Loading...
HomeMy WebLinkAboutBLD-19-001986 Th ll Pemtit# 0 �F'C-1 d• J-��H i'Pamit expires 6 months from SN� rt/3 j(issue date. EXPRESS BUILDING PERMIT APPLICATION n c,/- TOWN OFYARMOUTH BLb-tq - DDI 1b 50 Yarmouth Building Department t.. 1146 Route 28 R E C E i V E l South Yarmouth, MA 02664 ��•yy�� (508) 398-2231 Ext. 1261 OCT 02 2018 CONSTRUCTION ADDRESS:T(1�-�_u31. cillsa 1- r _ .e...•0 / 21 MENT ASSESSOR'S INFORMATION: Map: 34 Parcel:cZ� .( OWNER:.srl lht'2'�`'ln��1J��� E PRESENT ADD SS TEL # CONTRACTOR. ■e_b.. a .L.l• ...,del 1. ,�}�-/('V "�/ h? gm Or ?] . ,'AME 44 a gs f . I ' _ eL8 t Residential ❑Commercial ❑Est.Cost of Construction S i DOC) Home Improvement Contractor Lie.# )LOSS-4 Construction Supervisor Lia# (0:S ritt Workman's Compensation Insurance: (check one) Z I am the homeowner 0 I am the sole proprietor - '._ve W'orker's Compensation Insurance Company Name'(!1lu 1..1 01-10\--C DILE . o-ser's Comp.Policy(rt©Q(c&c—a181) &-1 WORK TO BE PERFORMED 0 Tent (Fire Retardant Certificate attached) 0 Wood Stove Shed Siding: #of Squares 0 Replacement windows:# 0 Replacement doors: # 0 Re-roof. #of SquaresWooer tion O Shipping old shingles' ()going ova layers of existing roof ❑ Old Kings liighway/Histonc Distnct Roofing/Siding(Like for Like) 'The debris will be disposed of at:f c C)SQQ�.--)n nAD ■ 1. . . ..Ai .a a_ Location of Facility I declare under penalties 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 any license and for prosecution under M.O.L Ch.268,Section 1. ',fr� Applicant's Signantte: �• Date:�®},� Owners Signature(or attachment_i•_ �ttionrlin .. ,,,. Date: Approved By: �V Data: /O /g Building 0%: ul j Cignee) Zoning District: Historical District: ❑ Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes U No O Yes n• No 3101 , DocuSIgn Envelope ID:74BCOBEF-2755.45EA-AC76-1E7CF9434B8E ; 'far Permit Authorization i1tst mass save Form Site ID: 3394718 Customer: David Dempsey I, ,owner of the property located at: (Owner's Name,printed) 100 Wilfin Road South Yarmouth, MA 02664 (Property Street Address) (city) 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. OocuSlgned by: Owner's Signature: P '- VUMpSuj twe•exeae6443e Date: 5/15/2018 I 9:15 AM EDT S44**4101(10 l4tle AWe3F e41M'Brre Mei w 044 a ase rt 044 44M 4dNitth , d.4 ,t di 44*4a AW4 < a u 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 Office Use Only Rev.102015 r -- .. I • , • ,`a' x The Commonwealth of'Massachusetts ,,'' —-- Department of Industrial Accidents 1 Congress'Street,Suite 100 =3�a '.�j Boston, 414 02114-2017 • - �, www.mas's'.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/EIectrlcians/Plumbers. tO Ise Ia❑ En ash I It I nt: PF.RMITl Inc At;[PORI n'. Applicant Information Please Print Legibly Name QhnsrnutdOrsuuranun9ndaclAua : o )l-ICe -e,. lf �eSSiJaCS 1�� ___ .._._ Address:_` -/FQ.1,l)i( tL : `—_ _—__-- ---__—. (.CityiS late!Zipa t tr--i erlAett.e )631 Phone#:77Q:a3-7 0.Ill�----_---_... Are lou an enlployer!Cheek the appropriate hos: Type of project(required)' II ..lain a employer wilt 1�__ertpinven du'.l aud,nl pardon l• 7, QNew construction7O I ana colt proprietor or porton clop and have no employes wo kap trar me in S. J Re m odds ng enc oapauq INo weeken'sump mumnnrr mginied! 9. E.]DLIII1Publun •3 I::I am a homeowner dome all work myself lNn ail Acrd tel as.lr aner ren arid l' 10 Q Building addition 40 I amhomeowner and will be biting to toothier allsuck on my properly I will ensuret wa that all contractors either have urkeis'compensation Insurance or are sole ILQ Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5 Q I ars a genial contractor and than:htre.t rim cat...rune:has limed on the nnached sheet 13 U Roof repo]N '.hesecub-cinlrac'ois have a maloyees dad k is c urn Sets'comp Ihu61e1.e: • b Q We arc a corporation and ns officers hose cam(ind then nude rl ex now on lar MCIL e, _— 15 E-7"the t�trbtth t '1(( 0 J.$1nal.dol we"are no employees 'No wor Arr- curly ms.nuae Icquned j 'Any apply ant that checks bus el must also till out the ice two leo, Lhomm{melt Makers rowpemalron poli)rnronnulu.n ' Homeowners who submit this affidavit indicating they arc doing al wank and urcn hire outside contralon most salami a rcw af4d:w a m(lunuug.su.h :t,untraetots Nan ehctk this Mu must attached an addnm,usl sheet showing the ware or the sub.counanuls and stale IN hcdwr or not muse erunms have employees IC the sub-contractors have employee..they mit provide their swl kg's'Comp policy number I ant an employer f/rat Is providing workers'compensation insurance for my employees. Below is the policy and job site information, { , " I �}s�--�y .,/� �,. p �'�(1 (� f� Irvllance Company Name.Ftut.�_rel,1.t.t,✓!-'T )....r,�p,..C.-i-1 a,j2—.M-� ()El-_)_ . Policy d or Self-ins.Lie. &C-(DO aco(SvIs-±-ao R Expiration Date: 3J19 ) 1 _ ___ ^n Job Site Address/I:n(4 t�(A 1.1..Lei . _--. City'State a `'r • • aA- Attach a copy at the workers'compensation policy declaration page(showing the polo er e n expiration datQ9p /_( !/ Failure to secure coverage as required under MGI,c 152,§25A is a entninal violation punish. 'a fine up to S 1,500.110 I(SSJJ�,J�-1 and/or one-year imprisonment,as well as civil peralt:es in the turn of a STOP WORK ORDER. n fine of up to 5250 00 a day against the violator.A copy of this statement may be fon‘ tract to the 011ice of Investigation of the DIA for insurance coverage verification. _ /to hereby certify under th tri 'and penalties of perjury that the information provided above r.siqia01111 correct. Signutuu__, .. Dale' - /J- Official use only. Do not write in this arra,to he completed by city or town official C its or Town: -- Pei_Pei mit/License M Issuing Authority(circle one): I. Hoard of Health 2.Building Department 3.Citsriossu Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other- Conine(Person: Phone K:_____--__ _ _ _. • Construction Supervisor Specialty G++rw�aeaan ci Massacnasc:l3 Attended to n .sron or Professional L mensal CaSstc•incaution Contrags Bo art o'9...i nit Regulations and 5'a tor os ea Sexvso'>..._.r CSSt .13Fy4' Exp"es ZF ' 232C FRANCIS S SHEERAN -w 202HARWICH RB _ BREWSTFR MA 02621 Failure to possess a current edition of the Massacturens State Boddeng Code Is cause for revocation at lies license. For information about Ma best rs ' Cax!61t)727-206w visit wow mass gondol Commiss:orer • ./7;t Yrnrurrirr.-rv.///.e/a./4:✓rreitttr/h Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Comoraticn before the expiration date. If found return to: I Reoistratlon e Exoiration Office of Consumer Affairs and Business Regulation 160654 - 09/07/2020 1000 Washington Street-Suite 710 FRONTIER ENERGY SOLUTIONS - II Boston,MA 02118 FRANCIS SHEEHAN x502 HARWICH RD BREWSTER,MA 02631 Undersecretary Not valid Y signature s I ,'' .../......1 ® DATE(MMIDDIYYYY) AC REP CERTIFICATE OF LIABILITY INSURANCE T MM/00Ya 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 jA"G"tie ExO: (508)398-7980 FAX E-MAIL mall ro ers ra com MAILADDRESS 9 g_ Y• 434 ROUTE 134 INSURER(SLAFFORDING COVERAGE NAICN SOUTH DENNIS MA_02660_ _ INSURER A_ AIM MUTUAL INS CO __- 33758 INSURED INSURER B: FRONTIER ENERGY SOLUTIONS INC INSURER C_ INSURER 0: 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 /LTR 'IINSD ft/nnI POLICY NUMBER (MMDD/Yi POLICY EYYYI LIMMLDDNYYYIXP I TYPE OF INSURANCE LIMITS COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE ____ 5____ __ _ _ _ ' ' 1'- 1 'DAMAGE 1O RENTED I CLAIMS-MADE OCCUR PREMISES jEaoccurrence) __ S__ _- r.__)__. •MED EXP(Any one portion)_ $_ _-_-__-- N/A ,PERSONAL&ADV INJURY __$_ , __ - GEN'LAGGREGATELIMITAPPLIESPER: GENERAL AGGREGATE IS ___ F _ .1 PO- PA5 POLICY -1 JE T r]LOC PRODUCTS_COMP/OGG ' I OTHER ' - - - I f ____ AUTOMOBILE LIABILITY ' COMBINED SINGLE LIMIT $ SeccldenD_ ANY AUTO BODILY INJURY(Per person) $ I -. I ALL OWNED SCHEDULED )AUTOS _- AUTOS N/A BODILY INJURY(Per accident) $ ' ' AUTOS ED PROPERTY DAMAGE I HIRED AUTOS Per occident f I . , AUTOS 1 2_______ _ • UMBRELLALIAB I OCCUR EACH OCCURRENCE $ 1 EXCESS LIAB I CLAIMS-MADE N/A .AGGREGATE �5__ _ OFD I RETENTIONS I I j I5 WORKERS COMPENSATION XI PER 0TH- AND EMPLOYERS'LIABILITY __L 1_UTE I TER _ A •OFFCERIREMBEREXCLUDED?ECUTIVE Y® N/A N/A VWC10060153152018A 03/14/2018 03/14/2019 ELEACH ACCIDENT $ 1,000,000 '(Mandatory in NH) E L.DISEASE•EA EMPLOYEE $ 1,000,000 DSsCdIePscONOnFdOP ERATIONsbeI0W EL DISEASE-POLICYLIMIT E 1,000,000 I N/A 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 10 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-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 5rX Harwich MA 02645 ' ic .0 Danieiel M.Clay,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