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HomeMy WebLinkAboutBLD-18-4284Date: Pursuant to 780 CMR 109.2 'The building official is authorized to accept reports of approved agencies, provided such agencies satisfy the requirements as to qualifications and reliability". This affidavit is to-certifv that all,wgrk WMpJq Wd at: Village: ' has bee nspected by a certified Building Performance Institute (BPI) Inspector. All work performed meets or exceeds federal and state requirements. The work conforms to 780 CMR, 811 Edition, and 1 do hereby certify under the pains and penalties of perjury that the information provided is true and correct. 780 CMR R109.1.5 "the Building Official may... require any other inspections to ascertain compliance..." Permit application n er,;hd Issue date: 3 Sincerely, Francis Sheehan President Frontier Energy Solutions, Inc. 502 Harwich Road Brewster, MA 02631 Office: 774-237-0410 Email: fssfrontierenergy@gmail.com RECEIVED JUL 27 2018 BUILDING DEPARTMENT Permit # 2,r�p a z 3/_ C tFxS_ I :Permit expires 6 months from 0 IH �' Mwii n twv�'T 51smedam. - EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH `. �' V Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 J6fl6U ZOO (508) 398-2231 Ext. 1261 1 LI ^' ^� BUILDING DEPARTMENT CONSTRUCTION ADDRESS: t� NY oy ASSESSOR'S INFORMATION: Map: IParcel: "CONTRACTOR ..A.ME ILLN MA6 L 6'Rcsidential ❑ Commercial ❑ EsL Cost of Construction) Home Improvement Contractor Lie. # Construction Supervisor Lie. # 71�(?WWv Workman's Compensation surutce Ir: (check one) D lam the homeowner / D I . m to sole�pt error ave Worker's Compensati�3'�•�� 7a� Insurance Company Name: {� ' v Worker's Comp. Policy# WORK TO BE PERFO&1tED D Tert (Fire Retardant Ceni5cam attached) 0Wood Stove Sbed D Siding: # of Square ❑ Replacement windows: # ❑ Replacement doors: # ' ,, ❑ Pe roof: # of Squares alms- t. *The debris will be O Stripping old shingles- O going over layers of existing roof ❑ Old Kings Highway/Historic District I declare under pamaltie 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 revocation of my license and for prosecution under M.O.L. Ch. 268. Section 1. Applicant's Signature. Data tar Owners Signature (or attachment) _ Date: Approved By: Date: Building Official (or designee) Zoning District: Historical District: ❑ Yes 0 No Flood Plain Zone: D Yes ❑ No Water Resource Protection District. Within 100 ft. of Wetlands: ❑ Yes ❑ No ❑ Yes ❑ • No 3101 I s � mass save mass entrtWV*fi W"VV Project ID:3319531 Permit Authorization Form Customer: SHAW owner of the property located at: (Owner's Name, printed) 51 Winter Street Yarmouthport, MA 02675 (Property Street Address) (Clty) t'N terror/ej PAR CIPAnna CONTRACTOR hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. Owner's Signature: az/�— Date: *600*90000e &ea Wets ease +k aU*000064MV6000M4 *00 FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date Name: RISE Engineering Phone: 401-784-3700 Email: For Once Use Only Rev. 102015 The Commonwealth of Massachusetts V�Worlrers'Corxnperutation Department ofIndustrialAccidents I Congress Street, Suite 100 Boston, AIA 02114-2017 tvtvw,rnass.gov/din Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PER.4trrrlNG AUTHORITY. Name Address: Wl- 4(,- rtArit,L. M City/State/Zip: Kra GJ Sfip/ MA C2.6 Phone i#; 7 7 `i = 'G S /' C7 L{1 Q Are you •o ..player? Check the appropriale bort ' © Type of project (required): l [3/1ama employer with employcestfull end'or part -lime).' 7. Q New construction 2.❑ 1 am a sole proprietor or partnership and have no employees working lox me in $, a Remodeling any capacity. tNo workers' comp, insurance required 1 9. ❑Demolition ).a l am a homeowner doing all work myself. [No workers camp, insurance required J. A 2 am a homeowner and will be hmn comracmre to conduct all work on menY, i will A Y 10� Building addition ensure that all contractors either Rave workers' compensation Insurance d've sole re l I ❑ Electrical repairs or BQdlhonS proprietors with an employes. 12,E] Plumbing repairs or additions S.Q 1 am a general contractor and I have hired the sub -contractors lived on the attached shwt These have t 3 QRanf repairs subinntsactors employees and have aw kers' camp. ituurarstt? 14, 6❑We art a corporation and its oMeers have esertised their right ofexemption per.MLe. the. 152, 11(4). and we have no employees. (No workers' comp. insurance required:) 'Arty applicant that checks box 41 muss ala 611 out the section below showing their workeri compensation policy information, r Homeowners who submit this aCldaut indicating they are doing all work and then hire outside eanrracton must submit a new arYdovii indicating unh. tContractos that check this box must attached an additional sheet showing the name of the suacontnctm and state whether or not those entities have employes. If the subcontractors have employees, they must provide their woken camp. policy mantem 1 am an employer that it providing workers' compensation insurance far my employees. Below is flee policy and joh site information Insurance Company Policy N or Self -ins. Lic. N:ywl.' (cJ- moi 531 Expiration Dater/ a01rs (f��J Job Site Address: Wl1 '�? I CirylSM,�expiratfion t •4Attach a copy of the workers' compensation policy declaration page (showing the po ' y nu Failure to secure coverage as required under MGL e. 152, §25A is a criminal violation punishable by a fine up to 51,500.00 and/or one-year imprisonment, as well as civil penalties in the font of a STOP WORK ORDER and a fine of up to 5250 00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of dhe DIA for insurance coverage verification, certify under Phone N: '774- 2.3i7 - GLf l d. I 1 a Ojricfal use only. Do not write in this erect, to be completed by city or town offlelal City or Town: Permit/License N Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CiryfTown Clerk 4. Eleetrteal Inspector 5. Plumbing Inspector 6. Other Contact Person: - Phone N: )) l '7/IC ihAflK<+ItKVYtlf!/1�"i(l(Au//<"�I!-i/.'�l5 Office of Consumer Affairs S Business Regulation ryI„.�h HOME IMPROVEMENT CONTRACTOR ? tr. Registration '16mI Type: Expiration 9/8/2018 LLC FRONTIER ENERGY SOLUTIONS';' FRANCIS SHEEHAN _ 502 HARWICH RD— BREWSTER, MA 02631 `" Undersecretary Construction Supervisor Specialty Restricted to: CSSL-IC- Insulation Contractor Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. DPS Licensing information visit: WWW.MASS.GOV/DPS License or registration valid for individual use only before the expiration date. if found return to: Office of Consumer Affairs and Business_ Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 N t val ithou ignature (v - Massachusetts Department of Public Safety V - Board of Budding Regulations and Standards License: CSSL-105941 Construction Supervisor Specialty FRANCIS S SHEEHAN 602 HARWICH RD `-' BREWSTER MA 02631"x' —' Expiration:. Commissioner 02/77/2018 ACORO® DATE (MMrDDIYYYY) ACi CERTIFICATE OF LIABILITY INSURANCE 03/1s/zo17 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 NAME• RO ers and Gra Processing ROGERS & GRAY INSURANCE AGENCY INC AICC No•ETA TaD: (508)398.7980 AJ Ne: 434 ROUTE 134 SOUTH DENNIS MA 02660 INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS INSURERS) AFFORDING COVERAGE NAIL R INSURER A: AIM MUTUAL INS CO 33758 INSURED FRONTIER ENERGY SOLUTIONS INC 502 HARWICH ROAD BREWSTER MA 02631 INSURER B: AUTHORIZED REPRESENTATIVE INSURER e: POLICY EFF MMIDONYYY) INSURER 0: LIMITS INSURER E: COMMERCIAL GENERAL LIABILITY INSURER F: r.nVF RArAFA CFRTIFICATF NIIMRFR- 11dA75 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 TR TYPE OF INSURANCE ADDLSUBR AUTHORIZED REPRESENTATIVE POLICYNUMBEq POLICY EFF MMIDONYYY) POLICY EXP (MM1DD"yY1 LIMITS C. Daniel M. Croy, CPCU, Vice President —Residual Market— WCRIBMA COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE f CWMS-MADE OCCUR N PREMISES Ea occunence S MED EXP JAry ane person) f PERSONAL d ADV INJURY $ NIA GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE f POLICY PRI LOC PRODUCTS •COMPIOP AGO S S OTHER: AUTOMOBILELUIBILITY OMBINED SINGLE LIMIT f BODILY INJURY (Per person) f ANVAUTO - BODILY INJURY (Par accident) S ALL OWNED SCHEDULED AUTOS N/A PROPERTY DAMAGE S Per acddanl NON -OWNED HIRED AUTO AUTOS f UA LAS OCCUR EACHOCCURRENCE $ AGGREGATE f EXCESS LIAB CLAIMS -MADE N/A DEO I I RETENTION f A WORNERSCOMPENSATION AND EMPLOYERS•LIASIUTY YIN OF EXCLUDED? ECUTIVE N/A (Mandatary, In NH) WA NIA VWC10060153152017A 03/14/2017 03/14/2018 X STATUTE ERµ E.L. EACH acaDENT f 1,000,000 E.L. DISEASE -EA EMPLOYEE f 1,000,000 E.L. DISEASE - POLICY LIMIT 1 $ 1,000,000 ffr describe uncia, DESCRIPTION OF OPERATONS bebw N/A DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached It more spats is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of Insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage - Coverage Verification Search tool at www.mass.gov/twd/workers-compensationAnvestigationst. CERTIFICATE HOLDER CANCELLATION O 1988.2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WALL BE DELIVERED IN Frontier Energy Solutions Inc. ACCORDANCE WITH THE POLICY PROVISIONS. 502 Harwich Road AUTHORIZED REPRESENTATIVE Brewster MA 02631 C. Daniel M. Croy, CPCU, Vice President —Residual Market— WCRIBMA O 1988.2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD