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Bld-20-000619 sty,�p a Permit# ft- I !Fees 35 :Permit expires 6 months from ' vjo-v.... to.dd �:ssue date. I. EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH _... Yarmouth Building Department RECEIVED ' 1146 Route 28 South Yarmouth, MA 02664 AUG 01 2019 i (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: ' I 1�/"�� '�-�J) In BUILDING DEPARTMENT Y i ASSESSOR'S INFORMATION: Map: 33 } Parcel: fQ(c OWNER: -.0 1 T SS T #719 1 ogl V CONTRACTOR a _ ___JA..i...c 3frajSi 4c1)? %Hi/WA-CP-11A NA. M DRESS esidential 0 Commercial 0 Est.Cost of Construction S •�+ I 0 ---(-( Home Improvement Contractor Lie.# I(CO Construction Supervisor Lie.# I D Cj(.{. Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor have Worker's Compensation Insurance Insurance Company Nan A Worker's Comp.Policqpk y ` �= WORK TO BE PERFORMED Tent (Fire Retardant Certificate attached) 0 Wood Stove Shed Siding: #of Squares 0 Replacement windows:# 0 Replacement doors:it Re-roof: #of Squares Insulation ()Stripping old shingles* ()going over layers of existing roof 0 Old Kings Highway/Historic District Roofing/Siding(Like for Like) AJ� �� ���*The debris will be disposed of at: „� �� ) 1���_ " � � < Location of Facility J I declare under penalties of perjury that the statements herein contained 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 of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: ®° b Date ( 1115 Owners Si .a : re chment) d���- b to Date: -- � i . Approved$y: ��`� � Date: �j '/S Building Offic... -•es it.--N 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 0 No ❑ Yes 0• No 3/01 `SO)0 I En ° ci-OAri 1 , 0 Ris ENGINEERING' OWNER AUTHORIZATION FORM 1, Jo Occhipinti (Owner's Name) owner of the property located at; 11 Dayton Road (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. A # Owner's Signature,/ II Date RISE Engineering,a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 J 508-568-1926 www.RISEengineering.com The Contmortwealth of Massachusetts Department of Inehatrial Aechlents 1 Congress Street,Suite 100 P411 Boston, Ai:402114-2017 ‘4•-b:74.,0% ww.mass.(mv/dia 'Workers'Compensation Insurance Affidavit:BuildersiContraetorsiElectriciatts/Phimbers. 4 TO n.Fll i n\VI 111 111E PEtoirtIl No Al.IDOntrY. Applicant Information Please Print Legiblx NaIlICf‘Ei nsi n us3lOrgarnzatonl rally du al): ‘arl,:lfal? I A ddretts: Tti City/Statelb. (:-.3"1;;,. C 13 Art tau My employer?Check the Appropriate hos: Type of project(required): on iOyer w Aft Q flrlpinyee5 e;pro i 7 jj New constracnon L_iwrt 50ie PrOlmetOt or Panfle4ShlY and hrive(10 e:nploye,..., Cor no In 8, 1 Remodeling any Uli'44:4), [No svorkerS'Conn', intinrane,e rerinired 9. '„„1 Denwlition 0 sin a homeowner doing ad work myself No workers'toil!),,n,..nance requqcd ' I 0 Duilding additten zhomeowaerami will krelnring nornntnnns to ncnnitn.,t all Wiltier.411rtY PrOperly I wilt emore that all contractors either have!set:d:sr,:compratSatiOn in4,,it004e or tOO lOO I I fi Electrical'repairs or additions 1 puipuelon, tin no iimployees, ICJ Plumbing repairs or additions And Ito ic teirt.,1 he ,h„. ni on o ! 1 3.0 Roof'repal • hood entplayee,', ut,t,i.tarr I I 4.f. therb.,-tATItC7.4441: elj Shy 414 4:orpornnon and ns officer:hinN exereised;hell l'e.rrit of exemption pet c. ! t4),non we tinve int employees 'Na,tvorkets'cony ow.w:Innt;ieclulnd; 1 *Any applicant that check tiox 4'1 must also NIl ottt thn sentlen in...10,..snon,n,e,their workets.compensation One)infonnotion, Homeowners whO butntlit this affidavit inthcatirig,they art dottiv all work lord then hire outside enntraeterS 0011 Sabrritt it new affidavit Indicating ouch. ;LInornutors that check this box must abashed on Firkin iona I sinnn show tag the mane 01 the sub-nonunerols and state Whether or not those entities have employees. If the otancontractotottove Omployets.they must nsov ale their ,,,yoke,S romp pOlicy ntontiet 1 um art employer that irp,ovidiitg workers'cfoopen+.ation insurance for my employees. Below is the policy ad jots site information. Inuralice Company Name: -Azt, „ 1,44 _ _ or Sell ins,lac $1‘1W,C-10(..>-4,4"`C.)1 S.31590)9 , Expiratton Date. 31.1(.1 190 Job Site Address: CiiwStatc./2.p C$19.6(0(4, Attach a copy of t o war ers cot pe tsation policy declaration page(showing the po' number and expiration date). Failure to secure coverage as re' 'ed under Mf1l c. 152, .;25.:6,is a criminal violat it purishabie by a fine up iu 1,500.00 andlot une-year inwrisonment, iv well as el ei!priuuiiicn in the form an STOP WORK ORDER and fine duo to$250,00 a Jay against the violator,A copy of Inn;stat.;:rmr.1 ),*It xi ice to i at I)Ihe e 01 In vest;gniiOns of the 1)IA Ica insurance coverage verification. do hereby certfir under th ui and penalties of perjury that the information provided oh ve L true and correct Cit41_0 Official use only. Do not write tills area,to he eamoksied hp city or town official, City or Ityrert: Per Accuse a Issuing Authority(circle one): I. Board of Health 2.Building Department 3.t'ityierowit Clerk 4.Electrical Inspector 5, Plumbing inspector 6.Other_ Contact Persom____ _ . Phone#. • rn Construction Sutaervieix Specia.Ity Cmoa o*xereatth ci°aassachuest?s Rcs ctrd 2a: * a,v,,mon or Professional t3censole sL4C.•nauEatian Contractor Scam o'Surdag Regulations and SSlancards CSS1-10-6941 Expire%.Q2;I''2020 FRANCIS S SHEEHAN a-,t Sift RARW3CH R€3 13REWSTS1 MA 02631' ." ': Fail urc to prixsesx a current edition cfthe Massacriaiset%s State$ui#dinS Code Is cause for revocation of this license. Foe triforolatiort about this fit-ease. Call(6t7)727-3269 or visit sinew,mass.govF4pl Cot'%°Iroiss o:ior �� rr.ri.cr zrisPz 7/tj�./46T 3r r r,,Jr•1!J Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corporation before the expiration date. If found return to: Registretidn Expiration Office of Consumer Affairs and Business Regulation 160e l , 09/07/2020 1000 Washington Street-Suite 710 I FRONTIER EUERG'tSOWI'tDNNS Boston,MA 02118 FRANCIS SHEEI4AN 2 CC • .502 HARW ICH RD BREWSTER,MA 02631 Undersecretary Not valid . i igrtature • -- - . ® DATE(MMIDD/YYYY) ACCORD CERTIFICATE OF LIABILITY INSURANCE 03/18/2019 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: Rogers Rogers and Gray Processing ROGERS & GRAY INSURANCE AGENCY INC (n/CC,N,Est): (508)398 7980 (A/C,No): E-MAIL mailQ�1ro ers ra com ADDRESS: l: 9 9 Y• 434 ROUTE 134 INSURER(S)AFFORDINGCOVERAGE NAIC# SOUTH DENNIS MA 02660 INSURERA: AIM MUTUAL INS CO 33758 INSURED INSURER B: FRONTIER ENERGY SOLUTIONS INC INSURER C: INSURER D: — 139 QUEEN ANNE ROAD UNIT 6 INSURER E: HARWICH MA 02645 INSURERF: COVERAGES CERTIFICATE NUMBER: 379170 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 ADDL SUER POLICPOLICY NUMBER (MM/DD EFF POLICY EXP /YYYY) D TYPE OF INSURANCE LTRINSD WVD D /YYYY) (MMDIYYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: AUTOMOBILE LIABILITY CO aBINEDI SINGLE LIMIT $ (EaANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS N/A BODILY INJURY(Per accident) $ AUTOS NON-OWNED PROPERTY DAMAGE $ ' HIRED AUTOS AUTOS (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y/N E.L.EACH ACCIDENT $ 1,000,000 ANFICER/M OFFICER/MEMBER EXCLUDED? /DXECUTIVE A (Mandatory in NH) XCLUDED? N/A N/A N/A VWC10060153152019A 03/14/2019 03/14/2020 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 (Mandatory in NH) If yes,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 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/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 Road Unit 6 AUTHORIZED REPRESENTATIVE sr Harwich MA 02645 'i Daniel M.Crowj'ey,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