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HomeMy WebLinkAboutBLD-19-002799 y�F'C;Ajf ?Permit# 69� 2 " ' 3S— • 90 .9 'Fees Yerrnit expires 6 months Cram � 7r✓_'; ?issue date. ht � Ynm%� `" BCb-!Q-uDa--7 g ct EXPRESS BUILDING PERMIT APPLIC r ' • E I V E D TOWN OF YARMOUTH Yarmouth Building Department • 1146 Route 28 NOV 0 6 2018 South Yarmouth, MA 02664 '.�, (508) 398-2231 Ext. 1261 6Oi:tip +i 'T Jr By: r CONSTRUCTIONADDRESS:3.9 EfAtELo a .. s ASSESSOR'S INFORMATION: Map: 9C) _ Parcel: 7 OWNER: U Si! . 0 0 _ • V• r. 61,01--S-3N E — PRESENT ADDRESS /y/yI�,TEEL. # CONTRACTOR: . A � rs� f n !"i )1/1{ 'n, f l L937-04/6 esidential 0 Commercial �/(1 0 Eat.Cost of Construction$ TBi CO 2 • Home improvement Contractor Lic.# !DS l —1 I Construction Supervisor Lie.# 1 CJ V�(1 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 2 ..4WWorker's Compensation Insurance Insurance Company Nam e• A obAcal .0Q2Worker's Comp.Policy (icS'590 49ri- WORK TO BE PERFORMED o Tent (Fire Retardant Certificate attached) 0 Wood Stove Shy 9 Siding: #of Squares 0 Replacement windows:# 0 Replacement doors: # 0 Re-roof. #of Squares non ()Stripping old shingles' ()going over layers of existing roof 0 Old Kings Highwayftlistode District Roofing/Siding(Like for Like) Q Q �a3 X11 ' 'The debris will be disposed of at: 13� L� '► 1 tor• . _.. '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 tmowledge and belief. I understand that any false answer(s) will be just cause for denial or revocation of my license and for prosecution under Mal.Ch.268,Section 1. Applicant's Signature: _ _ DatC110 Owners Signature(or attachment) "'wile OF 4— laaw s Date: ofill Approved By: / i Date: 7/ /7 .--/‘ Buil.' :O s.- a(or designee) 4 Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District. Within 100 ft.of Wetlands: ❑ Yes J No ❑ Yes ❑- No 3/01 RISE ENGINEERING OWNER AUTHORIZATION FORM I, Marie Keough (Owner's Name) owner of the property located at: (Property Address),32 Brae Burn Lane South Yarmouth, a (PropeMArty Add02664ress) 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 ., u 0wnet"s ure �f C Signat I ; I , � rr i :, I � 16 iy + ,1ar Xv74w' JL nr+ ., j , , I .{• oaf : Data.' + , s y, LS' r T , •3.t ,d':,;, r I i I ity Sy a E','.. ' s, ; —^ "\ The Commonwealth of Massachusetts k7 Department of Industrial Accidents t"—t FM_ 1 Congress Street,Suite 100 ',1/44r- Boston, 414 02114-2017 Skc noun mo.ss.gov/din Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. II) Ise ru I n WI I n f111'.Pfltall l ING AC ruoarcr. Applicant Information ('lease Print Le>;ibl) Name ill,srncssOrgan,zatiun'Individuall:r /J1-sr ..,_ x2ttei- Gr'_1217.co.S..ll.Lt__. . - Address:_Ca—i-{.iZL...tip-:\ ._- - — —... _-- _____ CiI,'Stale/AlanI tott,M,fk ct63( Phone# 7y_. a 37- Cx-E.I. Are Hull an em plover (.heck theappropriate hes: Type of project(required): Illi am a employer w'.Ih_ .0_employees ifoil unto:iglu times' 7. ❑New construction 2 U I am a sole pmprmnr or partnership and have no employees wo;kmi for we in 8 U Remodeling 'n .p ,eai:ty [No weaker:'comp insurance 'coned.! �-� 9. n Dent o IIIA, U 3 I an a homeowner doing all work myself (No workers'snap,n mince required i', 10 ❑ Building addc.:on 4.E]lam a homeowner and will be hiring ontrNcloin to conduct allwork on ray p+operly. I will ensure that all contractors either have worker S.compensation ma ranee or are eine I LU PItci tical repairs or additions proprietors with no employees, 12.E Plumbing repairs or additions 5 El i am a Ke:eml.:ntiaeItl and thaw tin ei:A.srl ni•n,Lor!MI ht.:aimed thea 13.U I(oorn:pais 'hesea-cemrat nhave en:oloyecs end h. t .y ,thvith it c r �.1�k 14. thet�A.�=lr-1-Ia1i .�I4r✓ (,0We me n . menan nand its idlicers have ort wd Men l an of es apron pm MGL e. -.. f I mai,end w hive no mimics ens IN shirkers comp list railer i equmed l 'Any Applicant that checks box o NI must also till out the section new:showing men worker: c ongknsauon policy mini mum:A t Humeownns who submit(bra altalavil indicating they are doing all work and them hire outside cuntrnoory must submit a now afralion Indican ire with tcumrecroN thin check this hog aunt aimKhed an additional sheet showing the name oldie euh.e,pnactors mrd stare whelhm or earl those cornice hart nrq+loycuv. II the'sub'cOniitaClOtm have employees.dies nowt ptovmy they mo:kris: policy•romnun T--,_. /am an en:plover that is providing workers'cmnpensmlion invu min'efor toy e'nlplorers. Below is they polity and job site Win-motion. � ��t--7-/ ,(� (� (� Insurance Company Vzmeklji-t �k,Jll.70 l.:a- uy►,�C.. -....0`_s�i\P pais)._ d or Self-ins.Lie.A4& „roc-100 I �-_ . l.Str7Da}2, Expiration Date: 'i l j]Cj. Job 1.1e Address: ____, City/State/Zip' _. .... Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGI.c 152, @?A is a criminal viol Liman punishable by a line up to$l.500.O0 acd/or ore-year imprisonment.as well as clot pena'irc.in the ern of a S'i OP WORK I'Rot K and line of tea In)82.50 COa day against the violator.A copy of this slalom:nt run) Lc Io:`.; i dcdi to tine(yl f;ee o1 Inseot.galions of the DR to: insurance coverage verification. I do hereby certify under t8 tri 'and peitaltie.e of perjury dual the information provided above is true and correct. Signalulc _. Date —_. _ -.._...,_ O/fn ietl ace only. Do not write ler Otis area to I t e�anpfetr 'by rill'or town off lint — --_= n Cin or"town: I'er mit l icense n___ _... --......_-I _._ Issuing \uthorily(circle one): I. Board of health 2.Building Department 3.Ciryi'Ibwn Clerk 4, Electrical Inspector 5. Plumbing Inspector G. Other ____ Contact Person: Phone#:_____________________ • 1 n a Construction Supervisor Specially una„anxeean of MassachusettE Reserl,dlo- n n or P'o'es tonal Latino. CSSl+C•tnsu4nn un Conuaa Soara-n!S nyno Rt9ubbOns sou Staos CSS.-10590' tepees Sat',2.32: FRANCIS S SISRERAN 502 HARWICH RD BREWSTER MA 02631 Failure to possess a current eaten of the Massachusetts - State Building Code Is cause for'notational this bans*. f a inlormatten about this license n r � Cau{61T)727.1200 or visit www.mass.gov:Ap Corem,ss•one• • ./7:, yy.,# ,,v.i..m/J4 et/4r,w am.”V/.J Office of Consumer Affairs&Business Regulation I HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corcorabon before the expiration date. If found return to: Regisb-ation .. Exniratioft Office of Consumer Affairs and Business Regulation 160864.--- 09107i2020 1000 Washington Street-Suite 710 FRONTIER ENERGY SOIJJTIONS Boston,MA 02118 .FRANCIS SHEEHAN ' ' 502 HARWICH RD t--` BREWSTER,MA 02631 Undersecretary Not valid " • signature .., A�® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 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 Rogers and Gray Processing ROGERS& GRAY INSURANCE AGENCY INC jNcjlo,Eat): {508)3.98-7980 FAX E-MAIL DDRE mail©rogersDray.com 434 ROUTE 134 __INSURER(s)AFFORDING COVERAGE NAICN SOUTH DENNIS MA 02660 INSURERA: 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. INSR DL )2 POLICYEFF POLICY EXP LIMITS LTR TYPE OF INSURANCE MDWVD POLICY NUMBER IMMIPD/YYVY) IMM/DDNYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ -DAMAGE TO RENTED CLAIMS-MADE _ OCCUR PREMISES(Ea occurrence) $ MED EXP(My one person) $ N/A PERSONAL f ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY[ 1 JECCT [J LOCPRODUCTS-COMP/OP AGGS_ OTHER: I i I i S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ _LER accident/ ANY AUTO • BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ _ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS _- AUTOS (Per accident) $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ _ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ I DED RETENTION$ i $ • 'WORKERS COMPENSATIONXLTAPERTUTE.f__ ER 0TH. AND EMPLOYERS'LIABILITY ANYPROPRIETORIPARTNERUEXEOUTIVE Y/N E.L.EACH ACCIDENT $ 1,000,000 A OFFICEROAEMBEREXCLUDEDY N/AEl N/A VWC10060153152018A • 03/14/2018 03/14/2019 — _.. (MandatorylnNM) EL.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below EL.DISEASE•POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule.may be Beached If more space le 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 Harwich MA 02645 Daniel M.Cr Daaniel aWy,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