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HomeMy WebLinkAboutBld-20-004474 .o-•• .k. Anat-20 -ea • ( 1.Amount Nr1/4W.'", l•Permit expires 180 days from issue;date • EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH 1-4----E a-E---cv--E-. i . Yarmouth Building Departm r -—- 1146 Route 28 South Yarmouth,MA 02664 p ; -- f (508)398-2231 Ext 1261 B ' P31MENF friss-t,ad CONSTRUCTION ADDRESS: il 7 ?,43 1, I e_ .Betteit ASSESSOR'S INFORMATION: . I Map: 7 0 Parcel: / OWNER:bg/Se_ fieclerte-o I/7 htikegtch Way cod-Pit Ilerinfot4 an (z_03)913-1-‘5.W7 NAME PRESENT ADVRESS 1 C? 2b4/ TEL # Email Addri CONTRACTOR:1riz, 4fite -D.e.-P 'Os cilm4s.bury, 11A pi CL!S--- b—Ce-N172--6q 4 1 NAME MAILING MO DRESS TEL.# Email At Residential Commercial Est.Cost of Construction$ /6 Z --- some Improvement Contractor Lie.# /lot7e S Construction Supervisor Lic.# 07 00'7 7 Workman's Compensation Insurance: (chPeir one) I am the homeowner I am the sole proprietor N./Kaye Worker's Compensation Insurance Insurance Company Name: Aden; I d 11;0 A #7r d .•4 n Sti at/1 CP a Worker's Comp.Policy# rtAfe. 55.6 575 1 1 . • WORK TO BE PERFORMED ' Tent Duration (Fire Retardant Certifi cited?) Wood Stove - Siding: #of Squares - . Replacement win ows:# 3 - Replacement doors: # - Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation ____Old Kings Highway/Historic Dist. ( )Replacing like for like _ -- *The debris will be disposed of at tile..S'i ... ilttli civifirt— ' Location of Facility I declare under penalties of. - ,ril statements herein contained are true and correct to the best of my knowledge and belief. lunderstand that any false mime will be just cause for denial or.,,.r,„ of my license and for is,-,.. ;.11 antler M.G.L.Ch.268.Section 1. . • ' Air 1 , 2.111-12-0 Applicant's Signature: Alr.4114*/,/Pa Date: Owners SNaature(or a.:IT, „,410, - 5e€ achek ConTat c.-f- — Duet Approved By: vz / Date: ----/3 --,;• 0 IIII -.Metal(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 . ``1 Home Improvement Agreement: Pagel • Home Depot License#'s - For the most current listing www.Homedepot.com/LicenseNumbers MA: 107774, 112785 Janice Campbell Salesperson Name: Registration No. (if applicable): Home Depot U.S.A., Inc. ("Home Depot") or Service Provider named below will furnish, install and/ or service the equipment listed below at the price, terms and conditions as outlined on this form. FREDERICO DEISE New England South 1-PKZK4N8 Customer Last Name Customer First Name Store #/Branch Name Customer Lead/ PO# 47 Pebble Beach Way South Yarmouth MA 02664 Customer Address City State Zip (203) 482-5217 deisefrederico@gmail.com Home Phone# Work Phone# Cell Phone# Customer Email Address NOTICE OF RIGHT TO CANCEL: YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT: 908 Boston Turnpike Unit 1 Shrewsbury MA 01545 Address City State Zip Or Email: customercancellationnortheast@homedepot.com Service Provider Email Address BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE SUPPLEMENT PROVIDES A DIFFERENT CANCELLATION PERIOD. THE STATE SUPPLEMENT CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE. YOUR PAYMENT(S) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME DEPOTS RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME DEPOT OR SERVICE PROVIDER, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE SAME CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED TO YOU. OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN SHIPMENT AT HOME DEPOT'S EXPENSE. THE LAW REQUIRES THAT THE HOME DEPOT GIVE YOU A NOTICE EXPLAINING YOUR RIGHT TO CANCEL. PLEASE SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL AND WRITTEN NOTICE OF YO RIGHT T CANCEL. Acknowledged by: �j- 01/20/2020 Cust mer's Signature Date Contract Price and Payment Schedule : Payment of the Contract Price is due upon signing unless a different payment schedule is required by law, specified below or in a payment addendum. Contract Price: $ 1626.0o Includes all applicable taxes. Excludes finance charges.* Sales Tax: $ o.00 (If applicable) *Maximum deposit ONLY applicable in MD, MA, ME(33%), NJ, WI(99%) Dep. 25.0 % Deposit Amount $ 406.5 Remaining Balance $ 1219.50 The Home Depot-2455 Paces Ferry Road,N.W.Bldg.B-3,Atlanta,Georgia 30339-Customer Care:1-800-466-3337 480FI HDE Customer Agreement(24 Jul.18) v 0.1.8 `1 1 Home Improvement Agreement: Page2 Finance Charges: *Any interest payments or other finance charges will be determined by Customer's separate cardholder or loan agreement, to which The Home Depot is NOT a party, and will be in addition to Customer's payment under this Agreement. Customer is subject to the terms and conditions of the cardholder or loan agreement, as applicable. No funds should be made payable to Service Provider; however, Service Provider may collect Customer's payment(s) made payable to The Home Depot. Insurance proceeds will will not be used to pay some or all of the total amount of sale. Description of Work to be Performed: Installation of Windows A more detailed description of the work to be performed is included in the section entitled Scope of Work which appears on page 3 of this Agreement. Anticipated Delivery Date/Installation Schedule Approximate Start Date: 03/16/2020 Approximate Finish Date: 04/13/2020 All dates are approximate and subject to change based on unforeseen events including inclement weather, permitting delays, and delays in confirming insurance coverage of Your claim for any repair, if applicable. Electronic Records Authorization: You are entitled to a paper copy of this Agreement if you choose. If you consent to an e-mailed copy, your consent applies to this Agreement and all subsequent documents and written communications related to this agreement. By contacting your Service Provider, you may update your email address, withdraw your consent, or obtain a paper copy of the Agreement or related documents at no charge. By providing your consent and verifying your email address above, you confirm that you have access to a computer that can receive and open emails and PDF documents. B " i • i g this paragraph, I consent to receive only electronic records related to this transaction. Initial Acceptance and Authorization: By signing below, you authorize Home Depot to (a) arrange for Service Provider to perform Installation and/or (b) order and arrange for the delivery of special order merchandise, including special order merchandise that may be custom made, as specified in this Agreement. Do not sign if blank or incomplete. (Service Provider's/permitting information may need to be provided to You later.) By signing, you acknowledge that you have read, understand, and accept this Agreement in its entirety, including the General Terms and Conditions and State Supplement, if any. You further acknowledge receiving a complete py of this Agreement. Keep it to protect your legal rights. X 01/20/2020 The Home Depot Customer's Signature Date Service Provider Name X 01/20/2020 908 Boston Turnpike Unit 1 Co-Signer (if applicable) Date Service Provider Address X 01/20/2020 Shrewsbury MA 01545 Si ture n(ehalf a Depot Date City tate ip R-I-073-13-00016 Service Provider Phone Number Service Provider License Number The Home Depot-2455 Paces Ferry Road,N.W.Bldg.B-3,Atlanta,Georgia 30339-Customer Care:1-800-466-3337 460F1 HDE Customer Agreement(24 Jul.18) v 0.1.8 Commonwealth of Massachusetts Division of Professional licensors Board of Building Regulations acid Standards Constr ri SUpervisor CS-070077 1 Aires: 1213012020 JOSEPH C DtiARTE r� 15 FALL ST WAREHAMMA2571 Commissioner Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Partnership before the expiration date. If found return to: Reaistration Expiration Office of Consumer Affairs and Business ReguWlon 132349 01/10/2021 1000 Washington Street-Suite 710 JOSEPH C.DUARTE Boston,MA 02118 D/B/A J&J REMODELING /6„,..)„,4 e JOSEPH C.DUARTE - :� 15 FALL ST. of valid without signature WAREHAM,MA 02571 Undersecretary The Commonwealth of Massachusetts . v (? Department of Industrial Accidents :irk„ 1 Congress Street,Suite 100 _.:1`_ Boston,MA.02114-2017 www.massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH 173E PERMITTING Au'l"ttORTTY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): N pr- . ti ep-i- Address: G OS B S-{'nn Tu ril p;K e., City/State/Zip: &r-e S f v/'y1 MA Dl S 4 S Phone#: 7 7 4 -z 1 5 - 2 l 5 Are yo an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 20 O+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. 0 Remodeling 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 10 0 Building addition 4.Q 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.: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.] IA n l k)C. *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I 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'pomp.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:. ,✓a7 -(7ovf (..h1 1 .I ire he.qur/1/CR �,.,ea/y ._ Policy#or Self-ins. t ' fLiic..,#: )(/,t/C 566,551 7Expiration Date: — I '—2 0 y� Job Site Address: ( ( ? O1k N4 LO City/State/Zip: So aPl N! /r Attach a copy of the worker§'compensation policy declarationnpage(showing the policy number d 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 imprisonm-•r ell as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. ' . . this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify un .4r.' an' •enalties o r,%', - , , •• information provided ab ve is true and correct Signature: . . '11111)1' // / Date: 2_ 1 ?� Phone#:, 1/0 I- . 3/ 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#: Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement:Eontractor Registration Type: Supplement Card HOME DEPOT USA INC • Registration: 112785 P O BOX 105451 • - 1 Expiration: 04/22/2021 ATTN: LICENSE MGMT TEAM = ATLANTA, GA 30348 Update Address and Return Card. SCA 1 0 20M-05/17 ./fie Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE4polement Card before the expiration date. If found return to: Reaisfr!tien Exoiration Office of Consumer Affairs and Business Regulation 04/22/2021 1000 Washington Street Su' - 10 HOME DEPOT fl Boston,MA 02118 ANDREW SWEET ,' /- / 2455 PACES FERRY R C 11 HSC . i ATLANTA,GA 30339 Undersecretary No ailde •ut SI•nature Q® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 02/06/2019 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(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 CONTACT MARSH USA,INC. NAME: • TWO ALLIANCE CENTER A/CNNo.Extl: (A/C,Nol: 3560 LENOX ROAD,SUITE 2400 E-MAIL ATLANTA.GA 30326 ADDRESS: --- INSURER(S)AFFORDING COVERAGE NAIC N CN101642069-HomeD-GAW-19-20 INSURER A:Old Republic Insurance Co I24141 INSURED INSURER B:New Hampshire Ins Co '23841 THE HOME DEPOT,INC. HOME DEPOT U.S.A.,INC. INSURER C:HomeRisk Captive Insurance Company 2455 PACES FERRY ROAD BUILDING C-20 INSURER D ATLANTA.GA 30339 INSURER E: • • INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-004353439-28 REVISION NUMBER: 21 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 OF INSURANCE ;AODL(SUBR: POLICY EFF I POLICY EXP I LIMITS LTRLINSDIWVD'. POLICY NUMBER IMM/DD/YYYY)IIMMIDD/YYYYI A X I COMMERCIAL GENERAL LIABILITY I MWZY 314574 03/01/2019 i 03/01/2022 !EACH OCCURRENCE !3 1.000,000 CLAIMS-MADE ;`J OCCURi DAMAGE TO RENTED PREMISES Ea occurrence! $ 1.000.000 • X SIR:11,000.000 • !MED EXP(Any one person) i$ EXCLUDED _ ; PERSONAL&ADV INJURY '$ 1.000,000 •GEN'L AGGREGATE LIMIT APPLIES PER: i GENERAL AGGREGATE $ 1,000,000 X !POLICY':J PRO- LOC1,000,000 JECT J PRODUCTS-COMP/OPAGG 3 OTHER: • !$ A AUTOMOBILE LIABILITY MWT8314573 !03/01/2019 10310112022 COMBINED SINGLE LIMIT $ (.000.000 ! (Ea accident) X ANY AUTO BODILY INJURY(Per person) 1 $ OWNED . OW SCHEDULED SELF INSURED AUTO PHY OMG BODILY INJURY(Per accident)!$ AUTOS ONLY AUTOS • HIRED NON-OWNED :PROPERTY DAMAGE i$ ;AUTOS ONLY 'AUTOS ONLY !(Per accident) 3 UMBRELLA LIAO J OCCUR ' EACH OCCURRENCE !S EXCESS LIAB !CLAIMS-MADE i AGGREGATE $ DED ! !RETENTION 3 $ B I WORKERS COMPENSATION I I i WC 012717099(AK,NH.NJ,VT) I 03/01/2019 i 03/01/2020 I X i PER ; ,OTH- ; •AND EMPLOYERS'UABILITY STATUTE i ER B ANYPROPRiETOR/PARTNER/EXECUTIVE Y/N ! WC 012717100(WI) 03/01/2019 '03/01/2020 5.000,600 !!OFFICER/MEMBER EXCLUDED? N N/A E.L.EACH ACCIDENT Si (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE$ 5.000,000 If es.describe under Continued on Additional Page • • I 5.000,000 :DESCRIPTION OF OPERATIONS below 9 : !E.L.DISEASE-POLICY LIMIT;$ C 'Excess Auto 297110011002019 !03/01/2019 i 03/01/2020 ;Limit I 4,000,000 A Excess General Liability I I I MWZX 314580 03/01I2019 I 03/01/2022 I Limit: 8,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION HOME DEPOT USA,INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 2455 PACES FERRY ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN BUILDING C-20 ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi MukherjeeQyLApl.a ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN101642069 _ LOC#: Atlanta A ADDITIONAL REMARKS SCHEDULE Page 2 of 3 AGENCY NAMED INSURED MARSH USA.INC. THE HOME DEPOT.INC. HOME DEPOT U.S.A..INC. POLICY NUMBER 2455 PACES FERRY ROAD BUILDING C-20 _ ATLANTA,GA 30339 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Workers Compensation Continued: Carrier:Indemnity Insurance Company of North America Policy Number:WLR C65890549(AL.AR.FL,ID.IA,KS,(Y.LA,MS.MO,NE.NM.NO.OK,SC.SD.TN,WV.WY) Effective Dale:03/01/2019 Expiration Dale:03/01/2020 • (EL)Limit:35,000,000 Carrier New Hampshire Insurance Company Policy Number:'NC 012717098 (DC.DE.HI.IN.MD.MN.MT.NY.RI) Effective Date:03/01/2019 Expiration Date:03101/2020 (EL)Limit:35.000,000 Carrier:ACE American Insurance Company Policy Number:‘NCU C65890586 PSI) (AZ.CA,IL,NC.OR.`/A,WA) Effective Date:03/01/2019 Expiration Date:03/01/2020 (EL)Limit:34.000,000 SIR:31.000.000 SIR for the stales of AZ,CA,ILNC.OR,NA,WA Cartier:National Union Fire Insurance Company Policy Number XWC 5565596(OSI)(CO.CT,GA,ME,MLNV.OH,PA.UT) Effective Dale:0 3101 20 1 9 Expiration Dale:03/01/2020 (EL)Limit:34,000,000 31.000,000 SIR for the states of CO.ME,NV.MI.OH,P.A.UT $750,000 SIR for the stale of GA $350,000 SIR for the slate of CT Carrier:National Union Fire Insurance Company Policy Number.XWC 5565597(OSi)(MA) Effective Dale:03/01/2019 Expiration Dale:03/0112020 (EL)Limit:34,500,000 SIR:3500,000 TX Employers XS Indemnity: Carrier:lliinios Union Insurance Company Policy Number.TNS C65221019iTX) Effective Date:03/012019 Expiration Date:03/01/2020 (EL)Limit:310,000,000 • .. SIR:$1.000,000 ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD