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HomeMy WebLinkAboutBld-20-0002581 Office Use Only• •Permit# 3 h3 l,(Amount vat _ .arrnen asc "A,.ii°o c`�x Permit expires 180 days from g('--zu—�SS—iRECEIVE jissuedate EXPRESS BUILDING PERMIT APPLICATIO r D TOWN OF YARMOUTH Yarmouth Building Department NOV 0 4 2019 1146 Route 28 South Yarmouth, MA 02664 BU I 1 r E (508) 398-2231 Ext. 1261 COtASTRtiCTION ADDRESS: :- A..._._._ ASSESSOR'S INTORMATION: C Map: v Parcel: 1% Cf. t ---' - --. 14, 116-CtIC .01bC\P--- TNAME �— PRESENT DRESS 1 TEL. # `CONTRACTOR: y-:.- w :‘,, ,# j (-Je rf „-& t,v ` 7 q .- C 1 Q N" _ 'NAME D12 S . ryi p . , i c_ TEL.i YResidential C Commercial Est.Cost of Construction$ / I 0 0 . Home Improvement Contractor Lie.# I {06 Construction Supervisor Lie.# 1O '/t Workman's Compensation Insurance: (check one) � I am the homeowner I am the sole proprietor have Worker's Compensation Insurance ' Insurance Company Narnelit'�if L r ( ...=—._.... — —Vsorker's Comp.Poiley4P --F 'dC) 4-- 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 Iayers) Insulation t., ''�°' Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: `°,d*--� �' -0-41-- �( 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 and for pr seaation under M.G.L Ch.268 Section Applicant's Signature. c — — date: , .._ Owners Signature(or attachment) SD _ .Date:_-. Approved By:_ v Date: ,���� ? Building Orfici r e '__nee) ti ADDRESS: f I . ) ' -t.:._),1, t t dnfl Zoning District: Historical District: Yes CC No Flood Plain Zone: 2 Yes I No Water Resource Protection District: Within 100 ft.of Wetlands: Yes _ No ' _! Yes _ No ,-.2. i Permit Authorization Form Site ID: 3896312 Customer: Patrick Campion 1, P at ( C Ic C a pi to n ,owner of the property located at: (owner's Name,printed) 39 Nightingale Drive South Yarmouth, MA 02664 (Property Street Address) (OM 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 weatherization work on my property. Owner's Signature: Date: I o - 19 - 19 FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date Name: RISE Engineering Phone: 401-784-3700 Email: Page 1 of 1 For Office Use ofcy Rev.102015 .. Tho t rtrtE wotilt -.tt, `t la tokirs its • r .' DePortmediat17nti sftrta//I..c i"Ifs i ^ i .-r 1 Corr ss., treet,$tare M. 7#' &i tan' 1.4 1 4-2Q17 . t.' W14015,144s$40Viitia, • iiVorkete Ceutat'kettiailOrilOSCOOPCO AfillOttfAulitiersiOotttructorafitieteritiantilflifitiliers. ; TO OE Al'I #fINV1"I"tl'nit Pivt'ta11TTTNG:ALn bRI l' . Applicant litfortuatW Please tlttt Leal l CAM tatisinotskIrgintiMitinitritiiviiittiiiklit. C#CyrttYltt?Yttx- � . i -Aro you me employe?,Cheek ibt sPprupr4uttr hoe: Type ofproyett(required): 1., ' t tu^a emplayeru'ath ..13 empliiyeM ifull:trim 1iom4orml." 7. 0 New t 011st-ruction 2.0 t area sole liebriebnoreir,partners 4p wilco/eat)era,playe a workirij.for.mein a, {0'EtertIodeling any cap*-INewtxk tarnta.&a sraaea trquur t.i 9., l elp.otttfit 3�l torhointum orMP%ali tk Myself Ilito. rkor 'to,�pv>...r e requital' `' � ild g adStTttpn +tx�1mri a iord'efoeiaY aoiliwilt IiG tielple i i'u'ut'aiO4Q0r(0 E,ntm'r,er:Stiff dr k o11"#tty iaf9perty.:t wiill • .. 11,( El ttical molds,or additi s• mril ttrs:rir�' ?rtcecS�AFlapdtYsutirf�fTaS+fnlaY�t;ori�'sxrfle otepli et egw.uh +emptiiyeas. 12, ]Ttunibing repairs of addicit ns 9 DAM 444''bore rcuttrli r atitt i,,diva kiwi the eiiitr-r nin witi, tetl enft rht outalled:ehr t. 13.0 Roof raparrs " r,ut cuattErtors have st plwees id lute�wa t.ere 4�ttir ins e .- • ket3 Gil I....; of exemption thh;r MGrL e. P,. Wearyl(4,rt� timenoetn ees , .,orliar thema:..inv.:1 fcutaquitiri p,y appii,.wntaistc tek$.LSt#tt'E't`*et :outttasccia nowni$thrctr+xor*cr(OrniaerrtaittipnpcliDy itifonnatit5ln t ktyargr",wertea*who auhr 1haa i ltrl+tvit itkdioatio&Pioy'ttctt dot, "au wort ttttii Moot mimeo nffi etoce must atibtnit`e aew rei tilt+it imiti apr,t: rt,opirtttrl't is um chc*Ahla- ;rn atiecltedcalli41i[ nal Yta59>rtY:E)'fav ioK lh#Mono orThe saau 41101 :,Koat1 3tatOuticitn r tnitem'those theeentities have entpt;ayees.#i chesift,coeittectitlatlaove bp301004,Ottlibtrat Iroyide eii rkytS O =1i4!I of lu n r A am am arirpttryet tkat&s`pr tdttng vorker.c-corryarnsm n frrsirmnCe for my amp1+tt,Pees. Its/ow is the policy and jQh stte tnfttriTrtrttr�n. 3 . irtsu nee Company Narm i L t- � 1t - � � t�,� Exp3.rationi?aie; s� �. Policy orDoti'i as.Lie.44 1 ? 3 Ji J4ti✓) - _ Job S teAddress Mi-fps . G y/St e:` ip �1.. 4� �wo aat Hi. 'Attach a�trpy;�t1"tIr?�worts'C1 itusstttirt�>ftcy�et,►taratitttt page'' hovrirtg: Relay re �'at<r #d.e���ttl( `� / •Fit urii to 5�ure vei c es re Aired ttndhr M rL c..i ,- $A is:n primiiiat viaitt011 Putttxlaibie hy,a fine Up to S1,5OO:OO t141k1t t?t goat•irfprisotll tt$t,as'vell o,tivii-penult to the t'onn or a STOPW0AKOIWER avid a ms o€op to 1150.00 a day a ia#st ie'v{tiIatot.A copy of i s atatctttie:nt'ti:ay be forwarded to the'Office'ofloveethotions of the OtA for surtt o ver$ •vvt744'olti t t tr•hreebfy rer'i . udder"1l,� 'Oil•ttrttt penuttios trf petk,/tery MN the in forrtrofitrn'pr0uWWett ibiiire-is erUe and eirreet,' °a II'et • 7� dd w oly, Do riot write in ibis e14,rb+be< ttrrrtrleted by ett'y rar tuwo o. e CiCI ' i o irert#ilf/#zlcenep �:,: __. 1- Ciry 3r Town; �..�.......•- ..,.�...: . ..w...,. - Issuistl Authority(title ot*)t 1.Board oil1ealtit 2.Building_Deptir'tmetit 3.City'(Towo Clerk 4,Electrical Inspector S.Plumbing Inspector 6.Other_... ...,. ,..w.:...-._.,,.-,___*.._ aft#mot I'Iwtttrrb ._ _ -.A - 0 i ill!: �t $� 6 i � z 14 i I 01 cc� as n� a ::2 * 'a 4 I i r- c . 1.III! ! yrhI W co w ws W SU cc o '�.MIN A�D® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 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 CONTACTNAME: Rogers and Gray Processing ROGERS&GRAY INSURANCE AGENCY INC lac No.Extl: (508)398 7980 FAX Not: mail@ 9 9 Y•ro ers ra com ADDRESS: 434 ROUTE 134 INSURER(S)AFFORDING COVERAGE NAIC S 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 POUCY EFF POLICY EXP UMITS LTR TYPE OF INSURANCE INSD WVD POUCY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL UABIUTY 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: COMBINED SINGLE LIMIT $ AUTOMOBILE UABIUTY (Ea accident) BODILY INJURY(Per person) $ ANY AUTO ALL OWNED _ SCHEDULED N/A BODILY INJURY(Per accident) $ _ AUTOS N PROPERTY DAMAGE NON-OWNED (Per accident) $ HIRED AUTOS AUTOS $ UMBRELLAUAB — OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ OT WORKERS COMPENSATION X STATUTE ERH- AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT $ 1,000,000 W A OFFICER/MEMBEREXCLUDED? N/A N/A WA VC10060153152019A 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 ACCORDANCE WITH THE POLICY PROVISIONS. Frontier Energy Solutions Inc 139 Queen Anne Road Unit 6 AUTHORIZED REPRESENTATIVE C... Harwich MA 02645 Daniel M.Cr y,CPCU,Vice President—Residual Market—WCRIBMA I ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD