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HomeMy WebLinkAboutBld-20-004053 (2) :g Office Use Only .ap Permit# a ' 1 s Amount )., t w:1'v .. +'""'" � Permit expires 180 days from issue date ,B EXPRESS BUILDING P T APPLICATION TOWN OF YARMOUTH ______ Yarmouth Building Department RECEIVED !;,, 1146 Route 28 ----- 1 South Yarmouth,MA 02664 �F (508) 398-223.1 Ext. 1261 , `E $Ui__ 'e'a " l d •j CONSTRUCTION ADDRESS: 1 � i �' ay lPM _ - ASSESSOR'S INFORMATION: Map: I Parcel (S. (c, OWNER AD S L 4 ; L),.j yTEL. i \ CONTRACTOR.:- . . NAME -IvIAP, ti.3 m TEL,# �I k�Residential 0 Commercial Est.Cost of Construction$ Home Improvement Contractor Lic.# Construction Supervisor Lic.# I(3 1Li Workman's Compensation Insurance: (check one). 0 I am the homeowner 0 I am the sole proprietor 4 ve Worker's Compensation Insurance Insurance Company Name ,N44 jeti. ..,.y Worker's Comp.Polio j X ? { 1 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 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at t e e � + ,+1 t ci m! f (-04 Location of Facility I declare wider penalties of perjury that the statements herein contained are tnie and correct to the best of,my knowledge and belief. 'understand that any false answer(s) will be just cause'for denial or revocation of m• d .1 prosecution under M.O.L.Ch,268,Section i. Applicant's Signature: Date: / 0,9100 Owners Signature(or attachment) Date: /J Approved By: . L../ - Date: 13 d.0 ityl Building omcial(or designer) EMAIL.ADDRESS Zoning District Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District Within 100 ft.of Wetlands: 0 Yes 0 No 3 Yes 0 No DocuSign Envelo•e ID:EFA295EA-168B-4CBA-AB33-1C28C06FB424 Permit Authorization mass save Form Site ID: 3737364 Customer: Lillian Steele Lillian Steele I, ,owner of the property located at: (owner's Name;printed) 543A Main Street West Yarmouth, MA 02673 (Property Street Address) (City) 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. t—DocuSigned by: Owner`s Signature: U01 Sfulc. 12/17/2019 ( 9:14 AM EST Date: 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 Only Rev.102015 f - 3 14. I0 H girl .E Ski " y :ems{ �. ��/ C14 S. t a 0 v *4 0. E -1" 4,— _ 3 A ...... . , . . ., , , : 1 4.4,, 4 46 € �. ...5 11 ;4''' ,t1 .,,,,,,4 --', t''' I g i 1 1 II —14:44 PI: .Z-4'. . tio) /IL 40.. alt .41 1 - , ti ,_1 I # .. w . b .' ,„ -I y i. 1 i r ;{t' ' ! . m � 31 � 1V'1 F I � <':�.R3+' i. 'ti t it .1 S .A tl 'I ^' Sir+/: `.i .f U- p W i. 41 ^4 p yj 1 it i ;+' 9+ 0 .1 ` ,m..r„r R 0 y ti may. 't 1 i ;.. t ; gip- -, w �' � 7 ®ACORD 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 P"O Ne,Et); (508)398-7980 A/C. No): ADDRESS: mail@rogersgray.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 INSURER C: 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR wvD POLICY NUMBER IMMIDDIYYYY) (MMIDD/YYYY) COMMERCIAL GENERALUABILITY EACH OCCURRENCEGE 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 JEo- LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ _ _ NON-OWNED PROPERTY DAMAGE HIRED AUTOS _ AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE OTH- ER AND EMPLOYERS'LIABILITY EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBEROEXCLUDED?ECUTIVE N/A NIA NIA VWC10060153152019A 03/14/2019 03/14/2020 E.L. (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS I 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.govAwd/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 REPRESENTATNE Harwich MA 02645 /a 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 0 11 _a i =$1 I °1 c � w ii''1 1 a _ 1 / I liii z m.630 i 1 id il 1118ii I 5G F a. $ ice „ .. et I i I •z„ j,i ,., , kt. da --, finn es 01 "1 2 1 O s