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HomeMy WebLinkAboutbld-20-001394 p` '�'H,t Office Use Only t 0 Amount(\,,,,,,44:0) ,PPermit/ �J � ..,�•" `Permit expires 180 days from i --zv-43 q issue date EXPRESS BUILDING PERMIT APPLICATI ---- TOWN OFYARiViOUTH ECE9VED Yarmouth Building Department 1146 Route 2& sEp 1 1 2019 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BU I I • L3y _ _ CONSTRUCTION ADDRESS: ASSESSOR'S INFORMATION: Map: 3 1 Parcel: I"t OWNER: ' NAME s - To y1 6 CONTRALTO �-- \ u NAN MAIL G ct aeesidental is Commercial Est.Cost of COnStI11(,t10P.$ O Home Improvement Contractor Lie.# 1 ((QUA 7 Construction Supervisor Lic.# / -4._- Workman's Compensation Insurance: (check one) ( 1 ❑ I am the homeowner ❑ I am the sole proprietor ave Worker's Compensation Insurance Insurance Company Name _ Worker's Comp,Policy' n WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows: # Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: Location of Facility I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief I nderstand that any false answers) will be just cause for denial or revocation of my li for prosecution under M.G.L.Ch.268,SectionI. Applicant's Signature: ��, Date: 77/(/ l 7 Owners Signature(or attachment) r ✓i Date: Approved By: ✓ _--e-4 Date: CA -11 —I C Building Official(or designee) .EMAILL ADDRESS Zoning District: Historical District: C Yes a No Flood Plain Zone: a Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: Yes 0 No `0 Yes CJ No MMOI H --(- --.O.4Lod .C(DrY) Permit Authorization mass save Form Site ID: 3863641 Customer: Pat Torcasio I, ,owner of the property located at: (Owner's Name,printed) 7 Checkerberry Lane West Yarmouth, MA 02673 (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. Owner's Signature: Date: - 7 - l 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 Far Office Use Only Rev.102015 \ The C'oxttntonwealth ?al'Massachusetts �` Dcparttneent of Industrial Accidents t - , ', I Congress Street,Suite 100 t . Boston, 41.4 02114-201 i ti�,",,;' v wivw.rta4.5'5 0v/di(' \i'ttrkers`(-":oiniicnsAlion lustsr anee Atiidaait:fluilcicrstC:"ontractorark lect)'icians/Plitiiiboirs IC)ISI. Hi i 1)\\11'I1 I ilk 1'htt)'111T11MC.i At.[liORrIN. Applicant Infojniation s _ f Please Print L ogibly 1 tldSilf'. (Cius nt s()r atnzht un'Indtt;dash): ito`t 6.� .:5 ..t Sr Address: ,* 's- sf irw -.A ,...„ 'F .L.L."'__ ....._--_:.. .._..._ C ity,'Sttuc,li ��.t � Phone#€ .2t -: �C)1' _.1) Are you a+i employer.'Chuck the appropriate hos: Type of project(required):, 1 ". Nis':atntpioyriw at: ..t. ___etrtillyccstVI tat,.otear,item" ':. ?, New co ns(nLCUon 1 sal a iota pr pr 4ror paxtu rxhpp and h,lvc no employs:,y�e::i.ntir for me or 8, (�Rt',t;ocieh0g an,,c.apaor [No wtt(Kora`'c,rmts urlul,101100 u'ijau Il r-' y. ._, DemolitrGn 3 Ili Itflx hotnuoioncrdoing'ail twirl myself iNto e''Lark.. 'comp,au,.n ante Iestt reti f' 1!)El 13tulding addit:cn 4 1--]1 xrn a homeowner and will he Muni;eontlat 1.:'to at,,no a ail work nn in?piorcrt, t will �" oswuro dun all,a otraclans either h.1vP sv.lrkci: amp .nsnts o Irr,i anee or on,.(re 1 I l [loch-Ital repairs or additions p,omete-;will:.no upltay c 12 Li['lambing repairs or additions L.]i 5tti a g..I...YS .,0tit,ytt t Nt;I ha,,c 1':ite'I Illy`I I*-. 1 i ,,,11•1 1 11 ih: n t,.h._d ihtr-G.l, ......JJ 13.[J Roof rc PalrN n9S t9Lan.._£ n t"Moei s,piwte ; t u 1 a ✓., c LJ..,-,k,it!n,u,noratiOnat:aitsc_ f'ttihilv..xec,„:kuillnt.r. :All of ..etpl;impel lvti;.C. :i i h„Ana tin .r.e ttirr,i ip i yem, 'NO.turlk:r, <or p rill who)'ice,utrati; t 'Any applicant Ilan c6t ck>box al mustaio fall CIA rhtt•sr uon n x'. r tw Iron/wn Mi n t.olupcnsatten peltcy itfonnout;n i i i.inreux Iron tvnv,.thirst this an-alas/It Indiction they are doing.a,1,,'Ott,ax4 t Icn htu outman contractors most suornit s row affidavit indic.rturg au.h ;t-r,ntraaotous that check ithis tuffs.most attached no additional v,ect shmv sap rho'Burns or the?`iuh-coutratatu,<mid it:uc w hcthei is'rat those entities have cuiplt7yccs. tithe sub-cantractora i)nwr employees,Lacy mto e t� r. t+orke Y comp policy rit,nrwr _ I ant an employer that is providing xw©rkers'cotttpensution insurance for troy etnpltry°ees• ileiole is file pnlr'cyrntrl joh:srte infc+rnttrtnn. �~� Ir,suriuree Company Name: U .._ .=r a - ck . 4. ! ls,t;lic:;n t)r Self ins.l.ic.i '. �'' .`. . 0;"(4t I1 a5 )t7 P Expiration Date, - loth Site Addre$s:_ __ �c„/� _ ___. a tit /S '' 5: � Attach a copy of tfiie wo ker.' of ttnssttbn Ixilic raiitin page 'bowing the puke tint ,:anti expiration date'. � Fatlnre to secure coverage as recluirexl iurdcr MCI c 152, ,25,A i,a err ii al viktlation ptmidlt c y a floe up tc.$1,500.00 lid/Or one-year imp isonittent as well as n on: ncrait co i di t Itlnn n. a SLOP v\i)RK(,)H I)I h d:;floe t;l tip t l 525()00 a day against the vtolatot.A copy of'this stet.,!'. t Inay fit t,. t „track'to t to()I flee,ct Intest.gatiui,s of the DtA Cr insurance coverage vettficat:on. _ I do hereby cervift antler the rri 'and penalties of pinyury that the information pr av'itletl ahot- is true t ul correct. >hCit k .,77 ... ___ _ _. .._. Uffitra!use only. Do not write in flits aura trr I'm'etnrtj i-rerl by city or inns'!ti fitted. City or`I'o+tm_ _ .__..Ptrfilit.''Ilcm5e p _.�..>_..._.., .__ Issuing Authority(circle one). I. Board of Health 2.Building Department 3.City/T'o%vo Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Cvtitnet Person__ _. Phone#:� .__..�_ ____...._. .._........___ I. ___ _.._ air Construction Supersaisof Specialty Q rnonweattdt pi=AaffiSdcnuSCtlS Res gutted to: Dss sttfn sod Professional tteensure CSSu EC•;Isudaeian Corstra&Iaf sw.idArig Regulations and Stanaa ox CS5Ls1t) 94' Exp,ret; 02 „:2020 FRAHCIS$SHEEHAN �' SO2 HARWICH RR BREWSTER MA 02511 " €enure to possess a current ed*ton of the Massachusetts State Sur duig Code is cause for revocation of this license. for infornattion about this license Call(Sir)TTT3200 or tristt www.rhass.govidgt Cam,r:ssfone> .:("-/✓%/r (f /4z;v+2;441)e//) Office of Consumer Affairs&Business Regulation HOME IMPROVi=MENT CONTRACTOR Registration valid for Individual use only TYPE:Corporation before the expiration date. If found return to: Registr t1dn Expiration Office of Consumer Affairs and Business Regulation 14 ,-.09/07/2020 1000 Washington Street-Suite 710 FRONTIER ENERGYSa .,rs s Boston,MA 02118 fi FRANCIS SHEEHAN 502HARWICH RD « P`—^ BREWSTER,MA 02631 Undersecretary Not valid ignature • a- •ACGRD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 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 CONTACT NAME; Rogers and Gray Processing ROGERS & GRAY INSURANCE AGENCY INC (A/cc..No,Ext);ONE (508)398 7980 (A/C,No): E-MAIL l mai ro ers ra ADDRESS: @ g g Y•com 434 ROUTE 134 INSURER(S)AFFORDING COVERAGE NAIC# SOUTH DENNIS MA 02660 INSURERA: AIM MUTUAL INS CO 33758 INSURED INSURER B: FRONTIER ENERGY SOLUTIONS INC INSURERC: INSURER D: 139 QUEEN ANNE ROAD UNIT 6 INSURER E: HARWICH MA 02645 INSURER F: 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 SUBR POLICY EFF POLICY EXP TYPE OF INSURANCE LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO RENTED $ CLAIMS-MADE J OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JE? I LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ I NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS 1 AUTOS (Per accident) I 1 UMBRELLA LIAB 1 OCCUR i EACH OCCURRENCE $ EXCESS LIAB L1 CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE ERH AND EMPLOYERS'LIABILITY A OFFICER/MEMBER EXCLUDED?ECUTIVE E.L.EACH ACCIDENT $ 1,000,000 N/A N/A N/A VWC10060153152019A 03/14/2019 03/14/2020 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS I 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 Frontier Energy Solutions Inc ACCORDANCE WITH THE POLICY PROVISIONS. 139 Queen Anne Road Unit 6 AUTHORIZED REPRESENTATIVE Harwich MA 02645 'an Daniel M.Crq�v�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