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HomeMy WebLinkAboutBLD-19-002752 • • '• 1:9:0074-41.\ IPermit# 6(g ` ' V^ " '�Ca Permit ez irs 6 months from ^' 41;1' 14 issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 140V 02 South Yarmouth, MA 026642018 (508) 398-2231 Ext. 1261 ` B UI 11a1, N MENT CONSTRUCTION.ADDRESS: ASSESSOR'S INFORMATION: Map: sq Parcel: LSP OWNER: nO-11`J �I A t NAME PRESENT ADDRESS W Et:-� res' CONTRACTOR: ,Fi *.. I e - , MOPS • of . Iii Ll ./ Ad ,'AME M.41LLVGADD• ;: LA.( NI "b Qdential 0 Corr rercird /� 0 Est.Cost of Construction S i a/000 Home Improvement Contractor Lic.# )(QcJ% `i' ConsuetrcticuicEtsor Lic.# /DSc L{ j Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole ^prooQprietorave Worker's Compensation Insurance Insurance Company Name:.nt I j4 Ak Worker's Comp.Policy#,C,401-cc:asaN - WORK TO BE PERFORMED ❑Tent (Fire Retardant Certificate attached) C Wood Stove Shed ❑Siding: *of Squares 0 Replacement windows: D Replacement doors: * ❑Re-roof: Al of Squares Lion ()Stripping old shingles* ()going over layers of existing roof 0 Old Kings Highway/Historic District Roofing/Siding(Like for Like) *The debris will be disposed of at: ,J__0aJ wLts kf tt;, Tl/tp Qeck`r Location of Facility ))) I declare under penalties of perjury that the statements herein contained ere true and contact to the boat of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or revocation of U ' and for prosecution under M.O.L Ch.268,Section I. /0/3) jJ Applicant's Signature: ; " Date: Ownen Signature(or attachment) /fir • 20 Date: Approved By: -" els is< Date: //—‘5:79 Building 0E5 o ":gree) / 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 t] No 0 Yes D• No 3/01 Cape Light nit Compact MI. 5 Dupont Avenue South Yarmouth, MA 02664 .aha OWNER AUTHORIZATION FORM 1, KENNETH FEMINO 4w �'},1 (Owner's Name) owner of the property located at: 15 Hosking Lane (Street) South Yarmouth, MA 02664 (Town, State, Zip) hereby authorize i e)//01 . (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 Sig ture -Sign Date 4/24/2018 The Commonwealth of Massachusetts Department of Industrial Accidents q = . a . ii 1 Congress Street,Suite 100 1 :447= - Boston, 111 02114-2017 1 erica art as's'.�ov/dirt Workers'Compensation Insurance Affidavit: fBuildersierintrnetors/Rlectriciansi Plumbers. TO RE I'll I'D 11ITH THE: PERMITTING AUTHORITY. Applicant information r-yf PleaseesPrint t Legibly Name (DusincssOrganization'IndiVidual:EQ.(� :11:E ,�_G Q.al SOL -Y_-S...1LLe.. CitySLItei/ l ► E.L.L. -01-4.1.1\.CO 631 Phone 4: 7711 37-.0x_. I. 0 _.__. Arelap all employer!Check��th'�eet appropriate hoc Type of project(required): I ton a employer wok,_�yt, ampluyeek i littl matzni parr•unlet" 7. 0 New construction 2❑I am a.Arlo pmpnetoror partnership and have no employees working for lie in S, fr'�Remodeling nay valiancy [No workers'comp insurance regwred.J IBJ • 9, Demolition 3'J I am a homwwner doing all work myself (Nn workers'comp.insoranee required j' , 10 El Building addition 4U n am a hnneow ner and will be hiring vordractoisQ Catalual al wl:k vilely properly I will ensureure duct all corm actors eitherh a rkelss lu sn Ira' an 'or art sole II.[ J—t Electrical repair'or addition.; E Ix I rs with y h 12 Plumbing repairs or addition: . 5E;role gra' nlati andLiHier•i .,l - ih, .i'J,ul, rcI j by sSVuiat rsha-e en'pisyt l.c l,.,, I a. r. 1 1 t J Ro I ental t:[J)kN.repthcrll, H'i}tom Z( 1i � are a:nnwmn t and Its offers have .arc Ido l h..ole phun/AAAIldc 5 p l(4).and whive no employees 1Nomorken i'p inSrr ace reguaed J — - „- 'Any applicant that checks box 01 must also fill out the secoon m below vhowt nb then workers'compensation policy inhumanity 'Hnmu woes who subunit fins affidavit indicating they ire doing a-I work and then biro outside contracture most submo a mw arid:au dada caring such lk nniMclolc oral cheek this box 1111151 attached all additional sheet showing 1hr mune or the sub4llntractorS and stale w hotpot or nil Muse colics have employees lithe Subaonhaciors have employees.then must provide the,' reo'kels'comp pol ley mamocl ____ 1 ant WI employer titan is providing workers'cranpt'nµuirui iii hitruns'ofor nn'rnIntOy•cs. Renew ie the pnlirr and jolt sin• , information. ` , *�-7 (� Insurance Company^tame: � '�__k O1 V .(....) r -e�1 L� Q� -0-um )ñ-) \j q Policy d or Self-ins.Lie.A J,U)Q -(OQ—(cv ISvl5_E'.Daf Expiration Date: 3 /9 1 ...._._ Job Site Adctre>1_ Y..1`. - _T t __ Citytstatri '�1t �,.L,/t IA.I(�t- /l r— Dom.,/J/ Attach a copy of the workers'compensati n polis t eelaratiot� page(showing,the poli• number and e i ii /titin dga t_c). 1 (•(� iptcgt Pdilult In secure coverage as required nutIt ll.c 152 r25A la a criminal violationpunishable by a line rip to$1.500.00 andMlr Ort,-vr•ar imprisonment,as well ;It;, In1 I l t<in thd I .rut of I STOP WORK OR DI 12 oral a fine of on to$250 00 a clay against the violator.A copy of this smtcn u I ma) in. o:'\,mated to the UIlice(.I [is tst.gatiomN of the DR It insurance coverage verification. I do hereby by certify under dl al and penalties of-perjury that the information provided above/s I.e an Corry t. _Sign au Ic,-, . ., —_- Dale • Official rine only. Do not write in t/tis Into, to be completed by city or tuna'u/firiot. • Cies or 'Town: - Pel mil/License h. _- ..-.__._.-_.. .,...-...,..._ Issuing 1 uthorlty(circle one): I. Hoard of Health 2.Building Department 7.(:icy/'Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other ___ Contact Person: Phone g:—..-._--_—_—....--___._...._-- n i e Construction Supervisor Specialty Commonwealth 01'Sasso( s 'rs R.an,etM te• N,S On Y1 p Iorenn,Onai LK ,t CIELJC•InaYL+IiM Contractor 3 o'Sund,na Regulations 4^0:"a-ca-as CSSLL 1159e• _ ea Y7 x2020 F+�t S I SHREfUN SO2 HAR HARWICH RO BREWSTER MA 02921 f rail we to possess a current eabon of the Massachusetts State Building Code Is cause for revocation at this license. Far reformation about Bis License fair Call It17)727-130B>else www.mass.Seelepl Corom,ss,oner ::"1„ - f Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Cameration before the expiration date. If found return to: Reoistrat1On-. Expiration Office of Consumer Affairs and Business Regulation 160854..--'i-09'072020 1000 Washington Street-Suite 710 FRONTIER ENERGY SOLUTIONS Boston,MA 02118 FRANCIS SHEEHAN 502 HARWICH RDrf; s✓`,7 ""-i rr-w.J.�✓ i BREWSTER,MA 02631 Undersecretary Not valid signature ACO® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDn'YYY) `./ 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: .9 RO ers and Gra�ProcessJn ---_ 9 ROGERS & GRAY INSURANCE AGENCY INC lAtc_Jin,Exp. (508)398-7980 FAAX Nd): ADDRESS: mail@rogersgray.com 434 ROUTE 134 INSURER(S)AFFORDING COVERAGE NAICM SOUTH DENNIS MA 02660 INSURER A: AIM MUTUAL INS CO 33758_ INSURED INSURER B: FRONTIER ENERGY SOLUTIONS INC INSURER C: INSURERD: 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 TYPE OF ADDL SUER POLICY EFF POLICY EXP LIMITS LTR 'NCO WVD POLICY NUMBER IMMIDDIYYYYI IMM/DDIYYYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE I _ __ CLAIMS-MADE OCCUR DAMAGE T6 RENTEDenrolsES(Ea occurrence/.-. MED EXP(Any one person) $ _ - N/A PERSONAL ADV INJURYS GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ _ POLICY °E T LOC PRODUCTS-COMP/OP AGO $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ — ALL OWNED I SCHEDULED N/A BODILY INJURY(Per accident) f AUTOS NON-O I—_.—_.— - HIREDAUTOS __ NON-OWNED PROPERTY DAMAGE AUTOS `c UMBRELLA LIAR OCCUR EACH OCCURRENCE $ __ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE f _ DED RETENTION$ _ $ WORKERS COMPENSATION X AND EMPLOYERS'LIABILITY STATUTE ERµ A OFANFCERPMEM EREXCLUOED?ECUTWE Y WA N/A VWC10060153152018A 03/14/2018 03/14/2019 E.L.EACH ACCIDENT S 1,000,000 (Mandatory In NH) E.L.DISEASE•EA EMPLOYEE $ 1,000,000 II yes,describe under •DESCRIPTION OF OPERATIONS below I E.L.DISEASE.POLICY LIMIT S 1.000,000 N/A • DESCRIPTION OF OPERATONS/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 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/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 l Harwich MA 02645 (� Daniel M.Cro(fay,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