HomeMy WebLinkAboutBLD-20-3865 Office Use Only
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Permit#
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issue date
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH •
Yarmouth Building Department
1146 Route 28 ( -� 0
South Yarmouth,MA 02664 .�`(
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 7 S41j 74 -I\ •
ASSESSOR'S INFORMATION:
Map: �J� Parcel: t
OWNER:/%)or\4 &In rsan 7 S rill Q r�p��h m A �315).1Sez' �
NAME ADDRES� 024g TEL Email Address:
./ y
CONTRACTOR:/1 PCo O I II P X Ce/r St.dirn/-lA o/�o / _ /-SOO-342-2 2.I/
N MAILING ADDRESS TEL.# Email Addres
Residential Commercial/ Est.Cost of Construction$ "1,) r L
Home Improvement Contractor Lic.# J'16,s/9 Construction Supervisor Lic.# //0 7 (o.3
Workman's Compensation Insurance: (check one)
I am the homeowner I am the sole proprietor have Worker's Compensation Insurance -7
Insurance Company Name: 6U� 'Gf t/ i-i?S. i C &) Worker's Comp.Policy# /lf ✓( ) 3 l 7
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares Replacement windows:# ! (2 Replacement doors: #
Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation
Old Sings Highway/Historic Dist. ( )Replacing like for like
*The debris will be disposed of at: AM See co= r7-r n 1 AlJ.14 el 0141
Location of Facility
I declare under penalties of e statements herein contained are true and correct to the best of my knowledge and belief. I derstand that any false answer(s)
will be just cause for denial v • of my license and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signatre: /' Date: 7
Owners Signature(or ent) $ 2 e-f ei LT Date: ll
Approved By: ..' Date: /' 5 - 4.0
Building Official(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
,
Page 1 of 14
MA Reg S146580
CT Reg.0605216 //
r
ifNM.
Federal ID#20-2625129 N
Window/ Door Contract ,� I c( _�
Customer Information l.P > �--
Norma Ganderson (315) 382-2327 {} Date:12J09/2018
7 Smith Road normaganderson@gmail.com Rep: Kurt Reggio
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 on the following'pages
•
af this agreement (collectively,this"Agreement")at the..premises located at
7 Smith Road
South Yarmouth MA 02664
Windows Being Installed 16
Doors Being`Installed
Window Details
"' Location: Dining Room Series: Ecomax Double Hung
interior Color: White Screen Type: 1/2
Exterior Color: White Grid Pattern: None
Hardware Finish: White Grid Type: None
Additional Labor: None Glass Options: None
w Location: Dining Room Series: Ecomax Double Hung
Interior Color • 'White Screen Type 1/2•
'' Exterior Color • White GridPattern: None,
'�^ Hardware Finish
White -Gnd Type: Jove•
:
Additional Labor: None Glass;;Options None_,
Location: r Dining Roo Series: Ecomax Double Hung• Interior Color: �31�. Screen Type: 1/2
Exteirior Co r: > {�+ ite Grid Pattern: None
H• dwarel ( White Grid Type: None
14,= , None Glass Options: None
i Location: Dining Raom Banes: Ecomax Double Hung
L_. Interior Color
White 'Screen Type ; 1(2
A
I Exterior Color: White Grid,Pattern:
N
Hardware Pintail:: White Grid 7Ype None
Additional Labor
None`:: ,Glass:Options _None
Location: Kitchen Series: Ecomax Double Huinig2
: Interior Color: White Screen Type.
Exterior Color: White Grid Patten: None
Hardware Finish: White Grid Type: None
Additional Labor: None Glass Options: None
!.n3PTUDigi!Al,can 1.5.3
Page 2 of_14
Location ;:Bedroom 1 Series Ecomax Double Hung°
Interior Color White Screen Type: • ;1/2;
Exterior C for : White Grid:;Pattern: None`;
Hardware finish White ;Grid:Type• Noner'.
Additional Labor ;(Sill) , Glass Options None::
('�" .I Location: Bedroom 1 Series: Ecomax Double Hung
►,s,f Interior Color: White Screen Type: 1/2
``` Exterior Color: White Grid Pattern: None
Hardware Finish: White Grid Type: None
Additional Labor: (Sill) Glass Options: None
Location ••• Bedroom 2 Series Ecomax Double Hung;:
Interior Color White • Screen Type: 1/2:
Exterior Color White Grid Pattern; None`
Hardware:Finish:` • White Grid Type None.
Additional:,tabor; ;(Sill) Gla•ss;Options None
h' Location: Bedroom 2 Series. Ecomax Double Hung
Interior Color: White Screen Type: 1/2
`' ` Exterior Color: White Grid Pattern: None
'""""' Hardware Finish: White Grid Type: None
Additional Labor: (Sill) G• lass Options: None
Location • Bedroom 3 Series: Ecomax Double Hun .
-- Interior Color: White Screen Type: 1/22
Exterior Color IAlilite • Grid Pattern: None
Hardware Finish White Grid Type None;
Additional;Labor:= -(Sill) Glass:Options None;
Location: Bedroom 3 Series: Ecomax Double Hung
J..':'''=;'^ Interior Color: White Screen Type: 1/2
Exterior Color: White Grid Pattern: None
Hardware Finish: White Grid Type: None
Additional Labor: (Sill) Glass Options: None
Location Bedroom 4 Series Ecomax Double Hung;
Interior Color White Screen Type; .112,
• .- Exterior Color White :` Grid Pattern; None
Hardware Finish White Grid Type Norm'
Additional Labor "None. Glass'Options None
Location: Bedroom 4 Series. Ecomax Double Hung
Interior Color: White Screen Ty : 1J2
I kiwiExterior Calar: White Grid Pattern: None
Hardware Finish: White Grid Type:
pe None
Additional Labor: None Glass Options: None
•
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Ecomax Double Hung
Interior Color: 1/2
Exterior Color:
Location: Living Room Screen
None
1:'•'.1-:,,
None
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White Grid Type:
None
Hardware Finish: White GridcSeries:reePna t.rt ye Pr ne:::
Additional Labor: None Glass Options:
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Capping Texture Smooth
Capping Color 4 :wtlte,27243..,•.,.:1.
Additional Details
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... 126.iioict-:
Estimated Start&Completion Dates , , , ,
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Page 13 of 14
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.
A' 4 A V'ln
Norma Ganderson
12/09/2019
Date
a-4
Kurt Reggio
12/09/2019
Date
This space intentionally left blank
leapToUigiral rrm 7.&.3
The Commonwealth of Massachusetts
. • r Department of Industrial Accidents
s 1 Congress Street,Suite 100
6 Boston,MA 02114-2017
N.. 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): jkl .t Pro <`�er'Cv�'�1) Li—C
Address: Z 6, CeAa r SI--;
City/State/Zip: W 0(lone),M A oleo t Phone#: /—$0 0 —3 +-i Z - 2 2— I
Are youpa employer?Check the appropriate box:
�+u�(/ Type of project(required):
I. 1 am a employer with 2.0 employees(full andlor part-time).* 7. ❑New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in
any capacity.[No workers'comp.insurance required.] 8. ❑Remodeling
3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. 0 Demolition
A_❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition
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
5.0[am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractorss have employees and have workers'comp.insurance.: 13.0Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14,Other 0
152,§1(4),and we have no employees.[No workers'comp.insurance required.] 1149/1
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy info a[ion.
t'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. lithe sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'co» nation insurance for my employees. Below is the policy and job site
information.
git
Insurance Company Name: kl?„A -41J...94.R141.0-6 03%94,11P
Policy#or Self-ins.Lic.#: A ` E.IL&O2 e'7 7 g _ Expiration Date:S. i/2..a
Job Site Address: 7 Gi 2 11 / 6(. City/State/Zip: S , �'• )-11A j'�
Attach a copy of the workers'compensation policy declaration page(showingthe policynumbhrand expiration'
P g p otl 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 impriso• 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: . •.y of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verificatio fr
I do hereby certify nd; ;pains and penalties of perjury that the information provided' •ove true and correct.
Sienature: . /
Date:
•
Phone#- - ` —8 q y—, •
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#:
ACCORD CERTIFICATE OF LIABILITY INSURANCE DAM GAINDDNYYY)
AFAIN°°"'"")
`..� 12/31/2019
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(les)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 doss not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER CWICT Melissa Pflug
The Hilb Group of N.E.,LLC dba Mackintire Insuranc I(PAHrcONEE (508)366-6161 I ,No)' (508)366-5202
11 West Main Street ADDRESS: melissap@mackintire.com
INSURER(S)AFFORDING COVERAGE NAIC i
Westborough MA 01581-1931 INSURER A EMC Insurance Companies
INSURED INSURER B: Guard Insurance Group
Newpro Operating LLC INSURER C: Colony Insurance Co
26 Cedar St INSURER D:
INSURER E:
Wobum MA 01801 INSURER F:
COVERAGES CERTIFICATE NUMBER: 19-20 Master 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.
ILTR AWL SUM POLICY EFF POUCY EXP
TYPE OF INSURANCE INSD WVD POUCY NUMBER (MMIDD/YYY r) (MMIDCWYYY) LIMITS
X CO1NERCIAL GENERAL LIABILrtY EACH OCCURRENCE S 1,000,000
DCLAIMS-MADE C OCCUR PRREISES(Ea occurrence) $ 500,000
MED EXP(My one person) S 15,000
A 6D15090 12/31/2019 12/31/2020 PERSONAL&ADV INJURY S 1'CM'CM
GEN'LAGGREGATE LIMITAPPUES PER: GENERAL AGGREGATE S 3�'�
X POUCY EEC LAC PRODUCTS-COMP/OP AGG $ 2'°°°'°°°
OTHER: S
AUTOMOBILE LIABILITY C SINGLE LIMIT $ 1,000.000
ANY AUTO BODILY INJURY(Per person) $
A OWNED X SCHEDULED 6Z15090 12/31/2019 12/31/2020 BODILY INJURY(Per accident) s
AUTOS ONLY AUTOS
HIRED X NON-OWNED PROPERTY DAMAGE
X AUTOS ONLY !� AUTOS ONLY (Per accident)
Uninsured motorist BI s 250,000
X UMBRELLA LLAB OCCUR EACH OCCURRENCE $ 5'000'000
A EXCESS UAB CLAIMS MAC 6J15090 12/31/2019 12/31/2020 AGGREGATE $ 5,000,000
DED XI RETENTION S 0
WORKERS COMPENSATION XI AND EMPLOYERS LIABILITYN STATUTE ERR
B ANY PROPRIETOR/PARTNER/EXECUTIVE Y(� NIA NEWCO28778 05/01/2019 05/01/2020 E.L EACH ACCIDENT $ 500
OFFlCtoiyIn EXCLUDED? I I 500,000
(Mandatory In NH) E.L DISEASE-EA EMPLOYEE $
If yea,describe under
DESCRIPTION OF OPERATIONS below E.L DISEASE-POUCY WAIT S 500,000
Limit $1,000,000
Pollution Liability CSP304242 12/31/2019 12/31/2020 Aggregate $2,000,000
DED $5,000
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,AddkionM Remarks Schedule,my be attached I 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
To Whom It May ConcernACCORDANCE WITH THE POUCY PROVISIONS.
AUTHORED REPRESENTM1VE
®1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
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Update Address end:Return Card.
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Office of Consumer Affairs 3 Business Regulation
-CME IMPROVEMENT CONTRACTOR Registration ialid or individual use only
TYPE:Shoolement Card before the expiration date. If found return to:
ReaistrsNon Expiration Office of onsumer Affairs and 3usiness Regulation
4558 i 05iO4P202-1 1000 ington Street •Suite 710
NEW o2ERATIf.idT,i.C. 3bston,. A 02118
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dersecre t.ary
'.iassachusetts Department of Puoiic Safety
3oard of Buildrng Regulations and Standards
i ieense: CS-110763 -M
JEFFREY CONNORS
64 OLD FIELDS ROAD
SOUTH BERWICK ME 03908 1
;inn*uS; OnCr 05105/2020