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HomeMy WebLinkAboutBLD-19-003043 ii ,,rant II 411�'1C�!;� I:Protan expires 6 months from • , \_C ,1,. mfr'' tissue date. G EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department . 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS:aga j Th us .__ ASSESSOR'S INFORMATION: IMac p: /97 Parcel: OWNER: � �QCE IM7 " PRESENT ADDRESS a 77 - 37 • (0 CONTRACTOR: ie a.►" ! .'11_ - . .s- A S r s .'& d L!(.i 2 - ' . . NAME MAILING ADDRESS TEL# 'it: -Ci a' 0 Commercial 0 Est.`/Cost of Construction S Si 6o0 Home Improvement Contractor Lie.#.( /l6 015SY Constructloln�SV c?t'Csor Lie.# 'c ,C: —.9( ( r Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor : ,�a1ve Worker's Compensation Insurance / j Insurance Company Name:�v(� , LLA 6?t/1 cF+ _ Worker's Comp.PoliegtDea J (S- WORK TO BE PERFORMED J Tent (Fite Retardant Certificate attached) C Wood Stove Shed D Siding: #of Squares 0 Replacement windows:# 0 Replacement doors: #__ 0 Re-roof: #of Squares ion _ ()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: a e ' di •1 •fit•. t ry iii 11/t . .% II 4 e• •cauo fFacility 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 of; e and far prosecution under M.G.L.Ch.268,Section 1. ♦ `' cc Applicant's Signature: �,;/ ` Date: /fl/kii Owners Signature(or attachment)_ �Q Debt ���"'TTT/ Approved By: <.. Date: 11—t6 -t7 Building Official(or desi Zoning District: i Historical District: 0 Yes 0 No ••. Flood Plain Zona 0 Yes 0 No E C E I V E D Water Resource Protection District Within 100 ft.of Wetlands: Yes 0 No o Yes 0• No . I NOV 16 2018 . . mist,ctfh3,• --rof i Cape Light Vii. Compact sr. a ;; 5 Dupont Avenue South Yarmouth, MA 02664 OWNER AUTHORIZATION FORM I, WAYNE HJERPE (Owner's Name) owner of the property located at: 222 North Dennis Road ---- -- (Street) ---- Yarmouthport, MA 02675 (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. -Customer Signature -Sign Date ----- --------- 5/4/2018 • • . The Commonwealth oJ'Massachusetts —' Department of Industrial Accidents • . dila I Congress Street,Suite 100 �r Boston,414 02114-2017 • t www.toa.ss.gov/dia • Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE Fii.ED),\TTII IIIE PERMITTING AU'TfIORITV. Applicant Informadon — Please Print Legibly s/L Name fnmsincssOrganizanou'Indivldnaq' i )-'s(_ .. ..),fl het/.—,.,:]L vusji2S....j. ., —..._.. Addfes3:_ +/ -�J� Ham.-- - --- ------- CitystateiZi)x yL L }{ ( _631 Phone#: ��37.- CX�a �� — Areyouanemployer?Check the-- appropriate hos: • Type of project(required): r-J r • I urn a crnpinyur with,,.L.k-1,_,_employees I Iidl eudrot purllnncte 7 0 New construction 201 a•navole pntpretor or pamtership and have on employees wn:kuri for me in R. 1 Remodeling ' an'.captor, !No woe'kir,•comp msurnnee iequrted l !—t Y. ;—J Demolition 3 0I am a homeowner um:la all nor k Myself !No,corkers'comp :I ,ince avuued J' 10 0 Building addition 4.0 I am a homeowner and will he hiring contractors to conduct all wodr on my property Iwill entire that all contractors either hove workers'compensation insurance or are sole I I.O Electrical repairs or additions proprietors wall noemployees. 12.0 Plumbing repairs or additions 50Iems general contractor and Hiatt hired the stilodownwrois listed On he attached sheet, 13.0 Roof repairs 'heti.sub Umimc.i,s have enlployees and hive wet Sac:Quip. nsurl lie I 60 Ws are a trporoutnand int omcrshaexercisedihentightalc spruulwrMGLe I4.aothe1t,L }�[}1 � fl I 5:,$I(J and wFaye no employees rNworkers'comp err,puce ietainedi *Any applicant that checks boa k I must also till out the sectolr he:o,showing their workers'eompenaabon policy rnlonnainn. 'tlomemk nos who submit this affidavit intimating they are da.ng lir work and Own hire outside contractors must within rt a new affidavit intimating such rl onnnciors that check this box moat attached an:uldiliunal-lied showing the mune or the subeonlraaots and slime whether or not(hoar MINN have employees. If the sub-conmaemts have employees,they must p'ovide the wake's'rm'tp Ixrl my nun1Ma r^ 1 ant an employer that Is providing workers'compensation insxn'nneefur m y enrpdayees. Below is the policy and job site information. Rv tInsuanceCompanyName:biEjt3 L..fr _MQ- 0Z p- �- __ Policy dorSelf-ins.Lic.INILL,C—(06--.40(5-VISaxn. Expiration Date:__ZJ19 yl___, Job Site Ai!dress( i q��.,�y.(��\ J_�(!nV _..�'„Y )..Ci;ytStatr;lip: Attach a copy o e workers'compi•nsationnoheey declaration page(s(owing the policy n m c'an expiration date . • Failure to secure coverage as required under MGL.c. 152, 625.A is a criminal violation punts able by a line up to$1,500.00 • and/or one-year imprisonment,as well as civil penalties in the form ora STOP WORK ORDER and a fine of up to 1250 00 a day against the violator.A copy of this statement may be forte:vdcd to the Office of Investigations of the WA for insurance -coverage verification. l do hereby certify under th ter •and penalties of perjury that the information provider /1/4‘1,clt'and correct. Sig!lalulC ...... Dales /frt//- (b/ __..._ ...._ PJB 'Si__ ..7_LL-_.a _ - _..---. . .__ .-..__ _... Official use only. Do not write in this arca.to he completed hro cup Or town official. City or Town: __ _ -PcrmidLicense h_ Issuing Authority(circle one): I. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector • G. Other.. —'----'--____ Contact Person: __-___ Phone#: • `s I ®D DATE IMM/DD/YYYYI A`C:PRCERTIFICATE OF LIABILITY INSURANCE DATE 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 GrayProcessing_ ROGERS 8 GRAY INSURANCE AGENCY INCc°NrNo Ern; (508)398-7980 ?(Alc,No): E-MAIL ADDRESS: ro 9 gmail ars raym co 434 ROUTE 134 INSURER(S)AFFORDING COVERAGE 1—NA-IC t SOUTH DENNIS MA 02660 INSURER A: AIM MUTUAL INS CO _3.3758_ _ 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. ___ INSRrypE OFINSURANCE ADDL SUER POLICY EFF POLICY EXP LIMITS LTRINSD WV() POLICY NUMBER (MMIODIYYYYI IMM/DOIYYYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED _CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) § N/A PERSONAL SADV INJURY $ - _ r GEN'L AGGREGAATT1E LIMIT APPLIES PER', I GENERAL AGGREGATE f _^ POLICY TA 1 I LOC PRODUCTS-COMPrOP AGG $ OTHER: 1 1 I S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ,j�acodenJ_ ___�_._.__. — ANY AUTO BODILY INJURY(Per person) I$ ALL OWNED SCHEDULED N/A BODILY INJURY(Per accidengr$ AUTOS _ AUTOS NUN-OWNEDPRaE AGE $ HIRED AUTOS _AUTOS 1Per accident)aenU . $ UMBRELLA UABOCCUR EACH OCCURRENCE S — EXCESS LIAR 1CLAIMS-MADE N/A AGGREGATE S DED RETENTION$ $ WORKERS COMPENSATION I X STATUTE 1-...1 ER{_ AND EMPLOYERS'LIABILITY YIN ANYPROPRIETOR/PARTNEWEXECUTIVE ci E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBER EXCLUDED? N/A N/A VWC10060153152018A 03/14/2018 03/14/2019 - --- (MandatoryInNH) EL.DISEASE.EA EMPLOYEE $__1,000,000 II yea,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT $ 1,000,000 N/A • DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101.Additional Remarks Schedule,may be attached It 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 Harwich MA 02645 Daniel M.Crawley,CPCU,Vice President–Residual Market–WCRIBMA I ©1988.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD • 1 ' a • Construction Supervisor Specialty Commonwealth ol Massachusetts Restocked<N ‘7' :rvsion of Professional La emwe CsSLaC-thumbs..Connacto Board a'guesmg Regulanons era Standaros l,. on Sorr.•rso'incc.ar; f CSSL•1554, !Sprat 01:17.2020 FRANCIS S S&CEEHAN SO2 MARWICKRD BREWSTER MA 025)1 ^" ? Failure to possess a current edition of the Massachusetts i . Stam etMding Code is cause for revocation of this kensa. Foe iofv<Mion about this license cn J7 Caa(117)7274200 cc .. vise ww.mass.govNlpl Comrn;ssioner ��M•• t {. • .ab 1:011/n riww///. (f:.474)47/%'&e/4 Office of Consumer Affairs 8 Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:COrooration before the expiration date. If found return to: - - Rectistr'atOq f?cpiration Office of Consumer Affairs and Business Regulation 1606.54.'.-. - 09/072020 1000 Washington Street•Suite 710 FRONTIER ENERGY SOLUTIONS Boston.MA 02118 FRANCIS SHEEHAN �2-CCect —. • •502HARWICHRD L. - I BREWSTER,MA 02631 Undersecretary Not valisignature