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BP-91961 TOWN OF DA►RTMOUTH 1411LDING DEPARTMENT RECEIPT - _.PHONE 508 910 182U t FA : 508-910.1838 Name: Owner ;Property ( 1 .r f i / Date i, 's Job Location: / Map: Lot: , Description General Ledger#'s Ref. # Amount Building & Build��o bs&�r,�o 01000-44105 5/, ;y7 l' s rY ,) Electrical ,,o ,p G ' i,, 01000-44106 ` Plumbing & as 01000-44107 APP 8 ,1019 lV i V O Trench Safe 01000-44129 Other Departn e vegue p% 01000-42420 BE I T E H M E N TS COLLL,-� White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received / e ff}� E^ f n THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS . RESIDENTIAL ❑ Phased Approval pp al(R106.3.3) $25.00 APPLICATION YEE IS NON IUE-EITI IRIL LE at NON-TRANSFERABLE ur \ DATE RECEIVED ill -° s`,� DARTNIOUTH BUILDING DEPARTMENT ` ;�( '.` 400 Slocum Road z i_'I Da tmouth, NiA 02747 , Phone: 508-910-1820 Fax: 508-910-1838 °= wwvni.town.dartmouth.ma.us APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TW FAMILY DWELLING THIS SECTION FORtWEICIAL USE ONLY RECEIVED BY. BUILDINGPERMLT NUMBER: ( / DATE ISSUED: SIGNATURE: . 13 l 4 y �/ DATE: ! CU�Building'Commissioner/Inspector of Buildings 9 Proposed �^ Zoning-District:-District: Use: Zone: Et B ❑A 0 V Aquifer Zone: - ;. THE FOLLOWINGAGENCIES SHOULD BE NOTIFIED: DPW - ❑Board of 0-Board of . C Cons 0 Planning ❑Address ❑Engineering U Cross - Appeals ":Health Commission " - ,Card Connection, ❑Fire ❑Gas 0 Electric O:Other ❑Water Card 0 sewer Card 0 I 0>C - -Chief Cut-Off -_ Cut Off Cut Off Cut Off '.DEPARTMENTAL-APPROVALS[ Board of Health: Signature: Date: i Conservation Commission: Signature: Date: D.P.W.: Signature: Date: Fire Chief: Signature: Date: Other: Signature: Date: Brief description of work being performed: Sr/ / 13M7(,) f SO 7 :SECTION `-SITE[NFORM�4710N l 1 1.1 Property Address: ) Sh iilaI e _t J Ln 1.2 Assessors Map& Lot Number: Contact Person: i3tich _7pnn/s 07i • Map__ 1 - Lot 027 - Phone Number Ho ( — 2.Z R— g R a o 1.3 Historical District ❑Yes 0 No 1.4 Water Supply(MGL c40 s54): 1.5 Sewage Disposal System: Year Built 0 Municipal ❑ Municipal 0 Altering more than 25%per side of building 0 Private Well ❑ On Site Disposal System Has application been submitted to the Historic Commission? ❑ Yes ❑ No Date: Revised 5/13 CONSTRUCTION PLANS SITE PLAN ENERGY REPORT RESIDENTIAL SECTEJta 2-P,ROPERTY_OWN_ERSHIPIAUTHORIZED AGENT 2.1 Owner Record: Z 5Aln5/e_ YSL*t%/ L/1 • ,bi �7%icrti qv. g rf /Serf t,/%it is v n n iEn,✓`l/-} (92-7 47 nt- 9 D e 4 Name(print) Contact Address Phone Number 2.2 Authorized Agent: /o Reservoir 'r<c{' 4c( ?ri1n /aon/lrscai S AJ r,JtinJVv/S �� fl, F e(d 2Z 62117 22rp-qso 0 Name(print) Contact Address Phone Number SEGT(ON 3,.COTISIRUGTION'S RVICES y _ 3.1 Licensed Construction Supervisor/Specialty License: /3r14,1 /'/Lt LS0/1 License Number: 095 707 Company Name/Contractor Name: Jnr/Pterr AA„iCA54;4,1 Gt/nJow S 11-1-(. Aj / Ws.)` t°" /73293 Address: /Q PSefvn;C QU 7/ 7 Expiration Date: hi IC- 9-48-I O S/- - -2-2o Signature: Telephone: yo -22e-gtoo 3.2 Homeowner Exemption -One&Two Family Only Section 110.R5.1.3.1 Exception: FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT Exception: Any Homeowner performing work for which a Building Permit is required shall be exempt from the provisions of this section;provides That if a Homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor. For the purposes of this section only,a'Homeowner'is defined as follows: Person(s)who owns a parcel of land on which heishe resides or intends to reside,on which there is,or is intended to be,a one or two family dwelling,attached or detached structures accessary to such use andior farm structures. A person who Constructs more than one home in a tvvo-year period shall not'be considered a Homeowner. - If you are applying under this section sign below: Signature: -.+ ' S0CT10aki WpE K SCOpQQ'r,NSAT,(-O NSURANO AFFIDAVIIAM.OVO.'10§-25) 1-. _, _ Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: I!Yes ❑ No _SECTION S-tESCRIPTION O,F PROPOSED WORK(Cheek Till applicabIa) _ W s ❑ Deck 0 Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace 0 'NoodstoveiPellet Stove ❑ New Construction` 0 Accessory Bldg. 0 Addition 0 Roofing/Siding Replacement window/door (Energy report required) (Shed/Garage) (Energy report required) No.of windows Doors ❑ DEMOLITION (specify): Location of debris removal(per MGL C.40 Sec 54): ❑ Dumpster on site 0 Dumpster On Street Facility Name: Location: 'If new construction, please complete the following: Single Family: No. of Bedrooms No. of Baths Two Family: No of Bedrooms Unit 1 No. of Baths Unit 1 No of Bedrooms Unit 2 No. of Baths Unit 2 ❑Furnace(hot air)-fuel gas(natural or propane), fuel cil, electricity,other(specify): ❑Boiler(heating)-fuel gas(natural or propane),fuel oil,electricity,other(specify): ❑ HVAC(combined unit)-primary fuel,natural gas,propane, electricity,other(specify): ❑Air conditioning-(separate unit) ❑None of the abor + d 0 Hot Water: G - , — - - Electric Fuel Oil Other ' - SECTION 6=ESTIMATED CONSTRUCTION COST:. Item Estimated Cost($)to be completed by permit applicant 1. Building y n 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Total = (1 +2 + 3 +4) 9 `f 0 --- '4ECTI01:4•7A' OWNER AUT 4ORIZATION (to be completed When owner's agen(or gonfractor applies for building permit) (Please Print) , as Owner of the subject property hereby authorize to act on my behalf, in all matters relatJ to work aut rized by this building permit application. Signature of Owner Date • SECTIONTB-OWNER/AUTNORIZEQAGENTDECLARATION I. 2 ria�t /.vt./ � n , as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and enalties or perjury 1/— - f@ Signature of Owner/Authorized Agent Date SECTION 8-OFFICEANSPECTOR'S:H9TE$ ':' / Less Application Fee: {{417 Remaining Balancer Total Permit Fee:$ /. Other$ Amount$ Gross Area- New Construction total sq. ft. Gross Area-Alteration tota sq.ft. y� _ �� /) �✓ Permit Issued to: �pQ�/ �� �-'C� /4 Sa // ( i) re/0/4 ce,rrenf del or no S-KUC 4U ret f __ 1 Permit No. BP-91961 a Project Location: 2 SHINGLE ISLAND LN Commonwe a ttl .. +r r,� sachusetts TO 0'dqi r ` i4UTH Y op , 4 tv .frr J P4 Contra. r ® e:• : ':one#: BRIAN"1 .: • SON , . 707 � 1)228-9800 �,.' Architect:. �o .r Phone#: Applicant a®oa g®'- Phone#: SOUTHERN i `..G A.1j rj OS { (401)228-9800 OWNER: 4a * ae®ea®s®esssaasa� � WILKINSON HERB f DATE ISSUED: ir / TO PERFORM THE FOLLOWING WORK: Installation of one patio replacement door; SAME SIZE, SAME OPENING DATE TIME TYPE OF INSPECTION&REMARKS R,JN te��newal Agreement Document and Payment Terms bdersen' dba:Renewal ByAndersen of Southern New England gl Patricia Tavares&Bert Wilkinson 7•7;H Legal Name:Southern New England Windows,LLC 2 Shingle Island Ln. RI#36079, MA#173245,CT#0634555, Lead Firm#1237 North Dartmouth,MA 02747 WINDOW NE IACENIENT 10 Reservoir Rd I Smithfield,RI 02917 H:(508)998-9084 Phone:866-563-2235 I Fax:401-633-6602 I sales®renewalsne.com C:(508)353-8812 Buyer(s) Name: Patricia Tavares & Bert Wilkinson Contract Date: 03/18/19 Buyer(s)Street Address: 2 Shingle Island Ln., North Dartmouth, MA 02747 Primary Telephone Number: (508)998-9084 Secondary Telephone Number: (508)353-8812 Primary Email: pattslp@comcast.net Secondary Email: Buyer(s)hereby jointly and severally agrees to purchase the products and/or services of Southern New England Windows,LLC d/b/a Renewal By Andersen of Southern New England("Contractor"),in accordance with the terms and conditions described in this Agreement Document and Payment Terms, any documents listed in the Table of Contents,and any other document attached to this Agreement Document, the terms of which are all agreed to by the parties and incorporated herein by reference(collectively, this"Agreement"). Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. Total Job Amount: $4,940 By signing this Agreement,you acknowledge that the Balance Due,and the Amount Financed must be made by personal check,bank check,credit card,or cash. Deposit Received: $2,470 Balance Due: $2,470 Estimated Start: Estimated Completion: Amount Financed: $4,940 6-8 weeks 6-8 weeks Method of Payment: Financing We schedule installations based on the date of the signed contract and secondarily on the date in which we complete the technical measurements.The installation date that we are providing at this time is only an estimate.We will communicate an official date and time at a later date. Rain and extreme weather are the most common causes for delay. Notes: 50% deposit-GREEN SKY; 50% balance due upon completion-GREEN SKY Buyer(s)agrees and understands that this Agreement constitutes the entire understandings between the parties and that there are no verbal understandings changing or modifying any of the terms of this Agreement. No alterations to or deviations from this Agreement will be valid without the signed,written consent of both the Buyer(s) and Contractor. Buyer(s) hereby acknowledges that Buyer(s) I)has read this Agreement, understands the terms of this Agreement,and has received a completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first written above and 2)was orally informed of Buyer's right to cancel this Agreement. NOTICE TO BUYER: Do not sign this contract if blank.You are entitled to a copy of the contract at the time you sign. YOU,THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME NOT LATER THAN MIDNIGHT OF 03/21/2019 OR THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION, WHICHEVER DATE IS LATER.SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. Legal Name:Southern New England Windows,LLC - dba:Renewal By Andersen of Southern New England Buyer(s) C'- — r B � Signature of Sales Person Signature Signature Chris Hutson Patricia Tavares Bert Wilkinson Print Name of Sales Person Print Name Print Name UPDATED: 03/18/19 Page 2 / 11 7( ,J///.2,«{22//ie//J Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston. Massachusetts 02118 HDme Improvement Contractor Registration Type: Supplement Card Registration: 173245 SOUTHERN NEW ENGLAND WINDOWS. LLC Expiration: 0 9/1 81202 0 10 RESERVOIR ROAD SMITHFIELD, RI 02917 Update Address and Return Card. Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Supplement Card before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Reouation 17324-5 09/18/2020 1000 Washington Street-Suite 710 SOUTHERN NEW ENGLAND WINDOWS. LLC Boston,MA 0211/3--N \BRIAN DENNISON Nii C=3; -- � ��,, \ 10 RESERVOIR ROAD _.� SMITHFIELD. RI 02917 mu• au without signature Undersecretary Oo -zn Pr"ith, of Massachusetts ',� ✓vision. of Prciess'cnai Licansura Board of Building Regul!a ions and Standards Construction Supervisor CS-095707 Expires : 09/08/2020 si a s BRIAN 0 DENNISON ;x 8 BLACKWELL-DRIVE. 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Cr‘ t.AF 4a N A p. - e a N a (" na o� 'o (A o 4 433 it, a WOm AO i la c3:31 4 A J OA-1laN F A -1 GO0 0 a *"Fi44 11 O . r ONi Ncoy O iE+ 3 X El n to �a Al N '-‘ 0 0 O A a) O ' 0 2 c 313 7• 331 3-3 O ' O o Lo 7 O if O. to q _ b l7 ^ a m CA 0 5 o w o A 0 W O O DElP V EF LA 2 6 The Conunottwealth of Massachusetts P. - Department oflndustrialAccidents f :144. 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.nurss.gov/dia Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNIICrING AUTHORITY. Applicant Information + f Please Print Legibly Name(Business/Oranimtion/[ndividuat): SO/Alb e t _ lie 1 J t03/Of)" � -S J6) i n cinw Address: uOt r g.� - �) City/State/Zip:3 m rfrivge(ct/?- ( Oz9 /7 Phone#: 40/- 2-2••Sr- 98-0v Are y an employer?Check the appropriate box: -��t. Type of project(required): 1. t am aemptoyer with 20'L ompfoyecs(full and/or pan-time).' 7. 0 New construction 2.01am a sole proprietor or partnership and have no employees working for me in 8: ❑ Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself(No workers'comp.insurance required.]' 9. ❑Demolition I am a homeowner and will be hiring contractors to conduct all work an ray10 O Building addition 4. ❑ property. I will ensure that all contractors either have workers'compensation insurance or are sole 1 l.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions i❑[am ageneral contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance.: [3.❑Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[✓'OOther Pa-f O 6 0 U 1 152,§1(4),and we have no employees.[No workers'comp.insurance required.] rep/4 t P�E _ r 'Any applicant that checks box eel must also fill out the section below showing their workers'compensation policy information c-f' 1 • t Homeowners who submit this affidavit indicating they am 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. �� 'r /� ',r Insurance Company Name: Tl remens /f7$L(.IQAPN a, . o y A 1), tC- Policy#or Self-ins.Lic.#: we /A 3 lc $ 7//2- 2- U • Expiration Date: /- /—2 D 2..0 Job Site Address: Z Sti;i1(�2 TT(G�tc( ��, City/State/Zip: Attach a copy of the workers'comJpensation 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 imprjsatment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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 sera under the pai d penalties of petjury that the information provided above is true and correct Signature: '.... r . Date: W- 3— / q Phone#: IQ '--7.7- - 7n Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: —�—Th ACORD� CERTIFICATE OF LIABILITY INSURANCE OATE(MMDOVYYY) 12/28/2018 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 be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT CoBiz Insurance, Inc.- CO NAME: 1401 Lawrence St., Ste. 1200 AC.No Eat): 303-98&0446 INC,Not:303-988-0804 Denver CO 80202 E-MAILDsS: COMail©cobizinsurance.com INSURER(S)AFFORDING COVERAGE NAIL k INSURER A:Acadia Insurance Company 31325 INSURED ESLERCO-01 INSURER B: Firemens Insurance Company of WA,D.C. 21784 Southern New England Windows, LLC. dba Renewal by Andersen of Southern New England INSURER C: Homeland Insurance Company of New York 34452 10 Reservior Rd INSURER O: Smithfield RI 02917 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:787175890 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 TYPE OF INSURANCE AODL SUER POLICY EFF POLICY EXP LW TYPE NW• POLICY NUMBER (MMIOO/YYYYI (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY 1 CPA315B728 1 111/2019 i/1/2020 EACH OCCURRENCE $1,00190)0 DAMAGE 10 D CLAIMS-MADE X OCCUR PREMISES Ea occu occurrence) $300,000 MED EXP(Any one person) $10,000 PERSONAL 8 ADV INJURY $1,000.000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY i I —i E T LOCI PRODUCTS-COMPIOP AGG $2,000,000 ' I OTHER: $ I A AUTOMOBILELIABILITY 0PA3158728 1/1/2019 I 1/1I2020 COMBINED SINGLE LIMIT I I (Ea accident) ' S 1 000 000 X ANY AUTO I BODILY INJURY(Per person) $ ALL OWNED —] SCHEDULED - _ AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS (Per accident) $ . $ A X UMBRELLA LIAB XCPA3158728 _ OCCUR 1/1/2019 1/1/2020 EACH OCCURRENCE $15.000A00 EXCESS LIAR CLAIMS-MADE AGGREGATE $15.00D,000 DED X RETENTIONS 9 WORKERS COMPENSATION _ $ 'NCA3158]2924 111I2019 1/1/2020 AND EMPLOYERS LIABILITY YIN X STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE 81.003.000 If yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 C Pollution Lability 7930073340000 1/1/2019 1/1,2020 Each Occurrence 52,000,000 Claims-Made Policy Aggregate $2,000.000 Retroactive Date 06/20/2013 Deductible $25,000 DESCRIPTION OF OPERATIONS/LOCATIONS I 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. FOR INFORMATIONAL PURPOSES ONLY AUTHORIZED REPRESENTATIVE Alt — ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD