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HomeMy WebLinkAboutBLD-19-001692 li 17111 �r� iS� _�` It !'Fce$ a. 3s0� s.y, rH Permit ezpues 6 months fro-n "tip ='?344. I%issue date. sem . EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department ' . 1146 Route 23 RECEIVED South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 SEp 20 2018 C6CZ /-fit CONSTRUCTION ADDRESS:- 2Z1 Pd/0.11 IT / Ta -,-1..,-.1_ 4 ASSESSOR'S INFORMATION: I Map: 3(4 I Parcel:. J c . e t 1 OWNER J�'."� : _ ■ 1� �' r� ..- l •` NAME PRESENT ADDR'SS TEL. # CONTRACTO:• to _ _ _ :►3 I. 0_ al . :hi . /! am NAY E MAIL NG ADD' oS 9/ % a r31 - r r "1" i esidentia1 0 Commercial C Est.Cost of Construction$ a SOD Home Improvement Contractor Lic.e 1laCCIRS-CI Construction Supervisor Lic.# , oSgLJ I Workman's Compensation Insurance: (check one) 0 I em the homeowner 0 I am .e oleproprietor / ave W'orkei s Compensation Insurance ) Insurance Company Nam ;al (,rf/�Y( '/ �a T. (► % 'ter'sComp.Policu�00`�o01S3)C� )1 WORK TO BE PERFORMED 0 Tent (Fire Retardant Certificate attachod) C Wood Stove Shed D Siding: te of Squares D Replacement windows:N 0 Replacement doors: is ❑Re-roof il of Squares 0 uon ()Stripping old shingles,* Q�f�[[ ()going ova layers of`eexxtt/stttiag doff ���0 //Oll/d(Kr/inngs�H�igghhhwaayy//Hiistoric District Roo� 'vCSL/ ////�r/f/�i..{r�'J-�_ f '1LSS-Y'"`--e+SY-'' SSS-/' iS'a.'�.`r.-'f� *The debris will be disposed of at: t�,,,1(�(Xf'/t' _. cation of Fact rty�� I declare under penalties of perjury that the srato:nens herein contained art true and corrst to the best of my Imowiedge and belief. I understand that any false answer(s) will be just cause for denial or revocation of my lie e d for prosecunon under M.O.L Ch.268,Section 1. Applicant's Signature; Date: "1fit! - Owners Signature(or attachment) „ �P as/_ .ne. :`I Date: ys 9�y �y _ _ Approved By: % HOME OWNER WEATHERIZATION WORK PERMIT: PLEASE COMPLETE AND SIGN THIS FORM AS THE APPLICANT HOMEOWNER. I A ASAQ<1". hereby consent to and agree that weatherization work may be done by the Weatherization Pr_ogram of Housing Assistance Corporation on the property • located a t'e 2v r CJ1�� ��CJ l.�S) iu i The weatherization work done will be based on programmatic priorities and availability of funding and it may include all or some of the following measures: Weather stripping; air sealing; attic & basement insulation; exterior wall insulation; ventilation measures In consideration of the weatherization work to be done at my home I agree to the following: 1. I give permission to Housing Assistance Corporation to access the property with such equipment and materials as may be necessary to perform weatherization. 2. The Housing Assistance Corporation reserves the right to inspect the fuel or utility bill for the weatherized unit on an ongoing basis for no more than five (5) years after the weatherization work is completed. I have read the provisions of this agreement and give my consent. Home Owner(signature) Home Owner email: Date: ( tCq LV Agent(algnature) Date: Agency Approved Weatherization Company All Cape Energy Alternative Weatherization Cape Cod Insulation Cape Save Cazeault Frontier Energy Solutions Lohr Home Improvement Agency Signatur;I—Ska( 12 L L Gk Date: For Natural Gas Customers: I have received the National Grid Discount Rate Application form from my auditor. Customer Initials • • • S.:\ The Commonwealth of Massachusetts (� Department alIndu.strial Accidents killit—...' 1 Congress Street,Suite 100 . a-= Boshm,'A1,102114-2017 norlv.mu)s.gov/lite Workers' Compensation I nsonince Allideuu fluilders/CnntnlctorstElcctricians/Plumbers. 10 RI I•11 1 D\\1111 1111.pf.Rs111"1ING AV1110R1 t1. 1 Applicant Information _ Please Print Legibly ray Name(flusmess'Organaationdodtvtdua0eQ., : �}-yI _ ,.(1L C?�.l2i101ae..)LC_ ,.__ — __ � Address:_ rf 1t,�) Cf � t - ,_.�.__ __.—_../J ____._.-----___.___. City/State/Ziprl aLt std-J-tf1 CO Phone#7'ju_-x377 G-E I.LT ___— - Are sou an employer?('neck tthee sppi update hos• Fs pe of project(required) IE in -�,n a employer with __employees d full wd in yinl 'noel" 7 0 New construction 20 I wo a sole pmpncooror pnrmeiship and have on employees wo king for in 8. ❑Remodeling one caving INA wolkets'comp insurance leg Oiled f 9. ❑Demolition 3 01 am a homeowner doing all wick myself INo workers•coop m,.trence required I' 10 0 Building addition 40 I am a bantamnet and will ther hay 4:armaIa c to conduct all work on my N opedy Iwill ensure ilio oil mnnmMnn either have wurkrl a'compumats-m retie or are aUe II.El I leekteal repairs or additions proprietors with no employee, I_ ❑Plumbing repnli's or addition, 5 0I am a aener:demu a-tut end!.,1..,1.L tic I IW u I, r„ t a h ,ii 111. han.hcd.don l , , I :J Root eoa.,, . 'hese sonnnlmcnors have cmplo)re•,mt.i i., ", y.,- I I',,,,.I,u ' ,�,l 14 Zook ILa-t'r talczWUN.) (:0 lye arc a:onxnmant and as officers have coins ncd nLcu code til uehnpLou txn MGL v' 152,$1(41..inn we have no employees Ni,waiters'comp mss i.irrv.eicqu'I •Any applicant that cheeks Iron PI must also till out the socuun holo, sha,nog then workers'compensation policy ultimata 'Homeowners who submit hats affidavit indicating they pre deny all wok and then biro outside contractors must sabot a yew ar idanit indicating,ate h c amraelnrs that check dila box must attached an additional shad show my the uaue of the sub-contractors And Mane wheihm or Mn thew comics have employees If the sub-contractors have employees.they meq ramie Oleo ivake,i comp policy number I ant an employer that is providing worA vis'compensation irnarurrt't'fur sett employees. Below in the policy and job sift information, (� 1 t l �-r .,` p /� Irsurance Company Name' l!-I_EkS t �. 4`•.,. ..a s--id-.QQ,�. Cohn Pft.�+L�____ __— PolicydorSelf-ins.Lie.At�LJC"fGC�.-�`uIS-81St .[d Expiration Date: -.' /'I9 1q.__ ___ lob Site Address'tocc (b urz ipa get—-- - --City/State%'/.tP 7 O( fri 000 Attach a copy of the workers'compencat on policy declaration page(showing the policy num r and expiration date). ''�� r /( ' Failure to secure coverage as required under MGI.c 152,F2IA is a criminal violation punishable by a fine up to 51,500.00 ( tp 10`•') .mil or ore-year imprisonment,as ssell as el vii perm i cv in the limn ora STOP WORK 01401 14 and:.fine el up to'625000 a day against the violator.A copy of this a:animr'd mat 4.4. lois,aided to the 011ice til Ins noacbitons of the DIA W: insui ance cescrage verification I do hereby cc rify under Ola ai •and penalties of perjury that the information provided above //s true aid n) yet. tiign afore,_,. /�-'v�t -�_/-�--- - Datc• 9�!_ [/ ------- Phope t _77gd 7— e•'�`i/_LJ_-'-- - -_ ------ —__ — ."-'-- Offcial nee only. Da not write in this urea. to he completed by rite'cit town official (1n or Town: __ _ __ __ _- -. _. Pei nun license h_ ____ _ -_ --____. _.__- ___ Issuing kuthnrity(circle one): I. Board of Ilealth 2.Building Department 3.Cit)/owa Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: __ Phone k: - _____ • • • Construttton Supervisor Specialty tt -mmnnv Nlln Vl'rlaflaLnV 3lI13 Rmtnete010' • Sm man of prJ'e544NI Ctenswe CSSL S•IMu'anon Commit-tor Beard o'Bann,"Re 3ulalron3 and Scanner°, a ,]n. penrSo'O:roC.a'. d_ CSSL.10E5a' !spires Gail-d]20 +, FRANCIS S SHEENAN S0IHARWICH RA BREWSTER MA 01611 t Failure to possess a current edAlon of the Massachusetts State Bunking Com is cause for revocation or mn wense For information about fhisinnse Gap id for 727420ti a vise idpl Commissionc' .4�i rnmrmroNrw'/2 r/. Xr,.u..r .ir/LI - 1 Office of Consumer Affairs 8 Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corporation before the expiration date. 11 found return to: Registration Fxoiratiorl Office of Consumer Affairs and Business Regulation 11 160864 09/07/2020 1000 Washington Street-Suite 710 FRONTIER ENERGY SOLUTIONS Boston,MA 02118 • FRANCIS SHEEHAN 302 HARWICH RD BREWSTER,MA 02631 Undersecretary Not valisignature - I - b ACS® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNYTY) 04/3012018 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 CONTNAMEACT Rogers and Gray Processing ROGERS& GRAY INSURANCE AGENCY INC PHONE .Eaq 506)398-7980___ -------- FAX mro ersra om ADDRESS, all @ g g rc 434 ROUTE 134 _____ INSURER(S)AFFORDING COVERAGE _ I NAIC!_ _SOUTH DE_N_NIS .__ _ M A 02660_ INSURER A_AIM MUTUAL INSCO C I 33758_ INSURED INSURER B: FRONTIER ENERGY SOLUTIONS INC INSURER C: _ ___________ _____..__ INSURER 0: 502 HARWICH ROAD INSURER E• BREWSTER MA 02631 INSURER F: I 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 ' INSR TYPE OF INSURANCE IADDL SUER �OLICYEFF POLICY EXP LIMITS LTR 11NSD wvD I POLICY NUMBER (MMIDDn'1'YY) iPOLICY'YYYI LCOMMERCIAL GENERAL LIABILITY _EACH OCCURRENCE I$41 _ i OAMAGETORENFEO - CLAIMS-MADE OCCUR DAMAGE((ny occurrence) E MED EXP(Any one person) f N/A PERSONALE ADV INJURY J s LGEN'L AGGREGATE LIMIT APPLIES PER: it GENERAL AGGREGATE_I f____ I-1 POLICY C 1 JE T L_1 LOC I PRODUCTS•COMPIOPAGG t!_ O• THER , 1 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ _(Ea apFLent) ANY AUTO BODILY INJURY(Per person) $ — -- A• LL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per sodden) $ - --------- - NON-OWNED PROPERTY DAMAGE y ' HIRED AUTOS AUTOS Ler accident)_ UMBRELLA `_OCCUR I (EACH OCCURRENCE ;S - EXCESSTLITAB__ _C_LAI_MS_MADE N/A [AGGREGATE_ _ _ I$___ -- WORKERS I I RETENTION f • I�/ f ' WORKERS COMPENSATION X1PEATUTE_j I ERµ__ _ AND EMPLOYERS'LIABILITY YIN ANYPROPRIETOR/PARTNER/EXECUTIVE _E L.EACH ACCIDENT $ 1,000,000 A OFFICERMEMB REXCLUDEDT I� N/A NIA VWC10060153152018A 03/14/2018 03/14/2019 (Mandatory In NH) EL DISEASE-LA EMPLOYEE $ 1,000,000 I/yes.describe under DESCRIPTION OF OPERATIONS below E L DISEASE•POLICY LIMIT $ 1,000,000 N/A I DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD lel.Additional Remarks Schedule,may be attached II more apace 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/Iwd/workers-compensatIonf'nvestigabonsh ' CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Frontier Energy Solutions Inc ACCORDANCE WITH THE POLICY PROVISIONS. 139 Queen Anne Rd Unit 6 AUTHORIZED REPRESENTATIVE Harwich MA 02645 DaDanielniel M. SIX .Crivjey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD