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HomeMy WebLinkAboutBLD-19-001691 . seoY'y'gR °.+',". Permit# .. iigg �o SJ tl0Y '*I Pmm a F, r•• �. Permit ezpirs 6 months from i. �� �� Tissue date. , y;;, BU)— C1 —b0ICO9 EXPRESS BUILDING PERMIT APPLIC • ItteSt E I V E L TOWN OF YARMOUTH Yarmouth Building Department SEP 20 2018 • 1146 Route 28 South Yarmouth, MA 026641 I. . (508) 398-2231 Ext. 1261 BY 4 - - CONSTRUCTION ADDRESS: e1 r /_ �._ _ ASSESSOR'S INFORMATION: Map: q- I Parcel: q I OWNER: P,UJI 0Q O C�(�1 _ �—J t. NAME C PRESENT ADDRESS �p,� TEL. # 7 0 / '\, CONTRALTO �PP �P r. 0 /l� )�' 5.--27/-)37-04 / e� `' esidential 0 Commercial 0 Est.Cost of Construction S tit 400 Home improvement Contractor Lic.# Ii,00Construction Supervisor Lie.4 / IlDSU J Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor .orheve Worker's Compensation Lnsurance "" Insurance Company Name: N`i� \4011)“ Worker's Comp.Policy4JDOsCO b I S 31 Sail WORK TO BE PERFORMED o Tent (Fire Retardant Cert:Scate atmched) 0 Wood Stone Shed 0 Siding: #of Squares Replacement%dadem:# 0 Replacement doors: #__ 0 Re-roof #of Squares _ 0 tiers ()Stripping old shingles* ()going over layers of existing roof 0 Old Kings liighway/Historic District ��` ^,. . l 1 / �Roofing/Sidingg(Like /lfor (Like) `The debris will be disposed of at: 1 ZTl CZki� 1 +I AL�`-i r . �[L(n-4 Lacauon of Famlity I declare under penalties of perjury that the at erne is herein contained are nue and correct to the best of my knowledge and belief. (understand that any false atsswet(s) will be just cause for denial or revocation o .ay . • ' ar prosecution under MQ L Ch.268,Section 1. Applicant's Signature: ^b � Data 9fr9lil t e Ownen Signature(or attachment) OP / _• a Date: 9 Approved By: - Date: / � -odd;�ftcial(or designee) ff' Zoning District:____,___.� Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes O No ❑ Yes ❑- No ,. 3/01 DocuSign Envelope ID:D8D25A17-9293-426A-BFEA•3543A4034E88 Cape tight Compact 5 Dupont Avenue South Yarmouth, MA 02664 -r,,, II �,j F OWNER AUTHORIZATION FORM 1, IRWIN BRENZEL (Owner's Name) owner of the property located at: 27 Sisters Circle (Street) Yarmouthport, MA 02675 (Town, State,Zip) hereby authorize , (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. This form is only valid with a signed contract. The Permit will be secured by the insulation contractor, at no additional cost. It is the homeowner's responsibility to close out this permit by contacting their municipality at the completion of this work. 1—DocuSiyned by kat enVi511 �':Ci9'ilEP reTtrgnature 5/12/2018 19:13 AM EDT -Sign Date 05/09/2018 �_ ` The Commonwealth of Massachusetts -'- 1 Department oflndustrial Accidents t4 I =A 1 Congress Street,Suite 700 = • -- Boston, 41.102114-2017 V.se nth n.ruass./;ov/dim \1'url.ers'Compensation Inset ranee Alfidas it. Builders'Cnntrac••tors/ElectriciansiFlumbers. ' Ic)RI FII l It\atilt IIII l'F 11311111NC ACf IIOft1I\, / Applicant I nforntationPlease Print Legibl\ -s� rr-yy)) ,gip s Name([Icslncss'i)rgamzanunrindlvidusl):�e.(�j.,JiTttr,=,t.._��,_.�s..trl-� Siot./604 S..JL.ti.e:..._.__._._ Address: +{�� f,� N C _ _`—____._.___.._ ____ C i tr'S tateizipel tE.L'C)63( Phone#_7.I(L.:.aS7__CX-4,1..0._..._-- Are sou an employer?Chock 11the appropriate hoc T)pe of project(required) _ I Ain a employer w it _,`�._,.employers t All nu,di p,nu n ru 7 L]New construction 2EIIa•na tole pmprmnr nr pamsenM1 psoul have no employed,an dna for mem R. ❑ Remodeling any rapamq (No s ukerri rump insurance Intoned; - -� 9. ❑Demolition 3 J I am a homeowner clomp all work myself N a norkeri torp 'n..rnuue required j' 10[]Building addition 4 I amNuncio, and will be biting tors to conduct all work on my monody Iwill ensureeworker that an contractors either hove workers'compensation lasagne or resole 11.0 Electrical repairs or adthtions plopnmma%ah no employees. 12.[]Plumbing repairs or additions S O l ant a genmai amNaUm and(have hoed the si.t. tit,.it ti•h u, in Phu mottled,lira 13 Li Roo 1't'pmlt •he.e,eYtimn?r'au have employer;am-I I..,,I .Or• ..•,•1 ' t:.'::: y� ,,,��ss itl ., A 14 j� du.iLr`ltifl}(lW�1 1 C:u we a re a,uroomun t and as officer,.hos a etc',std dtri �-I t,itnpe,e CJ Meet t J[- _ Is:.SIM Alin we nave no employers '`d..vd!`heiV X Ilii rmu.eyuntd j L !_ 'Any apply net doss checks box al must also till inn the mutton hetod shoo olp then workers'compensation policy int flu 1 Flnmcmvnes alio submit Ills affidavit indmanng they all;douuw all work and then hire outside contractors must subinu a rev/afridavt indicating mull :Contractors that check dos boa must attached an additional sheet showing the came of the suh.convartorn and state w hcrha or mit those cauucs have • employees. If the subcontractors have employees•they must provide cher workers'comp policy number /um an employer that is providing workers'conrprncotton insurance for my employers. Below is the policy and job site information. ) �\ (� `, Insurance Company Name. (Ft k- orri41,,,T> ...e fiOQ. G VI pfr..).,),.1.______..__ Polis d or Self-ins.Lie,#40-,e,,,,-(00-(40)s81•s- UA R Ex iration Da:e: 3)f t-i 19 ___ Policy a P t Job See Address:,rte j3 s._ al� _ _ ..�—.__Cicy/Starr%/til ,}�,�/� /��^'' Attach a copy o Wei ['kers'compensation policy declaration page(showing the policy t tuber and exp rat n ate . �' ' ' ill"/ 1 Failure to secure coverage as required under MCiL.c 152,Sj25A Is a criminal violation punts table by a tine up to$1,500.00 and/or one-year imprisonment,as well as clod peralres in the Ilirm ala STOP WORK ORDER and a fine of up to 5250 00 a day ag,misl the violator.A copy of this suns-ins-it mat it, loss tided to the Ot lice of In escedtiuns of the DIA to: insurance coverage verification. _ — I do herrby certify under th tri kpn . __ __ d',rookie*of perjury that the irrfonncufion provided above 'ss true aid, erect. tiignaturr_.....,. nate: 17 ��1. ---- - - pllyratt. _l /.=L._a_.2n -- ----- --- -pp. - -- Official use only. Do not write in this area,to he completed hp ci0y or town official Issuing \uthonty(circle one): I. Board of Health 2. Building Department 3.Cacti own Clerk 4. Electrical Inspector S. Plumbing Inspector 6.Other_ _ --'-- Contact Person: _ _____ Phone k:__,_,_. Construction Supervisor Specialty • ® Connnnweenn el'Lassacnusens R's^'tted t.CIe' aph•sion of Professional CiCensuit Can •tnamatnn Contractor so in"e•Bnamnq Fequi+eonsanti$pnwrds - CSSL.13S941 Espnes 02:17-232: .i FR 502 HA S S WC}$REW1N • #+' Seg Rn BREWSTER MA 02531 �' Failure to possess a torrentedition aline MassaCnun sef 'ar State Banding Code is cause for revocation of ibis license. For information about this license Call Olt)72732200 or vise www.rnass.govfdpt Comrnissionea • Office of Consumer Affairs 8 Business Regulation f HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corporation before the expiration date. It found return to: Reoistratioq. . FE,eviration Office of Consumer Affairs and Business Regulation I j 160854 - 09/07/2020 1000 Washington Street-Suite 710 i i FRONTIER ENERGY SOLUTIONS Boston,MA 02118 I FRANCIS SHEEHAN 502HARWICH RD' BREWSTER,MA 02631 Undersecretary Not valisignature r A�o® CERTIFICATE OF LIABILITY INSURANCE DATE(MMJDD YYYY) 04/30/2018 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 NAME; Rogers and Gray Processing _ ROGERS& GRAY INSURANCE AGENCY INC PHONE a Ext (508)398.7980 I iaC Not _ E-MAIL mall ro ers ra com _ADDRESS: @ g 9 y' 434 ROUTE 134 INSURERtS�AFFORDING COVERAGE NATO N_ SOUTH DENNIS MA 02660 INSURER A: AIM MUTUAL INS CO __,_ 33758 INSURED INSURER B: FRONTIER ENERGY SOLUTIONS INC INSURER c' INSURER D. 502 HARWICH ROAD INSURER E; ________ _______ - ____ _.__-_____� __--_ BREWSTER MA 02631 INSURER F: COVERAGES CERTIFICATE NUMBER: 263414 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. INSBr —FADDLSUBR'- POLICY EEO-7-POLICY EXI T LTR I TYPE OF INSURANCE 'INSD WVn POLICY NUMBER IMM/DOIYYYYI:IMMIDD/VYYY) LIMITS l I COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE ,S "--' :--' -DAMAGE RENTED - 1 f_ J CLAIMS-MADE .__i OCCUR I PREMISES(Ea occurrence) $ MED EXP)Any one person) f__ N/A PERSONAL B ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER' GENERAL AGGREGATE E_ 6 1 LI POLICY 1-1 JEPROT n LOC PRODUCTS-COMP/OP AGG $ I OTHER $ AUTOMOBILEILITY COMBINED SINGLE LIMIT $ t LIABILITY (Ea eccltlanD_ _+__ ANY AUTO BODILY INJURY(Per person) I$ ALL OWNED r iI SCHEDULED AUTOS N/A BODILY INJURY(Per accident)I, $ NON-OWNED I PROPERTY DAMAGE '$ L_ ,1 AUTOS -(Per.accident)c.accident) I ERRED AUTOS I I I f . UMBRELLA LIAB I_ OCCUR I EACH OCCURRENCE $_ EXCESS LIAB 1 CLAIM$_MADE N/A AGGREGATE E DEO RETENTIONS $ ' [WORKERSCOMPENSATION XI STATUTE I ETH_ I AND EMPLOYERS'LIABILITYYIN -'- IANYPROPRIETORIPARTNER/EXECUTIVE E L.EACH ACCIDENT $ 1,000,000 A I OFFICER/MEMBER EXCLUDED', N/A N/A N/A VWC10060153152018A 03/1412018 03/14/2019 i(Mandatory in NH) I LEL DISEASE•EA EMPLOYEE $ 1,000,000__ If yes,describe under !DESCRIPTION OF OPERATIONS below 1 E L DISEASE-POLICY LIMIT I$ 1,000,000 II N/A I I� I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space 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/lwd/workers-compensationhnvestigations/. 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. Frontier Energy Solutions Inc 139 Queen Anne Rd Unit 6 AUTHORIZED REPRESENTATIVE r 4f Harwich MA 02645 +� I Daniel M.Crowley,CPCU,Vice President-Residual Market-WCRIBMA ©1988.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD