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HomeMy WebLinkAboutBLD-19-1522 - ' f rq�, i \} t 1'i Ir Potmit capirs 6 months from'' • ...„r ;:'�+ j'issue date. 52 id. EXPRESS BUILDING PERMIT APPLICAT IL _._ TOWN OFYARMOUTH RECEIVEa- . Yarmouth Building Department • 1146 Route 28 SEP 13 2018 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 stn apt =_ 7;ji,fr, l.NT By. vsr CONSTRUCTION ADDRESS: ll 7PrJ4eCT-{ £ i) ASSESSOR'S INFORMATION: Map: -1 7 Parcel: '1.4 / I I . +' 1M4 Q3ISc NAME -RESENT ADDRESS TEL. # CONTRACT°-.IOlt, • 1 _ .00I . ' ' M. -, . _ �,i # 1.�: .a^. u-,. 3 r l • • NAME . nit,it, - .. v�uy L.# esidential 0 Commercial 0 Est.Cost of Construction s c 0 0 Home Improvement Contractor Lie.# 1(0/0 ({, teConstruction Supervisor Lie, /S Workman's Compensation In ante: (check one) 0 I am the homeown . 0 the sole proprietor le . .ave W'orker's Compensation Insurance Insurance Company Name: {IA/� l�, Worker's Comp.Polis c 1 8C1 gli WORK TO BE PERFORMED 0 Tent (Fire Retardant Certificate attached) 0 Wood Stove Shed 0 Siding: #of Squares 0 Replacement windows:# 0 Replacement doors: # 0 Re-roof: #of Squares ()Stripping old shingles" ()going over layers of existing roof 0 Old Kings Highway/Hrstonc Dtstnct Roofing/Siding(Like for Like) *Tie debris will be disposed ofat:,J3 a.. 1 i _ .. __rar 1lc Locauoo of Facility I declare under penalties of perjury that the statements herein contained ere 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 revoca license and for prosecution under M.G.L Ch.268,Section 1. _____91104_< Applicant's Signature: "" I . • ry ''rr _^Date Owners Signature(or attachment)_Se_ i �`�L'r,� Date: Approved By: _ a/ Date: 7-/5 e R, : " tial(or designee)/ Zoning District: Historical District: 0 Yes C No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes O• No — — ,/pl Cape light Compact 5 Dupont Avenue South Yarmouth, MA 02664 OWNER AUTHORIZATION FORM I, GERARD MULLIGAN • - - (Owner's Name) .. • owner of the property located at: 11 Elizabeth Lane (Street) . West Yarmouth, MA 02673 --— (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. Snatureøs yiyig Sign Date - — — 03/19/2018 . 1 lid C'nrnnrnm.'en/dt of.11anerclul eras es17:2: 1--- Prynruna•nt of lnJtnfr'ial.in urlenn , `.' "•j""I " ! Cow;revs Street. Suitt 140 . 4;177 '; ,'..• el--;fl 1301b111. 11.1112114-2f)17 - 13'or1,e r, l'om:.rn.no.n.Insorv:u r \fIWeu:: It ulidrl,l motA Actor o,I.Icen'lcla ntI'hn beer, . 1.1111 ,Il r9 Nile nvF VF!XIII 11y1. 41111"41i\ \pnhganl Inform,Jlon _-LI _ I'Ica,rJLiol I t"1h1. i .<...or,e. .t L ✓ .n -n lm:i .1, .1,a.. 1"'14 ;., * _.4 .5 ,, . .a (..:-t ?� ,.ffl] TttRd =r-.: ..._ - -_— .- _ , 1- Adt.IC?<i. Aa�. / 11- .A..J, 1 Au yon u..,mi44)ert rhea urrr 44ornpn,rz Il.u. Type of project 1 r'equirrd 1 DI am 1cr .1. nr. 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AIN 11A/1�'{�'"��.{,{/I �{�)y fir,Q '�/�/� \/�m (y rMJ.110.e t nmr'j`.IIT'',i'OV. t 1'' ` 1 1l/r u' `V '--/"'N.?..C_a,TJ. ;.Q_ W m�' ` . ..... _---' poht,::el'ScII.it—wur.VLA lx i ...LOIIIS-3l -9.0t&A -.. .a: .,.I1:',. 3)i X97 \Hath a ion, I, he ,.,oF1.,rc e. np.•4 nun p..hty tleti.vah..4 poor i,how log the policy toter and aspiration Hatt). I.1,,ort:0 stein e..,ym.rrw i s;eapl:n:d Wider M(1:.c I i:,$f i A l:a cr-,mmol 31011110n punlsnahlr by.I fent up to 61,50o Oh, litd'am one.,t If Eno'r:o'tr11011 .454,,11.as4:tr'cruel;:¢.',the('rn of a,S"I'(•P 1)!1;11+K iRf)rtt;utJ.1 iot'of un to S:in OPa .Ia' n;:r:l,t the to'nl,'r ., .1 ,:'reoc r•.-.1. 1...••••‘•P..c:;•n'-e(owcc.c'hr.t,,:.4.11: rv')E:oc 1il, fair—...ranee .n.ruwc,cru i:m..n ... _ '.w_ �_.... ( In hereby 1pr1b r:trier he prlm\vu �"uues.._j-,_:.:r tlrn:nitr,_o.ln. 'hut ..'w_:8,.a-n-•-'. 7rUr Rte^r -- I r-_rI. i H.142...H.142...... 77`.4 —D37—Ot-tit; I —_.. . . (> itml✓ler oink Po nut lttrite or do sero..)he completed by on.Jr fawn WOOL 1 ! • Cm or Tnwn• • ' _i__...... _.__.. PernaI hence.y .._.___..._. ....__._ 1 (,ruin, lttthoril\ !circle ono: . - -- I I:'urd Ul 111.11:11 1. LAn.'ILng Dip.:rim,m' 1 t'.n 'I 1..Y-1 t lnl, 4 II,:,n,'1 I1141101.H I'lunthlnp lu.prrou 14.Other ' i I{ t'owaJ ('rr,oq' ..— _ .__ 1", :< -__:.: _�c—a:z_„a'.•--- JI Construction Supervisor Specialty Commonwealth al Massachusetts RatkbW for ® ON,Hon of Professional Licensure CSSLaC-Insulation Connecta Scat of Biotding Regulations and Standards • • v. ..o S. a rsc.i....a.t. t C5SL-105941 Exp"es 02:172020 - FRANCIS S SHEEN/JI i 502 HARWICH RD BREWSTER MA 02631 Cadent to possess a cwreed edition of the Massachusetts I' State Bonding Code is cause for reverence of this license. L/ 17)i27420 for vital dinsm.ss.g it Cal f6 a information vital los c ss.ew/Apl Commisstoner N ✓i. Yr/marrow wzliia/.l/,...a./.,lgt Office of Consumer Affairs 8 Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corooratlon before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 160854 -- 09/07,4720 - 1000 Washington Street-Suite 710 FRONTIER ENERGY SOLUTIONS Boston,MA 02118 j 1 FRANCIS SHEEHAN 502 HARWICH RD • ," L • BREWSTER,MA 02631 Undersecretary Not valid signature • Ac® CERTIFICATE OF LIABILITY INSURANCE GATE IMMIDDmrr) 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 i 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 INC.ExO�(.069395-75505 _ jlai Nd)_ ___ E-MAIL DDRE mail@rogersgray.com 434 ROUTE 134 INSURERIS)AFFORDING COVERAGE SOUTH DENNIS MA 02660 INSURER A: AIM MUTUAL INS CO 33758 INSURED INSURERS; - - ,_. 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 INSR -ADDL SUBR, _ - 1 POLICY EFF I POLICY UP I - - - - ---- _ LTR TYPE OF INSURANCE INSD WVDI POLICY NUMBER IMMIODIYYYYI (MMIDD/YYYYI: LIMITS COMMERCIAL GENERAL LIABILITY I I I EACH OCCURRENCE r 5 —4 DAMAGE IO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence)__:f _____ _MED EXP JAny one person) S____ _ _ N/A PERSONAL&ADV INJURY $ - GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 5 1 POLICY f JPEo- LOC PRODUCTS-COMP/OP AGG E-_______--___ I OTHER I ,5 COMBINED SINGLE'LIMIT $ AUTOMOBILE LIABILITY 1 (r a arcdunl) _ __ ANY AUTO __ I j - BODILY INJURY(Per person' I S - _-___ ___ - ALL OWNED SCHEDULED ' AUTOS AUTOS N/A BODILY INJURY(Per eccrdenp:$ NON-OWNED Per accIdenOAMAGE )i --- $ HIRED AUTOS AUTOS 5 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ — L EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ — II DSS ED T-RETENTION$ $ WORKERS COMPENSATION I x I STATUTE _,6R HH- I AND EMPLOYERS'LIABILITY - ANYPROPRIETORIPARTNER/EXECUTIVE YIN i '1 EL LACH ACCIDENT 15 1.000.000 A IOFFICERIMEMBEREXCLUDED, NIA I N/A ' N/A I VWC10060153152018A 03/14/20181 03/14/2019' ' (Mandatory In NH) E L DISEASE•FA EMPtoyrrI $ 1.000.000 _ ___ II yes.descnbe under r DESCRIPTION OF OPERATIONS below I I : EL DISEASE-POLICY LIMIT 1 5 1.000,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be'Method 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 expiralinn 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 Harwich MA 02645 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