhos haprovaosd caaw5Uora and sWcenhatiou shall be!mastered and Cal any Imams abort a anima or wbcamaga ramie lea rdpsomee slhavnl bo
Mom,et Mee N Coawarar MWri and SWIMS Aepdsloa,Ten Park Plare.Site 6170 Bartow.MA0211&Pteoer.(Ut71913-a700
lye warn stall Mph prior 1e the shake el the conked sad Irsumleal to Me owner at a copy rd seen anima.
Window Wale el Boon under prosistol of Gaeta 142A el are oeneal lane Is required to may Far ant obtain an cameection awed Pua1As.Window Nbrhl al
Balder Ikd astbe deemed responsible for delays to them*desaWadla ins apeansm caused by retsdator5 pores Brseelg agates,arhorwes is mdeiduuls
Roller N Me PIR1CHASER(8)eNalea his own eeukratlee rallied panrdle for Me wort dumbed Undo/tole aaaemaW a dads with uersgilei.daxteerlers.
the PURCHASER(8)Is hereby sdalaed Mel la the anal of a dls p1 Wte,lodgement ad nonpayment.lbe PURCHASERS)rapt be aided to make a dale w
cWaeaoa from the mum*fond aWRshed by ellaple,142A.N.OA-
You tics boyer may camel Ib(i trogeetlen al any time prior le midnight Mille Ihfrdbuslnaas day e-Ner to da6•d-fthls troasacllen.
Notice et cancellation meal be In wilting postmarked no later than midnight of the feltowing third business day.
JH(TIS A Cji$rOM•OeDER NOT FOR RFSALEI •
.,.... - Tls Maw WNW Flied**is ingepoidorty owned aid awake)by L a P Boston Door/torn led Med Saone km landau deadd re, �._
--r3(1.1. C,,W,rca (-70r9y.3/79
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:!�r�••�'-+� .l (Nara Do nmrlf.r 11 a n� yjwR spoep. own
Srasmen-Do not a it Moro are leek spaces. �r O,wlw 0o not e15n it sea as any blank apes... Dale
sragnora white Copy•Orlpnal weiorCary Fria Pert Copy Customer rw«n....r r.e Ill/..,e
Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
J!'straction SUperv,sor
CS-072772 Expires: 04/07/2020
JEFF C STEELE
24 SHERWOOD AVE
DANVERS MA 01923
Commissioner
•
7 4 tiemommen'€€//f
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
TYPE:LLC
'ReglstreHon Exeiration.
186025 04(11/2020
WINDOW WORLD OF BOSTON,LLC.
JEFF C,STEELE .2`CC"`U
15A CUMMINGS PARK
WOBURN,MA 01801 undersecretary
-_--_ -1--,a ( ,);1! p'Up,v,,i ]17,;s r '.'L _'.T
Dgpq.-ime;li of Intl us r[at A ide.??Is
.7 1 Congress Street, Suite 100
7 , `J Boston, 'L-{ 021_11-2017
-,,, 7 www,mass.gov/dia
'Nal•kkers' Compensation Insurance Affidavit: BuildersiContractors/Electricians/Planibers.
TO BE l+'ILED WIL'H rah PERMITTING ALTHORITY.
Applicant Information ,l / Please Print Legibly
Nam
e Bus inessiOrgani7ationiIndividual): I2, j c/on 4 et2-��4 j-4/7C. .e,) /4 ;✓A(J)w:✓ci'J d-4.Za 3 -V-7
Address: I5 A Ct)m,T\i )s f `((
City/State/Zip: Uia. NI, . Phone 4: 7 'I - 1 S 1--- '0 5
Are yog an employer?Check the appropriate box: Type of project(required):
1.fLblt/I 3m a employer with 3 0 employees(full and/or part-time).* 7. ❑New construction
2.0[am a sole proprietor or partnership and have no employees working for me in 3. 0 Remodeling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
3.0 I 3m a homeowner doing all work myself [No workers'comp.insurance required.]'
10❑Building addition
4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors zither have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with ao employees.
P12.❑Plumbing repairs or additions
5 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.FROof repairs
These sub-contractors have employees and have workers'comp.insurance.'
I4.ZOther w i,:,oL__•./
5.❑We are a corporation and its officers have exercised their right of exemption per HGL 3.
152,41(4),and we have ao employees.No workers'comp.insurance required.] I":e (4-1.&1•
*.-kay applicant that checks box 41 must also 511 out he section below showing their workers'compensation policy information.
' Homeowners who submit this affidavit indicating they are doing all work and'hen 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 sot 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 Sgnc; ex:f e d (/"el u ye.r 5 —
Policy#or Self-ins.Lic.#: W C -5-DO- co I g(o O r1- Z o/ 1!{ Expiration Date: d/- S- 2 0
Job Site Address: / gaAlo%^ <-e• City/State/Zip:le:cry...iv/4W, /1A
Attach a copy of the workers' compensation policy declaration page(showing the policy ner and Ixpirltion 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 this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verific. 'on. l
I do hereby certi and he pa' a ),4 enalties of pedury that the information provided above is true and correct.
Signature: it ' // / ) Date: Z—1 Cow.ZU
Phone#: 0 e-Z 4; A 8- '7 3 c S
Official use o . 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#:
AC0RL CERTIFICATE OF LIABILITY INSURANCE
414.....----- 03/26/19
P
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 ACT
NAME: amy roberts
M.P.Roberts Insurance Agency Inc. PHONE Ext): 978-683-8073 FAX No): 978-683-147
1060 Osgood Street E-MAIL
North Andover, MA 01845 ADDRESS: amy@mprobertsinsurance.com
INSURERS)AFFORDING COVERAGE NAIC#
INSURERA: WESTERN WORLD INS COMPANY
INSURED INSURER a: MERCHANTS INS COMPANY
L&P BOSTON OPERATING,INC INSURER c: ASSOCIATED EMPLOYERS
DBA WINDOW WORLD OF BOSTON INSURER D:
15A CUMMINGS PARK
WOBURN, MA 01801 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 ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED DR 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.
INTSRR TYPE OF INSURANCE I SD W D POUCY NUMBER (MM/DD�Y) (MM/DD/YEXP
YV1') LIMITS
X COMMERCIAL GENERAL UABILITY EACH OCCURRENCE $ 1,000,000
TO D
CLAIMS-MADE X OCCUR PREMISEGE S(Ea occurrence) $ 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 APPLIES PER: GENERAL AGGREGATE $ 2,000,000
X1 POUCY n JECaT LOC PRODUCTS-COMP/OP AGG $ 1,000;000-
OTHER: $
AUTOMOBILE UABILITY COMBINED SINGLE UMIT $ 1,000,000
(Ea accident)
ANY AUTO BODILY INJURY(Per person) $
B OWAUTOSNED ONLY AU X SCHED TOSULED MCAI002569 04/05/19 04/05/20 BODILY INJURY(Per accident) $
X HIRED X NON-0WNED PROPERTY DAMAGE $
AUTOS ONLY _ AUTOS ONLY (Per accident)
. $
X UMBRELLA UAB 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 X MUTE EMPLOYERS'UABILTY STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 1,000,000
C OFFICER/MEMBER EXCLUDED? I N 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/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 BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
EVIDENCE OF INSURANCE ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REP NTATIVEF
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O 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD