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HomeMy WebLinkAboutBLD-19-3610 0� If§t t•tl•'- /9=07)1/0 3-r °0\,IFroS Permit expires 6 months fr • ‘;'),C.:.5. 4. 'fissile date. EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH ........... . Yarmouth Building Department { C C k v 1146 Route 28 — — — South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 I DEC 14 2018 CONSTRUCTION ADDRESS:37 eeLi-ekilf BUILDINGDET'ARTi.laIT ASSESSOR'S INFORMATION: /�S1 Map: (x/93 Parcel: / 2 /y J� OWNER: LQp `i 'Q f'I 1TN 37ags1SWJ lQ f 714 -9-53 w/o CONTRACTOR�_llvvnnMM:—}(B O J`F ` nnn���DD . el 'T'P is A1)Ylq.•ea- . . :'AME a DRE'S • 0 rsl A-caflAI . ❑ . ential 0 Commercial�--, { p ❑lEst. �Cost of Construction S�J'SI 0 0 , Borne Improvement Contractor Lie.# f IQYS Y Construction Supervisor Lie.# 'C..---q-CI I Workman's Compensation Insurance: (check one) 1 � 0 I am the homeou - 0 1 am the sole proprietor `'_"[have Worker's Compensation Insurance Insurance Company Nam; I //''�� cy��V0(� I� ( P y• U M a� Docker's Comp.Poli WORK TO BE PERFORMED 0 Tent (Fire Retardant Certificate attached) 0 Wood Stove Shed 0 Siding: #of Squares ❑Replacement windows:# • 0 Replacement doors: # ' ❑Re•mof: #of Squareson ()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 otaaA 41 _ Ad A) .' l %L 1 Apt . I II //ll,_, Location of Facility I declare under penalties of perjury that the statements herein oontalned are 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 o my license and for prosecution under M.O.L Ch.268,Section 1. n Applicant's Signa • ®.a .. Date /CJ`/IO/i? Owners SI• lure(or attach -at)% /S•I�/" a ij';7 Date: om Approved By: ' 4_ Date: /2- s//t( '//f Building Ofc'• ord« !�i Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Ycs D No ❑ Yes 0• No 3/01 I RISE'. ENGINEERING' OWNER AUTHORIZATION FORM 1, Leslie J Altman (Owner's Name) owner of the property located at: 372 Route 6A Street (Property Address) Yarmouthport, MA 02675 (Property Address) hereby authorize (Subcontractor) Fr 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. Owner's Signature rD /ib (C Date RISE Engineering, a Division of Thlelsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508.568-1926 www.RlSEengineering.com -4±L''� The Common wealth of Massachusetts Department of Industrial Accidents 9 t• it' ca rate 1 Congress Street,Suite 100 !INE . Boston, MA 02114-2017 /s wlvwnras.s.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO UI.Ell I'D WITH THE PERMITTING AUTHORITY Applicant Information - y� CCI -�Ple�asse Print�/ Legibly Mame(fusincss'Orgamxation!Individual)ThfEC-,,_.ce `-Q/i.)S7 s,,l_C�s_.Jk ____ CityStitteicipant Etfk_CO,63( Phone#: 77Q. 37..S.xk.I ��__ Art you an employer?Check the appropriate hos: Type of project(required): I ( tin a employer w oh l. --rinployees'full auto.parol:olti• . 7. 0 New construction 2 Di am a sole proprietor or partnership and have no employees wo:king for are in 8. 0 Remodeling my rapacity 'No wan ken'romp insurance r¢gmied.I I--I , 9. ❑Demolition 3 I vn a homeowner pomp all wok myself'No workers'comp.insaraue required I' r� 10 0 Budding addition 4 01 am ahomeowner and will be hiring pro to conduct all work on my property. I will ensurea worker that all colanders either have workers'compensation montane or are sae 11.0 Electrical repairs or additions proprietors with no employes. 12.0 Plumbing repairs or additions 50 I am a general contractor.and;have hired the use ,nlalmn tilled Jlt the attached shed 13.0 Roof repairs J These sub-contractors have employees ua.ht ,,w . n n t romp. Isucef -� 6 0 Ws are a m xnai rn and its officers haveexercised their rush!of as inphuu per MG L u. I4.�lhCr�A- } �,(. 152,) t Ilgl,and se rive no employees No svncLen rap mrnn a requited) ___ __..- __.._ 'Any Npplk sat that cheeks box SI mast also till oin the section helve-slo'w'ing their workers'comnpcnsanan policy in lonnaorn. t Hnnmuwnms whu mh:nit nus affidavit Indtatnng they are doing all work and Then hire oanido pamperers must submit a new affidavit mdmating such :Contractors that check this box must attached an additional slicer showing the name of the sub-ennhactors and shite w hclhei or not throe comics have employees. If the sub-cunlrielots have employees,they must provide(heir sse:kers comp policy number I am an employer that Is prodding workers'compensator-insurance for my employees Below is the policy and job.site informalion. Es; �-r �'�, p ,p (� Insurance Company Name! lt"' u vAle,t.)..ar��,,,.e`..'.ifl 0 U' t-' - _______ Policy e ur Self-ins.Lic.a4UOC._ (QCU-fee l_s-31.S-_-a 3.. Expiration Date _3ii.y 19__— Job Site AJdressa de,rr�[7CirylState/lip �mQ ..1,6 Attach a copy of the workers'compensation policy declaration page(showing the polis ,I umber and expiration date Failure to secure coverage as required under MGL.c. 152,425A is a criminal violation punts rabic by a tine up to$1,500.00 and/or ore-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250 00 a day against the violator.A copy of this statement may be forwarded to the office of Investigations of the DIA for insurance coverage verification. I do hereby certify under tit ar and penalties of perjury that life Information provided abovv..'is nu and correct. Signature.: . « p Date. /9 i/) P ...__.- _. Official use only. Do not write in this arca,to he completed hr city in awn official Cit or Town: • Permit/License p _.._ Issuing Authority(circle one): I. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: __— Phone k:_ — ____ ''s• - . . 1 i • S . . Construction Supervisor Specialty ttattclefl to: 7 vsoncoor Protossional L m.r.v....Cl"risssacnusens OrICCOSL.10 C-ISL4C-Insulation Cootractor Sena o!&Mains ReDawson*vitt Strop-us - a •.1 es,...::,an Supe'-neo-.3. c a I CSS1•105941 !series 02:1712020 FRANCIS s SetEEtUtiN , 502 HARWICH RD A BREWSTER MA 02621 ,ista, f Wipe to possess a current edition ottneMaseacituselts Sin Bonding Code lacause 1 ,.vocation a Mt,tense. Fat iolormalion about Mee Ac cita f , •• all11 - C ( 17)727420$or visit sewwss .ma .povided Commiss,oner a i - . • 1 i ...R.; ).....;winerni~git e,/,/Keb;.sar4nor/4 • Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Ccrporabon before the expiration date. if found return to: 1 I I Registrant:In_ Expiration Office of Consumer Affairs and Business Regulation ...... .- 160084.z:- .l.,--09/07/2020 1000 Washington Street-Suite 710 FRONTIER ENERGY,:SO‘LITIONS Boston,MA 02118 ; . wit5ate., ,FRANCIS SHEEHAN"!2' ".. cy-Cear-e--- s ' .502 HARWICH RD ‘'Z -.•--- BREWSTER.MA 02631 Not valid Tsignature Undersecretary i 1 i I , I ... . AC CERTIFICATE CERTIFICATE OF LIABILITY INSURANCE DATE IMMIDD YYYY) 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 pollcy(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 CON Rogers and Gray Processing ROGERS &GRAY INSURANCE AGENCY INC PHONE p a_(508)398-7960 lac,No): ADDRESS: mail©rogersgray.com 434 ROUTE 134 INSURER(s)AFFORDING COVERAGE NAICt _SOU_TH DENNIS_____ MA 02660 INSURERA: AIM MUTUAL INS CO 33758 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. I`Tq TYPE OF INSURANCE IADDL SUBR POLICY EFF POLICY EXP LIMITS INSD MEL POLICY NUMBER IMM/DDIYYYyn (MMIDD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE E MAGE TO RENT CLAIMS-MADE n OCCUR PREM SES(Ea occurrence ce) f MED EXP(Any one person) f _ N/A PERSONAL f ADV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER; GENERAL AGGREGATE f 1POLICY PRO- LOC PRODUCTS.COMP/CP AGO E ECT OTHER, S I AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea— LI ectoderm ANY AUTO BODILY INJURY(Per person) f 1 ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) E AUTOS NON.OWNED PROPERTY DAMAGE S I HIRED AUTOS — AUTOS (Per accident) UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE N/A AGGREGATE 5 DED RETENTIONS �/ STAS WORKERS COMPENSATION X TUTE IOT I AND EMPLOYERS'LIABILITY A OFFCERMEMBERE CLUDEDPECUTIVE N/A N/A 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 S 1,000,000 II yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT S 1,000,000 N/A DESCRIPTION OF OPERATORS I LOCATIONS/VEHICLES(AGGRO 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/lwd/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 to M. Crq Daniel Croy,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