Loading...
HomeMy WebLinkAboutBld-20-003529 (2) Y` lurnee Use Only • O: Permit# Oi _ H !Amount Vet ems' Permit expires 180 days from !issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 ``JJ (508) 398-2231 Ext. 1261 C V 5 y Lp CONSTRUCTION ADDRESS: I Z I CAMP T ASSESSOR'S INFORMATION: Map: Parcel: OWNER: Gain NcY K.c OU�- lit cAnieser. s 56s - 7 3/ - 3.210 NAME PRESENT ADDRESS TEL. # CONTRACTOR: 5(00 ,DLC(IU5(J 15aS 4-t aT p._0e. s g 7(A^ 68a0 NAME MAILING ADDRESS pa , r ,/1 rvE.Q TEL.# esidential ❑Commercial Est. Cost of Construction$ 1,5-412- S Home Improvement Contractor Lie.# NI tag 0 Construction Supervisor Lic.# CS — 0 8 I �f 3 Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor B'I have Worker's Compensation Insurance Insurance Company Name: s a'K w ekr fEfc t SFt-GPCEY Worker's Comp.Policy# S'4((a7L( aB I S WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows: # Replacement doors: # oZ. 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: l 3S A I ite0 f 1 - ` A'L-4--- 1 v`-"—,/ µA 03- a Location of Facility I declare under penalties of perjury that the statem-• -• m•.ntaine. 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• lie .and .ros= ution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: Z1 2a 1 l Owners Signature( attachment) Date: Approved By: �� Date: -I 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 F-CO G c &oPU . corn The Commonwealth of Massachusetts I t'/ Department of Industrial Accidents :Iilfr= t 1 Congress Street,Suite 100 =E�d= 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 ' r Please Print Legibly nt Name (Business/Organization/Individual): ?FAM/( 'I I/0 i'5 Address: 13a5 Al (Leo al- (2-f) • City/State/Zip: A. ,/,, IZA Uay r'VI A 0aiA0 Phone#: 5-0 010 IDS Are you an employer?Check the appropriate box: Type of project(required): Liam a employer with 56 employees(full and/or part-time).* 7. ❑New construction 2. I am a sole proprietor or partnership and have no employees working for me in ❑ 8. 124emodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.)t 9. El Demolition 4.0I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 El Building addition 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. 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. 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: 5TA V-IC1N IK - % S('�Gf t e Policy#or Self-ins.Lic.#: S P (0 7 L O 8 I 8 Expiration Date: 0 5 I 0 l ( 7,020 Job Site Address: 12l CA In P. 5 rr UN i T. 8$ City/State/Zip. W• WWIIC>c!T1rI J rtAA 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 •enalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy o r i t. may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and- the p:' a 1 , èrt,sapthfl1ff,eInformationprovided above is true and correct. Signature: Date: Phone#: SO: (CI (O (ogAO 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 i Contact Person: Phone#: cileW 0/c/(//,cmocteAtaan Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 Boston, Mas achusetts 02108 Home Improveme �agttractor Registration .. Type: LLC PFR ACQUISITION LLC !' Registration: 149840 3 ; _.v_ ix3fr J w t i Expiration: 02/12/2020 1325 AIRPORT ROAD s FALL RIVER,MA 02720 g = t t4 • Update Address and Return Card. SCA 1 c:; 20M-05/17 PYge I a oacluioela Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:LLC before the expiration date. If found return to: Registration`, Expiration Office of Consumer Affairs and Business Regulation 149840,-; 02/12/2020 10 Park Plaza-Suite 5170 PFR ACOUISITIQN LL'C :=:: Boston,MA 02116 �Yr CHARLES MILOT � ,Q„CGQ, ---- Ots-A.A. 1325 AIRPORT ROAD FALL RIVER,MA 02720 Undersecretary Not valid without signature Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constt s .rvisor CS-081843 * Eplres 02/06/2020 '4µ STEPHEN T DI Ki 5 AZALEA LAN . . '' PLYMOUTH MA: 36 1 x` i A.-- A Commissioner Client#:73461 PELLAWINi ACORD. CERTIFICATE OF LIABILITY INSURANCE I DATE(MMIDD/YYYY) 04/26/2019 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 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 CONTACT Melissa Tanguay Starkweather&Shepley PHONE 401 435-3600 PO Box 549 (A/c,No.Ext): lac,No 401 431-9658 Providence, RI 02901-0549 E-MAIL DRESS: mtanguay cQstarshep.com 401 435-3600 INSURER(S)AFFORDING COVERAGE NAIC X INSURED INSURER A:Employers Mutual Ins 21415 PFR Acquisition LLC INSURER 8 DBA:Pella Windows&Doors INSURER C: 1325 Airport Rd INSURER o Fall River,MA 02720 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 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 jNSR )m/n POLICY NUMBER POLIO EF POLICY EXP (MM/DD ) (MMIDD/YYYY) LIMBS A X COMMERCIAL GENERAL LIABILITY 5D67408 05/01/2019 05/01/2020 EACH OCCURRENCE 51,000,000 PREMISES i CLAIMS-MADE X OCCUR Ea occu(rencel S500,000 MED EXP(Any one person) $10,000 -- PERSONAL S ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 TTPOLICY E Sri 0 LOC PRODUCTS-COMP/OP AGO S2,000,000 OTHER: S A AUTOMOBILE LIABILITY 5Z67408 05/01/2019 05/01/2020 (CO EakiggploSINGLELIMIT 51,000,000 — ANY AUTO • BODILY INJURY(Per person) $ ALL OWNED SCHEDULED _ AUTOS X AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE S (Per ecddent) X Drive Oth Car S A X UMBRELLA UAB X OCCUR 5J6740818 05/01/2019 05/01/202 r EACH OCCURRENCE $10,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $10,000,000 DED X RETENTIONS10000 $ A WORKERS COMPENSATION 5H6740818 05/01/2019 05/01/2020 X STATUTE ERR- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/NN OFFICER/MEMBER EXCLUDED? NIA E.L.EACH ACCIDENT S1,000,000 (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 If more space Is required) CERTIFICATE HOLDER CANCELLATION PFR Acquisition LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN DBA:Pella Windows&Doors ACCORDANCE WITH THE POLICY PROVISIONS. 1325 Airport Road Fall River, MA 02720 AUTHORIZED REPRESENTATIVE —.c CD 1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) 1 of 1 The ACORD name and logo are registered marks of ACORD #51305339/M 1305328 PRMBT ..ing Project Name: King,Quincy Order Number: 7387620WX Quote Number: 11945591 .at this may not result in the affected areas being restored to their original condition. .,contract shall be governed by the State of Rhode Island or Massachusetts depending on the location of the work to be performed. ce,ek,uk,; , ��t\ Order Totals er Name (Please pint) Pella Sales Rep Name (Please print) Taxable Subtotal $4,670.60 Sales Tax© 6.25% $291.91 Customer Si nature Pella Sales Rep Signature Non-taxable Subtotal $2,580.00 10 • `t • (1 Total $7,542.51 Date Date Deposit Received Amount Due $7,542.51 Credit Card Approval Signature r-__ ---._s__......4:.,...........•:....••.e fi.,;.tio.... .noan•onont•o contiro anti warranty of all Palladb nrnducts.visit the Pella®website at www.pella.com