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HomeMy WebLinkAboutBld-20-001823 '3AOSV 0310N NOIIOn211SNOO d0 S3OYIS 'NOIIVOIdILON N311111M 210 St/a3nSSI SI IIW213d 3H131da JO SH1NOW XIS SnOI2IYA 3H1 a3A02iddV 3NOHd3131 A9 110d a3ONd2121Y 39 NYO NIH11M a3111VIS ION SI mom NOIwwnd1SNO0 SVH 21O1O3dSNI 3H11IINn a2Ivo SIHJ NO 03IVOIONI SNOI1O3SdNI AI GIOA OW TnN 3WO039 TIIM 1IWH3d a3300dd ION 11YHS>111OM I :2j3H10 S1Vn021ddV SNO1103dSNI ONIaiIms 1332I1S 1/11O2Id 318ISIA SiSill OS CRIVO SIHI 1SOd 31na3H3S '3GYW N339 NOI103dSN1 a31IV13a 01113d911(b AONVdn000 SVH NOIIO3dSNI 1YNId 1IINn a31df300 3H0d38 NO1103dSNI 1VNId(E(ONR13A00 'SNOLLV11VISNI 1VOINYHO3W 38 ION TIYHS owning HOnS`a321In0321 HSINId 210 HltJl 210d Aab321)S2138W3W CN`d SYO/ONIBWf1d SI AON`ddf3O0 JO 31YOId112130 V 3213HM 1d21nlOnHSI ON1213n00 OI 210121d(Z'SONIlOOd 1HOR113213 2!Od a3211n0321 '3CVIN N339 SVH NOIIO3dSNI 1YNId 321V S1IW213d 3IV Vd3S lllNn a31SOd ld3N a21VO SIHJ(NV 90r 110 SNOIIVaNfOd(1. :>1210M NOI10na1SNO0 318V011ddd 32I3HM NO a3NIV132I 381SnW SNYnd 03AO Iddd 11V 210d a3211fO321 SN01103dSNI WfWINIW 'SNOIIOI211S32I NOISIAIa9(1 S 319V011ddV ANY JO SNOIIICNOO 3141 1A1021d INVOIlddd 3H1 3SV31321 ION S300 IllAkI3d SIH1 AO 3ONVfSSI 3H1 'S>I2IOM OI18nd JO 1N31/4121dd30 3H1 141021d a3NIV190 39 MTV S213M3S onand AO NOIIVO01 CNN H1d3a SV 113M SY S30`d21O A311d 110 1331119 'NOIl3laSl2lnr 3H1 A8 03AO21ddY 39 iSnw '3a00 ONIamIn9 3H1 213GN11 a3111W213d Al1HOIdI03dS ION 11.1213dO21d 0112nd NO SIN3WHOV021ON3 'Al1N3NVV 3d 210 A1R1b210dW31 213H113 dO3213H1 121Vd ANY >11VM3OIS 110 AA-11V 133111S ANY Adn30o 01 1HOI2I ON SA3ANOO 11110i3d SIHI O Ur ti99Z0�s t/Wi H1nOWdVA H1nOS= 2iMd11V213N3O 9'S2113 N332IfVW 3d33>1 SS321aad A9 1d39 ONlalin9 1" 'J S2119mm3O21030 3d33>I1 213NMO s t£9Z0 WI '2131SM32181+ I 00 9E1 ($)33d 11W213d 00 0001% ($)1S001S3 a 091 91 1 1799 I ad OS)V32IV ' a21 HOIMHVH Z091 NVH33HS SIONVHd91 1 i SNOIiniOS AO213N3 213I1NO2Ud I6 1 wewanoadum awoH1 I t 1 17980911 3SN3011 ___ __ _ 21010d211N00 1 (06170-L 2 171L)uo11e1nsul Ile1SUI Jleda2i S>i21t/W321 C-211 dnOHO 3Sn € 8 Ay.,. 3dAl 1SNO0 139 01 SI ONlalln8 99 8901 101>IO019 dVW NOISIAIa8nS 1 1eiluaplsa2d •:ed,t1 PI9 i µ017 10I2I191a ONINOZ [ 1nOW2iVA H1nOS a21 30N32IMv11Vel3N3O 9 (N0I1d001)lv MaN O111W213d NVH33HS SIONb2Id 1NVOIlddV *` ctss 66oZ/£o/o I. alga 3nssl f'1 K3`Y{!1 M, OHV3 213H1`d3M aor illAutnd £Z8io0 oZ-a18= ON 1IWb3d f' J N l a-u n e I,9Z 1•4Xa L£ZZ-ss£ (sos) " }uaua edea fiulplln8 H1f1OW21VA 1O NMO. vi.' 6/1g// pqYwg- r r Office Use Only .Y�, C 3 y 4 'Permit* 0 J Q y Amount .e. rig, �;' ab..... a `Permit expires 180 days from SU.. 2'' I ta3 1 issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department , .. 1146 Route 28 South Yarmouth, IVIA 02664 OCT C)3 2019 # (508) 398-2231 Ext. 1261 CONSTRUCTION V ADDRESS: _... L.�� W. Q VV 3 )JS-± ASSESSOR'S INFORMATION: Map: `Q� Parcel: OWNER: Lit g Q A) 1I-0C2 cCe 1t'Q ( — NP PRESENT ADDRESS TEL. # CONTRACTOR: F .... ` it. I C -,,.e Dvio .- '7`7 Li 9 w7 o('1 G) NAME D,It I�)4_0 c TEL.# V residential I-_-_,Commercial �✓ Est.Cost of Construction$ 1// 00 Q Home Improvement Contractor Lie.# i U`5' ( Construction Supervisor Lie.# l Li f Workman's Compensation Insurance: ("check one) L. I am the homeowner I am the sole proprietor : lave Worker's Compensation Insurance Insurance Company Name f' { Worker's Comp.Policy (, CXD OCI( ni S /1 WORD.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 lavers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like,for like Pool fencing *The debris will be disposed of at:135_,G, . C) _., 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 p nd for prosecution under M.G.L.Oh.268.Section Applicant's Signature: -. Date: Owners Signature(or attachment) Date: Approved By:_ V Dater /®" ' Building Official(or sir EMAIL ADDRESS: -^, ')$ -, e , ,( Zoning District Historical Di;--res Yes L. No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: D Yes ET, No Yes No C\1 + -&J e - = .00 - 2.o f, ` oc.Q t CD ' RISE ENGINEERING OWNER AUTHORIZATION FORM I, Maureen Keefe (Owner's Name) owner of the property located at: 5 General Lawrence 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. Owner's Signature Date RISE Engineering, a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com The C'n trttrrttiviceulth of Massachusetts _yi1 el�urrtrtcynftt/lreilxtstricri Accidents ��r - cj 1 Congress Street,Suite 100 t' g' Boston, AlA 02,114.2017 � 4 k '" svrvw.ntu:ss.gOl/dia \Vurhtrs' ('ootlmlrsatunr Ins tripe A Hid ttit:fiuiid(,rsiC."rule,za(torsiElcctricians/I'ttuttkssrs, ,* it) t;i-. tIifla}VIIIi IllsflKVI-11-IA( \t. IlIWIT) 1 Applicant Intor:at ation 11 [y }__. t �__tc Please Pritet L gibly 'stile ,[iu,nc,fi+I)r`ganlzat:elntIndiv'e'i all. ,�;�J�'t4, Y..� 1. 4' I/ 'd t t..!c. I ..._..... city``it to 'IiE Li tr—l„,,., .b3( Phone# '72(4,.. c')W D Art}oo a',eroplon-tr.(:iteh the appropeiaic hoc: .l`tpe of project(required): 1 ?---Ti,,,,,ci n:one1.,th i cr.y,it i .t :ai u. .,in w„tit` J N$t'v construction Li �r a ,map i i al rl l l.p 41 l 1$i it .. i.s., ,. l.+c alit1 ‘,1keI'. r,1 illk l,= ne..r1 .,.it IA. . 1ni1, ..nnl, i,si1 nu sc,i.u,d '1 1 r_.]1§pk.t,1 SolucAvneJ doing to)+work oivi el t.f No work:',. P'1,. ,-1'li V e r epu,rceI' Ili 0 Building ad(tit.cn d( 1 I AM a homemkoer ami wilt bchieingtvnutelus in,t1 1(iac1.11 work onnt} property. Iwill 41jaltr0 that all iontractorr-either loot workers npVilsuttoa I wttvano or:re.ro'e 11 E]Electrical repairs or additions plapiteunr r 1. rus uplcryec a r or additions 1 J Plumbing repairs i ri -ani a c 1 t < r1 nr t r sod 1 1+cc For ih e M. n . 1 t i On n flach„d ktircl I i ',3 L.j Ro,,r ropair'ti ' i . L.^ ` � i I Ac, .tt:,,is ,,:i.,9it f,, , ?1.. .. , ip„ ps ,.ie, , r Al,n r s,aot a t 1 k 1.1c r11 1 ,i.: i I l(..III. is s ,1 ,1 'h1. np 1» 1t 1 i t i i, x 1411E 1 t i 1r ceteraWilk) of lrut fill',affidavit indicating tls, arc cimog m.,coll.. t . men hoc u1r1 1 t 1.a.luc 1 u1 a:ct10 n 1 a rid ,i1 md1 rto>g au,'h. 1,tltilrictus t11.1,clrc.k this box must(ititIchtd art additions]+ct1„„1'>hitwtrlt!1iW.1131110 of the`.ab-etill tlnl'.ttIi, film state w baiter-I. not those cronies have employees. It the,nutr-ciu:tractors have eanployees Ihcy 1 rat,,..J,ttc ii ei: wit k^'S'coop Pestles 1,uln7Cr I am an inq)teeycr that it providing workers'compensation infierrrttree for my employees. lie/ow is flu'policy and job site infoi'mtttialt. ._.1.Insurance Company Name 1' } s- 1/ --- -". . ., _ I '_ P.,hr r Ne.L;tv 1-ic.i . c;C ..tOC --C. U l; i s )cT F-piratiotl late:_` ii.,y 100 Job Site Ad ir( s:_ r t slltior> sintpiol'�.ar�ttubcr and expiration Attach a copy of t to workers'compensation en policypagedate). Failure to secure coverage as required mulct tIC ii c. i 52, <'.oA is; i criminal 1 udattim ounhh ante by it line ttp tc'1I,500,0 it dior wle-Year i:ftlpiisollincnt Sis well as. 1vii peraii,es in the form of a STOP OP WORK()R0I R and.,One ci up to i250 CO a day against the violator A copy Or the stlitC111C ii nl:y .c d,.:t trticu tv t11e.Orrice.t'd I,t.c.stig ilitnna of the CIA for insurance covet age verification. 1 do hereby certify render tit air •and penalties of perjury that the i+tferotation provided above is true and correct. • / 0/S.) I 5_,_. .. ,.,... Official use art/v, Do not write in this arcu,trr be com freer/ll city or to1111 tr/frciat. (At),or Town: Permit/l:icenseto__ � __.__ Issuing Authority(circle one)t I. Berard of Health 2.Building Department 3.sits/Loan Clerk 4.Electrical Inspector 5. Plumbing Inspector b Other I C.ontarai 1'crson Plume#:__... .. �.. • • y. t •' f Constructk Superviso,Speddattp Cornsio & ',10 s ecnoieni Rpatatctedara ,•3. Drytnian,.r ;^. i L l6ensure $t•JC-I1S0.,aYF?d t:con,,,tor Board 3,n- ,._.,a and Standards Cws1•1059,1 �r. sres.?2 ""r2til2 . y F1tA1dC1S 5 SHEEHti7-: ', 502 HARINICIS RD a 1 RREWsTER VA s' x" failure try pns ss a c:rrr e-a€edition of the Marsinchttneds Stark 8w ding Cd t e cause,for revocation rAthis license. f-or infOrmafion about thin ficense 3 rk�y Can t617)727-3ZOtt or=non wvaw,messspav,rtpi ;omfiSY.`ss one. 7 v/✓.zcv.r/eei.CJ1i ,,, 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 1$08,egii 09/07/2020 1000 Washington Street-Suite 710 FRONTIER ENERQYOJT1ONS Boston,MA 02118 FRANCIS SHEENAN 2 C� 502 HARWICH RD BREWSTER,MA 02631 Undersecretary Not valid • i signature it iP ' f 1 ® DATE(MM/DD/YYYY) A i� 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 CONTNAME: Rogers Rogers and Gray Processing ROGERS & GRAY INSURANCE AGENCY INC N ,ext): (508)398-7980 FAX (A/C, E-MAIL mai ro ers ra ADDDRDRlESS: C 9 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. ADDL SUER POLICY EFF POLICY EXP INSR LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DDIYYYY) (MMIDD/YYYY) LIMITS 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 PE� LOC PRODUCTS-COMP/OP AGG $ OTHER: AUTOMOBILE LIABILITY (EaacccdentSINGLELIMIT $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ NON-OWNED AUTOS N PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) UMBRELLA LIAB �L_ OCCUR EACH OCCURRENCE $ _1 EXCESS LIAB j CLAIMS-MADE N/A j I AGGREGATE $ DED RETENTION$ $ !WORKERS COMPENSATION X STATUTE OERH 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 VWC10060153152019A 03/14/2019 03/14/2020 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 (Mandatory in NH) If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS I 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'v,(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