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HomeMy WebLinkAboutBLD-22-006531 l.Uci(4-)vt_ o n Gli,rc)� In a i / ` OfficeUse�{Only / ',Oi'Y`'�k 67422.,- RECEIVED Permit# � 3� __..___ VI I ' c ha ) z _ Amount ;� « i A:, � rMAY05271 Permit expires 180 days from , issue date BUILDING DEPARTMENT /11L.,D 02-ig Y/53/ B y [>--- vV EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: I iNCnao `elex, Its got ,. ASSESSOR'S INFORMATION: Map: Parcel: OWNER: p Y'1 q�G �G,Yti�,C. �f\'l`S I '"'�r o'J A soR-k43 0 - OFas NAME (� -1- PRESENT ADDRESS TEL. # CONTRACTOR: mar .i d VASCOYCeWS \SA CUmni•(1S'eaAC )dati 'n ' 1A—&'tK—PoW- NAME MAILING ADDRESS TEL.# Est.Cost of Construction$ 3 `�LC �2esidential ❑Commercial ,gyp Home Improvement Contractor Lic.# l6in _l S 1 Construction Supervisor Lic.# C- 0-.. SR Workman's Compensation Insurance: (check one) 0 I am the homeowner ❑ I am the sole proprietor Lk I have Worker's Compensation Insurance Insurance Company Name: ASS-C G*A t YY\el,0 yr Worker's Comp.Policy# S^0`09041 WORK TO BE PERFORMED n Tent L Duration (Fire Retardant Certificate attached?) Wood Stove I I Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares a N (❑)Remove existing* (max.2 layers) Insulation I I __2(Old Kings Highway/Historic Dist. CD)Replacing like for like Pool fencing cc.p P r'� r 2.' .. G �CQ. GuSl1z �tw0j_ C4�r•c sS ' *The debris ili'bC dtisposed of at: ` \ e' .) usN' � Location of Facility I declare under penalties of perjury thatthe spatementse and forcontainednta are true and d correct orr ct toh.the Section 1 best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or revocationY te: Applicant's Signature: 5-J -- - Owners Signature or attachment) Date: Date: Approved By: EMAIL ADDRES Building Official(or d gne . 6t. \614' Zoning District: Historical District: ❑ Yes 7i No Flood Plain Zone: 0 Yes D No itou -44‘`" Water Resource Protection District: Within 100 ft.of Wetlands: 13'?' 0 Yes 0 No 0 Yes D No The Commonwealth of Massachusetts Department of Industrial Accidents I. ,,' - Office of Investigations _.. Lafayette City Center =_ tk 2 Avenue de Lafayette, Boston,MA 02111-1750 —,..' wwx.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Window World of Boston Address: 15A Cummings Park City/State/Zip: Woburn MA 01801 Phone #: 781-932-4805 Are you an employer? Check the appropriate box: Type of project(required): 1.0 I am a employer with 10 4. ❑ I am a general contractor and I 6 El New construction employees (full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. ❑ Remodeling 2.❑ I am a sole proprietor or partner-ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9 ❑Building addition No workers' comp. comp. insurance.$ r insurance 5. El We are a corporation and its 10.0 Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no „G employees. [No workers' 13.� ff Other �w Ss- 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: Associated Employers Policy#or Self-ins. Lic. #: 5018609 Expiration Date: 04/05/2023 Job Site Address: \ 1.-,q,,( 0\.' . Y`c' -- City/State/Zip:1 qitrivtikkefiA- Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains a ea ties o erjury that the information provided above is true and correct. Date: /z Si ature:Phone#: 9 c�- 3 ! 6 q c Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): 10Board of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector 5OPlumbing Inspector 6.0Other Phone#: Contact Person: Act LI DATE(MMIDDIYYYY)CERTIFICATE OF LIABILITY INSURANCE oa/o1n2 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). CONTA(,i PRODUCER NAME: PHONE 978-6838073 FAX No): 978-683-3147 M.P.Roberts Insurance Agency Inc. (A/C,No,Extl: - 522 Chickering Rd E-MAIL ADDRESS: mike@mprobertsinsurance.com North Andover,MA 01845 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: WESTERN WORLD INS COMPANY INSURED INSURER B: MERCHANTS INS COMPANY L&P BOSTON OPERATING,INC INSURER C: ASSOCIATED EMPLOYERS DBA WINDOW WORLD OF BOSTON INSURER D: NAUTILUS 15A CUMMINGS PARK INSURER E WOBURN,MA 01801 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 AUULSUBH POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDDIYYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100,000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 A y NPP8735101 04/05/22 04/05/23 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER:X POLICY( Ter LOC 1,000,000 $ PRODUCTS-COMP/OP AGG $ OTHER: COMBINED SINGLE LIMIT $ 1,000,000 AUTOMOBILE LIABILITY (Ea accident) BODILY INJURY(Per person) $ ANY AUTO — OWNED X SCHEDULED MCA1002569 04/05/22 04/05/23 BODILY INJURY(Per accident) $ B AUTOS ONLY AUTOS X HIRED X AON-OWNEY PROPERTY DAMAGE (Per accident) $ AUTOS ONLY AUTOS ONLY $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 CLAIMS-MADE D EXCESS LIAB AN083990 04/05/22 04/05/23 AGGREGATE $ 5,000,000 DED I I RETENTION$ WORKERS COMPENSATION I STATUTE I 10RH AND EMPLOYERS'LIABILITY Y/N E.L.EACH ACCIDENT $ 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVEPROPRIETOR/PARTNER/EXECUTIVE N I A 04/05/22 04/05/23 1,000,000 C OFFICER/MEMBER EXCLUDED? N 5018609 E.L.DISEASE-EA EMPLOYEE $ (Mandatory in NH) If yes,describe under E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS 1 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. EVIDENCE OF INSURANCE AUTHORIZED RE EIWTATIVE a I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD GOmonwealtri-of Massachusetts ��`�a Division of Professional Licensure Board of Building Regulations and Standards • Constr,ii ii5I3' /yIsar • CS-090758 MANUEL D ap1res 10/21/2022 SC 31VCELfr 74 HOYTAYE�hI(11= •fir ��l '� r LOWELL MA S185a2 Commissioner THE COMMONWEALTH OF NIASSACHUSETTS Office of ConsumerAffali's,,A Business Regulation HOME.IMPROVEMEN7"..QONTRACTOR TYREL.B prgmertk,C.grd Re istl'atlon ?:Ex i motion LW BOSTON OPERAT11 6=,N;C D/B/A WINDOW WORD OF'g{St N MA NYCUI VAS O CEL 15A PARK. , WOBURN,MA 01801 ""G'.t,_. ,iIGL,�aG'.e4;" Undersecretary endow Window World of Boston MA HIC Registration Offices &Showrooms Number: 166025 U 15A Cummings Park O 295 Old Oak Street J 1000 Boston Turnpike Federal ID# It/ Othi Woburn,MA 01801 Pembroke,MA 02359 Shrewsbury,MA 01545 82-4898432 (781)932-4805 (781)826-6281 (508)845-6676 www.WindowWorldofBoston.com Customer: Nancy Harkins Phone(h) (508)430-0805 Install Address: 1 Randolph Rd Yarmouth Port MA 02675 Phone(w) Bill Address: 1 Randolph Rd Yarmouth Port MA 02675 E-mail n_harkins@msn.com INSTALLED ROOFING CONTRACT ROOFING SYSTEM MANUFACTURE: ® OWENS CORNING 0 CERTAINTEED SHINGLE STYLE: Architectural Duration Series 50 YEAR WARRANTY =' PN000INSTAItEN OF .`{�? OWENS cammes paonucro rt trI N17 SHINGLE COLOR: Slatestone Gray a'F Au �«M DESCRIPTION OF WORK STRIP EXISTING ROOFING MATERIALS.FURNISH&INSTALL LIFE TIME ELITE ROOF SYSTEM INCLUDING: LIFETIME SHINGLES,ROOF DECK PROTECTION LEAK BARRIER,STARTER STRIP SHINGLES,COBRA RIDGE VENT W/CAP SHINGLES.CLEAN UP ALL WORK AREA'S AND REMOVE ALL WORK RELATED DEBRIS FROM JOB SITE.SUPPLEMENTAL CHARGES MAY APPLY FOR UNFORESEEN ROTTED ROOF SHEATHING.(@3.75 PER SQ.FOOT)SEE PLATINUM PROTECTION ROOFING SYSTEM LIMITED WARRANTY FOR COVERAGE DETAILS. EXTRA'S: Includes releading and reflashing of Chimney. Includes closing off and shingling over all three existing gable vents. DISCLOSURE:WINDOW WORLD IS NOT RESPONSIBLE FOR THE EXISTENCE OF INADEQUATE HOUSE VENTILATION.THE INSTALLATION OF A NEW ROOF SYSTEM MAY OR MAY NOT REMEDY PREEXISTING ICE DAMMING CONDITIONS CAUSED BY INADEQUATE VENTILATION AND OTHER PRE-EXISTING CONDITIONS NOT RELATED TO THE INSTALLATION OF A NEW ROOF SYSTEM.WINDOW WORLD WARRANTS THAT WORKMANSHIP HEREIN SHALL BE FREE FROM DEFECTS FOR A PERIOD OF(10)YEARS. Materials Drop Location: Customer agrees to the terms of payment as follows: Driveway ?P ""`"°°F, Total Project Cost$ $23,515.40 `.)• $7,838.00 MEMBER 1/3 Initial Payment$ °244 -rPo 1/3 Progress Payment$_ $7,838.00 Dumpster Location: °R A55 Driveway Balance Paid to Installer upon Completion$ _ $7,839.40 Amount Financed$ $23,515.40 Window World of Boston anticipates starting this work on 4-6 wks and being substantially completed in=-3days.Security Interest:Yes No X And deposit required in advance of the start of the work SHALL NOT exceed 331/3%of the total contract price of the actual cost of any material or equipment of a special order of custom made nature,which must be ordered in advance of the start of the work to assure that the project will proceed on schedule.No final payment shall be demanded until the contract is completed to the satisfaction of all parties.All home improvement contractors and subcontractors shall be registered and that any inquires about a contract or subcontractor relating to a registration should be directed to:Office of Consumer Affairs and Business Regulation, Ten Park Plaza,Suite 5170 Boston,MA 02116.Phone:(617)973.8700 No work shall begin prior to the signing of the contract and transmittal to the owner of a copy of such contract. Window World of Boston under provision of Chapter 142A of the general laws is required to apply for and obtain all construction-related permits.Window World of Boston shall not be deemed responsible for delays in the work described in this agreement caused by regulatory,permit granting agencies,authorities of individuals. Notice:If the PURCHASER(S)obtains his awn construction related permits for the work described under this agreement or deals with unregistered contractors,the PURCHASER(S)is hereby advised that in the event of a dispute,judgement and nonpayment,the PURCHASER(S)will not be entitled to make a claim or collection from the guaranty fund established by chapter 142A,. This Window World°Franchise is independently owned and operated by L&P Boston Operating,Inc.under license from Window World,Inc. Bill Cimbrelo Tel. (781)974-3173 4Vmste lit s ^9 /` Owner:Do not sign if there are any blank spaces. Date ,t"J i 5,ds sT ` 4/28/2022 Sales Rep:Do!not�sign'iifthere are any blank spaces. Date Owner:Do not sign if there are any blank spaces. Date