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HomeMy WebLinkAboutBld-20-001823 (2) 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