Loading...
HomeMy WebLinkAboutBld-20-003006 y®, .yy, Office Use Only `- , ':-4-: Permit# 0y'` :; rj '"I Amount �� t 6' %{/� Permit expires 180 I Uk Z0 00010 e days from • issue data EXPRESS BUILDING PERMIT APPLICATION_ TOWN OF YARvIOUTH ' ' ' ' ' 4 Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 ; s' (508)398-2231 Ext. 1261 it .../16,,#, , w3.7 CONSTRUCTION ADDRESS:.2 I 11/4-11;)1-<C--)C1*-- ,-Vil....--- '---- ' ' ASSESSOR'S'INFOR IATION: Map: Parcel: 3cfl OWNER: \ � liI �"`'"�q i tc2 / N' 14 • PRE D S . # CONTRACTOR: )+fie - 1 'NAME D * �Zo . 77 q '17 Q J % Residential 0 Commercial Est.Cost of Construction S zip. 0P,00 Home Improvement Contractor Lk.# 1(4/0514 Construction Supervisor Lic.# 113s9 Workman's Compensation Insurance: (check one) ,.,r 0 I am the homeowner 0 I am the sole proprietor tilr� liave Worker's Compensation Insurance ' Insurance Company Name i , t�{� Worker's Comp.Policy C)0(C/O(S / /9 f- 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 t Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at:139 ,,,,'J ��'{I� ''" W(.. H "ii e.441(,,.j. 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 understand that any false answer(s) will be just cause for denial or,revocation of in ; ,,,d for,prosecution under M.G L.Ch.268,Section I. Applicant's Signature: Date: // Owners Signature(or attachment) (/� - Date: // Approved By: !" Date: f/ Bondi ' or d ignee) E ADDRESS:" , i g. t Zoning District; Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes C No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes D. No I DocuSign Envelope ID:01A44E59-5751-4402-A9C7-32FC896B2B02 , . RISE ENGINEERING. OWNER AUTHORIZATION FORM 1, George Rodrigues , (Owner's Name) owner of the property located at: 40 Wimbledon Drive , Property Address) West Yarmouth, MA 02673 , (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. cow OneuSigned by: atorit, rbelilipt.S '. 4.4Signature 9/25/2019 I 1:42 PM EDT Date RISE Engineering, a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 I 508-568-1926 www.RlSEengineering.com The C'ttttrt6totawealth ofMassachusetts Deportment of Industrial Aceitlents 1 (origrre),s Street,Suite 100 Boston, rlTA 02 11 4-'?017 wwrr mass fro v/di'a \Veykers'Compensation lncn ranee.Aflidutit uildersiContructorMecta'IciatIS/Plumbers, TO tat.t''C1 111 WITH t1 I HF.Pt'Ryf IT"C lC AL Ftl'ORI'T"Y. _ _ Please Print . *bly Applicant InformationlcJ>y __..� U.1111(: Rusin .r:t)tfhfn att,nt'Ir;tit';iuualj: f" t sy. . .t ' ,•.1 Acidte;s ("it; State Zil 3 >� - t'8c i Phalle e I I _ ACV utuov einlaoytrr'.'(.'heck the apprupz:'tatt hos: I',epe of project(required) t I ra;,.t tot p n.et .dt 't^tpit.itr.t .,1t r,,, p;p<D,,,rt°I ' 1.. ,__J New c,Onsnuction .,Li l a+wa ne;e Ptope clot tvr.;polhic,shhp.n dhave no.c.npiayc.ts i c.i.,nii,(or me PI 8. 7.3 Remodeling arty capita) IN°v"nttel.£`r,nmp illS111,ffiCc i.•d:iti.'d.j ). 7...1 Denjolitius 3 ri tiu•n,u,,ner(Rung ail FvarK myself ,tvC tc,trk'« imam. h,.nattfr-into red.I 10 El Building addition 4 Lii.tttratt to ,rru lnraillutLitii nti t 3k tu_ual work onflv „ttcrty will l t ,'1Muie tl.dt-Ih en .c t w, t 1•.1;,I0'" .,I reS' ..St. ,�.' i I. <i}CIv0 or itddiliot s ptopi ntt ')..ro.nttloyee< + �O'l:nn')itg emir,t:ro'a j d sht { )ICJ 3 dtFt a¢� tiild t J xt,t 1 � I>L1G 1 u t t � t I � j IZ(iJ7 C.l7A i'ti It l r Ir. fi tt hc$KA" II I'11U1( ,y i't •�i 1 ,'a n xc 14 1vt tau a.o,lhtrauoa ant i4 t.Cflcu',MY., rv..,,isE I,hv-+ ,..tilt,i a:npt att pet Mt3U c. ! . Li }>,, aad set,h:rve rtt ttvcrs 'Yt c tkvry i utls,t + t" Any ap;tlwant that checks Nix al must also fill cut the section beta, n t t'a5 erica ivorkarit compcnsittion patio);tralnnnutief, hI.111,COW acts who sulttrtit this affidavit indicating at.'itet duuig a=1 work antithen hire°instil_cantrhete.tt most stfltntt n nca"of itt..tutskatutg:iu.'h .antrzt"..tis thin cheak<this box must utthcltflel-utt adJititsii.J tIn t Shil4v,nl'the 7itttaa ot'the sub-cnuttakOcrts and state.babe:n r.<,t those enuucs brine r.npluvecs-. a thcautt-tor,tractol,have 'tnrzl;,yeen they MU'''. v ..N er no'k. ,s'to'np po1les!tt,inaor ant an employer door is providing workers'c('.rrtltt ltsutton i0 1,1 tree for my employees. Below is the ltnlit),,and job site anfor math n. Tt.,_ttat'ccC'ompar Name: "t' _ � _ L 4- )),1!„ .„ft' , ,� y . I .. _..__. ollc.y I;ur Self in Lit::i r _ C..! �,4*. ?I, S.,, 1.J0)cT l:'xpiratioo Date:: 3 i� "-t 1 ot1Stic 1tllrc,, - C(tytStatclil�: Attach a ropy of the workers'compensation policy declaration ation page(s..-owing'the policy taunter od Oiration date). I=aitore to seem cove (t'as required ;I eumi.of ,t lotion t7), 'a fine urr to ,.iOO.Oii dl3, ,.rc' thapt tsi;l',ttttt ,,.'ii its .• c' � :OP V:i RK P Of I',?mu: on ,I t, . r!5;t;00 a tl t.viOlat0i, .,t t. iti tst.t ..t ,he i.)tA Ior nsuta:rCc ftt Crag c Ifik.cilliJ:' 1 do hereby Cl'!tifp under th ai Ntantl penalties of perjury that the information provided above's true a id correct, aj � Official use only. Do not write in this arca,to hi'completed by city or to rt officm a! City or Iovrti: Pet'ntitI=teensc Issuing Authority(circle one); I. Board of Health 2.Building Deportment )t.t'its,`I'oo a Clerk 4.Electrical Inspector S, Plumbing Inspector 6,()titer (`[mCittet fcrsom Phone rt • .ear Construction Supervisxv Si' aity 'omir.a:�nceith pi'is5,dt 5 ,z 4?�2st€i[xdtcxt - 7;1V,SWIof Pro7essional cr e =63t- ..!osu€atiun Contrecto, boarttx,`9o.+sang Be9ota1 o.o a CS.55-A0594' °s s!1 FRANC IS S S EEHAN 502 Ha4RWICHRt) REWSTER MA 02631 ' as= failure to pOSS.M.%s etrITNIt Bdtio++s t 3 ,=ir?zs:<,�t:aou et5z State SuAtI g Code is cause far revcocasi;n o€lh s license.. for intertruttiOn abf+kuf this ttr.zctsm caii(617)122420 or visit www v moss. -y�yp9 COrntl,rss one' •�.� - • „� • .. /• /'/lrJirl/rairP<!!`,�1�1/.. �rlilil. /i�l//.r 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: Regisfrtlort Expiration Office of Consumer Affairs and Business Regulation 160 09/07/2020 1000 Washington Street-Suite 710 FRONTIER ENERGY SOT1ONS Boston,MA 02118 FRANCISSHEEHANiC 502 HARWICH RD t 4 BREWSTER,MA 02631 Undersecretary Not valid • ' signature ' A E D® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 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 PHONE CN o,Ext): (508)398 7980 FAX (NC, E-MAIL maV il��l1ro ers ra com ADDRESS: 9 9 Y• 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 INSURER C: INSURER D: 139 QUEEN ANNE ROAD UNIT 6 INSURERE: 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 LTR TYPE OF INSURANCE INSD WVO POLICY NUMBER (MMIDD/YYYY)I(MM/DD/YYYYI I LIMITS COMMERCIAL GENERAL LIABILITY ' EACH OCCURRENCE $ DAMAGE O CLAIMS-MADE I OCCUR PREMISES(Ea occurrencej_ $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY L PRO LOC PRODUCTS-COMP/OP AGG $ --I OTHER: ''. $ AUTOMOBILE LIABILITY i - 1 COMBINED SINGLE LIMIT $ (Ea accident) ANY 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 I OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE _�$ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE_ EORH- AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBER EXCLUDED? N/A N/A ! N/A j VWC10060153152019A 03/14/2019 103/14/2020'- —. — (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/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 �k._. Daniel M.Crowjley,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