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HomeMy WebLinkAboutBLD-23-001626 L nn a la 7 Office Use Only h1 �+I, S.RRo Permit# C� V 8"1� � O . !' �[[ H. Amount U LI Permit expires 180 days from issue date LD . -606 RECEIVED EXPRESS BUILDING PERMIT APPLICATI "-� TOWN OF YARMOUTH SEP 27 2022 Yarmouth Building Department 1146 Route 28 LBUI - South Yarmouth, MA 02664 By (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 0,C, L1_Cie A}- t0 C0 qA, 3 1 ASSESSOR'S INFORMATION: Map: � Parcel: (3© OWNER: R ij&/ 2Gi2�1,�c.Q o2O Gall C -s4- C u--_+\4e <) i ✓� �' 1/(-l!/� (�-(o�S NAME PRESENT ADDRESS Till.. # Si7/ '3U2_ 3)3 Lit CONTRACTOR:SD1tI)�C � Q/1 �/l�t'► l4.1___ C�«� k-)) NAME 1 MAILING ADDRESS TE SL)`6 - )IS - V ) S-. Residential 0 Commercial Est.Cost of Construction S 3. 0-1t11 Home Improvement Contractor Lie.# [(�"'? S? Construction Supervisor Lic.# C S - Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor *1 have Worker's Compensation Insurance Insurance Company Name: CO ( ,45-42-- Worker's Comp.Policy#LoCC --)g120gt WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove LI Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares (❑)Remove existing*(max.2 layers) Insulation I I Old Kings Highway/Historic Dist. (11)Replacing like for like Pool fencing The debris will be disposed of at: lGLC1,�-1 Location of Facility 1 declare under penalties of perju •that the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false ancwer(s) will be just cause for dcnia •vocati. of my license and for prosecution under M.G.L.Ch.268.Section 1. Applicant's Signature: MOW Date: U. 3 a Owners Signature(or attachment) In // Date: Approved By: v Date: Building 0 ( gnee) EMAIL ADD Zoning District: I listorical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No \, / Teiep*ore(508)398-2231 Ext 1292-Fax(508”398-0836 OLD KING'S HIGHWAY HISTORIC DISTRICT COMMITTEE APPLICATION FOR CERTIFICATE OF EXEMPTION Application is hereby made for the Issuance o'a Certficate o`Exemption bride'Sections E and 7 of Chapter 470 pf O Acts of 1973,as amended.for the proposed work as described below and on plans,drawings,or photographs G rn accompanying this application. x ;i Type or print legible /2 N K O m IWO Aggress of proposed work. cam& ct,-1c. t L%C�,e t -{ MaprtotA' ‘3� /CO- cC �'1 o .+C Ownerfsl .Y-,t-_,hei t- ' ..t LG�;-C Ptioneir SC'-cr. -2?t..Z -7)l3- * r- All applications must/be submittal by owner or accombpaniad by teller from owner approving submittal of application. < Mating address )l.% t�t1CAell'h L..-e•"t ,%.1CLi/p.3Lf t �,d,(A Year built (0,7}� Email Zr.T IA-?s P �r , �`( �Ck c‘V-.V1erPrelerred nobrieabon metnoC Phone Email AaentiContraclQr Sp(.,yC e. V-,\gdne .-tY)PC LGYIC-A4--. Phone lt- St%45-`1-)S-rnS-- Mairng Andress XR'.fit (•0^Zt,ic/nl< MA I52 L'c.! Email t S C t " .CA- C c=s,5t ' ' Preferred roeficationmethod: ✓Phone Email C X) o �r Description of Proposed Work(Additional papas may be attached if neresearv), x-, E V LAC��r ,�T `U-C �.JC...A.t Sra-4 Cs-A. C�f7JS, ID SiGLp iY GitilUe_l.Y"-1 ( .CLO/Cse�f� ; Qea,ttAte__ � f i 2. c.c.,k 10)C/ Cti C - CS NJ ,,A 5, Le CS,(�)e.ri T c Signed(Owner o agent( _ Date `'S`k 3,\a , i Y Ovascrca tracdager:l,s aware ghat a pond may to:eaared from the Buddng'De;armert tCheti,other departments.also.( > The oen teete,s good for one yea from slaw ova'dale or:von date cf e,,ration c'°u beg Pered.nnehever date snag De baler. For CommitM use only: Oa e- 1'112;- -forAp rrned de is A rowed wdh changes _Denied Amount s •t om} reason for dens; rl Rcvd by L'S as-er(a) 6 ADDENDUM TO CONTRACT If contract calls for siding and trim, or roofing; we recommend you remove any breakable items hanging on walls until job completion. NOT INCLUDED IN CONTRACT PRICE ,und -:-ado 4 ,.. �r do�-� �?penii,. 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. RIGHTS TO CANCEL The Owner may cancel this Agreement if it has been signed by the Owner at a place other than the address of the Contractor, which may be his main office or branch thereof, provided that the Owner notifies the Contractor in writing at his main office, or branch by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this Agreement. HOMEOWNER: DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Uwe accept this contract in its entirety and Uwe authorize Sprinkle Home Improvement to act on my behalf in all matters relative to the work to ' - perfow d on this job (i.e. permits, applications etc.) if necessary. _l 1 Homeowner Signature Date Contractor Signatu i Date 20 Ancient Way,Yarmouthport, MA 02675 Brad Sprinkle- R=.istration# 103757 ,�,.�—iNIN SPRIN-1 OP ID: JA AC'ORa CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `,.,,----• 05/05/2022 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 508-775-6060 'CONTACT NAME: Kelley A.Sullivan .-----. Bryden&Sullivan Ins Agency PHONE 508-n5-6060 ` FAX 508-790-1414 88 Falmouth Road Arc,No.Ext}: _i(A/G Noi:_ Hyannis, MA 02601 1R4�s Kelley A.Sullivan INSURER(S)AFFORDING COVERAGE 1 NAIC s 1 INSURER A:NGM Insurance Company 14788 NSIJR ' INSURER B:Associated Employers Insurance Spprinkle Home Improvement Inc. 199 Barnstable Rd ;INSURER C: Hyannis, MA 02601 INSURER 0 .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 j4DDL1SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD MID POLICY NUMBER (MNYDD/YYYY) I(MMIDD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY ' EACH OCCURRENCE y S 1,000,000 � I DAMAGE TO RENTED I S -- _ 100,000 CLAIMS-MADE , X I OCCUR MPT2640X 10710112021 0710112022 PREMISES{Ea occurrence} !! ' I MED EXP(Any one person) 1$ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: i GENERAL AGGREGATE $ 2,000,000 X 1 POLICY 1 jga 1 LOC ;PRODUCTS-COMP/OP AGO S 2,000,000 I OTHER: +Emp Ben. $ none COMBINED A AUTOMOBILE LIABILITY (Ea accidentSINGLE LIMIT $ 1,000,000 ANY AUTO M1T2640X 07/27/2021 07/2712022 BODILY INJURY(Per person) $ AUTOSI OWNED SC �E ONLY X AUTOSSUyLryED BODILY INJURY(Per accident)1$ X i AUTOS ONLY NON-AUTOS y ONL� I PQrOFER"entDAMAGE $ I J II I` 1 {$ A 'X ' UMBRELLA LIAB t X I OCCUR EACH OCCURRENCE I S 1,000,000 1 EXCESS LIAB CLAIMS-MADE CUT2640X 07/01/2021107/0112022 AGGREGATE 1_$ ' 1,000,000 DED 1Xj RETENTION$ 10000 B j WORKERS COMPENSATION ( PER OTH- X I STATUTE ER $ AND EMPLOYERS'LIABILITY YIN , WCC50050167472021A 01/01/2022!01/01/2023 500,000 :ANY PROPRIETOR/PARTNER/EXECUTIVE , E.L.EACH ACCIDENT S :OFFICER/MEMBER EXCLUDED? I i!NIA 500,000 E.L.DISEASE-EA EMPLOYEE S i If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below -_, I E.L.DISEASE-POLICY LIMIT+$ ' . i 1 ; i DESCRIPTION OF OPERATIONS r LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) CERTIFICATE HOLDER CANCELLATION TOWN-02 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Kelley A.Sullivan I ACORD 25(2016/03) Q 1988-2015 ACORD CORPORATION. AU rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts =*'mw. .l, Department of Industrial Accidents Eo =� ]_ 1 Congress Street,Suite 100 =�i� Boston, MA 02114-2017 %,, www.mass.gov/dia 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): 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): 1.0 I am a employer with 5 employees(full and/or part-time).* 7. ❑New construction 2.1=1 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.] 9. ❑Demolition 3.0 I am a homeowner doing all work myself. [No workers'comp.insurance required.]I 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q 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. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.12 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E Other Siding 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 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.#:WCC50050167472022A Expiration Date: 1/1/2023 Job Site Address:20 Ancient Way City/State/Zip:Yarmouthport 02675 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 statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u the ains and penalties of perjury that the information provided above is true and correct. Signature: Date: C 0)0\a Phone#: 508 775-1778 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 IContact Person: Phone#: II • THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street-Suite 710 Boston,Meseacnusetts 02118 Home Improvement Contractor Registration Typo. Como oacn Heg.otrntInn. 103757 SPRINKLE HOME IMPROVEMENT,INC. Et Oration: 07/08,2024 1BB BARNSTABLE RD. HYANNIS,MA 02E01 J adv.Andras,.nd Return Cord. THE COMMONWEALTH Or MAMACHUgTTE Dteo.of Coo.um.r Affair.a oatrrw R.0ulauon aogatr.tlon valid at IndIvldud uaa only*for*am HOME IMPROVEMENT CONTRACTOR .ornlon duo.If fund fatty,to: TYPE CoiportaAo Was of Canon.,M .and edAna..Ryal.11oll rtaO4m I000 Wa.lun5pMMn a1r..t.sun.110 00767 o7A132024 !Hatton,MA 02114 SVRWIQE HOME IMPROVEMENT,INC, BRAD K.SPRINKLE tat BARNSTABLE 90. ,,,�Y_0 AN ;�tdaV HYNIB,MA 0260t UndmsK'SM'Y Not Valid with lit a shaft,. • commonweattn of Massachusetts St Division of Professlonai Llcensure Board of Building Regulations and Standards CnnstN CtiOAtYper+isor C S•006643, Expires:10108/2023 BRAD K SPRfNKLE 1e8 BARNSTABLE RD, HYANNIS MA 02801 Commissioner Jtta K.`UrC,ni.Ira