Loading...
HomeMy WebLinkAboutBld-20-003005 Office Use Only .Y i i Permit# , ` NO a ri 0 # Amount a N ", . . 4,'' Permit expires 180 days from --. ,- issue date -db--D D3 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTx Yarmouth Building Department 1146 Route 28 7 ;;` ' j 1 South Yarmouth, MA 026644 (508)398-2231 Ext. 1261 CIC*I '/(" f J CONSTRUC?ION ADDRESS: lit �--�. k- (S-7 ASSESSOR'S INFORMATION: Map: Parcel: OWNER:VOIV(fAM)i,fq.CiLt, L Lj L (,t�'// u dit---\r ADDRESS CONTRACTOR. " .. � jI, 4 �.lC.tL4 ' .- L77" � -l/ 11itResidential 0 Commercial Est.Cost of Construction$' l G Home Improvement Contractor Lie.# 1r Qq Construction Supervisor Lie.# Ii t' .I Wcrkman's Compensation Insurance: (check one) .�r�^ 0 I am the homeowner ..: '�I am the sole proprietor ^rat ve Worker's Compensation Insurance Insurance Company Name ,i �; & Worker's Comp.Policya)CC.),( S ! -/''^ A_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 Iike for like Pool fencing J 9 C t-1i . - C6 4-1c H. rl� c '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 understand that any false answer(s) will be just cause for denial or revocation of ,; ,, d for prosecution under M.O.L.Ch,268,Section 1. 1/f /2 Applicant's Signature: 'x Date: ilk ' Owners Signature(or attachment) .�i/ 1, ", Date: Approved By: . %w'' Date: //� / Building Of i '-' or;..-tgnee) EMAIL AI) : rr1l S1i4i ? ! Zoning District Historical District: ❑ Yes 0 No Flood Plain Zone: 0 Yes C No Water Resource Protection District: Within 100`t,of Wetlands: 0 Yes 0 No 0 Yes 3 No Tenant under WAP program requirements.; The Agency may terminate this Agreement, by providing written notice to the Property Owner and Tenant, if the Agency determines that the unavailability of funds or ineligibility of the Tenant warrants termination. 14. The Parties acknowledge that this Agreement is under seal. It is intended by the Parties that the Tenant or any successor Tenant is the intended beneficiary of the Agreement and shall have a right of enforcement. Property Owner's Signature: ,, . C ` t - "" Date /d 'f9 Phone: 4/ .1. ',P- Address: . -7 .4 Tenant Signature 14ei` Date MI /d i# Agency Approved Weatherization Company Advanced Windows Inc / All Cape Energy /" Alternative Weatherization Cape Cod Insulation / Cape Save / Cazeault / M.T. McMahon &Son Inc. Frontier Energy Solutions / Lohr Home Improvement / MDH Construction, Inc Agency Signature Date 1,4 1.r 1 " e) __. l -r ft Housing -.414 44*-40404 8 Assistance Corporation cape Cod IMPORTANT'NOTICE Weatherization contractors must pull a building permit from your town prior to installing any and all weatherization measures ordered by the Housing Assistance Corporation energy auditors. In order for a town to issue a permit, all taxes must be current according to the town records. Your signature below indicates that all of your taxes (excise and real estate) are up to date. If work is completed and later discovered a permit cannot be pulled, an owner may be responsible for payment. If not, HAC will put your weatherization on hold until you notify HAC that it is OK to pull a permit. I acknowledge that my taxes are current. O ner's Si a Date 0 Ii , 4r& - jive learn work grow 460 West Main St. Hyannis, MA 02601 hac@haconcapecod.org 508-771-5400 fax: 508-775-7434 CI . • The Cotnittonwealth of-Mets.vaclursetts• Deportment of Industrial Accidents ,. , 1 Congress Street,Suite 100 Boston, MA02114-2017 st4'''::-5--0'.>. nom nrass.gOvidia \Vorl.cris`Compensation Insurance Affidavit:BuildersiContractorsili:lectriciarts/Plumbers, 4 TO RI HI it\\A III l'IlF,PKRMITTlf\G Al FHORI'IN. Applicant Information Please Print Legibly Name dti.sih,,iih?:imiat,, Hriii. dua ,. I L__.. i tp•-•.i.,." '- NIA!IU City/Stater:7,i '• ,• -;,--. atA 04.43( Phone;#: -77_4_.::49, .-7,.„ . . _ _ Are yfin aq cmployrr?Circrk the apprupllate box: Type of project(required): ,....., 1 f-Tfiliu a iaroloyet with,"0,,,,,_,,,,,,i,,,,,i(k,!i u,,,„0,,,m,," 7. Li New construction ...,.Li 14,13A lei prOpMiGt or pormershtp and have no tointrty.e.,tvettittint• toe nie oh 8, fl Remodeling aro:apace) INci•sklakeiq'Quuir liburalc.. “,.),..,Iccl 9. 7.:j Demolition nett a Inomeowner Coulg;oi sore myself;No venricift,. itoinp.anind,IctI ffttlu'red I Li tiuilding addiilen 101 J hOineo'.1 no 111-,d will be./ in ,,Oritta.:t.,s CO,:‘,1th.,:t..fl work cit ow piorect• I will I .?risure thilt 3P1 001111aCtOrS either 11:!ve voirttei it comp:Altai Ion insitiance or tisc ito1it I I I I'---' Heclineal repairs oi additions i piopmairs wan no oniployiiv's I l 12.D()lambing repairs or additions ant 3 101,,rte.L'elltill::-(01 and-..tJ1.ive 1,111:d lil,' ,l,b-,.e.g0,,o,,,!,,,:,(,,1 an th,L.11,4,hed itftri,t, 1 1. 1 3.0 Roof'repaitis 1 - l'aiisii sob-i:Onliiasors ISavo iiiiiiiioyin:S ).,kli'':`,c-..A.:(,!,,,...r, ,.',M1, U.i.',U .1C,' ,-, . . , 1 ,0 too.no 3,stirpkItll10:1 and its officers have ewerco.tal then t t•tin of i.,,,etnpf ant pa NMI_c. • ..... • 1 I.-1.1,te I ,4.'';,two no have no ninpftiyees "No\tin ken::cora: t twit:Ince tecunttd; i i 'Any Hopoc.i din,Locks box 41 run;:cs 0 ft II cot the,.,..ctl..rp.Sr.., ,n,1, ',!1 ne, rib i',,,mix-nsglion poke:, i„hi,,,,,,,cini WI ',iiitiin3t this ii,rh(h,vit inth,„iiiiiiki,,,hiiii,iii1,(1,,Ig.4,1,011.:arti f'loll too,anion.,,tinittittons inuid,a9,r11i kl F1,,,arldov a indicating:,11ch ilia:..:11,...k Oil,:bo,nthsi attsdied au;,(1.1,1,n.,1,..”,.1 )1,,,,,,t,,1,, ,,,o,..: it lh,,...,,b,:,?,:,t..;.,i,.11,1,,I.Jr'.,,hcfh,.. ..:noi tilos,:entiucs havt, Cflpl..);.,', I 1 I i:C Alb-CM:Ciacloi',.:1its';e.rip',,,,..c, uv:, 1u,',:,'.:1,.,.:, 0`.,,, :.)'c0,1p ,,A1..:.!1.011),1 I am at erni)loyer Mal is providing, workers comp on valort insurance for ply employees. Ile/ow is the polity and job site information, Insurance company Narnetk,'t M .... i ,..,.„,, Policy#or Self-ins.laic,44.0 ::-(PC2), 31 5;90)9 A. , Expiration Date: %...5,.,11.4 I .47,--u - 15() dab She Ai ddre ss...,, i+CkL. -)C ji.,,,,)C...if„. 7-(=i'r.'i_OlteiZip: , Mit.),...7 .'‘...4-- 1 144A-- .''.37 Attach it copy of the wor tars'compensation policy declaration page(showing the policy to -and expiration date). Failure to 'iietiri..:coveri:ge as required under lvI ill c I 52, ..,':15A is a erirninal violatiomporlshaole M fine III ID$i:500,00 ad/Or une-year imprisonment,as well as.Inn i ocrali'es in Me Imin o!'ii STOP WORK i.ifi.Df It anti:i.fine of up to 5250.00 a day against the violator.A copy of this stiminnisin ma.) tic fo,variled to t.le.Of lice 01. Invest.qualons of the DIA loi insurclaCc coverage,verification, Ic/us hetet);certify ander th ,ai •and penalties of per/try that the information provided ahoy' is rrUe and correct . M i ' __________.„., .,.... ., ....„_ .. ...............,.......................„... 1111 *tf: 17.7v...,„—.......d.„.:,...JLP--._.1.L.O. ... .___... . ._,........._..... ....,_ F712;it i a 1 447'only. Inf not wtne f/f fill%4•11 ,1, To 1%,cbt,ir,,t,q1 14 city;it'Iowa of/lclal 11 i City or Town: Pei mitTieense a 1 , .• .., ._ , i Issuing Authority(circle one): I I. Beard of llealth 2.Building Department 3 Cit 'Town Clerk 4 Fiectrichl Inspector 5, Plumbing Inspector i 6,Other 1 , ..ii Contact Person: Phone#: _ -.-- — -._ _- — • Cu .40 ,OS Uctusn SuperbisoS Spectsity Resirtc e- #ifrt of 4lossacrof 5er,5 3Sf,.d .=spa vi3nr. ntra&tas fss ,onai, ace ss€ CSS j 4 Esp,re Z .2 w,s r €A3 z SO2 H 5R Wit d BREWS.FF FaHsrr' •", ateniedatlorr fiRc 3«iassactausetts sS.r taffeta -+< Rats B_.e,1.. ,x.;v.is cause for revoceficm of Was license. F G'mfarntetiorn about this/*tense �+ '. '.m.,....,•' an 1 r in 727 4200 or-WWI www.roor-s.govidpt Corn.,,ss 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: Registration Expiration Office of Consumer Affairs and Business Regulation 160854 09/07/2020 1000 Washington Street-Suite 710 FRONTIER ENEROY SOLUTIONS Boston,MA 02118 FRANCIS SHEEHAN 4 502 HARWICH RD BREWSTER,MA 02631 Undersecretary Not valid • t signature ® DATE(MMIDD/VYYY) ACORD 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 (ac°.No.Extt: (508)398 7980 FAX No): E-ADDRESS: mail@rogersgray.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 INSURER C: _ 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 LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER IMM/DD/YYYYI IMM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED I CLAIMS-MADE L J OCCUR PREMISES(Ea occurrence) J $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE $ , POLICY 1 F12, JI LOC ] PRODUCTS-COMP/OP AGG $ OTHER: AUTOMOBILE LIABILITY 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-MADEI N/A YAGGREGATE $ DED RETENTION$ j $ 1 WORKERS COMPENSATION X MUTE OR H- AND EMPLOYERS'LIABILITY Y/N !I ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBER EXCLUDED? 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 I I i I I 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 Daniel M.Cro')ley,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