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HomeMy WebLinkAboutBld-20-003007 $'� TiOffice Use Only � 1 Perrrut OI 1., J'3 lAmount �f> ATTAGMG.LS[ �`°°'°" `° c'� i Permit expires 180 days from ����w��� ;tissue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261- — . COI t I 31 CONSTRUCTION ADDRESS: ,.. ASSESSOR'S INFORMATION: Ii Map: ipt 9 }Parcel: 1 61___ 0 VINEITY-etp23\IN ...).. 0 (AA-- - cic,):, e....... , ....,IE. IfRIS9CHQ)DRESS TEL, g CONTRACTOR: . " ? NAME m D it'll ril+ - t TEL..## kW Residential C Commercial Est.Cost of Construction$ 6 0• Home Improvement Contractor Lic.# I(4 ( Construction Supervisor Lie.# IDS-CI j Workmar.'s Compensation Insurance: (check one) I am the homeowner 2. I am the sole proprietor s -t have Worker's Compensation Insuranc ` Insurance Company Name: „ U1ij \ Worker's Comp.Policy#I D00001 S' 3 L 0. WORK TO BE PERFORMED Tent _,_ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows: .T Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing Iike for like Pool fencing *The debris will be disposed of at: i R " '' . C_,.H , r Lis- 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 m td for prosecution under M.G.L.Ch.268,Section 1. Applicants Signature: Date: l 00 • I1001 � l`l Owners Signature(or attachment) e ✓ Date: Approved Bv: A Date: //-2- 71 Building Official de ec) E.'ULAIL .SS: '$}0,1k>1'ietiot ci--ocit,1, 'att.0 ,a.#v Zoning District: o Flood Plain Zone: Yes No r Historical District v Yes �_ N�r Water Resource Protection District: Within 10C1 ft.of Wetlands: I D Yes No v Yes _ No I DowSign Envelope ID:OAADD4CB-E7D2-4635-91364-888134327FC07 RISE ENGINEERING" OWNER AUTHORIZATION FORM 1, Teresa Visconti , (Owner's Name) owner of the property located at: 226 Wood Road (Property Address) South Yarmouth, MA 02664 (Property Address) hereby authorize , (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. This form is only valid with a signed contract. DocuStgITI by Eci 91M64eVtignatUre 10/1/2019 I 7:21 AM EDT Date RISE Engineering, a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 I 508-568-1926 www.RISEengineering.com • 'MeCoiltifeiftwoOth j' fad b°ris tfS xi tty ,_ i Dept,rt it rch ii, rdArei ' t r 1 COit ess Street,Ssitt 100 •i , e 1/4 na rs e.S "r�7 Worker 'C,:e.Atpentrtttiort 4-t t trmeiM`ltttat ntl rsiepntx orVitlert mint i iiin l.ers. 4 . TO ISE PILED WIN THE PEI:6.111t'G ACT'}ft itre, Applic t Informs[ n „ . Please rtitil Lezit)ly, Inttte(L usiness.'f rgatlsi nilridiyidu ly '#- t ,. r•.1 i t res$ ie'l11t t At: }. Areyl:miaa ptuptuwr'i Chock•tha AttprulAare boa: Type of pM,ect(required):, T ten a arupilty t iinih 1,0employe tAil!.t ri•t,perr-iurrty' 7. 0 feed citlt tmotion x 0}am a•si to prO tarfix pnn ship aftat ban no entpleyccs wort:ti;ter mein a, Q Remodeling *Ay pp <( w+rarkatit'cumin salsnrnnte, required.+ r3 DtiPlitiOil " .0 t etfl t tofteo+cv£t %.ttil murk myself•INo wprkem cowp rnaztr cactu,rad,r 3k 0 Bikiidi Addition 4,01am*.ieanc ncriutirwilllte ttcure,esitits apteteentslt 6tailtatkwi, e?PrenetlY• [wilt 4864e11**140•00400,11441109ioveli§rktreOmp tatidNIrscirai tic Mt 010 1l.0] : firiiIii•rOp.iiiIS or additions prepii.ttaxsttirtin+saiitittans• 1-2.0 itonbirrgrepairsoradditions 9 ;ltna e.gefterithott.0410.f and tnva e l the W E atSxt . h aim 40,?2he attnsfieti b t, 13.0 Roof repaii3 , 'these sutr railehashays.eui tayoe arid have elft:eri' rsirp uasueiiNe: f ti, We area w rtiotaiecta atxi_ats ot€er'rxfi t axes scwi efacn+fi;,t,a Of t',00 rt,tui g,w'MC; c III (4. tirdiT fi 1:52,4I 41,ata.ole havc rin empnSf c 14ii workers'vomp ttwiranee iefweed; 'rAuY apSlltaantittAt 1* t MUP,I atm.all out iha ittettfei betuw efoweig their worked comperriatIOn pcNie)ititottAation, 'ktrniteuwra iota*•amte Uri tviThIspiit Yi iaatir*thy;.trextola g wkI wcicie.ild that uaatsnte eiunanctora attuatsabmit*mw aff4dawat a h ddrtgt,i is b. ;Centtechts tart eh*dtS mttsr Wirtelrc11u attetitW not iWxt'ithawanp the Iairla .aI1 °I''+ctantrttclit14tt$$1atc tiRcthvM+te it+it ili5isc a uatics hriee cowl l ,;cs, If thia40=clanatittup€ v009,10 ,ipeY' v;de t!sct c lketz a nl, fmtiq iount r.. .i COO ftii e r, ityet tl t*"014414'Workere,colvenottieti titlitranee fbr my•ennikret. e s. #}"iJ'tew'kr Me—:policy and job site . insw ace Crarrtpahy Name - " yam„ # . Polioy r or SaliAis.i.ic.'it rI JQ Q1 S 3I 590).I ", .. Exiiirtnioit late,./ j�..)i s Job Site s" �fi:.1 w ityiSt 4 Lip. '\j�— A.titttti a pY etin tlensat�iiei paitcy tiecleraiitlil•p*go'ii4lioW'dn.' a po it er atliR si date). vv Fnfbne to Senate eboveii ge as iesp red:under M3L,c I S2,§25A is a criminal vi011tion vpu ixhati bye Cane tip to.V1,5O0:00 . 'weft one—le one-lee impriSonitent,as Wrltl as iVi1-peasl1t, in the`torni it`a- TOFAh'O K OR. - ..and n fii e of up to i {)LOO a do,ug 4 ast t e'violat(*.: c+ of this statement iiiay t -ikirw+ardiai to the Office of Investigations of the OtA for insurance' ' cr vera t xterif 'i ri , . I die here iy rent[ 'CO—dirt, 'erii£pettaltias pfper#ry dial the information'pr ided aboiae-ii tart and a~reet, ( ) h Ofirtrtf use[only. •At,.nat write--in this 1rci:,to hi cttrtipletud by Miry or town trfjiziaL a - City or to Perniitil iettl4e t4.- �.• _ �._. _._:.._ Issuing Authority(circle on 1.Hoard afHealth 2.Building Vepartmetit 3.City/Town C"lerk". 4.Electrical Inspector 5.Piiimbing Inspector 6.Other . •.- Comae P rseiti, Phone i � , _ • a g AT, II « i Ewa ® 'F� Oi To ts II i ii! 2 " 18l 1 r as o m a g...21:f 4. o � L a ID 1 } S>.3pdbjF 3�y d i tezi,A • J tt`_ L 'fit 3 1(f f£, vY r y W 0 ^ 1 ® DATE(MM/DD/YYYY) ACGRD 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 CONTANAME:CT Rogers and Gray Processing ROGERS &GRAY INSURANCE AGENCY INC Paco.No.E:t): (508)398 7980 (A/C,No): E-MAIL ma ro ers ra ADDRESS: @ g 9 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. IP NSR ADDLTYPE OF INSURANCE INSD SUER POLICY NUMBER (MM/DDIYYYY) (MM/DDIYYYY) UNITS LTR INSD WVD COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE 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 CO BINEDtSINGLELIMIT $ (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 STATUTE ERH- AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBEREXCLUDED? 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 E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below 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 Frontier Energy Solutions Inc ACCORDANCE WITH THE POLICY PROVISIONS. 139 Queen Anne Road Unit 6 AUTHORIZED REPRESENTATIVE r Harwich MA 02645 "" Daniel M.Crgy,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