The URL can be used to link to this page

Home My WebLink AboutBLD-19-003890 J • ° Ya 'Permit# - 'FxS �Pennt e, x pires 6 months frompF ,;,_ issue date. �rr Nabp_�G () EXPRESS BUILDING PERMIT APPLICATJA . E E ; iy TOWN OF YARMOUTH Yarmouth Building Department SAN 2 2(11Q 1146 Route 28 { South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 _... CONSTRUCTION ADDRESS: gra / • a sit essi I 0 ASSESSOR'S INFORMATION: Map: jaS Parcel: J� OWNER: .� � �fgni. i_ a I # 1 r_ �i�`Cl#`CS� e a a �V NAME PRESEN ADDRE TEL. # CONTRACT: cot r►.t . -Ago . Albs a oft r1a a f a) '..i NAMEOF AILING ADD; .eg / tat •♦ - ,I• . W Resi CTdentia) 0 Commercial 0 Est. of Construction$ �! Home Improvement Contractor Lie:# 1 Q rrik15 4 Construe ll-Zeor Lta# I (]S9L Workman's Compensation Insurance: (check one) O I am the homeowneer� 0 I ant the ssolle(proprietor °'I have Worker's Compensation Lnsurance �—�,,y Insurance Company Name: Ica U kta 1 A'Cu I orQa.comp.Policy#/ Co(not '3I 7 OO bn- WORK TO BE PERFORMED 0 Tent (Fire Retardant Certificate attached) 0 Wood Stove Shed • 0 Siding: #of Squares ❑Replacement windows:# 0 Replacement doors: # ❑Re-roof #of Squares D 1n51ilati7n ()Stripping old shingles' ()going over layers of existing roof 0 Old Kings Highway/Historic District n e�y�,,'�['��/J �ry/��f�J Roofing/Sidingr / / (Like for Like) *The debris will be disposed of at: f QLD JCcIVG9I'Q&tom F+QQ 1 i4 Q Location of Facility✓ I declare under penalties of perjury that the stat en • ereia 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 o hot.. • .rosecution under M.O.L Ch.268,Section 1. Applicant's Signature: Data 01006! Owners Signora! (or attach ent) i Date: Approved By: ' �� Data /r2't/ Building Offic.: (or•- , • ) s Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes ❑ No ❑ Yes 0 No 3/ll , Permit Authorization Set mass save Form SMV%" ,tbrC*4 n*o:Sy Oki.Y%4r Site ID: 3460245 Customer: Michael Orton iL„ . U itcyri s-) ,owner of the property located at: (Owner's Name,printed) 26 Kencomsett Circle Yarmouth Port, MA 02675 (Property Street Address) (Cdy) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. Owner's Signature: Date: t<AV'l 12✓ v`� AMYL 4ik a a 4 G a a M a a 8 a a a 4 Ib U'0444#3.W 804 Y 44Jt 4WID 44 4 W 0i 0448k M aG448044 k 40U0ke 44 FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date Name: RISE Engineering Phone: 401-784-3700 Email: For Office Use Only • a The Commonwealth of Massachusetts .sbc 1_t�' S�l Department ofIndustrial Accirlents a,au. 1 Congress Street,Suite 100 e• 214.1i-,s- i Boston, MA 02114-2017 www.niass.gov/dia ire Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers, 1'O BE Ell Er)WITH THE PF:R::llI TING AUTHORITY. Applicant Information rr--yy99 / Please Printtt Leaiblx Name(Busincss'Organizationrtndividual):. 0.3121,�, F ei l t)s-100,S4Q Address:SC' a+/A ujiLH Q-tom — City/State/Zip cy _, j..�1t 63t Phone#: -2]y.._- T7tcY- ..1., _..._,_.—_....._ Are you an employer?Check theappropriate hoe --_- Type of project(required)' I cin a employer with 1,0 employcm i full nicker pnrr•lunel." 7. 0 New construction 2 O I am a sole pmpnemr or partnership and have no employees working for vie a R. 0 Remodeling any capacity INo wnikes'cmnp insurance: required.) 9. ❑Demolition 3❑I am a homeowner doing all work myself f No workers'comp.insurance required J' 10❑Building addition 4.0 I am a homeowner and will be hiring conttaetorl to conduct all work on My property. I will ensure that all contractors either have workers'compensation insurance or are sole II.E1 Electrical repair or additions • proprietors with no employees. 12.0 Plillfibirqj repairs or additions 5 0 I am a genial contractor and thaw hired the aub-cnnWiciore listed on the attached sheet. 13.❑Roof repairs Ilex sub-contractors have embioyees amid have workers'comp muurann 1 - 6 0 We arca carlioratinn end is officers have exercises'their nolo nrcxcmpeau per MGL c. 14,[?Other{ fE�s 4J.f 152,51(4).and we have no employees (No workers'comp Insurance required i `Any applicant that checks boa al must also till out the section hal my xhownm,t their workers'cons pensal loo policy intannali n. - t Homeowners who submit Iles affidavit indicating they are douw all work and then hire outside convectors most isthmi a now affidavit indicating each k'ontmemrs that check this box most cinched an additional sheet showing the'mine or the suh•couvactora and state whether or not those cooties have employees. If the sub-contractors have employees.they must provide their workers'comp policy number I am an employer thefts providing workers'compensation insurance for my employees. Below is the policy and fob site information. (� l� � MM� ,n (� Insurance Company Name:l-E E ] i.OSSr'.!1... �S t 1n�1QQ._• .O.cY\Pais - q ._---. PolicydorSelf-ins.Lie.14 .(UUP ui r9_-� . Expiration Date: �.! 1 .1_ Job Adds: '_ `—Eng the _ _. . �,�pty.n Attach 4 copy o he workers et nutters po Icy declaration page showing the policy n bei nd expirn ion date). 1 a67s-- Failure to secure coverage as required under MGI.c. 152,625A is a enminal violation punishable y a fine up to$1,500.00 and/or unclear imprisonment,as well as civil penalties in the form of a STOP WORK ORDER.and a fine of up Is)$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investgatuns of the DIA for insurance coverage verification. I do hereby certify under dr ai i 'and penalties of perjury that the information provided ab ye ism. and correct. Signature_ lei ....' DatcahL(‘--_..-.._..-.. E sineH..JZq[__a —7— atm _.____._-._.__....� ._._ Official use only. Do not write in this area, to be completed by city or town official a City or Town:____ - _Permit/License p Issuing Authority(circle one): I. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other-- -- Contact Person: ,- Phone a: „__......�..—._...._._.......�._ . 1 ; L ConsVoaion Supervisor Specialty Reg*Sad to: oma. Commonreann oi'eassarnusens C.sux�rnswnq„Cown.aw �f DiosSOO of Professional Uc ensure 80ard of Suaang Re3u4rrons and Sahoards �.Vn$rrs:r•att S apc"d s0'>'FC-a(•.f so— CSSL•105941 Esp•=es.02/1711000 FRANCIS S SHEEHAN S0;HARWICH RD BREWSTER MA 02631 K C FaSun to possess a current edition of me Massachusetts Site Bulking Code Is cause for revocation as this license. 17)777 200 09 abwa w fw.ma nae Call 1 F lafartnatf p wad 1 this s iceuse '/dq Comnnssloner Cet • ' • Office of Consumer Affairs&Business Regulation +! HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Coro0raVon before the expiration date. If found return to: Pegist&atlOR , Expiration Office of Consumer Affairs and Business Regulation `,1608§4,7=,c.-;,-.09/072020 1000 Washington Street-Suite 710 FRONTIER ENETRGYSOWTIONS Boston,MA 02118 FRANCIS SHEEHAN ; _ 502 HARWICH RD BREWSTER.MA 02631 undersecretary Not valid .` signature • ` J AC CERTIFICATE CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIMYYY) 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(les)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 Gray Processing ROGERS & GRAY INSURANCE AGENCY INC PHONE 508 396-7980 FAX No: mail ro ers ra com ADDRESS: @ 9 9 Y• _ —.. 434 ROUTE 134 INSURER(S)AFFORDING COVERAGE NAIL SOUTH DENNIS MA 02660 INSURER A: AIM MUTUAL INS CO 33758 INSURED INSURER B: FRONTIER ENERGY SOLUTIONS INC INSURER C: INSURER D t 502 HARWICH ROAD INSURER E: BREWSTER MA 02631 INSURERF: 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. XP LTR TYPE OF INADDL SURANCE INSD$WVD POLICY NUMBER (UBR MM/DDYIYYVYI (MEFF M`DDmYY) LIMITS COMMERCIAL GENERAL UABILITY EACH OCCURRENCE - rMMMGA`E TO RENTED CLAIMS-MAGE n OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL S.ADV INJURY $ GEN'L AGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ POLICY JET LOC PRODUCTS-COMP/OPAGG S OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ _ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Par accident) $ — NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) _. f UMBRELLA UAB _ OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ �/ $ WORKERS COMPENSATION X PEATUTE ETM AND EMPLOYERS'LIABILITY A OFFICERIMEMBEREXCLUDEOTECUTIVE Y WA NIA VWC10060153152018A 03/14/2018 03/14/2019 E.L.EACH ACCIDENT $ 1,000,000 (Mandatory In NH) E.L.DISEASE•EA EMPLOYEE $ 1,000,000 H yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule.may be attached II 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 Frontier Energy Solutions Inc ACCORDANCE WITH THE POLICY PROVISIONS. 139 Queen Anne Rd Unit 6 AUTHORIZED REPRESENTATIVE Harwich MA 02645 ''r CJ o Daniel M.Cr q y,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