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HomeMy WebLinkAboutBld-20-004057 (2) ` y ; office Use Only :-• , ?v` i Permit# s _ o- Amount 35 0 c": Permit expires 180 days from "'.. issue date I -a L ,, - o EXPRESS BUILDING PERMIT APPLICATI ----1 TOWN OF YARMOUTH E C E I V E D 1 Yarmouth Building Department 1 1 1146 Route 28 JAN 9 3 2071 1 i South Yarmouth, MA 02664 (508)398-2231 Ext. 1261 BUi -S- By CONSTRUCTION ADDRESS: , CJJit J-' .fz---t.) ASSESSOR'S INOIRMATIOI�I: Map: Parcel: - OWNER AtvE S . # • CONTRAC`TdR. `-E... ." I J "� -27 q a .- o'4/J) q 1rResidentiai- 0 Commercial Est Cost of Construction$ c7/a{ Home Improvement Contractor Lic.# 1(00c8S—C.4. Construction Supervisor Lie.;# Its' Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor Viierraave Worker's Compensation Insurance ' Insurance Company Name t - Worker's Comp.Poli I.5--' ) W ORK 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 Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at:I 9Ci) -fi .-!" 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 answers) will be just cause for denial or revocation of I aa. ;t d r prosecution under M.O.L.Ch,268,Section 1. Applicant's Signature: Date: ,M. * _ /// Owners Signature(or attachment) ``+ Date: /a Approved By: Dale: - / - ...4,4:voila Building Official(or designe '` ENV&ADDRESS:f ilroc?lit c'°.Wt }°t'ir Ae4 it Zoning District: Historical District: 0 Yes a No Flood Plain:Zone: 0 Yes C No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No D Yes 0 No RISE ENGINEERING OWNER AUTHORIZATION FORM 1, Frank Scabin , (Owner's Name) owner of the property located at: 15 Lower Brook 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 4.7..„........, permit and to perform work on my property. This form is only valid wit a signed contract. Owner's Signature i I' )-4a-I9 Date RISE Engineering, a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com A 11 671 DO r x:t 1 r 1 ? r., re,� : tr' 1 S 'e 10 ' Woocer'CoCoto'entatio ircttwetono! t itovi'Atriftfersi entt to [ectiiii 1 'itii 7•ers;. ,� ; tO Or F'1! k:6\Vita IRE PKOIt'irlNC At."TItbRrr, Am:gimp I,r rm4 i , Pisase:J tiiut,Leoiblv Nathe kingT tirget5.i# ooeiiii i tcluel)I a a 1 ,, +lrcy-on.rnii th-*1" ktha apii irrtaarr do type of ge cl riey t ire • 1-5/wnaUti sloy+krwrth10 , ofy.ttyet rr;st: t,t;peri4tteer ' ".. 0 New 0.0nstrtittiOn 2.E:j No V;teXpiep*rarer jjpi"ttFo:%t1,o isO the no coptoyeo ww�i:irfia for mein ii. CI Remodeting 9. A+ acalitl t "t}4h�txt stti allwitnl tif1Ne+aaarl. telk atAi*e r fed � I irlt� diton. twit'4'300H ili0:l14fr d! ltl4(it°4et 0044)- 114 1 , t a. ` b rkeireomle tkOise+ -er :oto . • ' , c iep7i �r .as Fooataatyobaaaaaatoaet.. • ,Clixly itiirt r r" - dditiil 1 i"Ani a 04tooet tfftte and we bite0 the ut.4141.4- torbt010.tok Ole atifwo ved sheet• 1 .• • Roof r rains thew stitoe&t talra ttivsea�ees aftd Ya+a<visf&ers mint tp,,swilthce t 4, %t Utt a oerpontttou sod its et ufc ya exer iced ths=tr r tnllt of t"x4fnittxnli MOL c. t .t •t I51 fay4t,tied we tvive rurtnnpieoe s r4owvrke vrratp instu'enc> requited b t0rm • [aa g; -i4hl•s+attl t 1tsr wort r Ctn tttyny i flQ 1t f • ent' i ttr tt ' 5Cc rtx.tA " t :-t•bw a titda a ;ia atrIrMitx wltuat� tss iuhit t . ,44044.*Ii White hnt1c tract&%Infra-«orsuens t f G 4u, rn Gnhtt p* tt4st� tm> l> l# t stueettkt 9"teSu tit,$Q,k d i1'e ditt toes W have 1t i��. rarsa; rr Jt��'loyites. Oaii73 ic"*0',pnti`ey rptd, (� t. , IYtsui�#tCC Cttr ny ltt�rri� '. Policy,4 CtrSe1c-13 ,We.l '. "'; . , P 3i V0I C7 A- .Expi titltll ni i_, lq„j W'' Job'Site ilt ss, iWSt J, rp -� I Mint i rt*i f.�e r ,m .a a k dee 0-atitln p tho ng l le!a r iilit.e taWO OR O?, fait.uri V-VOW 4101011V as rigus`.r i:tkrtdir Mr1L,.c, I lk,R5.i4:24 rritrtio,ai vllI to r►t i h k-by-„ante Ap lto. i ,6t?` 0 *n vi> re liopilisottt ,,As it a v i.erral "irt tut itfti tOPWO ordnit, l4 O uF tlo 6p 9,0.a tuta gst$ at o ,t OO Of t galt f rt May rs T°f i an.IN in tilt office tt'I.ttr ti a } aft DIA For tr;«' S ri PWl u t`` €rr r 1, �i 1 af�'. Y t "� �fJ °ti. t t Yt tk,...' t cart `prrrtrttica Ori ontim pratvi edt rrfr v }, ue " flt eprrec. m a ,,,;, ,_ (� �J t O is 't'se•ttf ")il apt wilt ire ttttsarea,ri,tia•-tampiatot 0 crrt ar frpsyt alik t City-or T4wna _ Permit/Limn ii.,. ,, ...,�. ..., : .. :...�—. Insuiptilutharit eit olliink 1,Read of ttth 1aUfidittg Dtep stein 3.ettyfro n Clerk 4.l iartrical inupeettir S.�nnbin lave.Oar d.Other t Cora/Int P st`nt PbO #: AC O CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/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 CONTACT Rogers and Gray Processing ROGERS&GRAY INSURANCE AGENCY INC O (A/C.No. • (508)398-7980 (ac,No); E-MAIL ADDRESS: mail©rogersgray.com 434 ROUTE 134 INSURER(S)AFFORDING COVERAGE NAIC 0 SOUTH DENNIS MA 02660 INSURERA: AIM MUTUAL INS CO 33758 INSURED INSURER B: FRONTIER ENERGY SOLUTIONS INC INSURER C: INSURER D: 139 QUEEN ANNE ROAD UNIT 6 INSURERE: 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. IXP NSR ADDLTYPE OF INSURANCE INSD SUER POUCY NUMBER (MM/DPOUD/ YYYYY) (MM(DD/YEYYY) UMITS LTR INSD W1ID COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE $ DAMAGE CLAIMS-MADE OCCUR PR RENTED PREMISES Eaoccu occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JET LOC PRODUCTS-COMP/OP AGG $ OTHER: AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ — ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ _ _ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS (Per accident) $ UMBRELLA UAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE OTH- ER AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 A OFFICERIMEMBEREXCLUDED? 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 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 It 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-compensationfinvestigations/. 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 Cr v y,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 II 1 MC rc �G 00. le py ya ..'Af i1 .7 Orrµ a�It it 1 to a co ii hit.L. «. cc8 ` I sli els A Q$$��Q¢¢ V-...,,s, "t r , a g 8; W _ W=