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HomeMy WebLinkAboutBLD-19-001520 s - •ar Of•Yq' ,P:rnit# �/ �1G :,Fee . .?\:, O y,, /i'' Permit expires 6 months from S.:C.:ni`a elV �1 issue date. �4•eut%�2 Bch-{q --to Asa 0 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 23 SEP 13 2018 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUIL• Pi� '.'•1n By: _ • kiss CONSTRUCTION ADDRESS' _ ULW ASSESSOR'S INFORMATION: i I Map: 3 I ParcD _J / ` r I OWNER: _ ■ .e� (� .. is r • , a _ . ta,s If lb NAME -'RESENT ADD' S - — - EL #• - -637 atM CONTRACTOR%•teat '. r f I,1 i ' Il. ..• • jLwI • ri1 ; - e MAILL • •DRESS rettgclential 3 Commercial � Z Est.Cost of Construction S Home Improvement Contractor Lie.ft Iw%S("4 - Construction Supervisor Lie.# / 5-9 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor ave W'orker's Compensation insurance Insurance Company Naim\ M_ k\k., AtAY-- Worker's Comp.Policy f ►ia e a _ WORK TO BE PERFORMED 0 Tent (Fire Retardant Certificate attached) C Wood Stove Shed 0 Siding: 0 of Squares 3 Replacement windows:C O Replacement doors: 0 ❑Re-roof: d of Squares Irtsu • ()Stripping old shingles* ()going over layers of existing roof 0 Old Kings Highway/Fhstonc District tsAA//�� ��/��� �y/� .,t �� u Roofing/Siding(Like for Like)/ *The debris will be disposed ofat:� '_ILLCQTG`s'. 1 L1�'Cr1— — Locauon of Facility' acility 1 declare under penalties of perjury that the statements herein contained are true and corrxt to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or revocation of:ny license and for prosecution under M.O.I.Ch.268.Section I. _____MO Applicant's Signature: '1ci'..0 -' �,.(� Date: !/tO Owners Signature(er attachment) 'J v 4 ` '��.IX"•-� Date: /�' Approved By: _ �� Date: 9L/574 B ' g 0 —al(o esignee) - Zoning District:_.___ ___ Historical District: 0 Yes 0 No Flood Plain Zone: 3 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: C Yes U No a Yes - No 3/0l RISE ' :`. r; ""°' 5 Dupont Avenue South Yarmouth, MA 02664 ENGINEERING' • OWNER AUTHORIZATION FORM I, RICHARD H KAZANJIAN (Owner's Name) owner of the property located at: 20 Short Way • , (Street) West Yarmouth, MA 02673 , (Town, State, Zip) , hereby authorize 0000 (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. -----nt------------- . -Customer Signature -D— au — Ig -Sign Date 2/20/2018 • nr - .,K JUvtI.140.1,.1.,f lJalnll•11 '.. dui odor l Ii:)1.111.91 t Y'1>1 l omni.`i;.) (' ;I:mo na!aq nnqum}1 '1 Il;!tu1{ IIIA ell; 'I :lou. 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For information about this Sterni 3 Call tint 7274200 or riser s w.rnacs.gw/dpi 2 Commtsmoner ��M•� ' 1 1 I .224 i eivn,mw.ne,/i/i'r/,ll,,,4.1.4iO4e✓o Office of Consumer Affairs 8 Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE Corporation before the expiration date. if found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 160854 -- :, 09/07/2020 1000 Washington Street-Suite 710 FRONTIER ENERGY SOLUTIONS Boston,MA 02118 FRANCIS SHEEHAN • `t♦0 •502 HARWICH RD - = 61 BREWSTER,MA 02631 Undersecretary Not valid • 1 signature • r A�® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 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(les)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_ _r ROGERS &GRAY INSURANCE AGENCY INC PHONEyp FaO�(So0)399asso_ __j LAc.Ne): _______ E-MAIL ADDRESS: @99ra mall ro ers com _ y _ _.�_ __—______ 434 ROUTE 134 INSURERS)AFFORDING COVERAGE NAICN _ -- SOUTH DENNIS MA 02660 INSURER A: AIM MUTUAL INS CO 33758 INSURED INSURER B: _ _ _ __ __ _ ____-1 FRONTIER ENERGY SOLUTIONS INC INfuRERc: I rt INSURER P:502 HARWICH ROAD INSURER B: _^ 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. _ _ ILTRT PEOFIN. -- ---_-- AbOL SUER M_ _. ---- MIDDYEFF POLICY EXP ' LTRs TYPE OF INSURANCE INSp YArO' POLICY NUMBER (MMIDDIYVVTI (MMIOOIYYYV) LIMITS It I COMMERCIAL GENERAL LIABILITY 1 I EACH OCCURRENCE 1 l _I I DAMAGE TO RENTED — CLAIMS.MADE ` J OCCUR i PREMISES(Ea occurrence)_ 5 MED EXP(Any one Person) tS_ N/A PERSONAL&ADV INJURY ,$ GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE____I f_.___. _ _-_ _ -, POLICY L7 JEC _ LOC FPRODUCTS•COMPIOPAGG i$ OTHER I I I $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1$ i ANY AUTO I BODILY INJURY(Per person) ! `_ _5 I______-__._ .._-. __. I ALL OWNED SCHEDULED N/A I BODILY INJURY(Per sodden- 5 —I AUTOS - AUTOS NON.OWNED I •PROPERTY DAMAGE ,S HIRED AUTOS AUTOS ((Para eJonq _ r IE UMBRELLA LIAB _ OCCUR I 4EACR OCCURRENCEI S _ __ _ _ __ EXCESS LIAB CLAIMS-MADE N/A I AGGREGATE__ ___�I(E _ __ __ _ DED I 1RETENTION$ I S IWORKERS COMPENSATION I PLR DTH- ANDEMPLOYERS'LIABILITY I I IX(STATUTE-,--_!ER j___ ___-__ ANYPROPRIETORIPARTNERIEXECUTIVE YIN EL EACH ACCIDENT 1$ 1,000,000_ A I OFFICERiMEMBEREXCLUDED'+ N/A'N/A N/A VWC10060153152018A 103/14)2019 103/14/2019 'I(Mandatory in NH) I EL.DISEASE.FA EMPLOYEE4_5 1,000,000 _.— I11yes,descnbe under I DESCRIPTION OF OPERATIONS below EL DISEASE•POLICY LIMIT $ 1,000,000 I ' N/A I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached It 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 stales 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-compensation/investigations/. 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 '' yr HarwichMA 02645 1 Denial 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