HomeMy WebLinkAboutBLD-19-001988 • ..04.17g€71-4*\. 1
\� JPermit#
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'�„s .''' 6. °issue date.
EXPRESS BUILDING PERMIT APPLIC .TION
TOWN OF YARMOUTH RECEIVED
Yarmouth Building Department
1146 Route 28 OCT
South Yarmouth, MA 02664(508) 398-2231 Ext, 1261^7.A `T .
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CO\STRUCTIODDRF.SS: \\TJ�1�1
ASSESSOR'S INFORMATION:
I Map: Q I Parcel: Scc
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OWNER: I "" On 1* � {
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N PRESn T ADDRESS1.
/��7/TELL #//p
CONTRACTO` ''..eh AL. .L..( .. f �io • ,:Ii//ote
. NA. an lee' 0 t RF `-'t 1 • W v 4 //,
r- esidential 0 Commercial C En.Cost of Constmction S ,,ll ) V��
Home Improvement Contractor Lie.# `( O% f Construction Supervisor Lie.#A) q
Workman's Compensation Insurance: (check one)
0 I am the homeowner 0 I am the sole proprietor 0 -to Worker's Compensation Insurance
Insurance Company Name:niAte Worker's Comp.Policy/CO(001�TSa-riS m
WORK TO BE PERFORMED
:D Te.-.t (Fire Retardant Certificate attached) C Wood Stove Shed
C Siding: #of Squarm 0 Replacement windows:#
0 Replacement doors: #
C Re-roof #of Squares D Ins• 'tat#--------
()Stripping old shingles* ()going over layers of existing roof 0 Old Kings Highway/Historic District
�,,RR000fing/S�idrting(Like for Like)
*The debris will be disposed of a(: a S ' • , S Lk_ d YL—_
. Location o liana
I declare under penalties of penury that the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false=welts)
will be just cause for denial or revocation of ' ' and for prosecution under M.G.L Ch.268,Section I. // 1 'x/
Applicant's Signature: \ Date: (nil ) f V
Owner,Signature(or attachment)
_ ear ►� • Date: ll
Approved By: / l Dave:
Buil.' .c' Arr designee)
•
Zoning District:
Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yea 0 No
Water Resource Protection District: Within 100 ft.of Wetlands: •
C Ycs 0 No 0 Yes 0 h No
3/01
DocuSign Envelope ID:0306356F-703E-4140-BEOE-ADF4CACBF9D0
Cape Light 44
Compact 4, -
5 Dupont Avenue South Yarmouth, MA 02664
fln
OWNER AUTHORIZATION FORM
I, JOSEPH C BERNIER
(Owner's Name)
owner of the property located at:
9 Avery Lane •
(Street)
South Yarmouth, MA 02664
(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.
• 4 K-'-e..
C tom Signature
eLf. 5 2 0 l 4S
-Sign ate
•
4/2/2018
a.� i♦
_ .. • The Commonwealth of Blassacleusetts
Department of Industrial Accidents
T 7.111-075 ; 1 Congress Street,Suite 100 •
\�*=f 3; Boston, ,4f4 02114-2017 •
Y1/4.});,6- /1 norl¢mas.c.gnv/dig
Worker,' Compensation [neurones Ailidas in Itoildere/C'nntractors/Electricians/Phunbers.
I Ill illl D\slllr Inc I'l R\ll11 INN 1t.IIIORlt\.
Applicant Information
Please Pi int Leiibl 1
Name tflusiness'Organization'Indrviclualy,re_00-1et. �l,•,aLei/:s 1_t1S1(3!>.S,_1K ...- ___ __
lddress:_. 1hQl_i�jCt �-�_ _
Cjty stdteiZilxnt_,_1i:= 4tiR._F)63( Phone a_77QL"..a37_SX I-1_p-----
Are um an empinver?['neck the appropriate hot- t Type of project(required)•
I i con a mph))et wdh_10_,employee.i u.11 ti t or pool tailor• I ? 3 New construction
d❑I am a sole pnrpnaor or pamrtrdnp and have no employees woe kulp for me an S ri Remodeling
an,cupm.nf [NO wnIkelw'rump insurance required
9. ❑Demolition
d 10I am a homeowner doing all work myself INn workers gimp rover ante matured I' '
10 0 Building addl'ion
4 0 I am ahacr
nwner and will be biting coorconduct all work on my prnpeny I will
ensurea that all contractors either have workers'comm pensation insurance or are at II.❑Llecb9cal repairs or additions
proprietors with no employees 12.0 Plumbing repots or additions
s u i am a rooms::onlraaol nod I have loser rho•r I,.:earn,r,a.hoed on rho nnnched ahrer -
I 1.0 Roof repairs
;liar cuB.awinnows have mrp101 sea.un`bur.•r.,.er. .,oar, inur.r,u v'
tr0Weare a:unwomuonand nlo0dt'
sOnla9heea4ocrhrntwinorcanp:uupmMidc. I thtftl." -"lf 0
152,p I(as.4110 we have no rmplusecs rF:n.ud,rr.'romp rustmove rcgwledl ._ _ _ ___--_
•Arty applicant that checks boa 0I must also till nil the s%non helm Mowing t nen workers'mount matron polio) Intomwuon
' .Etonrouw nen who submit this affidavit indicating they are doing all work and then hue outside conmwIota mull snhmrr a Pew and.r.n mdit am*such
t4 uirraclors that check dos box must trundled un adds iuntil awl show nip hie utumc or the sub.co tracmis rind state whether or not those cnsues have
employees if the sub-cmuractora have employees,they must provide their nor kers comp policy nunrbrr
1 ant an employer that is providing workers'compensation insurance for nit employee.+. Below is the polity and job site
information, tt +�a-t .,/� f�tl (�
Ir.urance Company Name.A. FA..)til l 1. fi�„..C' e L Q• -0 C)\I-!er q _--
Policy d or Self-ins.Lie.AJOJ ,—(OO-(CIS IIS31.Sa a/n. Expiration Date. - 3Jte-1 1____
Job Sue Address, k ( _ _City/State%Lip �_ 1�
t
Attach a copy of th workers'cot .tint o r edarataor age(showing the policy null era d explratiol date
Failwe to secure coverage as requi. der/AGE.c 152,pn-IA is a criminal violation pumsl hlc 'ty a fine up to$1,50(100
amllor ore-Year imprisonment,as w s civil perail cs in the form of a STOP WORK ORD! ' Ida fine of up to%250 00 a
dry against the%relator.A copy of this still:me l inn be Iueta coded to the 01 life of Ins est lv,alwns of the I)IA tot insurance
:enetage aerdicdtion, .
/do hereby certify under tb ai 'and penalties of perjury that the Information provided// above im tras ander reel.
Signatwee: ____ 1 Date: /--O- ! /
..`— I-------'
Phone R7.7iLd - C-IL..7--•--'—
--
Official ace only. Do not write In this urea, to he completed by ripe or tower official
Cif!, or l own: _ _ ____.___ Pelmit'Ilcenwtr_.______________
hitting kuthnrity(circle one):
I. Board of health 2.Building Department 3,City/'town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other _-- .
Contact Person: _^-__ Phone k:�_�.---_- .___. -
n
•
s•
Construct son Supervisor Specialty
pa Cornmonweaan of'nassacnusetts Rwae�efed teeI
V3iwsson of Professional IKensurt CSfL4O-Insulation Contraries
3o and o'Swidm;Reau labors 4r0 S•andarOs
sr—
^_SS'- :35941 e_sa•'es 03:17.2020
FRANCIS S SHEEHAN
SO2 HARWICH RD
BREWSTER MA 025)1 - -r • Failure to possess a cwrent eeioon of the Massachusetts
State Budding Code is cause for revocation of this license.
Fa setamrtton about this license
(517)7214200 a volt www.nuss.gavidpt
COmmrsstonee C/ ' _ — -
•i
/it f./Ku-aa./rr--r//d
Office of Consumer Affairs Si Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:Corporation before the expiration date. If found return to:
Registratlag E oiration Office of Consumer Affairs and Business Regulation
1608$4.'- .. 097072020 1000 Washington Street-Suite 710
FRONTIER ENERGI'SOWTIONS Boston,MA 02118
FRANCIS SHEEHAN e —_`"NLCCP 1
•502 HARWICH RD `•, _7
BREWSTER,MA 02631 - Undersecretary Not valid signature
1
• e ACORD. CERTIFICATE OF LIABILITY INSURANCE DATEIMmroD/YYrrl
`...---- 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_ r
ROGERS & GRAY INSURANCE AGENCY INC i