HomeMy WebLinkAboutBLD-19-002649 a„,05:-C14\4._
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cc•eni'"�'; ;Permit expires 6 months from,.
bee. P BLD-Iq-coz(date.
EXPRESS BUILDING PERMIT APPLICATI 1
TOWN OF YARMOUTH RECEIVED
Yarmouth Building Department r
1146 Route 28 ; OCT 312018
South Yarmouth, MA 02664
(508) 3984231 Ext. 1261
CONSTRUCTION.ADDRESS:_1556 { e
ASSESSOR'S INFORMATION:
Map: sq Parcel: I[b
OWNER(PIII l JI PO 3X 1 O pc PRESENT6r
NAME 771-8„,- U I 1
CONTRACTOR: /tom.. As:. ,►1 -:
_ 1 :1 0 AP . '1l P f I(
, .'AME LNG.AD.RESS TEL#
D�esidential 0 Commercial
Jp .?Est.CD`)
�osst of Construction S
Rome Improvement Contractor Lie.# Ite Construe pe nsor Lie,# ` ”
Workman's Compensation Insurance: (check one)
❑ I am the homeowner 0 I am the sole proprietor 'e Worker's Compensation Insurance
G s Comp.PoliMyyJ ba 5-31 S C^
IInsurance Company Name: JLL)L
WORK TO BE PERFORMED
❑Tent (Fire Retardant Certificate attached) C Wood Stove Shed
0 Siding: #of Squares 0 Replacement windows:*
0 Replacement doors: # -
❑Re-root #of Squares tion
()Stripping old shingles` ()going over layers of existing roof ❑ Old Kings Highway/Historic District
Roofing/Siding(Like for Like)
*The debris will be disposed of at:J3Q p -O (
—fc
Location of Facility
I declare under penalties of perjury that the stolemea herein contained ere true end correct to the best of my knowledge and belief I understand that any false answer(s)
will be just cause for denial or revocation `m, ease and for prosecution under M.G.L Ch.268,Section I.
A
Applicant's Signature. Date. ''�
Owners Signature(or attachment) �C.S.e� Date: !' /D/9L0/G C
Approved By: Data: 10 3/- it
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:
C Yes ❑ No ❑ Yes C' No
3/01
„,
R I S 5 Dupont Avenue South Yarmouth, MA 02664
ENGINEERING
OWNER AUTHORIZATION FORM
1, CAROL M ROBBIO
(Owner's Name)
owner of the property located at: -
18 Burnaby Road
(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.
-Customer Signature
i u f/ice
-Sign Dat
01/24/2018
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1
Construction Supervisor Specialty
Restricted to: •
rth ofidahra. r •
Dnusion ci sreee3Ydnal Licensors CSSL4C-Insulation Contractor
•
Board of Bw:mnq Regulations anti Standards
.. ..0:VT SI:pentso'S car,: - f'
CSSL.105941 Eaptres.02:17.2020
44
i+'
FRANCIS502 HARWICH RDfUN .E''
RD •
.. BREWSTER MA 02631 e� fate to possess Cee i current editionrevocation
the Massachusetts
State Building Cede is cause for revocation st this license. •
. -
For thb
information Ghoulhs
Cali 161]1274200 or visa www.mass.g
ov/dpl
Commissioner :✓' l^
•
e E
Uffice of Consumer Affars C Business Regulation License or registration*slid 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 Par[Plaza-Suite 5170
Boston,SIA 02116 •
FRONTIER ENERGY SOLUTIONS
•
RANCIS SHEEHAN `
5:2 HARWICH RD
BREtiJSTF.R.1M^2631I ndrr,eti ersry Nit val.. -ithou ignature
•
• • At D' CERTIFICATE OF LIABILITY INSURANCE DATE IMMIDDA YYV)
• 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 _
ROGERS & GRAY INSURANCE AGENCY INC 1y2cs Ex,; (508)398-7980 FAx
E-MAIL com mail ro ers ra
ADDRESS: G 9 9 Y
434 ROUTE 134 INSURER(S)AFFORDING 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 INSURERF:
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 TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LIMITS
LTRINSD WVD POLICY NUMBER (MMIDDWYYY) IMMIDDNYYYI
I COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S
DAMAGE TO REN(ED
CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $
MED EXP(Any one person) f
N/A PERSONAL SADV INJURY f •
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
POLICY TCT LOC • PRODUCTS•COMPIOPAGG S
OTHER: S
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
(Ea accident) _ _
ANY AUTO BODILY INJURY(Per person) 5
ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) f
AUTOS H AUTOS _
NON-OWNED PROPERTY DAMAGE 5
HIRED AUTOS ___ AUTOS (Per eackenlj
$
UMBRELLA LIAR OCCUR EACH OCCURRENCE•5' ___
EXCESS LIAR CLAIMS-MADE N/A AGGREGATE
DED RETENTION$ $
WORKERS COMPENSATION X STATUTE ETH
AND EMPLOYERS'LIABILITY
ANYPROPRIETORIPARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $ 1,000,000
A OFFICER/MEMBEREXCLUDED? N/A N/A N/A VWC10060153152018A 03/14/2018 03/14/2019
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000
II
yes.describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 1,000,000
N/A
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Ia 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 dale 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
r Q+
Harwich MA 02645 ` I
Daniel M.CroG✓xy,CPCU,Vice President—Residual Market—WCRIBMA •
®1988.2014 ACORD CORPORATION. Alt rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD