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HomeMy WebLinkAboutBLD-19-003299 ,air,,.. RISE �,�... ENGINEERING' OWNER AUTHORIZATION FORM I, Jean Rawdon (Owner's Name) owner of the property located at: 36 Sunset Drive (Property Address) Bass River, MA 02664 (Property Address) 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. 91e-- 44ArtLei wner's Signature Ie 1 . • " IP Date RISE Engineering, a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com • • • • ` The Commonwealth ofMassachusetts 1_ tt Department of Industrial Accidents ' T' I Congress Street,Suite 100 • = I'�i .a Boston, MA 02114-2017 mlaw,!Hass'.gov/din Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. • 10 HE r L.EH)WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly • Name (ismcsslOrganizanon'Individual): .f2,ce.. .adcct' IIVY. j . ,..__ City/Salu/4;RPcI • R�.i._.it63( Pi,ono#_7.7q - 37-_C:X�J._l . ..-.__ A re)au an Check employer? the appropriate ho' v /1 Type of project(required): IE in a employer withay�__employca t MI,soman plonlumer• 7. ❑New construction 2.O I an a sole proprietor or partnership and have no employee'we.king for nm in R. El Remodeling en+capxrrly (No win kels'rump insurance 'inhaled I t—I Y. �,J Demolition 3 C I am a hmneow:.ter comp all work myself INo workers swop.in..anmce required)' 10 ❑ Building addition 6_0 I am a homeowner and will be hiring ul lrm:lois to unnluol all work on my property I will ra ensure that all contractors either have workers'compensation flaira nee or are sole I IC Electrical repatn or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5 0 I am a general:.ntra.tot and ttave hY l the shIbeomi into.,limed on thu attached sheet 13.0 Roof repairs - h setib-connot xs have enrployees amibt-e at tr lamp tnu gnu° • 6❑We arc a:orixnraun and its officers have exerchied then richt or excininam!Mr MGL a. 14.00therb-b1.i " ti ( 152,El(al.And we hive no employees INo thinkers'comp insiipmett lined; — _... •Any applicant dial checks box r I must also till out the section het __shoofly taco workers'compensation policy tntummtton. a Hnntenvncn who submit this affidavit indicating they arc doing all work and then hire nnlsaLL r nuataors',nisi submit a new afndava iodisation,such 'Cnnlrselor9 than check this lion must ullneltetl all addhionnl sheet showllll'the u01me of the 9'b.euntrnc tits and stale whcthcl or not Ihasc themes have employees. If the sub-ronaaams have employees.they must provide her win ke!s'comp Willey aumbta I an;an employer that is providing workers'compensation insurance for my employ'ee.s. Belie is the policy and job site information. it MOT � p `,n (� Insurance Company Name:XLI-�_ 4tj 1 ( f La.-/ '..,a�5,... k,R,c --10 um Pico, "� -.-- Policy rl or Self ins Lie.#40e (GCS-��CQk Sz, a.0 1-) Expiration Date: :41�i ( • ..._- • Job Site Addressal _._V.1b., _.--.._ (Thy/Stab:77i pl., Attach a copy of the workers'compensation policy declaration page(showing the policy in beg an expiration d:fr v vv-1 Failure to secure coverage as required under MGL.c. 1.52,¢25A is a criminal violation penis)able by a lineup to$1,500.00 • and/or ore-year imprisonment,as well as civil penalties in the form of ft STOP WORK ORDER and a fine of up to:5250 00 a day against the violator.A copy of this statement may he fonanted to the Orrice of Investigations of the DIA for insurance • coverage verification. Ik,hereby certify under th ni •and penalties of perjury that the information provided above is ncc and c;erect. i ' /^� � ---` Pate ---// '�V _._... p. Official use only. Do not write in this area,to he completed lar cit)or town official City or Town: __ Permit/Licensefs • .._ — Issuing Authority(circle one):~� • I. Board of Ilealth 2.Building Department 3.Cityil•own Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other_....... -_-----__......._ Contact Person: Phone 4:_.__...__.._-.....—_--- • • Construction Supervisor Specialty Cun•nwnweann al 7lassatnuse3s t»swicrW to: De.smn of professional L6enswe C33L4C.Insulation Connector Sward a'9..1.re Regulations ana S:anda.as r CSSL.1-3554' Exp.,e‘ 02:17 232:3 '41 44- FRANCIS S SstEEttAN s 'z- $02HARWICH RD r . BRE WSTER MA 02631 Failure to possess a current eaifon of the Massactweens State suckling Code is cause lot revocation&Mis leen se. For 1273200 se about visitw nsficesg se Call iF ,aI TnM a vis6 w«w liven Sov!apl Comms sone- t • . we mioiWii4 r/..7e,rF:Je.wiuer, Office of Consumer Affairs 8 Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Generation before the expiration date. If found return to: Registration -, Fxniration Office of Consumer Affairs and Business Regulation 160854 -- ...09/0712020 1000 Washington Street-Suite 710 FRONTIER ENERGY SOWTIONS Boston,MA 02118 3 I FRANCIS SHEEHAN / f`.-.'>--. •502 HARWICH RD "3 BREWSTER,MA 02631 Undersecretary Not valid signature • 1 A ! 7DATE(MODIYYYY) l-f Q CERTIFICATE OF LIABILITY INSURANCE 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 CONTNAME:ACT Rogers and Gray Processing ROGERS &GRAY INSURANCE AGENCY INC PtnMONC. EaO; (506)398-7980 FAX NP): E-MAIL mail ro ars ra com ADDDREDRE SS: 9 Y' _ 434 ROUTE 134 INSURERfSLFFORDING COVERAGE I NAICS SOUTH DENNIS MA 02660 INSURERA_AIM MUTUAL INS CO 33758-- INSURED INSURED _INSURER B: -- --_!-- -- FRONTIER ENERGY SOLUTIONS INC INsuRERc_ _____ ___ 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. INSR1 ADOL sueR POLICY EFF— POLICY EXP LTR TYPE OF INSURANCE INSDI VAID POLICY NUMBER —I—POLICY I IMMIDDIVYYYI I LIMITS COMMERCIAL GENERAL LIABILITY ' EACH OCCURRENCE E I DAMAGE TO RENTED CLAIMS-MADE U OCCUR PREMISELLEa occurrence) S MED EXP(Any one parson) S N/A PERSONAL 5ADV INJURY E GENt AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE E POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG E OTHER: E AUTOMOBILE LIABILITY , i I I COMBINED SINGLE LIMIT ,$ fEa accident)_ ANY AUTO __ I BODILY INJURY(Pe pe son) 1 E ALL OWNED SCHEDULED N/A BODILY INJURY(Peraccdenq�E • AUTOS AUNqTOS N-OWNED - — HIRED AUTOS AUTOS jPer ac den],_,,, rE la UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS-MADE N/A AGGREGATE S DED RETENTIONS �/ STA $ I WORKERS COMPENSATION X TI�TE SOTµ AND EMPLOYERS'LIABILITY ANYPROPRIETORIPARTNERIEXECUTIVE VI" - r E.L.EACH ACCIDENT E 1,000,000 A OFFICER/MEMBER EXCLUDED? NIA l N/A N/A VWC10060153152018A l 03/14/2018 03/14/2019 — /MandatoryInNH) E.L.DISEASE•EA EMPLOYEEIE 1000,000 R yes.describe under T DESCRIPTION OF OPERATIONS below I I E.L.DISEASE•POLICY LIMIT i S 1,000,000 • N/A DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES IACORD 101,Additional Remarks Schedule,may be attached If mon spec*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.govllwd/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 Frontier Energy Solutions IncACCORDANCE WITH THE POLICY PROVISIONS. 139 Queen Anne Rd Unit 6 AUTHORIZED REPRESENTATIVE Harwich MA 02645 ,A�q Daniel M.Crowley.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