HomeMy WebLinkAboutBLD-19-002650 Il
.+ " Permit#
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je 'Permit expires 6 months from
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EXPRESS BUILDING PERMIT APPLICAT , E C E f V E D
TOWN OF YARMOUTH
Yarmouth Building Department I OCT 3 1 2��8
1146 Route 28
South Yarmouth,MA 02664 : .._ CAC :; __
RME rr
(508) 398-2231 Ext. 1261y�
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CONSTRUCTION ADDRESS: � PL-f----0-44 fCW2-----
ASSESSOR'S INFORMATION:
Map: Or)) Parcel:3(3
NAME PRESS W I I ► L.Y-037-04/v
CONTRACTOR jQo
.` yPrn1AM:E � . ENG `'1 ( 01 4 a of O.
ei. Residential 0 Commercial 0 Est.Cost of Construction S C6 10006
Home improvement Contractor Lie.# / jpO Q p` FIes' Constr on uper isor Lie.# ,VVacet LI I
Workman's Compensation Insurance: (check one)
0 I am the homeowner 0 II ern thea sole(proprietor I have Worker's Compensation Insurance rr
Insurance Company Nam- , t �t"� "�`�� . A.1 .i • .. s Comp.Polic jOt7 Vn r t 3 )9:::1) O
WORK TO BE PERFORMED
0 Tent (Fire Retardant Certificate attached) C Wood Stove Shed
0 Siding: #of Squares 0 Replacement windows:#
0 Replacement doors: #
0 Re-roof #of SquarestX.Dla ion
()Stripping old shingles* ()going over layers of existing roof 0 Old Kings HighwayMistotic District
�nn y1(� �1{..t' yyy��� ��^ .�RR000lfing/S�i/diing(Like for Like)
I
*The debris will be disposed of atc- 9 `-"��Y C pl t( 1 ( �/I 1 i4— o Y S
Location of Facility 111
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 revocation oe and for prosecution under M.G.L Ch.268,Section 1,
Applicant's Signature: ..'.d � Date:
Owners Signature(or attachment) —011)/44
/ 1 )/ s —D Date: /DP h/r c
(1
Approved By: t ii Date: /0••• 3/ /6
Building Official(or designee)
Zoning District:
Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No
Water Resource Protection District Within 100 ft.of Wetlands:
D Yes ❑ No 0 Yes 0• No
It01
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DocuSign Envelope ID:F6965288-18AE-4698-80FF-336E08308ACB
Cape Light
Compact ,lms. 5 Dupont Avenue South Yarmouth, MA 02664
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OWNER AUTHORIZATION FORM
I, ROBERT J SIEMASZKO
(Owner's Name)
owner of the property located at:
22 Crowes Purchase Road
(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.
DocuSigned by
tornelSignnature
6/6/2018 I 10:46 AM EDT
-Sign Date
05/30/2018
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Construction Supervisor Specialty
Comnnnwealm o:Massachusetts Restricted to:
cSSl-aC-h.s..i icn Contractor
• Om Bron of Professional L ndceStansure
Board a?Building Regulations antl Standarps
n
e CSSL-10:941 Expires.02:17,2020
• sts- .... .
1t -
FRANCIS S SHEEHAN
SO2 HARWICH RD
BREWSTER MA 02631 faiure to possess a current edition of Me Massachusetts
State Building Code is cause for revocation ci this license.
For information about this Scene
✓1 Call4617)7n-3200 or visit wvr.mass.gov/dpl
Commissioner L�{v.. //f+/
n.i,...,.u. i
- _ OlYte of Consumer Affairs S Business Regulation License or registration valid for individual use only
- HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration:. 160854 Type: Office of Consumer Affairs and Business Regulation
Expiration: 9'812018 LLC 10 Park Plaza-Suite 5170
Boston,NIA 02116
FRONTIER ENERGY SOLUTIONS
FRANCIS SHEEHAN
k
502 HARWICH RD -
BREWSTER.FAA 02631 I ndtrsecretary - \it val 'ithou ignalure
ACOO® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY)
‘es ./ 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(!).
PRODUCER CONTACT Rogers and Gray Processing
ROGERS &GRAY INSURANCE AGENCY INC ;aCO,.NIo.EAn: (508)3984980 FAX rep(:
E-MAIL9 9 _-- —
ADDRESS:AIL mall f0 Bf5 ray.com
434 ROUTE 134 INSURER(S)AFFORDING COVERAGE NAICN
SOUTH DENNIS MA 02660 INSURER A: AIM MUTUAL INS CO I 3375.8__
INSURED
INSURER B
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.
ILTN TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS
INSD WVD POLICY NUMBER IMMIDDIYYYY) IMMIDOIYYYYI
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE E
DAMAGE TO RENTED
CLAIMS-MADE 7OCCUR PREMISES(Ea occurrence) $
MED EXP(Any one person) $
N/A
PERSONAL EADV INJURY $
GEN'/AGGREGATE LIMIT APPPLLIES PER: GENERAL AGGREGATE $.
[ •
I POLICY JEa LOC PRODUCT„5_COMPIOP AGG E
I
OTHER: 1
AUTOMOBILE LIABILITY • COMBINED SINGLE LIMIT $
_Lgcciden1,
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED r SCHEDULED BODILY INJURY(Per acddenp f
AUTOS _ AUTOS N/A
HIRED AUTOS NON-OWNED PROPERTY DAMAGE y
AUTOS (Per accident)
• UMBRELLA LIAB OCCUR. EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $
DED RETENTION$ $
'WORKERS COMPENSATION X I PER 0TH'
AND EMPLOYERS'LIABILITY STATUTE ER
ANYPROPRIETORIPARTNEPoEXECUTIVE YIN E.L.EACH ACCIDENT $ 1,000,000
A D I� N/AW
n MEMB REXCLUDEA VWC10060153152018A 03/14/2018 03/14/2019
(Mandatory In NH) E.L..DISEASE.EA EMPLOYEE E 1,000,000
0
H yea,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT f 1,000,000
•
N/A
DESCRIPTION OF OPERATIONS I LOCATIONS 1 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 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/lwd/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
r< r A
Harwich MA 02645 Daniel niel M.,C,
I Crow y,CPCU.Vice President—Residual Market—WCRIBMA
01988.2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD •