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Home My WebLink AboutBLD-19-003887 I + 1 (47:71).15.ii - l'Permit A ?` !Fees aS" " r-• . � ^Permit expires 6 months from cs, ;?'1�•,'✓iL4 $issue date. it EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH ) RECEIVED Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 I JAN 02 2811 (508) 398-2231 Ext, 1261 1 L T t• JE ' �RTi ENT CONSTRUCTION ADDRESS: 1534 C ilia s I f ASSESSOR'S INFORMATION: ------- -- - -- ' - Map: /95--- 2 Parcel: W OWNER: 0.9.114e7 YO /i4is/f�Jr//oi NAME -PRESENT T7 14- 37— owD CONTRACTOR: e0V's�tA1� n-PJGFDR7jf� ��R NAME esidential 0 Commercial 0 Est.Cost offConstruction S 1�(CO . Rome improvement Contractor Lie:# t yl' Constructi WPP5FF Lie.# 111ci(4( Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor aveWorker's Compensation Insurance / Insurance Company Name: A v _/I.i I A ! Comp.Policy#f tD(/)OI B VI 3-0001- WORK 00L a -WORK TO BE PERFORMED 0 Tent (Fire Retardant Certificate attached) 0 Wood Stove Shed 0 Siding: #of Squares 0 Replacement windows:# 0 Replacement doors: # 0 Re-root #of Squares . tir- ()Stripping old shingles' ()going over layers of existing roof ❑ Old Kings Highway/Historic District ��y ,,�j Roofing/Siding(Like for Lille) 'The debris will be disposed of at: 13?Cis ' _PQt&'/`- etoC ( Y�Il-gee(S Locatio ofFaciUty I declare under penalties of perjury that the statements herein contained are true and correct to the best of my Imowledge and belief. I understand that any false answer(s) will be just cause for denial or revocati•: '/Cr 'cense and for prosecution under M.O.L.Ch.268,Section I, Applicant's Signature: : i AO. Data Owners Signatur (or attars sent) s t at 'a_ If'. 'La - Date: / '�'"�?1�'r Approved By: f le='//lr Date: / �� ding 0 slyf�l!„”+../r2 1 Zoning District: Historical District: 0 Yes 0 No flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes ❑ No 0 Yes 0• No 3/01 I f I rs Permit Authorization mass save Form S.wr+,nx tlwt n$e.urwv,a'+114.'c Site ID: 3551406 Customer: Craig Holmes I, C ( a'S No I M CS , owner of the property located at: (Owner's Name,primed) 184 Eileen Street Yarmouth Port, MA 02675 (Property Street Address) (CIty) 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. ' deit7 ' / Owner's Signature: 1 Date: Iv - a3- Id�) 4 41 SI h 4,. n4ini ,>44 vp'.4 1. .] . d,1 V.. . , f h h44, .d 'AI Citi-, h e f& -a a h F4,4a, 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: Page 1 of 1 For Office Use Only Rev.102015 L' The commonwealth of'Massachusetts R.--..t.i.-€1- , Department of Industrial Accidents a.Pa�= 1 Congress Street,Suite 100 a�:l-= . Boston, MA 02 11 4-2 01 7 wwwma.ss.gov/din Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE Ell Fly WITH THE EE.R?HITTING AUTHORITY. 1 Applicant Information [" �.,, �^�P�lelasse Print Leaibh' Name(Businncsrs:iOrrgganizstioonttllndividuall re,0 ,l :_,�tzs./ -�j(,-11-1,e -42.Y_.Jr.a. .._-,......._. Address:_57C)ra_t ter-1L��LH le3a_ _ / ---- CilyStatezipag �,C�_.op6 1 Phone#: 7tQ.-aS tQcr.t._I.-0__— Are you an employer?Check,�thi�s1 appropriate has: Type of project(required): Dina employer with_j.yrmnployees[full torpor pan-tuna* 7. 0 New construction 2.O I sin a sole proprietor or pnrniership and have no employees working for me in 8. ❑Remodeling any capacity INo win n ker%'comp insurance removal! , 9. ❑Demolition ED3 I am a homeowner doing MI wink myself INo workers'comp.tosarance required 1' r-, 10 0 Building add mon 0 u lame homeowner and will ba hiring 1:011(Mit)11 kes'C to conduct all wok on my property. I will ensure thin all contractors either hove workers'compensation insurance or are role 11.0 Electrical repairs or additions proprietor with no employers. 12.0 Plumbing repairs or additions 5 0 I amu general contractor and hove hired the seb.a.,nracwi.listed on the attached sheet 13.0 Roof repairs 'hese sub-coomciers have employees ami have wmkerti comp insurance t 6 Q W%ara a arthwrriuon and its officers have uxmri.ccd ihrir right of exemption perMGL e. I4.Q'bthel1' .U• 15.,$1(4).and we have no employees ;Nn workers'comp matinee iequ red I •Any applicant that checks box Si must also till out the section below showing their workers compensation policy intonnnlvm. s Ilmmcow nem who submit this affidavit indicating they me doing all work and then hire ouuido convectors must submit a new affidavit indicating such :1.'un ouctors that check this hoz mut winched an add ii unnl chem showing the uanse of the sub-enutractorn rind state whether or not those enuoct have cmployces. If the sub-contractors love employees,they must provide then workers romp poi icy nunibin I am an employer that is providing workers'compensation Into ronCe for my employees. Below is the policy and job.site information. �,-r, 1 ''C''� '� O n �t1 /� peas_Insurance CompanyName:PcLf- ._k011,14�C2rf- ...yi.a�Ilyt�3 _l (pm-F f--t- q PolicydorSelf-ins.Lic. t.)C, (OQ"(0PL �VISQEL!P%. Expiration Date:_ Z3Jly. ,i_9I y� __ cob Site Address! ^ %. _ City/State/lip:� ' 1 cabx- Attach a copy of the workers'compensation policy declaration page(showing the policy nu ober and expiration date). Failure to secure coverage as required under h1Gl..c. 152,¢25.A is a criminal violation punishub a by a tine up lu$1,500.00 and/or one-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 Invest igah ions of the DIA for insurance coverage verification. I do hereby certify under th al 'and penalties ofperjury that the Information provideda ve L-true ant correct. Sign orrice ___ ._ Dale' Phone tf inNne? -7` OR.Q--_w—�._ _._._._....,__..___.._�_,...._...._._ ..._._.._.. Official use only. Do not write in this arra,to he completed by citr or tont official. City or Town: _ Permit/License N __._ Issuing Authority(circle one): I. Board of Health 2.Building Department 3.City/town Clerk 4.Electrical Inspector 5.Plumbing Inspector -6.;Othet_ — -_. contact Person: —.- Phone#:__-_ . i ' • a •- Construction Supervisor Specialty COmngnwNnn 01'.1aSSJCnuSe!!S OateMaJ to: DN,xbn Ol Piot.ssional LNentbre CanlK'IMVWino Contractor Board o!B011d1n6 Regulations and SNnduds • ♦ : OnS'r',V•]a SS oc.(,a0:'3Jc.].Afv CSSt•10$941 Eipnes.02:1Tr2020 FRANCIS S SHEEHAN 502 HARWICHRD • ^ BREWSTER MA 02621 Esau,*to possess current f rev of Massa livens Stow auiquf Code Is sauna fp/revocation of Ibis Wenn. for 727420wartbn about this license S Can(6 TT)2274206 or Wen mass.gewidp1 Commissioner 11 • - 1 Office of Consumer Affairs S Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE Corboration before the expiration date. If found return to: Registr'atidq ,, Expiratioq Office of Consumer Affairs and Business Regulation 180854..; 2.. 09/07/2020 1000 Washington Street-Suite 710 - I FRONTIER ENEROYSOUITIONS Boston,MA 02118 ' C,T••• FRANCIS SHEEHAN I,Q,Clp-- a "` .502 HARWICH RI)• (� f _ BREWSTER,MA 02E31 Undersecretary Not valid signature , , AccoRa ® CERTIFICATE OF LIABILITY INSURANCE OATE(MMNDY/YY) 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 polley(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 Rogers and Gray Processing ROGERS & GRAY INSURANCE AGENCY INC j HO No.Ea6 (508)398-7980 FAX not: Emaro ers ra MAIL ADDRESS: il @ g 9 y'com 434 ROUTE 134 INSURERJS)AFFORDING COVERAGE NAICN _SOUTH DENNIS MA 02660 INSURER A: 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 TYPE OF ADDL SUER POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER (MMIDDIYYYYI IMMIDDIYYYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ -DAMAGE TO RENTED- ---1 .1 CLAIMS-MADE OCCUR PREMISES(Ea occurrence) f MED EXP(Any one person) s N/A PERSONAL s ADV INJURY $ I GEN'LOLICYE GATE COMP/OP1?APPLIES AGGREGATE $ rPOLICY pi Tei PRODUCTS•COMP/OP AGG $ _ S OTHER'. COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident) S ANY AUTO BODILY INJURY(Per person) f • ALL OWNED SCHEDULED AUTOS AUTOS N/A, BODILY INJURY(Per accident) f NUN-OWNED PROPERTYAGE f _ HIRED AUTOS AUTOS (Per accident)kenp $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE s DEO RETENTIONS S WORKERS COMPENSATION X $ATUTE €TH_ AND EMPLOYERS'LIABILITY Y I N A ANYPROPRIETORMARTNER/EXECUTIVECUTIVE ® N/A N/A VW C10060153152018A 03/14/2018 03/14/2019 E.L.EACH ACCIDENT $ 1,000,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE f 1,000,000 SdePriOOFO PERATIONS below EL,DISEASE•POLICY LIMIT S 1,000,000 • N/A 1 DESCRIPTION OF OPERATIONSI LOCATIONS I VEHICLES (ACORD101)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 0613,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 L—' Y Daniel M.Cr Ay,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