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RE -INSPECTIONS I5T RE -INSPECTION . • $80.00 2ND ' -INSPECTION _ 580.00 3 OR MORE - S80.00 DUPLICATE % WEATHER CARD :; � ,• ',• �, S50.00. APR 12 ' I 2011�{L�� DATE. ADDRESS: PIZ ISSUED TO: REASON FOIA RE -INSPECTION: IA�ki BUILDING DEPT.:. ELECTRICAL: FIRE DEPARTMENT: GAS: OCCUPANCY PERMIT: PLUMBING PERMIT:, OTHER: w r TOWN OF YARMOUTH Building Department BUILDING _ .. _ _ _ _ _ _ (508) 398-2231 ext.1261 '- PERMIT NO B-11-1060_ ' PERMIT ISSUE DATE; - _318/2011_ _ ; PROPOSED USE . _ _ _ _ _ _ . APPLICANT Kevin Grignon : '"..""."" """"""""""'""""'"' .............................. JOB WEATHER CARD PERMIT TO Alterations AT (LOCATION) ZONING DISTRIC R-40 Bldg. Type: Residential 10030HATCH RD SUBDIVISION MAP LOT BLOCK 089.19 BUILDING IS TO BE: CONST TYPE 5-B USE GROUP R 3 LOT SIZE O CONTRACTOR remodel existing bathroom as per plans dated 03/08/11. REMARKS AREA (SO FT) EST COST ($ $11,000.00 PERMIT FEE ($) $100.00 OWNER ICOY, CAROL D BUILDING DEPT BY ADDRESS 0030 HATCH RD South Yarmouth MA 02664 LICENSE 63766 lGrignon, Kevin 1 Huntington Ave South Yarmouth MA 02664 7742121551 PHONE 5083943856 INSPECTION RECORD FIELD COPY Date Note Progress - Corrections and Remarks Inspector 3-Z- t!_ se -P/1 ov TOWN OF YARMOUTH Building Department g U I LDI NG BUILDING + , _ , _ _ _ , (508) 398-2231 ext.1261 PERMIT NO B-11-980 _ PROPOSED PERMIT •. ISSUE DATE ; _ 2/10/2011 _ ; USE _ _ _ _ _ _ _ _ APPLICANT MikeShastany .............................. JOB WEATHER CARD PERMIT TO Repair AT (LOCATION) ZONING DISTRIC R-40 Bldg. Type: Residential 10030HATCH RD SUBDIVISION MAP LOT BLOCK 1089.19 BUILDING IS TO BE: CONST TYPE 5•B USE GROUPFR 3 LOT SIZE strip and reroof, 14 squares, paper and vent to code REMARKS AREA (SO FT) EST COST ($ L OWNER ICOX. CAROL D ADDRESS 10030 HATCH RD South Yarmouth MA 02664 ] PERMIT FEE ($) $35.00 BUILDING DEPT BY —1 CONTRACTOR LICENSE 72755 Shastany, Mike 11 Winsome Road South Yarmouth MA 02664 5087601399 PHONE 15083943856 INSPECTION RECORD FIELD COPY Date Note Progress - Corrections and Remarks Inspector N 0 ONE & TWO FAMILY ONLY — BUILDING PERMIT APPLICATION TO CONSTRUCT. REPAIR. RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING Town o[ Yarmouth Building Department 1146 Route 28 • South Yarmouth, MA 026644492 508-398-2231 ext.1261 Fax 508-398-0836 amu use onh Permit N L I- 101nQ Date 3 Permit Fee S �6V Deposit Reed. SI 6� Dat.U' Net Due PWWaq Baud IddmuSoo 11M Wor'a1NAt Daw HMAhnp Due plat Mo. otnw Asuaw Dgwtrwe IMarnneow Her t.e Properly aman&Wc lw A►aa (sQ Fronuge lni taI �,,.,e. Secdom IN Onx BUltdhl Pe -�, .. ,�:;•'•. D8 Ititgi • tiWkrtl�Ot�r1 Otlelp C&d6f�ofwb-ft ".641 � r�ioi' ' ` reglrrel•' Secdon.1- S1I11nAftatt o Use Group: R-4 Typec S. 1.1 tA"wty Addn a 30 t.2 zortin Ineormatlorc Zoning District Proposed Use 1.3 w wbw se/Yaera Ini Front Yard Side Yards hear Yard RequkW Provided ReqLdrod Provided R Provided ire Waeee wy'Ip Ir+ e . e-10. a s/j "&a Pdvate 1.5 Flood Zw a kdonnrbK Carwatrea Zanet EFIR Secdon2-Ftopavownwam rtz@dAgwdl be Oar ee Ibewi tin^ D, Name 5 aura f� 0 hI hw� MailirgAddnaa / �3J ToMphone ss Awsw.tw r�/ Cr/� n/ �) 77V--21nz1 s9oduse rebpnom � /tivv%nom la-✓ Ar<" �• rti4vT�i M&[kV Address n,9 a 2 v Section 3 - Constnrctfon Servl n a.s c rabua wgwvlews f FA?t — MA i tW Appkable Q arm. Numbs. =/ u 2/ / ,j ter/ 'V E=Pw Dan 3 rNephor» 3.2 Registered Moms Improvement Contractor: eowwo" Meese ,�s rr� Not Applicable f] c� relaphorr 2 / Z �ceroe Num i S Erpradon Dam 1012 ' OVER 01 JQ4UQ �a+yl�tj(elrel to ensa•.�-`_ �-�7/Ullw� .ir.w .��� r� worker Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit wil result In the dental of the Issuance of the building permit. Signed Afffdavit Attached Yes .......... No ....840.6. sectfeoA �- D • d Work shed d! WpOtOft New CorMndlon 0 ft of tledraoree m d Boetl oto tlle� O aev�t�) 0 Anwada+s O Mdldn O Accessory 814O 1Ype Demolition Other Specify: Brief oeea+p W of Prapoaed tlVbrk Oe,44 e;.5 D w S /jv &701V sectlbn e- EW 4law Cdnsbtx:" cift Iter" / Estimated Coal (Oadm) to be Check Below 1. est (3 Conaervadon4& mkdon hllteq 2.151 clIF (Nappenue) 3. Mm. Ila&* p ofd range 1 r4 * -r a Hlatorkal COM, +. Mechanlal Hv Calaalon MWWd !. Ftre Pmhmdae (M apptka A) e.TOW w(1 •24.34.4+3) 7. total s¢lafe tt'1. (nw+na.. a adrlaal s ri• --M Own�e'sA ar ContrsetorA les for BU P#M* t/ Alt el L C' D � . as owner of the subject property hereby authorize to ad on _ my beh In al matt ra r atfw� wo authorized by this building permit appikatlon. st r domw OW SKS M - OwnedAutftaritsd A ere Oedaratlort .asOwnsdAuthortzedAgent hereby dodos that the Statements and Inform"On on the laregaing appiicadon are true and accurate, to the bed of my knowledge and beget. Signed under the pains and penalties of pwPO PrhA ntrt+e 91wa d aw wlAgan) Oata 9 -It -99 2 d 2 .11 PLEASE PRIM. TOWN OF YARMOUTH BUILDING DEPARTMENT CONSTRUCTION SUPERVISOR FORM Job Location: ?D -Ce' 4 LAi ,S vv7'4 �j9,f,vrov7—4 Number Street Village Owner of Property Code L C O X Construction Supervisor. Address:�-AL191w' .ro �16Ame;/ l Licensed Designee: (If other than Supervisor) Name 2.15 Responsibility of each license holder. No. License No. Phone No. 2.15.1 The license holder shall be fully and completely responsible for all work for which he is supervising. He shall be responsible for seeing that all work is done pursuant to the state building code and the drawings as approved by the building official. 2.15.2 The license holder shall be responsible to supervise the construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of building and structures only pursuant to the state building code and all other applicable laws of the commonwealth, even though he, the license holder, is not the permit holder but only a subcontractor or contractor to the permit holder. 2.15.3 The license holder shall immediately notify the building official in writing of the discovery of any violations which are covered by the building permit. 2.15.4 Any licensee who shall willfullyviolatesubsections2.15.1,2.15.2or 2.15.3 or any other section of these rules and regulations and any procedures, as amended, shall be subject to revocation or suspension of license by the board. 2.16 All building permit applications shall contain the name, signature and license number of the construction supervisor who is to supervise those persons engaged in construction, reconstruction, alteration, repair, removal of demolition as regulated by section 109. 1.1 of the code and these rules and regulations. In the event that such licensee is no longer supervising said persons, the work shall immediately cease until a successor license holder is substituted on the records of the building department. 2.17 The license holder shall be responsible for requesting all required inspections. Failure to do so may be deemed a violation of the permit conditions. I have read and understand my responsibilities under the niles and regulations for licensing construction supervisors in accordance with section 109.1.1 of the state building code. I understand the construction inspection procedures and the specific inspection as called for by the building official. INSURANCE COVERAGE: I have a current bility Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.152 Yes No ❑ If you have checked yo, please indicate the type coverage by checking the appropriate box. A liability Insurance policy Ef Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Cn of th ss. eral Laws, and at my signature on this permit application waives this requirement. Check one: Sign re of Owner or s A Owner I] Agent Signature: Building Official Apprnval: x I- The Commonwealth of Massachusetts Department of IndustridAccidents OJf` ed ofI n'esdgadons 600 Washington Stred Boston, MA 02111 v wwmmass gov/dla Workers' Compensation Insurance Affidavit.- Bunders/Contractors/ElecMcians/Plumbers Applicant Information Please Print L Idbly NameMwimaftwindowbdividw): fiat%6D 6t✓ yi�ArA Address: / Yds (t►u, id,fl Afl � 3 - Phone t Are yg� as employer? Check the appropriate box: I . I am a employer with 1!!,-'_ 4. ❑ I am a general contractor and I employees (M and/or part-time).* 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myselL [No workers' comp. instmmcs required] t 3a. ❑ I am a homeowner acting as a general contractor (refer to p4) have hired the sub -contractors listed on the attached sheet Tie yrs have employees and have workers' comp, insurance.t S. [� We are a corporation and its officers have exercised their right of exemption per MOL c. 132, 41(4), and we have no employees. [No workers' comb. insurance reouieed.l 26 Z J Type of project (required): 6. ❑ New construction 7. GlIGnodeling 8. [3 Demolition 9. [3 Building addition 10.0 Electrical repairs or additions I l.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other t•Mthat y applicant checks boa 01 new also till out the section below shooing disk waters' Homeownete who submit"ant&vk indicting they airs doing au work sad the hhv outride eooaaeON nnuu submit a aero Affidavit iadfating such. tCootraemrs that chick this box muse attaehad an addidooal sheat showing the same of the Md"050MM and seas whether or no cion taddeA have ea*k*wn It the sub-ammmceoo haw eayloy"s, that' must provide their wwkesa' coup. Polley number, anan employer that L pmIdlnl workers' coatpensadoh lmaranet for my emtployees. Below b the posey and fol.riri information Insurance Company Name: // t� l � / At d %tom ,q (..- Policy H or Self -ins. Lic. N: 4.16 / i/S 7l / Expiration Date: Job Site Address: JL L)4 I Gtr " City/State/Zip: 21Cy Attack a copy of the workers' compensation policy declaratloo page (showing the policy ars er ani expiratloa date). Failure to secure coverage as required under Section 25A of MOL c.152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 and/or one.} sr imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to SZS0.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the of of Investigations of the DIA for insurance coverage verification. do hereby ecru!/]► the pmlrts and peaaltip ojperjwy that the Information PrOW&W above Is tura and eorrax� 2 Of jfelal nese only. Do not write In this am, to be eompletrd by city or town of c&L City or Town: Permi lucease N Issuing Authority (eines one): I. Board of Health 2. Building Department 3. Cityfrowo Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other Contact Person: Phone 0: Information and Instructions Maaaachttwo Oeste:al Laws chs W 132 segtdese an eat 6*9 to pee" wahaa' "peados rbc their emPloytea. punned Io d& sbud R s s1ft� is donned set avay Pam h, the snin a cadet det say cmfsad o[h M cxpeem a impiie� ad or *dogs An spier► is da bod ae lass isdividml. paetnashipl uuxWic% cmPondon at other kph entitye a eery two a moee O[&.1eepitg a*4pd ie ajOjd enwjjrh% ad tsehadteg the kph tepeeeetstadvea do daesaead ®P1oMdo a the receiver err temtee o[ d bdNi A PWWWAIR arrodwm of other kw aft aopioyitg HO11'es owoat oh dwaWoi hoose hexing sot sten there three apaatmaslt and who [aid/ thepok wok ou � �ft � dwelling botsae o[anotI , *be employe Paaoaa M de mdntmsGM caasttocdoe a repeie ac as tb owns s or budding sppaetr»ed thaed shay not beams a[strch eatpbymeat be deemed to be as esopieyac' &MGL dwpls 132. 12=0 dw stdse that "Herr stale of bW Uaaedeg apacy strand wdMheld the Monaca or .-sewer d e 1lems er porsek lemp rax a bdeaat w leaeatrad bwddhsgs tr the ewMM wadM ate aey applfeaet whe gree Oat Peedsnd seeeptaMa avldeaea d e..*+bae wtM tdr Iaaraaee -...rags raelaitei' AddWaaaihr. MM chapaar 132.1:10M stats - Rdths the ooa�monwealtY stat snb o[ ha polided wft 68 ts os Shan ealow say coarser eat the Peeft m no of FM wash uod atawpesble avidsaey o[oompWeoe with the fawsaace MV, gtdnmab d thb cbepts haw ben peeeaaesd to the eaehae 1 f sudmaeby" plow t111 otd the wtielm Cnffv .,m-aW&"Puvql i lAbychoddm&ebomthdq*loYowsibmdm=41t soweoatrseta(a) mms(sN sddtaa(a) sed phos nembee(a) aloay with their eaedfics"(a) at LLhimed Llabitity Campmw (LLC) or Lholied LLb&y!•areaaeahlpe (LLF) wh! ere empbyeaa other there the enaeobeee ere p�taaea. sA O W eaety WIN.' eompeendoe boxon :e. It weLLC or LL! does bow a pommy in eequeed. lye advised that this &M&wit may be mbmMW b the Wpaetmms d b&§Wd A� for Caaermatim of taaeeance Cayseagu Abe be sew N sip sad dais the affidavit. 110 a rd 1 sbonW be eetumd b the city or MW that the appiieadoa ex the peewit a Hanume Is belay tegto M4 art the Deperbo t of lohd W AaidmSla wam yaa bow seer geaadoaa g the law or if yon m tagateed is obak a wvrhaea' comotandee Varier. plaeu Cllr the Dapmunow d the sambas th ad I an I. Said ttaaed ooeeePdes shoaM eats thrix CMy w Teva OMAk Mane be mm that the alddtvp Is coo>pMs sad 0101104 lefibly. The Dqw m d here proridad i space at the bMM of the atsdavit As yoea to till ad be the swat the Mae of tavadpsow bw to eooeaot yea repo 'I the apPRCM& Pksea be neo b an to the pa -"!* ,ease memhs which will be and a a eelbtence Mubw- to sddldo% r sppNesot that nwd nlxnk maidPk perm"' Ou" aPpBndaae;. my shve year. Head ody submit aoa amdavit immucaft maaet pOHC ld�(l[oaemeary) mi tmllar'7ob Spa Ad kue ft VOICaat aboard writ "an SOCOWs le (city► or ftwW ere podthst a nW a®dnit b as lhAttta Pem.1- at Scumm A new alpdavit -mat be lUbd at seri y&WM a home owes or Cltisae to obWnteg a license of permit eat telatsd W say bartssw Or ooaserCW reaftare (La. a do/ lieeaaa or paean to been leaves els) said pennon Is ►`w f 0 k 1+' to eomPle- thio aMdavit The Other of taw,dpdom womM Iib to thank you is advaeee Ibr yes eoopRa"w ad shaW yea bare any gmddonsr please de cot haaib" to Show a calL ri„ DePeoulm 'a adamm tehom sad As ataahw 'M Commoawealth of Manschwetts MVarftcd of fn&Md Accidents OffPoo of hmogBdau 600 Waswgft sQtd Bod01% MA 021 I 1 TSI. M 617-727.4900 ext 406 or I-W-MAssAFS Fax N 617-m-7149 l svised 11.22-416 "v.mm gov/din w• For Office Use Only Permit No. Date TOWN OF YARMOUTH AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MUL a 142A require that the 'reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition or consuuctim of an addition to any pre-existing owner -occupied building containing at least one but not more than four dwelling units or structures which are adjacent to such residence or building' be done by registered contractors, with certain exceptions, along with other requiranenM Type of Work: 61:1 4 tmoogc Est. Cost o0 Address of Work Owner Name: l'Ao , C r o X Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under $1,000 Building not owner occupied Owner pulling own perrtit Other (specify) Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. Signed under penalties of perjury: I hereby apply for a permit as the agent of the owner. )t;"-, 41-f% fy i Date Contractors Registration No. IINA Notwithstanding the above notice, I hereby apply for a permit as the owner of the above Property: 01 D. Cox. Date Owner Name ,� f, TOWN OF YARMOUTH BUILDING DEPARTMENT 1146 Route 28, South Yarmouth, NIA 02664 508-398.2231 ext. 1261 Fax 508-398.0836 BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G.L. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section l 11.5, I hereby certify that the debris resulting from the proposed work/demolition to be conducted at 10 fc� L.✓ Work Address Is to be disposed of at the following location: Oart d.rlk�- Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter I 11, Section 150A. Signaturef Application Permit No. -1249/r// Date United Kitchen and Bath Inc. 1 Huntington Ave. S. Yarmouth, MA 02664 508-760-2023 * Fax 508-760-2024 March 4, 2011 Town of Yarmouth Location: 30 Hatch Rd. Main bath remodel: Footprint will remain the same. Removal of tile on walls, Install new tub, vanity, tile the floor and install new toilet. This is a complete update. Thank you, I Massachusctis - Djepartment of Public Safeh Board of Building Regulation. and Standartls Construction Supervisor License License: CS 63768 ' Restricted to: IG KEVIN DGRIGNON 74 HILLSIDE DR, E DENNIS, MA 02660 " ►' Expiration: 3/!212012 ('ummisioner. TO: 18012 - Biqa mapon 099Z0yW�H1llomw.H1f10S .'_ 3I�V 140101slm f1H 1�E! $} : 12ION0111J NIA3N `SNI( WrbHoil-031iNn, uonei6d0 �IeNtd � 986Z6Z faluolluldx3 8ZL6VC�Gope17s168a: -dOj,3MN001H3 WT. 3Ab21d W13WOH eopgaEay mgtag V 9+IaI1V aamamo0)o »gyp' 11 TOWN OF YARMOUTH Building Department Town Hall Yarmouth, MA 02664 (508)398-2231 ext.1261 BUILDING PERMIT TRANSMITTAL Temp Permit No.: T-11-342 Applicant Name: Kevin Grignon Applicant Phone: 7742121551 Building Location: 0030 HATCH RD Owner's Name: COX, CAROL D Owner's Addres 0030 HATCH RD Application Date: 3/7/2011 South Yarmouth MA 02664 Owner's Telephone: (508) 394-3856 Comments: remodel existing bathroom NA• REVIEWED BY: (OFFICE USE ONLY Recorded By. IC Permit Fee: $100.00 Deposit Rec: $100.00 Payment Type: Check ChkNo.: 528 Net Owed: $0.00 Application Date: 3/7/2011 Issue Date: N/A: Expiration Date DATE: Comments: remodel existing bathroom NA• REVIEWED BY: 1. WATER DEPARTMENT: DATE: WA: 2. ENGINEERING DEPARTMENT: DATE: N/A: 3. CONSERVATION: DATE: N/A: 4. HEALTH DEPARTMENT: DATE: N/A: 5. BUILDING DEPARTMENT: DATE: WA: 6. FIRE DEPARTMENT: DATE: N/A: PLEASE NOTE COMMENTS: RECEIPT OF COPY: SIGNATURE OF APPLICANT: 089.19 DATE: Date Printed: 3!7/2011 µY ~ •1 iF` + t"- �'' � yYt V F i'C •� Y J. "�i - ' •t � 5. s?^=.' u7 itr «'i AC!'. �� _ .�.-. IsJ � t a�. fi S {. 4ti r • - - h � t_- -"". r+. w ? fJ .L�. -. f ? /^411. F 'J >1 1 •:' R , j.,y, F. �{ Y .. ¢ ham; t , I,� r _. 1r ) [ti. ./. s f _ •i! „`.. '� v . - ' - . t .r � : _-. � �: '. Rr : :i9 tyx i moi' N s-� .�Y a _rr [ ..a zi i" J r r y f f7. L Y +.ta 1 4' �.s_ '> - f' + i'1 ,' -•� a i> sG ^t rr ,� } �, Y+-- _f'i 1 ♦ v Aja .s *al a .- F s -�S'.; f � -_; ~'� �' r t- .� rf 7 v ♦- ��; ." t r4 , ZfY tf ! r'�C va� /-• v +1 '� ' ��. l r`�y ( l r " ;Y L'.,. ;`. Y •t Lr J y�}t •t �.!� � c , •.,., f �'f �, t [ t + • f°� f..r n+� M+7 .''it 54:7 rf+ 3,�y iy.4 Y,•+} Fys � . . y _ 'J - '1 ti; 1:'i• Lh �{IS r \ .J - n } Y Vr. 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R _ . ♦ K:. i • S T-1 C Iy k -i W '/' ; yi< h 4'. ��55:�- S • r +, i �.,`! t....1- Ls✓ }� + a r TOWN OF YARMOUTH Building Department BUILDING (508) 398-2231 ext.1261 PERMIT NO �--B-11-814-� PROPOSED USE PERMIT •. ISSUE DATE ;- _1/4/2011. _ ; APPLICANT .Kevin .-.."-""----- .............................. JOB WEATHER CARD ---.....---- PERMIT TO Repair AT (LOCATION) 10030HATCH RD ZONING DISTRIC R-40 Bldg. Type: Residential SUBDIVISION MAP LOT BLOCK 1089.19 BUILDING IS TO BE: CONST TYPE 5-B USE GROUP R-3 LOT SIZE O repairs to bathroom due to water damage - install exhaust fan REMARKS AREA (SO FT) EST COST ($ $9, OWNER ICOX. CAROL D ADDRESS 10030 HATCH RD South Yarmouth MA 02664 J PERMIT FEE ($) BUILDING DEPT BY INSPECTION RECORD PHONE CONTRACTOR LICENSE 63766 Grignon, Kevin 1 Huntington Ave South Yarmouth MA 02664 7742121551 FIELD COPY Date Note Progress - Correcti ns and Remarks inspector -a 3-Z= // O/144 Cottvrwnuieat"t!s o` i'liadsachad.ild Official Use Only Permit No. lift - .lJeParlmen� of �in Jirviced Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. I/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 ;�D k'PLEASE PRINT ININK OR UPALL INFORMATION) Date:_/ —�� - 7,4 City or Town of:/hn= v -fes To the fnspector of Wires: N �y this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) �'Q H4 f el, =Orr or Tenant C� 44-s e wse `'Owner's Address -36 r�r->�� ti Is This permit In conjunction with a building permit? e Yes IN No Telephone No. (Check Appropriate Bo:) Purpose of Building Utility Authorization No. Existing Service Amps / ZA / 1t( t) Volts Overhead Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Comolohon o/the followine table may be waived by the Inspector of Mres. No. of Recessed Luminaires No. of Cell.-Susp. (Paddle) Fans r o of al Transformer KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires oven- Swimming Pool rnd. ❑ rnd. ❑ o. o Emergency Lighting Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. o elect and ces Initiating Devices evivi No. of Ranges No. of Air Cond. Tons . No. of Alerting Devices No. of Waste Disposers taTotals umber ons Detection/Alertln nDevices, No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Cyonnection No. of Dryers Heating Appliances KW Security of Devices or Equivalent o. o aterKW Heaters o. o o. o Signs Ballasts Data Wiring: No. of Devices or E uivalent Eo. Hydromassage Bathtubs No. of Motors Total HP a No. of D vicesoor Equivalent THER: e7 Attach additional detail jdesired. or as required by the inspector of ivirer. Cstimatcd Value of Electrical Work:. 4. (When required by municipal policy.) Work to Start: �-l.o 11 Inspections to be requested in accordance with MEC Rule 10, and upon completion. SURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. �• CHECK ONE: INSURANCE P BOND ❑ OTHER ❑ (Specify:) I certify, under the pains V4 penalties of equty, that the information on this application is true and eompleta FIRM NAME: ✓LO4'- LIC. NO.: Licensee: � t_ 2 Signature —LIC. NO.:? y 7 r z applieable, enter "exempt" In the Ucenie number line.) tr ge Bus. Tel. Nod y 2-$ o « 3/ 4Address: Alt. Tel. No.. *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not haye the liability insurance coverage normally required by law. By my signature below, l hereby waive this requirement. I am the (check one) 11 owner owner's a ent. Owner/Agent PE&WT FEE. S Signature Telephone No. i FEB 10 2011 3S EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 unite Use firm Permit/13— S� Fce S � Permit expires 6 months from issue date. CONSTRUCTION ADDRESS: ,sO� ��( r- (> Or �igOwl a `f%j ASSESSOR'S INFORMATION: Map: / Parcel: l / OWNER: C—o x Z O /`t!b 5: 1 /�x�1_�+i�h Z clfit` — ' NAME PRESENT ADDRESS TEL # CONTRACTOR: MA UNG ADDRESS TEL # *s1d nal Commercial 0 Est. Cost of Construction S cnzq. �5— � SS r— Ilome Improvement Contractor Lic. # Construction Supervisor Lia r Workman's Compensation Insurance: (check ones I am the homeownereLattrtt -sole proprietor Insurance Company Name: I have Worker's Compensation Insurance Worker's Comp. Policy# WORK TO BE PERFORMED 0 Tent (Fire Retardant Certificate attached) 0 Wood Stove Sled 0 Siding: # of Squares 0 Replaccn=t windows: # 0 Replacement doors: # 0 Electrical Permit # ❑ Re -roof: # of Squares g old shingles* *The debris will be disposal of at: I declare under penalties of perjury that the will be just cause for denial or rsyocali6V Applicant's Signature: Owners Signature (or 0 Insulation () going over layers of existing roof ❑ Old Kings Highway4listoric District _Z n Roofing/Siding (Like for like) Location of Facility ined are true and correct to the best of my knowledge and belief. I on 'Utand that any false answer(s) sectition under M.G.L Ch. 268, Section I. /A Date: JV Y rlor.. =J � �/.• — /� Approved By. Date: Building Official (or designee) Zoning District: I(istorical District: Yes 19C Flood Plain Zone: Yes Water Resource Protection District: Within 100 It. of Wetlands: / No Yes y(� 101 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 `4ITtP'' www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizatiodlndividual):. S - Phone Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees full d/or part-time).* �2. 14 so a proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required:] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required] t 3a. 111 am a homeowner acting as a general contractor (refer to #4) have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.: 5. ❑ We are a corporation and its officers have exercised their . right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance reouired.l Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. [1 Electrical repairs or additions I 1.❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other •Any applicant that checks boa #1 mast also fill out the section below showing their workers' compeasatiod policy information. 1 Homeowners who submit this affidavit indicating they are doing all work and thea hire outside contractors must submit a new affidavit indicating such. tContrsctors that check this boa must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub-coatractors have employees, they must provide their workers' comp. policy number. ,ram an employer that it providing workers' compensation insurance for my employees. Below is the poUey and fob site Information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: O M City/State/Zip. Attach a copy of the workers' compensation policy declaration page (showing the policy num er 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 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 $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 cove;ige verification. I do hereby eero under that the information provided above is,true and correct Phone #: ` QO7elat use only. Do not write M this area, 0 be completed by city or town ofciaL City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. Cityfrown Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 Mpdres all employdra to provide workers' compensation for their employee,. ' Ptssuant to this statute, an empkyre is defined as "...every person in the service of another under any contract of hire, eV" or implie4 oral or written." An mpkyn is defined as "an individual, Partnershilk associatios, corporation or other legal entity, or any two of more of the foregoing engaged in a joint enterprise► and including the legal representatives; of a deceased employm or the receiver at trustee of an individual, pastnerd* ."We tiaa at other legal entity, employing employees. However the owner of a dwelling hoose having not more than three apartments and who resides therein. cc the occupant of the dwelling grouse of another who employ, persona to do maintenance, consttuction or repair work on such dwelling boom or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be as employe:" MOL chgw 152,125(:(6) doo states that "every stab or lava! licensing ageaey shall wlthhoM the lansuce or renewal of a Mean" w permit to operate a buslum or to construe! buildings In the eemmoawealth for arty table evideacs of eornpltaoa with the lura , s,cores" requlrW appikastt who has trot produced asep Additionally, MOL chapter I A pCM states "Neither the commonwealth nor any of its political subdivisions shall enter Into my contract for the performance of pubtio work until acceptable evidence of compliance with the Wswwm requirements of this chapter have been presented to the contractus a t1wity." Appueaats , plena IM out the workers' compensation affidavit completely, by checking the boxes that apply to your simadot and„ If fir, supply sub.00ntractor(s) name(s), sddtess(es) and phone number(s) along with their certtBeate(s) of insurance. Limed qty Companies (LLQ Or Limited Liability partnership (LLp) with no employees other than the members or partmers, are not required to carry workers' compeasadon insurance. [fan LLC or LLP doeshave employees, a policy is required, Be advised that this affidavit may be submitted to the Department of Industrial Accidents for eon6rmation of hom mea coverage. Abe be ran to sip and date the aflfdavfL The affidavit should be returned to the city or town that the applicadom for the permit cc license is being requested, act the Department of Industrial Accidents. Should you have any questions regarding the law err if you am required to obtain s wai l ms' compensation polity, please call the Department at the am: I ilsted below. Self-insured companies should enter their ..rf t..MM.."rA been" menhar on the aaDeoosists lice. City or Two OQIdak please be ase that the aM&vit is complete and printed legibly. The Department his provided a space at the bottom of the laidevit for you to fill out in the event the Offiee of Investigations has to contact you regarding the applicant please be we to 1311 in the permiNieem number which will be used as a reference number. In addition, an applicant that mast surb®t multiple perm Mcemo applications in any given year, need only submit one affidavit indicating current policy information (if necensty) and under "lob Silo Address" the applicant should write "all locations in (city or town)." A copy of the a®dsvit that has been officially stamped or marked by the city at town may be provided to the applicant as proof that a valid aflida it is on tilt for NWG permits or Ileemses. A new affidavit meat be filled out each year. When a hams owner or citizen is obtaining a license at permit not related many business or commercial venture (La. a dog license or permit to burn leaves etc.) said persons NOT regmiled to complete thin affidavit. The Otites of Investigations would like to thank you in advance for your cooperation and should you have any question,, please do not hesitate to give us a "I nm Department's address, telephone and fax munbes The Commonwealth of Massachusetts Department of Industrial Accidents Offlet of Iavtstiptlons 600 Washington Sheet Boston, MA 02111 Tel. !1617-727-4900 ext 406 or 1-977-MASSAFE Fax !1617-727-7749 Revised I1-224)6 www.mass.gov/dis unice Use unty r PermikE ye Fee $ Permit expires 6 months from issue date. EXPRESS BUILDING PERMIT APPLICATION; TOWN OF YARMOUTH Yarmouth Building Department J u Lj 1146 Route 28 JAN 0 4 2011 South Yarmouth, MA 02664 /(508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: _ 349 11I91Gk Lf • (//9/!/nor% ` ASSESSOR'S INFORMATION: Map: Parcel: OWNER: ('Adel- r ox 9ts, Alk - c NAME PRFSENTADDRESS J� d I�7�, CONTRACTOR: NAME aw- yiy-zip isr1 TEL # Residential Commercial �j, 0 Est. Cost of Construction $ 9 X00 Home Improvement Contractor Lia # y 9 7.2 .� �/\ '1—Construction Supervisor Lia #1 7�. L �i �1�?Jr) Workman's Compensation Insurance: (check one) I am the homeowner I am the sole proprietor I have Worker's Compensation Insurance// Insurance Company Name: l //JK %/ Al 11711.4 L Worker's Comp. Policy#�i1G/— WORK TO BE PERFORMED 0 Tent , (Fire Retardant Certificate auachat) 0 Wood Stove Shed 0 Siding: # of Squares 0 Replacement windows: # ❑ Replacement doors: # 0 Electrical Permit# &7% Rgl%foi2 .. 4 PD 0 Re -roof: # of Squares ❑ Insulation Ex'/ rr U �f / F17 N () Stripping old shingles* () going over layers of existing roof ❑ Old Kings Highway/IIrstoric District Roofing/Siding (Like for Ukc) *The debris will be disposal of at: / %�✓y/iia%✓ `//M ��t%�_ (tri( L v, _ 1.,.,A rTEt 7 Ifocation of Facility I declare under penalties of perjury that the statements herein contained are we and correct to the bract of my knowledge and belief. 1 understand that any false answer(s) will be just cause for denial or revocation of my license and for prosecution under MG.L Ch. 268, Section 1. Applicar Owners Approve Zoning District._� Historical District: Yes IVB Flood Plain Zone: Yes �o Water Resoa Protection District: ' 1 Within 100 ft. of Weti ds: _ No Yes , 3/M The Commonwealth of Massachusetts Department oflndustrial Accidents Ogee of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectrlcIans/Plumbers Aoalicant Information Please Print Leeibly Name (Business/Organvationtbdividual): eitis% re9 lelrc4Go�- Address:_i 14tw22w T ,✓ A✓E .,tt l.7wmfzI : XR17r,+1,✓TA Phone #: Ta Are you an employer? Check the appropriate box: I.0I am a employer with 1_ 4. 0 I am a general contractor and I employees (full and/or Part-time).* 2.0 I am a sole proprietor or partner. ship and have no employees working for me in any capacity. [No workers' comp. insurance required:] 3.0 I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 3a. ❑ I am a homeowner acting as a general contractor (refer to #4) have hired the sub -contractors listed on the attached sheet. These sub -contractor have employees and have workers' comp. insurance.t S. We are a corporation and its officers have exercised thew right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp, insurance reauired.l Type of project (required): 6. 0 New construction 7. BICemodeling 8. 0 Demolition 9. 0 Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.0 Other 'Any appliam that checks box #1 must 9w till out the section below slowing their worker' compensatiod Oolicy infonmtiom t Homeowners who submit this affidavit indicating they aro doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors 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 wotkm' 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: 4 lVe-A 1\/ /yt v j vq L - Policy # or Self -ins. Lic. M [✓r / — 315- 3 L 4 ,?L 3 -O/O Expiration Date:14111 Job Site Address:-- 30 ygTc v City/State/zip: V l Attach a copy of the workers' compensation policy declaradon page (showing the policy number and ii✓�.�rr1i4 _ oLCCrj/ 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 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 $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 and penalties of perjury that the Information provided above is true and correct Signature: eIXC . i Phone #: risk- 7l 'j rr - Ofjleial use only. Do not write In this area, to be completed by city or town ofJ?elai City or Town: Perralt/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other Contact Persom Phone #: "I. Information and Instructions r M-4140 husem General Lawn chapter 152 requires all emPloy2rs to provide wotn rkers' compeation for their emploees. y Pursuant to this statute, an "Wleyte is defined a "...every person in the service of another under any contract of hireq express or implied, oral or written." An emplgw is defhud as "an individual. partnershi4% association corporation or other legal entity, of tuy two or more of the farep lug engaged in a jold enterprise, and including &a k.0 repraenfadves of a chased empktya, a the receiver of trustee of m indlvidusk partuerahipr associative or other legal entity6 employing employees. However the owner of a dwelling bvuse baying not more than three spattmenta and who resides therein or tier occupant of the dwelling house often dw who employs Persons to do maintenance. construction or repair work oa such dwelling boom of an the grounds or building appuatutenant thereto shall not bemuse of such employment be deemed to be an emplo7a." MGL chaptar 152, f 25C(6) also States that "mry stab err heal licensing agsaey sltaY wfthm" the taa.aaa or nmwsl of a license w permit to operate a bu doess err to construct buildings to the ces19moewoalth far say spptleas t who baa 19191 prodoeed aaepQ& svideaee of eompllaaa with *a Wwrsaes a mnp requirW AddidoOdly. MGL cher, , '152. pIM statue "Neither the commonwealth our any of its political subdivisions aball eats into any contract floc the paffxmana of public work until acceptable evidence of compliance with the inmrance regtukwzzb of this chapter have been presented to the contracting autbaih." Applimste , Please fill out the wofloara' compensadoo atlld"it completely, by checking the boxes that apply to your situation an4 if ere wearyl supply ffub.contractor(s) nsme(s), sddren(a) sad ph" nu mba(s) along with their certlfiesta(s) of instaancL Limited LWA ty Codd (LLC) at Limited Ushiiity Partnerships (LLP) with no employees other than the members of Partnerk an not MV&Vd to >=7 worlren9 wnpeneadoe iannanea. If an LLC Of LLP does bane employem a policy Is requite fie advised that thin afd avit may be anbmmed to the Department of Imiu uW Accidents for tong&& a of logumnee coverage. Abe be sun tesip sad date the OUSTib Ther atlidavit should be retUR to the city or towa that the applimtin for the permit or license Is being requeste4 set the Department of Industrial AmkkM . Should you have any Q°estl00e regarding the law or if you on regnk to obtain a woskanI compensation policys pkaso call the Department at the number listed below. Self -tanned cera Amies sbmM enter their self.[" P P - license number oa the 100fop912101 lion City w Town otlfelak , Please be sure that the atndsvit is complete and printed legibly. The Department has provided i space at the bottom of the affidavit for you to till out in the event the of&* of Investigations has to contact you segsadfag the apPHc2nL Pleasebe asn to fid in the pernait/ikense°ember wbich will bo used as a refereom nu:a, r Ia addidou. sn applicant that most submit multiple pemsW& ens@ applicadow in my givea yearq need only sobunt one alfdavit indicadng current po(hr h&rmadoe (if necessary) and under "Tab Site Addie»" the applicant should write "ail locadoaa in (city or town)." A copy of the atgdavit that has been officially ata19>ped atmarltad by the city a town may be provided to sloe applicant as proof that a valid af)Sdavh is on Me ex Aldus permits a licenses. A new amdavit must be tilled out each year. When s home own" or cia m is obtainilicense or permit we related to my business orcommercial nen=@ (i.e. a dog license or pe Mt to burs leaves ete.) acid person is NOT required to coa>Qkes this afIIdaviL The O(Ra of invadpdmu would lila to thank you is Wvaaee for your cooperation and should you have any quesdom please do not hesitate to give m a tail. [he Department's addms& telephone and fax munba: ilia Commonwealth of Massachusetts Department of Industrial Accidents Of&* of Its atlpdons 600 Washington Street Boston, MA 02111 Tel. 0 617-7274900 ext 406 or 1-877-MASSAFE Fax Al 617-727-7749 Revised 11.224)6 www.mass.gov/dln United Kitchen and Bath Inc. 1 Huntington Ave. S. Yarmouth, MA 02664 508-760-2023 * Fax 508-760-2024 01/04/2011 Yarmouth Building Department Job Discription : 30 Hatch Lane, South Yarmouth Home owner has had plumbing companies in her home because of water leaks on three occasions. They were unsuccessful finding any leaks. She called us and we found the exterior walls to be soaked and the installation frozen to the exterior wall. We opened the walls to dry. We will now need to do a bath remodel following the exact footprint with out change. We will upgrade the toilet, vanity and top, change the shower and the shower valve. The electrical will be updated and the only change will be adding a bath exhaust fan. Thank you, Kevin Grignon I 1,95 I-H� j I 1 _ i I--�--,- I I 1 i • 1 1 __ _ _-may- =- ---- --� -r I I. . -,--1 I ►OZI 17.7 I I - I I I I !7 _{-- 01/04/2011 10:30:00 AM TELAMON INSURANCE NETWORK PAGE 2 OF 2 A� ve CERTIFICATE OF LIABILITY INSURANCE �4i oi� 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 pollcy(les) must be endorsed. N SUBROGATION IS WANED, 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(*). PRODUCER Marketing Associates Iasuraace Agency, Inc. 150 Wella Avenue Newton MA 02459 Dawn Halandra AIB, CIC PNONE (617)964-5360 rAX. x .(617)969-1049 EODAESS:dmalandra8telamonins.com 00006246 INSURER(S) AFFORDING COVERAGE NAICI INSURED JSB Corp. Inc. 56 Katherine Lane Brewster HA 02631 INSURER ARearless Insurance Company 4198 INSURER•Harle s ills Preffered 35696 INSURER C: INSURERD: INSURER INSURER P! COVERAGES CERTIFICATE NUMBER:CL30112205516 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. WSA TYPE OF INSURANCE ADDLrUOH Town of Yarmouth CYNUMB 1146 Route 28 OU LIMITS A GENERAL UABILMY X COMMERQAL GENERAL LIABILITY CLAIMS41ANDE ®OCCUR -'-� '�-'G'-Y;?s 001460 r1/5/201O 1/5/2011 EACH OCCURRENCE i 1,000,000 I R i 100,0001 MED EXP we naso 5,000 PERSONAL a AM RWRY i 1,000,00 GENERAL AGGREGATE i 2,000,000 GENL AGGREGATE LIMIT APPLIES PER PR X POUC•/ JE LOC FI PRODUCTS -COMP AGO 2,000,000 i 8 AUTOMOBLZ LIMIUTY ANY AUTO ALL OWNED AUTOS Z SCHEDULED AUTOS E HIRED AUTOS Z NON -OWNED AUTOS 000000564960 /12/2010 /12/2011 COMBINED SINGLE LIMIT (Ea&=den) i 1,0001000 BODILY INJURY (Par per=* i BODILY IN.URY (PST rxiderq i PROPERTY IwvLCE i include (PPor acriracckrdwO PIP -Sank e RELLA UAB UAB OCCUR CLAIM3-MAGE EACH OCCURRENCEE88 AGGREGATE 4UCT13LE i i A WORKERS COYPEN6ATIONWTU- AND EMPLOYERS' LIABILITY Y ANY PROPMETDRIPARTNEWEXECUTNEri OFFICER,MEMBER EXCLUDED? (Mandatory ti NK II yyeess 9mcnba under DES(`371PTION OF OPERATIONS bebw NIA 5001659 1/5/2010 1/5/2011 OTH- LEL EL EACH ACQDENT : 100,000 EL DISEASE - EA EMPLOY EL DISEASE - POLICY UNIT S 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Auach ACORD 101, A"Sonal Remake SMedula, H mon space Is r#gWmc ) CERTIFICATE HOLDER CANCELLATION (508) 398-0836 SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED W Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth. HA 02664 -'-� '�-'G'-Y;?s Michael 8usco/JE88Zl: •— —^'••^"r ACORD 25 (2009/09) 0 1988-2009 ACORD CORPORATION. All rights reserved. INS025 ( u9m) The ACORD name and logo are registered marks of ACORD 57R a WN OF YARMOUTH Building Department (508) 398-2231 ext.261 BUILDING PERMIT NO B-1 G-345 - w ISSUE DATE ; _ 911W?QQQ _ ; PRQ3 SED USE ; :::::::: PERMIT APPLICANT _Stephen Restaino _ _ ... (�j _ _ . _ ... . JOB WEATHER CARD PERMIT TO Alterations AT (LOCATION) 10030HATCH RD ZONING DISTRICT R-40 Bldg. Type Residential SUBDIVISION MAP LOT BLOCK 1089.19 BUILDING IS TO BE: CON TYPEH] B USE GROUP R-3 LOT SIZE E� 004 REMARKS 16 replacement windows VIi i AREA (SO FT) EST COST ($) $11,000.00 PERMIT FEE ($) $40.00 OWNER COX, CAROL D BUILDING DEPT BY ADDRESS 10030 HATCH RD South Yanriouth MA 102664 INSPECTION RECORD Date No Progress - Corrections and Remark Jo CONTRACTOR LICENSE CSSLWS99560 Restaino, Stephen 345 Greenwood Street Worcester MA 01607 5089626942 PHONE 15083943856 FIELD COPY t Fee.... 42THE COMMONWEALTH OF MASSACHUSETTS � No. 2 7 TOWN OF YARMOUTH 3 ...... ...................... pa- 9 b� OCCUPANCY PERMIT "No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." .c�v�• L µ . Issued to:... (e ........T .ZJddress: ..3.......I ...f.�....r. Wiring Inspect �. .......Jnspection Date..:�:�:3........ .... Plumbing Inspe ... .l ................ Inspection Datee,5./ .......................... ' Fire Department...... �' . � r�:t!%...............Inspection Date.. /Y.4!.................. cirri Building Inspector....... �..�Y.�... .... :�s a�Grr� ....................Inspection Date.... .....2Z .................... Assessors...................................................................................Inspection Date........................................ THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN RROUIREMENTS. Date:.... �Af..../ ...... Building Inspector G APPLICATION FOR PERMIT TO DO GASFITTING (OFFICE USE ONLY) TOWN OF YARMOUTHey O Imo, . $ 1 PERMIT NO. Building - ' Owner's Date 4zg 19� AT: Location &2 7ellName �?1 Fes! Type of Occupancy U New ❑ Renovation ❑ Replacement Plans Submitted Yes ❑ No El�" (PRINT OR TYPE) C eCK On Installing Company Name I!F- /� Of UldfR_/.0 - ff�/�J �_ Cort). Address14 ox f Partnership D�GGs� ❑ Firm/Company Business Telephone �- Name of Licensed Plumber or Gasfitter INSURANCE COVERAGE: Check O e have a current liability insurance policy or its substantial equivalent. Yes Er ❑ If you have checked yes, please indicate the type of coverage by checking the appropriate box. A liability insurance policy. ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check One: Owner ❑ Agent ❑ Signature of Owner or Owner's Agent 1 hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 212 Signature of Licensed Plumber or Gasfitter License Number TYPE LICENSE: ElElA'aster Plumber Gasfitter ❑Journeyman tJ � rn Y Z vi ' N M 0 ¢ N 0: a J U) W m Z _¢ s mU w W 0 s a aWa �D N N O W = Q S O W ' W 2 N J Z 0 Q= R N M W 0 = W E" C 0 t= y 0: 2 Q W =� Q= t F } 0 m Z O W 0 F- W cc = 0 a= LL M 3 c a g o a 0 0 X> ►W SUB-BSMT. ' BASEMENT 1 ST FLOOR -- 2ND FLOOR 3RD FLOOR (PRINT OR TYPE) C eCK On Installing Company Name I!F- /� Of UldfR_/.0 - ff�/�J �_ Cort). Address14 ox f Partnership D�GGs� ❑ Firm/Company Business Telephone �- Name of Licensed Plumber or Gasfitter INSURANCE COVERAGE: Check O e have a current liability insurance policy or its substantial equivalent. Yes Er ❑ If you have checked yes, please indicate the type of coverage by checking the appropriate box. A liability insurance policy. ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check One: Owner ❑ Agent ❑ Signature of Owner or Owner's Agent 1 hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 212 Signature of Licensed Plumber or Gasfitter License Number TYPE LICENSE: ElElA'aster Plumber Gasfitter ❑Journeyman RECEIVED SE ,%i8 2009 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 U0 South Yarmouth, MA 02664 (508) 398-22 1 Ext. 1261 CONSTRUCTION ADDRESS: 4S 0 � `1 ASSESSOR'S INFORMATION: Map: Parcel: 19 utttce use unty Parmt - w -3 Fee S—tris Permit expires 6 moa from issue date. OWNER: ADDRESS ;08 3N-3 TEL # CONTRACTOR:T_0 slepA74l s44f"No 3 496>teevwxp !s more , A N E f MAUJNG ADDRESS 0107 TEL# Residential . Commercial Est. Cost of Construction $ / i Home Improvement Contractor Lic. #J-1531 Lryn Construction Supervisor Lic. # i Workman's Compensation Insurance: (check one) I am the homeowner I am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: e'U All) P5� if 7 t r° I &L Grj Worker's Comp. Policy# WORK TO BE PERFORMED Tent (Fin: Retardant Certificate auacheq Duration Wood Stove Shed ❑ Siding: # of Squares Replacement windows: #Z6 Replacement doors: # Re -roof: # of Squares () Stripping old shingles* 'The debris will be disposed of at: () going over layers of existing roof ❑ Old Kings Highway/Historic District M Roofing/Siding (Like for Like) Location of Facility I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or/�ree of my license and for ution under M.G.L. Ch. 268, Section 1. 9 Applicant's Signature: = Date: ! 1S �O/ Owners Signature (or auxturicat) Date: Approved Building Official (or designee) Zoning District:. Historical District: Yes Water Resource Protection District: des No Date: Flood Plain Zone: Yes o Within 100 ft. of Wetlands: Yes XO 3101 vagi Are you an employer? Check the appropriate I. to I am a employer with _ 4. E employees (full and/or part-time).'. 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 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.t 5. ❑ We area corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' insurance Type of project (required): 6. ❑construction 7. emodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions I l.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other, 'Any applicant that checks box 01 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they ue doing all work and then hire ouuide 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 _ n information. Insurance Company Name: Caw t Uff a f Pti 2 / D Policy # or Self -ins. Lic. #: Expiration Date: 3 l 3 Job Site Address: City/State/Zip: 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 51,500.00 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 u the pains and ppeena�lliiees ofperjury that the information provided ab a is true andcorrect. A�/l / T-�-. 7 /L I —I// # � G -1 ( Phone 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 InspNor 5. Plumbing Inspector 6. Other Contact Person: Phone Licensee Details The Official Website of the Executive Office of Public Safety and Security (EOPS) Mass.Gov Horne Public Safety Department of Public Safety Licensee Complaints License Type Home Improvement Contractor License If 153140 Restriction Company Nu -vision Installations Name Stephen Restaino Address 32 Oval Drive City, State, Zip West Yarmouth, MA, 02673 Expiration Date 10/31/2010 Status Current No complaints found For this Licensee. gukTo Su[ h c f uui•cl tit' S�,ilclin . Zc ul:�itions.and Stitndai-ds -�. Constn cation auoelrvisoi Speo aJty License + License: CS SL 99560 t w Restricted to: WS f>•�.7-1A0 S,�rr STEPHEN RESTAINO r� .h 32 OVAL DRIVE- WEST RIVEWEST YARMOUTR MA`02673 t'I,fonti:•it,n���• N(,, V,5,10q Expiration: 1/22/201.2 TY: 99560 Page 1 of 1 07/15/2009 14:21 FAX 508 775 a - h Y gcoRD. CERTIFICATE OF LIABILITY INSURANCE o TDATE (MMIDDIY STEPH-2 07 15 0909 TI NSR TYPE OF INSURANCE POLICY NUMBER OATfi YN/OOlYY TE msl �� GENERATYPEO IN EACMOCCURRENCE 2500000 A COMMERCIAL GENERALLIABBJTY BP00004763 07/13/09 07/13/10 PREMISES Eeocerenee 3100000 CLNMS MADE M OCCUR MED EXP (Any Ane Pin) $10000 - PERSONAL iADV INJURY $500000 X Business Owners GENERAL AGGREGATE 31000000 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION aooucoi ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Ilde Cape Cod Insurance HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR lart ha Findlay ha Finter ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. '96 Street CO 91NQED SINGLE LIMIT S lyannis MA 02601 Phona:508-771-3300 Fax:508-775-3821 INSURERS AFFORDING COVERAGE NAICX ISUREO INSURER~ Safety Insurance Co 39454 INSURER 0. S ephe n M R®staino D�B7A Nu-Bi3ion installations INSURERC: west Ylarmouth MA 02673 INSURERa INSURER E: :OVERAGES THE POLICIES OF NsuRANCE LISTED BELOW HAVE BEEN ISSUED To THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REDUIR6MENT, 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 AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CIAN& TI NSR TYPE OF INSURANCE POLICY NUMBER OATfi YN/OOlYY TE msl �� GENERATYPEO IN EACMOCCURRENCE 2500000 A COMMERCIAL GENERALLIABBJTY BP00004763 07/13/09 07/13/10 PREMISES Eeocerenee 3100000 CLNMS MADE M OCCUR MED EXP (Any Ane Pin) $10000 - PERSONAL iADV INJURY $500000 X Business Owners GENERAL AGGREGATE 31000000 GEN'LAGGREWTS UIdITAPPUES PER: PRODUCTS-COMPIOP AGG f 500000 POLICY PEQ- LOC ai AUTOMOBILE UASILITvY CO 91NQED SINGLE LIMIT S ANYAUTO ALL OWNED AUTOS BODILY INJURY i (Pr P&MON SCHEDULED AUTOS HREDALTTOS BODILY f NON-0WNEO AUTO$ PROPERTYpAYAGE f GARAGE UAINUTY ANYAUTO AUTO ONLY- EA ACCIDENT OTHER THAN EAACC f AUTO ONLY: AGO S rXCESSMMBRELLA UABIUTY OCCUR CLAWIS MADE EACH OCCURRENCE S AGGREGATE L i - i DEDUCTIBLE RETENTION S. i WORKERS COMPENSATION AND EMPLOYERS UABaJTY Y LIMITS CA EL EACH ACCIDENT i LLD ISEJASE-EAEMPLO S ANY PROPRIETORIPARTNERITXECUTNE Of fir.ENJMEMBER EXCLUDED? EA. DISEASE -POLICY L"T I f VVw. d"w1be under ECIAI PROVISIONS UwIw OTHER 7-1 PROPERTY 3510 1 N weroivnnu Knvnenncw_aii[H.A7tONSlvEwCLES1EXCWSWNS ADDED BY EN00RSEMENT/SPECW. PROVISIONS VIS�.., Corti£ieats holder is an Additional Insurod The At-UOme'Services, Inc DSA The Home Depot at the Service 2690 Cumberland Parkway Atlanta GA 30339 ti. 4 `, ..- ai (i :R U SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BRE THF¢il MATMI DATE THEREOF, THE ISSUING INSURER WILL EMDEAVORI%'0 MAIL 1, DAMWRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO 50 EHALL IMPOSE NO OBUGATION OR LL401 Y OFANY KIND UPON THE L43UPSA ITS AGENTS OR REPRESENTATIVES. -ACORDrr CERTIFICATE OF LIABILITY INSURANCE DATE 20/09"""' PRODUCER - 1-404-995-3000 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Marsh USA, Inc. CONFERSONLY AND O N THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTENDOR homedepot.certrequestemarsh.com ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. UMIt3 3475 Piedmont Rd NE, Suite 1200 Atlanta, GA 30305 Pa: (212) 948-0902 INSURERS AFFORDING COVERAGE NAICS INSURED INSURERA: Steadfast Ins Co 26387 THD At -Home Services, Inc. - INSURERB:Zurieh American Ins Co 16535 INSURER C: NATIONAL UNION FIRE INS CO OF PITTS 19445 2690 Cumberland Parkway Suite 300 Atlanta , GA 30339 INSURERD:New Ham shire Ins Cc 23841 INSURERE: Illinois Natl Ins Co 123817 SS a ree: THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED 70 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. MSR kDO L POLICY NUMBER POLICYEFFECTWE POLICYEXPIRATgN UMIt3 A GENERALLIABIUTY IPR 3757 608-02 03/01/09 03/01/10 EACHOCCURRENCE $4,000,000 PREMISES (Eamcw,nce)51,000,000 X COMMERCIAL GENERAL LIABILITY LIMITS OF POLICY ARE EXC SS MEDEXP Anoro non $EXCLUDED CLAIMS MADE O OCCUR '07 SIRI $1,000,000 PER CC' PERSONAL 6 ADV INJURY f 4.000,000 GENERAL AGGREGATE f 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG 54.000,000 X POLICY PRO- LOC JFCT B AUTOMOBILE LIABILITY SAP 2938863-06 03/01/09 03/01/10 COMBINED SINGLE LIMIT $1,000,000 X ANYAUTO (Ea accident) BODILY INJURY S ALLOWNEDAUTOS SCHEDULEDAUTOS (Perpenon) BODILYINJURY S HIREDAUTOS NO"WNED AUTOS (Par accident) PROPERTY DAMAGE $ X SELF INSURED AUTO PHYSICAL DAMAGE (Par acudenl) GARAGELIASILRY AUTO ONLY. EAACCIDENT S OTHER THAN EAACC f ANYAUTO AUTO ONLY: AGG $ A EXCES$IUMBRELLA LIABILITY IPA 3757 606-02 03/01/09 03/01/10 EACH OCCURRENCE $5,000,000 AGGREGATE SS,000,000 X OCCUR F-1 CLAIMS MADE f S DEDUCTIBLE S RETENTION S C WORKERS COMPENSATION AND 3566916 (CA) 03/01/09 03/01/10 X WCSTATU DTH. E L. EACH ACCIDENT 51,000,000 D EMPLOYERS' LIABILITY 3566915(AOS) 03/01/09 03/01/10 E ANY PROPRIETORJPARTNER/EXECUTIVE OFFICERMEMBER EXCLUDED? 3566917 (FL) 03/01/09 .03/01/10 E.L. DISEASE - EA EMPLOYEE $1,000,000 Et. DISEASE -POLICY LIMIT $1.000,000 N n, describe undw SXECIAL PROVISIONS bebw D OTHER Workers Compensation 3566918 (KY, M0, NY, WI, 4v) 03/01/09 03/01/10 F TX Employers Excess TNSC45694422 (TX) 03/01/09 03/01/10 ccurrence/SIR 25M/IM C Workers Compensation 4801323(pSI) 03/01/09 03/01/10 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENTI SPECIAL PROVISIONS REL EVIDENCE Of INSURANCE AT-HOME SERVICES, INC. 2690 CUMBERLAND PARKWAY SUITE 300 ATLANTA. CA 30339 USA 25(2001/081ckomraus hd 11172180 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO 00 SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR AUTHORIZED REPRESENTATIVE 1988 Burd at gaiming Rcpdattaaa mw Suadardx =i HOME WpROVENENT CONTRACTOR i Reg aVAU0 s: 126893 i Expiration: 5r3r2010 TM: Supplement Cud The Moms Depot A1440M SO"" DARREN DEMERS 32200 COBB GALLERIA PKWY 620 C: w.Q+— i ATLANTA. GA 30339 Aduitistrater u License or registration valid for individul use only before the expiration date. If found retara to: 1 Board of Building Regulations and Standards { One Ashburton Place RO 1301 Briton, Ata. 02108 Not valid vriltost aigaatstre _, SEP -03-2009 19:22 Branch Name: Boa on Branch Namr !4 ONorth 333 nth 31 Installation Addreu : Paratusetrtk: •. : ^ • • . HOME DEPOT HYANNIS P.001 HOME IMPROVEMENT CONTRACT PLEASE READ THIS Dau 0R Sold, Flmoisbod and Installed by: . -1. .THD At -Home Services, Inc. dbla.The Home Dcpot Ai -Home Services -'45A Greenwood Strect, Unit 2, Worucatez• MA 01607 Toll Fra (SW) 657-5182; Fax (508)7564&23 Fodtsal LD # 75-2698460: ME Lic # C 02139: RI Cont. LJc# 16427 Cr Lie # 565522; MA Home ament Comrxror Reg.# 126693 •�vfh`arm�'� oa66�( Cit Sate Zip .. .F •�J ,. �. � J ... .. .N..O ......0 DGuam, CoClEnuY Door .. c264 _ Hems Address: (If different from tact dlaeon Address) . • • City • State Zip F man Address (to r eeive pm ecYeommunicadons aad Home'Depot updates):.. Q TDO NOTwrsh tc •receive muymatkctwg ernails from The Home Depot, 4_0i, anion! 'Undersi8ncd ("Cnstomen ttu owneis of eLe property located at the above Idsallation address, agrees to buy, THD At -Home 3 Yvices, Ina ('rhe Home Depot-) azr'cca to'frLtii s .dcliVr arid artaage, fid the iastallition C astallatioo') of all materials• describe Lon: the below and'on thexcfacocod'Spec Sbxt(s), all of. Which are incarporatod into this Cootract by this reference, along with ray applicable, State,Supplement and, PaymartSummary,attachedNetero and any Change Orders (collectively, ]ehW e.•._u ".v.�.: Cw Cf..d/d!•'. 'VenL.v,Amnnwf u/ Rmfing Sidor; Windows InAalaLioa ... S • . DGuam, CoClEnuY Door .. c264 _ • Gag, Siding Windows insulation .. $ - . ❑Gotrua/Covers QFaaYDooLs ❑ . DRoohog ElSidiog U Windows r„s.t, e S �Guttail4;ovas �nY Door ❑ . - ring Uswms U Windows L3 Inswiltion s • .. �GtLaen / Casein QIJ:try Door. ❑ .. .. 3Ialasson Z A Depod :otComraaAmnant due Upon euaLka of "C=Un &M.. • Tow Contract Amouut' : S • bGdoePmeMsrgsatt satLlcpo6tmoretbmoapthirdpttheCoutractAmou" Customer agrru, that; immediately:upon completion of the work -for eaili Product, Customer wiu execute a. letlon Cectifiau (one.foi tach'Product is defrn+ed by an individual, Spec Sheat) aaQ pay say belanec due As applicable, each mer uadrr this Contract epcei to bej imdy and severally obUpW and liable beratndcr.: . The Home Depot rests ves.the right to issue a Change Order or terminate this Contract or any individual Products(s) included hercia, at is discrcdoo,:if The H4 me Depot or its srrihotved-service provider determines that it cannot pcdotmits obligations die to a structural problem with the bora I,.mvironmcotal harards aucb as mold, asbatoa of leadpain; other safety.eoactsns. pricing errors or because workrc4=cd to comp ktc the job was not included rim. . Payment Summary: The Payment Summary #_ •' included as part of this'Conttact,'am forth the mal Contractamount and,p tymeats required far the deposits and final payments by Product (as applicable): NOTICE TO CUSTOJTER You are entitled to a. ompletely mied-in copy of the Contract at the time you sign. Do not sign a Completion Certificate (sots there is one Compied an Certificate for each listed Product as defined by individual Spec Sheets) before work on that Product Is complete. In the event of tumli cation of this Contract, Customer agrees to pay The Home Depot the costs of matedab, labor, espeases and services providei by The Home Depot or Authorized Service Provider throogb'the date of termination, plus any other amounts set forth in i his Agreement or allowed under applicable law. THE HOME: DEPOT MAY WITHHOLD ANIOUNTS OWED TO THE H )ME DEPOT FRODf THE DEPOSIT PAYBIENT OR OTHER PAYMENTS MADE, WITHOUT LEMrMG THE HO tM DEPOT'S OTHER REINIEDIES FOR RECOVERY OF SUCH AMOUNTS. ice taace and tet LA70on: Customer agrees and understands that a this Agreeroam is the entire agreement between Custain The Home Depot L nth regard to the Products and Installation services sad supersedes all prior discussions and agtrements, either oral or written, relatia( :to said Products and Installation. This AgreemaLt cannot be assigned or amended except by a writing signed by Customer and The : Lome Depot.Customer acknowledges and agrees that`Crstomer bas read, wWcmiands, voluntarily accepts the terms of sad bas meeiv at a cony of this A moment. Customer -s Signanao r Dau ` X Customer's Signature ' Date Sabra( Y^ . ^..a: .I - • �./ � /� •.,,,.. Sala. , tanrs Signature � 5 • Dale Telephone No.r/ o Sala Consultant License No. CANCELLATION: CUSTOMER NIAY CANCEL THIS (Yapa>k+bk). AGREEMENT WITF OUT PENALTY OR OBLIGATION BY DELIVERING R Rr1TEN NOTICE TO THE HOME DEPOT BY MIDNI• MT ON THE THIRD BUSINESS DAY AFTER SIGN ING THIS AGREEMENT. THE STATE SUPPLED CENT ATTACHED HERETO CONTAINS • A FORM TO USE IF ONE IS SPECIFICALLY 1 RESCRIBED BY LAW IN /r CU!3TON1ER'S STAT, G NOTICE. ADDIia WAL 7IILMS AIM CONDITIONSARE STATED ON THE RYvn'.RS&SIDE AND ARE GRT OF THIS CONTRACT Of r� APPLICATION FOR PERMIT TO DO PLUMBING q TOWN OF YARMOUT � (OFFICE USE ONLY) rD •i, OVL1 III�I gy, $ JAN 14 20 1 Fee: / PERMIT NO. �T cy,_____ Date Building Owner's j-2 AT: Location �1� -4 Name Type of Occupancy\ V1N�.�— New ❑ Renovation LY Replacement ❑ Plans Submitted Yes ❑ No ❑ (PRINT OR TYPE) Installing Company Name 2�►1\N ins' Business Telephone Check One: ❑ Corp. ACCEPTED 4Y: _ ❑ Partnership LTJ Firm/Company Name of Licensed Plumber �—' Q'C - - Sf"\ xTH INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent. Check One: Yes ®-'INo ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. A liability insurance policy W ---'Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance voerage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check on Owner ❑ Agent ❑ Signature or Owner or Owner's Agent i all' I hereby certify that all of the details and Information I have submitted or I ifure'of Ucensed (or entered) In above application are true and accurate to the best of Plumber my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all �_ r1 \%-A 4' pertinent provisions of the Massachusetts State Plumbing Code and License Number Chapter 142 of the General Laws. Type: Master D00' Journeyman z z N p Y } U F N �a NY OJ 2 Q y F W= W H V 0: N Cl) 'O u. 2 a 2 ca 2 a 0 N W W W N cc Co ce a. U) LU Q N U) Y N O G 4 J Z dr a at O O�� W S F O Z= .! r• Q Y Q Ix w W 3 g m H g s N o O V o Y c o o< 3 0 SUB•BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR (PRINT OR TYPE) Installing Company Name 2�►1\N ins' Business Telephone Check One: ❑ Corp. ACCEPTED 4Y: _ ❑ Partnership LTJ Firm/Company Name of Licensed Plumber �—' Q'C - - Sf"\ xTH INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent. Check One: Yes ®-'INo ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. A liability insurance policy W ---'Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance voerage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check on Owner ❑ Agent ❑ Signature or Owner or Owner's Agent i all' I hereby certify that all of the details and Information I have submitted or I ifure'of Ucensed (or entered) In above application are true and accurate to the best of Plumber my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all �_ r1 \%-A 4' pertinent provisions of the Massachusetts State Plumbing Code and License Number Chapter 142 of the General Laws. Type: Master D00' Journeyman F-1 N P,.t ©cc— )-(-7 < < )?--� FIXTURES MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: r t3 4� 1;�i``a� MA. Date:` — 'Z!A -1\ Permit#f' — PType BuildingLocatiowaini �'IATL�� Owners Name C ,ny' of Occupancy: Commercial ❑ Educational ❑ industrial ❑ Institutional ❑ Residential New: ❑ Alteration: ❑ Renovation: Replacement: ❑ Plans Submitted: Yes ❑ No FIXTURES Installing Company Name: V-4) SaT`I \ a D 5 Mbi Address*Q (- '1 City/Town: - State: ±A1 Business Tel: y0 - Fax: Name of s7: Check One Only Certificate # ❑ Corporation ❑ Partnership Fim-dCompany 1 have a current liabilityInsurance policy or Its substantial equivalent which meets the requirements of MGL. Ch.142 Yes ['Flo ❑ If you have checked Yep, please indicate the type of coverage by checking the appropriate box below. A liability Insurance policy Ud Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ -, --• ••, ..•• •.. �.... .,,u m,Urtnauvn i nave suummea for ennreal regaramg tnis appncauon are true and accurate to the best of my �K ledge and that all plumbing work and Installations performed under the permit Issued for this application will be In compliance with all en ant provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. BY Type of License: L Tiue ,,_ / Igr�ture of Licen lum er t y Plumber City t ` Q'Master e Number APPRov I�FFICE USE �n ❑Joumeyman Licensr. a .. • n�lnnnnnnnnnnnnnnnnnnn�ln�onnnnunl� ,: • • I�nnnnnnnnnnnnnnn■�nnnn�llu�c�u��nu •• MMMMMMMMMMMMMMMMMMMMMW1MMMMMMM' • .. mmmmmmmmmmmmmmmmmmmmmolmw,,.,1imiW MMWMMMMMMMMMMMMMMMMMMM!==W= . , . mmmmmmmmmmmmmmmmmmmmmmi.M.. -MM M Installing Company Name: V-4) SaT`I \ a D 5 Mbi Address*Q (- '1 City/Town: - State: ±A1 Business Tel: y0 - Fax: Name of s7: Check One Only Certificate # ❑ Corporation ❑ Partnership Fim-dCompany 1 have a current liabilityInsurance policy or Its substantial equivalent which meets the requirements of MGL. Ch.142 Yes ['Flo ❑ If you have checked Yep, please indicate the type of coverage by checking the appropriate box below. A liability Insurance policy Ud Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ -, --• ••, ..•• •.. �.... .,,u m,Urtnauvn i nave suummea for ennreal regaramg tnis appncauon are true and accurate to the best of my �K ledge and that all plumbing work and Installations performed under the permit Issued for this application will be In compliance with all en ant provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. BY Type of License: L Tiue ,,_ / Igr�ture of Licen lum er t y Plumber City t ` Q'Master e Number APPRov I�FFICE USE �n ❑Joumeyman Licensr. 112S, Cammonwca o` ddacitadcled Official Use Only Permit No. 1JePar�nenl of ,.tin Jirviced Occupancy and Fee Checkedlug _ BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 Ieaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK - -- -- - All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 -- (PLEASE PRINT iN INK OR TYPE ALL INFORMATION) Date: 7 — 2,-Z- — Zd �jf: � City or Town oAV' Iii, o LrA To the Inspector of Wires: o iBy this application the undersigned lives notice of fio or r intention to perform the electrical work described below. N Location (Street & Number) 3 C) 12* N Owner or Tenant Owner's Address tt 1.1 a iL _ /r—,W, Is this permit in conjunction with a building permit? Yes ❑ Purpose of Building Existing Service ) d e Amps /_y Lt—!L6 Volts Overhead ❑ (v ,New Service Amps t Volts Overhead ❑ TelephoneNo.<,/Og lair"0 No U (Check Appropriate Box) Utility Authorization No. Undgrd ❑ No. of Meters / Undgrd ❑ No. of Meters t� Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work:.�ti 0 V Z v� ri Attach additional detail if desired or as required by the Inspector of;Vires. Estimated Value of Electrical Work.,4'-b 0 (When required by municipal policy.) Work to Start: ? — — U l l inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. ECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) .., I certify, under the pain and penalties ojperjury, that the Information on this application is true and complete. FiRM NAME: 910 /Ly j,� 1= . LIC. NO.: Completion o the fo/lowinr table may be waived by the Inspector of;Vires. No. of Recessed Luminaires No. of CeiL-Susp. (Paddle) Fans r o of al Transformers KVA No. of Luminalre Outlets No. of Hot Tubs Generators KVA No. of Luminaires oven- • Swimming Pool rnd. ❑ rnd. ❑ o. o mergency Lighting Batte Units No. of Receptacle Outlets No. of Oil Burners FiRE ALARMSNo. of Zones No. of switches No. of Gas Burners No. o Detection as Initiating Devices No. of Ranges No. of Air Cond. Tons . No. of Alerting Devices No. of Waste Disposers HeatPumum ons Det ction/AlNo. of tin Sell-ContainedDevices IE—ber No. of Dishwashers Space/Area Heating KW Local ❑ municipal❑ Other No. of Dryers Heating Appliances KW echo. of SysteDevicems:* or Equivalent No. o aterKW Heaters o. o o. o Signs Ballasts Data Wiring: No. of Devices or E uivallent No. Hydromassage Bathtubs No. of Motors Total HP a No of Devices or E uivalent OTHER: `Licensee: ✓ l-c.i Signature / LIC.NO.:-3 7t: L t �(Ifapplicable, ter" em " idAelicense,numberlinf.J Bus. TeLNo.�(r zyrs— a J M t� Address: 4 K l/2/ i�l f �' 'i &C /yl4 I6�� pit, Tel. No.: *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. (� WNER'S INSURANCE WAIVER: 1 am aware that the Licensee does not have the liability Insurance coverage normally required by law. By my signature below, i hereby waive this requirement. I am the (check one) C] owner owner's agent. Owner/Agent PERKIT FEE: S Signature Telephone No. 6117/2015 SlipGen- Portal Hone Town of Yarmouth 1 Template [Building Dept] 1 Slipshect Identiser [sg28079] Document Category Building Permits Map -Block Number 089.19 Street Number 0030 Street Name HATCH RD Department Building Parcel ID 12287 Backfile Batch Scan No Document? Additional Naming Info Index Operator Operator, Yarmscan Date - Time 2015-06-17 - 11:46 httpJAasedche121SlipceN 1/1