HomeMy WebLinkAboutBld-20-004220 (2) ; Office Use Only
r Permit#
Amount L3-5
Permit expires 180 days from
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EXPItEsS BUILDING PERMIT APPLICATI E C E t V E
TOWN OF YARMOUTH i
Yarmouth Building Department LAN 3_l 2{)?a
1146 Route 28
South Yarmouth,MA 02664 B oils, •
(508)398-2231 Ext. 1261
CONSTRUCTION ADDRESS: L.Je ) � f-
ASSESSOR'S INIPORI ATION;
Map: 1.t. Parcel:
e_otiF-J-1,.. (4. it. 1 -0
t�lAl . � r �,,D TEL.
Cf)I #RACT(SR � � - r' "t M*:M .-,C} /7 Q /Q
1(d�Residentia1 0 Commercial Est Cost ofCortstruetion$ C-- , 00
Home Improvement Contractor Lie.# 1 Q Construction Supervisor Lie,# I� 411
Worlcman.'s Compensation Insurances (check one)
0 I am the homeowner 0 I am the sole proprietor ve Worker's Compensation Insurance '
Insurance Company Name i. )4 r Worker's COmp.Pol cyIW b -�-4- ,��, z-vr/�' ,
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. 4:1 � �e4 ` J � ��yy
f�
Location ofhaslllty
I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belie. I understand that any false answer(s)
will be just cause for denial or revocation of d" prosecution'under M.O.L.Oh.268,Section 1.
Applicant's Signature: Date: I
Owners Signature(or attachment) erg Date: ?
Approved By: d i� Date: 3 �4
Buil ' ffici or•- : --1 EMAIL ADDRESS, I1 r O.
Zoning District:
Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0. No
Water Resource Protection District: Within 100 ft,oLWetlands:
0 Yes 0 No 0 Yes 0 No
DocuSign Envelo.e ID:204AA39E-B540-4F9E-98DF-OAEEB6A39C44
Permit Authorization
Form
Sakenparitir000nemeoprefedenoy
Site ID: 3931125 Customer: Katherine Tildes
Eric Coll ea
I, ,owner of the property located at:
(Owner's Name,printed)'
6 Wedgemere Road West Yarmouth, MA 02673
(Property Street Address) (City)
hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed
below to action my behalf and obtain a building permit to perform insulation and/or weatherization
work on my property. oocu$igned by:
Owner's Signature: 9R8959�5960145F
1/14/2020 i 10:30 AM MST
Date:
ae sees..
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 Mee u., iy
Rev.102015
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7 e DATE(MM/DD/YYYY)
A�O 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 NAy FACT Rogers and Gray Processing
ROGERS&GRAY INSURANCE AGENCY INC IAIc No.Exn; (508)398-7980 FAX
(NC,
Ao AIL mail@rogersgray.com
434 ROUTE 134 INSURER(S)AFFORDING COVERAGE NAIC N
SOUTH DENNIS MA 02660 INSURER A: 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 SUER PO W M/LICY EFF POLICY EXP LIMITS
LTR INSD VD POLICY NUMBER (MDDIYYYY) IMMIDDIYYYYI
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 JECT LOC PRODUCTS-COMP/OP AGG $
$
OTHER:
D
AUTOMOBILE LIABILITY (Ea accidentSINGLE LIMIT $
ANY AUTO BODILY INJURY(Per person) $
— —
ALL OWNED SCHEDULED AUTOS N N/A BODILY INJURY(Per accident) $
NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS (Per accident)
$
UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $
DED RETENTION$ $
WORKERS COMPENSATION X STATUTE OER
TH-
AND EMPLOYERS'LIABILITY Y/N
A OF ICER/MEM EREXCLUDED ECUTIVE N/A N/A N/A VWC10060153152019A 03/14/2019 03/14/2020 E.L.EACH ACCIDENT $ 1,000,000
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below EL 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/iinvestigations/.
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 - L.�
I Daniel M.Cr y,CPCU,Vice President-Residual Market-WCRIBMA
01988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
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Office of Consumer Affairs&Business Regulation
HOME IMPRb MENT CONTRACTOR Registration valid for individual use only
TY ' £ar before the expiration date. tf found return to:
igiCpiratioro Office of Consumer Affairs and Business Regulation
r"' W ' 09/072020- 1000 Washington Street-Suite 710
FRONTIER E S Boston,MA 02118
eV
FRANCIS SHEET f
t502 HARW ICH
BREWSTER,MA 02631 Undersecretary Not valid "' grtature