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Home My WebLink AboutBld-20-005040 n l '`'w s 0 F -n#- :_______Hr tr..,e,"4; s RE{CE VE- L: EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH 1 ! MAR .3 021. Yarmouth Building Department 1146 Route 28 L , ( j6 PART South Yarmouth,MA 02664 CI) (508)398-2231 Ext. 1261 �. p 1n / ��/�/1 CONSTRUCTION ADDRESS: q- I Se, t✓Wl d 1 j"L l�w!v q Jv ll ASSESSOR'S INFORMATION: f L/M,,ap': ,1.� �j (' n , !tPaarcel:,®I 0 / OWNER: 00 t/La.&-1 C S e ILt.Ctie V-e,(-1 �JM(tLLI-e )� e /V22 Cv� NAME PRESENT ADDRESS TEL. ' > t t,— 1.t,.. CONTRACTOR ck vh f.LK 1F/1!`Q �2�/1J i 12e4 , O LAI !t" (J L( MAJUNG ADDRESS '41 TEL f residential 0 Commercial Est.Cost of Construction S 1 k tk c�,0 — Home Improvement Contractor Lic.# I u�1 S') Cussiruction Supervisor Ire.# C S - w to( Workman's Compensation Insurance: (check one) I am the homeowner - I am the sole proprietor 6 I have Worker's Compensation Insurance Insurance Company Name: Y v\ TA ,A,c --_- Worker's Coin►.Pokey* e._L 3 C t%SC>(b i'-( 1c A WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 2,2--N ( J.IrRemove existing*(max.2 layers) Insulation / Old Kings Highway/Historic Dist. (.. .ritepiacing like for like Pool fencing *The debris will be disposed of at: - arYn M-4/1 nAtitl Location of Facility I declare under,-,, - of,-` I :. •Al ,herein contained are true and correct to the best of my knowledge and belief I understand that my false answer(s) will be just cause for den': : j, my license and for prosecution under M_G.L Ch.268,Section 1. Applicant's Signature: �� _1011 Date. 31i�, > Owners Signature .r attach t) L/_.riv.�!�� Date: / ' ` „%I/f .. �O�G7 Approved By: ''�� Date: �� Building Official(4, ....11i EMAIL ADDRESS: Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 IL of Wetlands: I Yes No - Yes No i If contract calls for si .44 ° items hanging on wars until job 'NOT IN(I I IDED IN CONTRACT PRICE tmfor 1f 1i {C P 3?t t I i 't Removal of existing doors and windows often reveals weathering, as well as areas that may or may not be previously stained or painted. As noted, Contractor will not be responsible for painting or staining these areas. Contractor will not assume responsibility for removal, re-attachments, or re-positioning of drapery rods, window shades, blinds and/or mini blinds, and corresponding hardware. 11,2 i 4.4...1 ,. ..._ e_ i ,.'to .. - '_ R. ... e _. -,. ._ e. HOMEOWNER: DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Uwe accept this contract in its entirety and I/we authorize Sprinkle Home Improvement to act on my behalf in all matters relative to the work to be performed on this job (i.e. permits, applications etc.) if necessary. / Tucker to Conti dor Signa re Date# 103757 Pau •Brad-Sprinkle- R ' _ The Commonwealth of Massachusetts ma, a Department of Industrial Accidents - 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mas&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):SPRINKLE HOME IMPROVEMENT, INC. Address: 199 Barnstable Rd. City/State/Zip: Hyannis, MA 02601 Phone#: 508 775-1778 Are you an employer?Check the appropriate box: Type of project(required): I.Q✓ I am a employer with 10 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. 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❑ Building addition 4.❑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. 'oof repairs These sub-contractors have employees and have workers'comp.insurance.t �� p 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El 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. tContractors 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: A.I.M.Mutual Policy#or Self-ins.Lic.#:WCC50050167472020A Expiration Date: 1/1/2021 Job Site Address:CI 2—. - City/State/Zip: v Ma.LI-6 004 1010 C5 7 S 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 penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this-s .tement-may-be.forwarded to the Office ofInvestigations of the DIA-for insurance coverage verificati s s I do hereby certify %y /nd pe aloes of perjury that the information provided above is true and correct. Signature: Date: '4 Phone#: 508 775-17 8 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#: �.•-..41 SPRIN-1 OP ID:JCA AW RO' DATE(MM/DD/YYYY) `wr.... CERTIFICATE OF LIABILITY INSURANCE 01/03/2020 fiHIS 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 508-775-6060 NAME: Kelley A.Sullivan Bryden&Sullivan Ins Agency PHONE 508-775-6060 I FAx 508-790-1414 88 Falmouth Road (NC,No,Ext): (A/c,No): Hyannis,MA 02601 E-MAILoRSS: Kelley A.Sullivan INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:NGM Insurance Company 14788 �R INSURER B:Associated Employers Insurance slNs I Pe Hoa`r>1eImprovement Inc. 114 li s�NIIAA buZ 1 INSURER C: INSURER D: 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. IN R ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE INSD WVD (MM/DD/YYYYI /MMIDD/YYYYI A COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR MPT2640X 07/01/2019 07/01/2020 DAMAGE TO RENTED 500,000 PREMISES fEa occurrence) $ X Business Owners MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JROT- LOC PRODUCTS-COMP/OP AGG $ 2,000,000 • OTHER: EC $ A AUTOMOBILE LIABILITY EaMaccidentSINGLE LIMIT $ 1,000,000 ANY AUTO M1T2640X 07/27/2019 07/27/2020 BODILY INJURY(Per person) $ OWNED SCHEDULED AUT�OpS ONLY X AUTOSWN�D BODILY INJURY(Per accident) $ X AUTOS ONLY X NON-OWNED ONLY (Perr accidentDAMAGE $ $ A X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS UAB CLAIMS-MADE CUT2640X 07/01/2019 07/01/2020 AGGREGATE $ 1,000,000 DED X RETENTION$ 10000 $ B WORKERS COMPENSATION PER OTH-. AND EMPLOYERS'LIABILITY STATUTE ER YIN WCC50050167472020A 01/01/2020 01/01/2021 500,000 ANY ICER/M BER PARTNEEXCLU EDECUTIVE N NIA E.L.EACH ACCIDENT $ (Mandatory m ) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ PROPERTY 51,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE IS ISSUED FOR PROOF OF COVERAGE. 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. Sprinkle Home Improvement Inc 199 Barnstable Rd Hyannis, MA 02601 AUTHORIZED REPRESENTATIVE Kelley A.Sullivan 1 ACORD 25(2016/03) 01988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD