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HomeMy WebLinkAboutBld-20-003578 r I.Office Ilse Only (tit ` ' Amount ' I.tI\ � Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 aU359 4f-c CONSTRUCTION-ADDRESS: I7 rfa' i 4/e_lI€T Vim/ • ASSESSOR'S INFORMATION: Map: 67 Parcel: / . KaPei oWNER 0-1/4;h-, ruleo /7 aria,,, lid;1/Pfr c./;.1 /IA 0264,4 7C(760-Iq°gi NAME iO rle �V ' TEL # EmaitAddre CONTRACTOR: r Il) • ii! DtP4 i 1 Zzge4Z O 3�lAME MAILING ADD S TEL# Email Ad• Residential Commercial Est.Cost of Construction S L f i g S -- Home Improvement Contractor Lic.# !73 zgs" Construction Supervisor Luc.# O 167D 7 Workman's Compensation Insurance: (cheek one) . I am the homeowner I am the sole proprietor /4 have Worker's Compensation Insurance AA,,{ Insurance Company blame: SR L 1us. j10 Worker's Camp.Policy# )nrn�!st6Y5'' WARS 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 Wings I ighway/Historic Dist. ( ),1 placing like for Irkce *The debris will be disposed of at lth./e At i.t (,P,r►� Sm;' ' 1 f (7L_ ilmetlon of Faclli I declare under penalties of perjury that the herein Contained are true and correct to the best of my knowledge and belief. Iunderstand that any false answers will be just cause for denial of tip •a and for prosecudon under M.G.L Ch.268,Secdon 1. Date: /Z -//'—/9 Applicant's Signature: (f�� �) Owners Signature(or attachment) S - Af �T ,1 Date Approved By: Date: / Building Official(or designee) Zoning District Historical District Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 it.of Wetlands: Yes No Yes No Renewal�, Agreement Document and Payment Terms bYAI ldersen. dba:Renewal ByAndersen of Southern New England� John&Karen Puleo I j r Legal Name:Southern New England Windows,LLC 17 Captain Weiller Rd . RI #36079,MA#173245,CT#0634555, Lead Firm#1237 South Yarmouth,MA 02664 WINDOW NE LACEMENT 10 Reservoir Rd I Smithfield,RI 02917 H:(508)760-1999 Phone:401-349-1384 I Fax:401-633-6602 I salesorenewalsne.com Buyer(s)Name: John & Karen Puleo Contract Date: 12/09/19 Buyer(s)Street Address: 17 Captain Weiller Rd, South Yarmouth, MA 02664 Primary Telephone Number: (508)760-1999 Secondary Telephone Number: Primary Email: lkpuleo99@gmail.com Secondary Email: Buyer(s)hereby jointly and severally agrees to purchase the products and/or services of Southern New England Windows,LLC d/b/a Renewal By Andersen of Southern New England("Contractor"),in accordance with the terms and conditions described in this Agreement Document and Payment Terms,any documents listed in the Table of Contents,and any other document attached to this Agreement Document,the terms of which are all agreed to by the parties and incorporated herein by reference(collectively,this"Agreement"). Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. Total Job Amount: $4,585 By signing this Agreement,you acknowledge that the Balance Due,and the Amount Financed must be made by personal check,bank check,credit card,or cash. Deposit Received: S0 Balance Due: $4,585 Estimated Start: Estimated Completion: Amount Financed: 8 to 10 weeks 8 to 10 weeks S0 Method of Payment: Cash/Check We schedule installations based on the date of the signed contract and secondarily on the date in which we complete the technical measurements.The installation date that we are providing at this time is only an estimate.We will communicate an official date and time at a later date.Rain and extreme weather are the most common causes for delay. Notes: Pay in full today Buyer(s)agrees and understands that this Agreement constitutes the entire understandings between the parties and that there are no verbal understandings changing or modifying any of the terms of this Agreement.No alterations to or deviations from this Agreement will be valid without the signed,written consent of both the Buyer(s) and Contractor.Buyer(s)hereby acknowledges that Buyer(s) 1)has read this Agreement,understands the terms of this Agreement,and has received a completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first written above and 2)was orally informed of Buyer's right to cancel this Agreement. NOTICE TO BUYER:Do not sign this contract if blank.You are entitled to a copy of the contract at the time you sign. YOU,THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME NOT LATER THAN MIDNIGHT OF 12/12/2019 OR THE THIRD BUSINESS DAY AH 11.R THE DATE OF THIS TRANSACTION, WHICHEVER DATE IS LATER.SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. Legal Name:Southern New England Windows,LLC dba:Renewal By Andersen of Southern New England Buyer(s) dcV6.— Signature of Sales Person Signature Signature John Harrington John Puleo Karen Puleo Print Name of Sales Person Print Name Print Name UPDATED: 12/09/19 Page 2 / 11 • Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Supplement Card Registration: 173245 SOUTHERN NEW ENGLAND WINDOWS, LLC Expiration: 09/18/2020 10 RESERVOIR ROAD SMITHFIELD, RI 02917 Update Address and Return Card. SCA 1 20M-05/17 .Te e-v»megyze•e¢gif`7` l/2:iifc/uo�elGi Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Supplement Card before the expiration date. If found return to: Reaistratioq Expiration Office of Consumer Affairs and Business Regulation 17324.5 09/18/2020 1000 Washington Street-Suite 710 SOUTHERN NEW ENGLAND WINDOWS,LLC Boston,MA 0211 BRIAN DENNISON 10 RESERVOIR ROAD SMITHFIELD,RI 02917 Undersecretary t4 without signature Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constru t on `Supervisor CS-095707 Ea, p i res: 09/08/2020 BRIAN D DENNISON .-- - 8 BLACKWELLf DRIVE ; CHARLTON MA/01507 � Commissioner CoL -: A The Commonwealth ofMassackussetts -s— r i� - Department of indusbzalAccidenis = _ 1 Congress Stree4 Suite 100 : _, ' Boston,MA 02114-2017 —�7 www mass.;ov/dia 'J Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERFtLITING AUTHORITY. Annlicaat Information Please Print Lesibly Name(Business/Org tnization/Individual): S 04.7'h e -pti jJe to tn51 Gm,/ GO l l Address: /0 ?e_Se.,rUOt r i4 . City/State/Zi : ni 1 t 4 de/ R. O29 / p S7 Phone#: 4O/—ZZ r- et 6 Are you an employer?Check the appropriate box: Type of project(required): t. tam a employer with 20 t'employees(Ill and/or part-time).* g 7. ❑New construction ` am a sale proprietor or partnership and have no employees working forme in S: 0 Remodeling airy capacity.[No workers'comp.insurance required] 3.01 am a homeowner doing all work myself[No workers'comp.insurance required.)' 9 ❑Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all wormer my property. I will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole 1 1.O Electrical repairs or additions • proprietors with no employees. 12.0 Plumbing repairs or additions S. I am a general contractor and I have hired the sub-contractors listed on the attached sheet �These sub-contractors have employees and have workers'comp.insurance.: 13•0 f repairs 6. We are a corporation14. er (Z-11 O !F Dor and its officers have exercised their right of exemption per Ma.c. 152,§44),and we have ao employees.[No workers'comp.insurance required] ('ern ,Pen e•t 1 `Arty applicant that checks bake(must also fill out the section below showing their workers'compensation policy intimation. • 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 chair 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 prodding workers'compensation insurance for my employees Below is the policy and Job site information. Insurance Company Name: "I"j remel'1l 1;1 w'ca m _ (-O - or W 1l b. (i . Policy#or Self.ins.Lic.#: WCAO/sox /off?0?y • Expiration Date: 1' /—2 D LO Job Site Address: /7 t,,odls'--'i GieWe-c City/State/Zip: S.Xr i - Nj 4Attach a copy of the workers'conIpensadon policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§2SA is a criminal violation punishable by a fine up to S 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 S250.00 a day against the violator'.A copy of this statement may be forwarded to the Office of Investigations of the DR for insurance coverage verification. ton. 1 do hereby ce - under the p ' penalties of perjwy that the information provided above is true and correct Signature: Date: /2- —/1— /1 Phone#: IQ i 724-- 9 oo 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 II: A C OW ri, CERTIFICATE OF LIABILITY INSURANCE CIA T5.(MIWDD/Y YYY) ' 12/28/2018 ' 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 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 CoBiz Insurance, Inc. -CO NAME: 1401 Lawrence St., Ste. 1200 INCNNo.Extl: 303-988-0446 FAX Nol:303-988-0804 Denver CO 80202 Amens: COMaii(gcobizinsurance.com INSURER(S)AFFORDING COVERAGE NAIL e INSURER A:Acadia Insurance Company 31325 INSURED ESLERCO.O1 INSURER B:Firemens Insurance Company of WA,D.C. 21784 Southern New England Windows, LLC. dba Renewal by Andersen of Southern New England INSURER C:Homeland Insurance Company of New York 34452 10 Reserviar Rd INSURER 0: Smithfield RI 02917 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:787175890 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 TYPE INSURANCE ADOL SUER . POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER IMMIDD/YYYY) IMM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY CPA3158728 1/1/2019 1/1/2020 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES!Ea occurrence) $300,000 MED EXP(Any one personi S 10,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE UMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY JECT I I LOC PRODUCTS-COMPIOP AGG $2,000,000 ' OTHER: $ A AUTOMOBILE LIABILITY CPA3158728 1/1/2019 1/1/2020 COMBINED SINGLE UMIT S (Ea accident) 1.000,000 X ANY AUTO BODILY INJURY(Per person) $ — ALL OWNED — SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS i X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ �_ AUTOS (Per accident) A X UMBRELLA LIAB X OCCUR CPA3158728 1/1/2019 1/1/2020 EACH OCCURRENCE $15,000,000 - EXCESS UAB CLAIMS-MADE AGGREGATE $15,000,000 DEO X RETENTION$0 $ a WORKERS COMPENSATION WCA315872924 1/1/2019 1/1/2020 X PER STATUTE ER y AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1.000,000 ' I/yes,desdlba under DESCRIPTION OF OPERATIONS below - E.L.DISEASE-POLICY OMIT $1,000,000 C Pollution Liabg$y 7930073340000. 1/1/2019 1/1/2020 Each Occurrence S2,000,000 Claims-Made Policy Aggregate S2,000.000 Retroactive Date 06/20/2013 Deductible 325,000 DESCRIPTION OF OPERATIONS/LOCATIONS I 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 ACCORDANCE WITH THE POLICY PROVISIONS. FOR INFORMATIONAL PURPOSES'ONLY ' AUTHORIZED REPRESENTATIVE I ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD