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HomeMy WebLinkAboutBld-20-000486 ie6�.. R O(. JH :FeeS G �,�, )4 :Permit expires 6 months from�.-.0_ n C s �-, , .� -2D— Li �� 'issue date. EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department I 1146 Route 28 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: C) 1.1 J ASSESSOR'S INFORMATION: Map: 1 71,3 Parcel: (19 OWNERI3CLUZ 44 1f I E AA s-c iA D NAME PRESENT ADDRESS T0370.0 0nA et/ rl CONTRACTOR 3 1� NAIfE MAIL TEL.# G: T c esidential 0 Commercial 0 Est.Cost of Construction$ @ (00. may' ,r ' Home Improvement Contractor Lie:# r CO C} Z1 Construction Supervisor Lie. ' �J I . Workman's Compensation Insurance: (check one) 0 I am the homeowner ❑ I am the sole proprietor a' Worker's Compensation Insurance Insurance Company name: K'LlLk Worker's Comp.Policy 'CCU � 5 /4�'�j WORK TO BE PERFORMED o Tent (Fire Retardant Certificate attached) 0 Wood Stove Shed O Siding: #of Squares 0 Replacement windows:# 0 Replacement doors: # ❑Re-roof #of Squares ta.insl ()Stripping old shingles* ()going over layers of existing roof 0 Old Kings Highway/Historic'District c 1LiRoofin Siding(Like for Like) *The debris will be disposed of at: i ^�r�J� 1Y1Y/,'yQ1�- Location of Facility i Oat 4\ 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 a .• e and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: 7 94/( Owners Signature _Date: (or attachment. Approved By: Date: B ' ' cial(or designee) Zoning District: Historical District: 0 Yes C No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No ❑ Yes ❑• No 3/01 fT' i'Y) I ).-/F e cc 3 tek_ I -6c 60, m DocuSign Envelope ID:04FE32E5-A491-44AA-9305-1C89B55191A9 , Permit Authorization ss SaVe Form Site ID: 3665841 Customer: Francisco Dafonte Francisco Dafonte 1, ,owner of the property located at: (Owners Name,printed) 40 Old Church Street Yarmouth Port, MA 02675 (Property Street Address) (ofty) 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 weatherizatk)n work on my property, DocuSigned by: ------ . Owner's 7/23/2019 1 8:44 PM EDT Date ,,, ,u 4,.. ,,.., , ... . , , 4,,, •••V I , , 4 $ 4%.4 ,g ' , V.44 FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project , ..... J , Participating Contractor Date Name: RISE Engineering Phone: 401-784-3700 Email: Page 1 of 1 For Office Ose Only Rev.102015 The C'otntnonwealtlt of Massachusetts I Deltartrsttnt offheditserial Acenterrts l 1 Congress Street,Suite 100 °�9 Boston, MA 0211,1-2017 e., ,.'7 tvvrr.ttlet..m;ov/dia \Mirk rs`Coniperisatttin tiisurriuee=lftidatit: BuilderslControctors/EIectriciaf/PhAnbers,. t .)tit I ll I Ii\LeIli I IIF,I'i 11y'lii'I v('aVt 1l f)Rfr', 1 Applica flt Inl'ornrativn �_.._ Please Print Legibly N tittl' ,li usi neu i)igamzati ii Indic!dual): ' . t /' ... ! --_- ,)1 .1(,).1.;• E ..._.....-_..._,. Arc too 4,1 employer cheek the appropi late trot- Type of project(required):- 1 I - l ttu.a employer it it ..t. __:rep i+.Es t:,,=l 1,,,: ,,phi ;Imo i. r Li New construction t L)rana snit prolinetornr p rouishi)an d have no npl ryt,:'s+t•.5.,nr; Or mite in 1 1 P IT-I,Ref°o elitig ray rap:tr oy (No sioritertil comp iusma ire ,,,I.,,,,,.! 9 ..,j Demolition I-am a hotitcOwneruotng<all work myself'No ii,ork..rs'currtp,,,i_..iraitce requ,rcoi`` 1 1 0 Building addition 4.E1 1im dlltnnCer�p ncr niece will he hiring edotractoitt to conduct all work on lily property 1 wilt ensure that all c'oniraeiori.;e ttipr have,•tirkei4 rw tipmrluunjn iri nt.lnct,or are late • 1 1,fl L.It?ctrical repairs or additions priyaietnr vra no employee, 1'2.i_)Plumbing repairs or additions I s[J hurt a ge,e:cal->.cntracm,hod I,¢iave hire:l thr*ul nto t.c. 1,t ri thei tt+clre:d sho 1 ut. . Root--repairsti ''I UJ C,l C 11 have n ttict ec 2 ti , `e t i - i 1=t [�,+"'"311he t tr: f td Liti=e , a i.hsaiuii IWOitsu , !3+1 st cxt.:,:1,,,I n ..i 1 r.tt ntpCi Mil',e I5 ..li .,.ant,e5, ,,ienoetupocu`h 'Y„_.,ix6, , .ai,f, .,, ...te...._."..i.f' i . { Any at ylaa n ihat et.`cko box 41 must also till out the s u.h t e, tt Ir r i i kcn'c wupcnsv,ion prl c', i it nowit n i'ii.ynteoa nor,alio salmi[this affidavit ihdtcating they,,re.ni,.i,u all 4u,k ar l oleo hire outside.ettotr.icto._moat xuv,nit a nevi ai'id.na tncli•tray;aucti< ;k eaiiractoru lilt,chock this box:anist imtltrcheit im atlduloirol arn:.a ahnwti e the uiamw ol•tlic sub-cnutrtitew,s and state•ahettier-ior not Ilion entities have employees, tfttrcetub--cotinraciotib hove eyikt?yce-s,they iiva.;ro alcti;ar: worl.:,i"comp policymaurnt>er I am an employer that zspa•oi'ifliogworkers'curnpertscrlicm ins'urtitace for my etntplrtyees. Maness is the policy uatrt,lob site inf(rt-tncation. Insurance t"ornpany Name: i, 1. fv,... 4,.' 'L s}. ,. -. .,4 _ .-. .. f...__3 _.__. __ W.: i,r11c,: or Soil ins i to,. a C.)C.-), 5`P{ 1 xpirati,rlt Date. / .( 90 . soh Site ,Aires: � .LI rN iik,..L.X(....- C`ity/StatcYin4\A r())/t--17,0... Attach t copy of th vot•kors cot tpetrxatrnnpolicy deelarnlioti page(showing the policy nu tb -and expiration date). i=uiiurc to secure coverage as required under uti nt.e. 152 t25A i;a enmutll violation 1)uni,hdhie by a lulu up to$1,5000C a:xllor one-year irnµrisonrnent as well as civil penaires in the form of a STOP WORK()RI)f:R and ,fint•chop to$250 0(a day ttgaillt tlhe violator,;A copy of this statement may tie fors,wrded to t.te.Ott cu of Iti esta,aliuns of the DIA lot ytmuruttee coverage verification, -..,,... I tier hereby certify under tie cri 'crated petittlta<t of perjury(bait the inforntatioti provided above is t ere omen cr re Via. ' . ...____ _........ „ag r)als. ., .. 7.7 „.... /_. _. 'r � ..___ -_�- __.__ Intl e H �.. Official lise only. 1)o'tot write in tills Lert'u,to be etc+trrptarett to city or ttnt,rr official. I City ur Town: 1'crnrit'I;icense tl_... __..,, „;. .._ _._:�_ __.- - .e...-.. I Issuing Authority(circle one); I. Board of Health 2.l uildingt'Depar•tment 3. .:itq,'i'oiku Clerk 4.Electrical Inspector S. Pitttrilving Inspector 6, Other .... Contact Person: Phone>r:,_ .--_.. _.., ___,_ • Construction supervisor Specialty Caarxn ooweatth of Massachusetts Restricted 24: `.'. Cretstonot Protessierra#t fceasure CSat..iit.`•rnsutation Contractor 5.oarti u*8r,tidtno geguiat,o ns and Standards CSSL•1 O59d it Expires:02r t 7,2020 sirs <ivy, FRANCIS S SHEEHAN 5rt2 HARMACHRO BREWSTER MA 0203s ' a Fedora to possess a cotteiat eattatat of the Massachusetts State Sudden Code is cause for revocation ot this rtcense. Fa information about this license: Casfe17}7Z74200or visa WatVarness.. pvicipt Corn,misasioner is /firrirfrrnrzrf}r/lfi'�/,rffrr'-a,.firi�cl Office of Consumer Affairs&Business Regulation HOME IMPRO WMENT CONTRACTOR, Registration valid for individual use only TYPE Oorporation before the expiration date. If found return to: Registry dA ., Expiration Office of Consumer Affairs and Business Regulation 09/07/2020 1000 Washington Street-Suite 710 FRONTIER EN {'�'rS61:1):t-Jl�NS Boston,MA 02118 v , FRANCIS SHEEI4AN" �C �' ° 502 HARWICH RD BREWSTER,MA 02631 Undersecretary Not valid -• t signature i• • ® DATE(MMIDD/YYYY) A► RD 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 CONTACT NAME; Rogers and Gray Processing ROGERS &GRAY INSURANCE AGENCY INC (Alc"N.Exn; (508)398 7980 FAX (A/C, E-MAIL ma ro ers ra ADDRESS: @ 9 9 Y•com 434 ROUTE 134 INSURER(S)AFFORDING COVERAGE NAIC# SOUTH DENNIS MA 02660 INSURER A: 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 LIMITS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DDIYYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO RENTED $ CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT 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) $ 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 ANYPROPRI ETOR/PARTNER/EXECUTIVE A OFFICER/MEMBEREXCLUDED? 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 I 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 ACCORDANCE WITH THE POLICY PROVISIONS. Frontier Energy Solutions Inc 139 Queen Anne Road Unit 6 AUTHORIZED REPRESENTATIVE Harwich MA 02645 Daniel M.Cro{ 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