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HomeMy WebLinkAboutBld-20-004056 (2) Office Use Only Permit# H t F4' _ Amount " j"� /l Permit argues 18(3 days from BL b V /'i�/,, issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUT-I Yarmouth Building Department RECEIVED 1146 Route 28 South Yarmouth,MA 02664 JAN 2 3 2C2[ (508) 398-2231 Ext. 1261 quit nn_,rj CONSTRUCTION ADDRESS: I J t rvll-)L-__ (" : By - ✓ 'o ASSESSOR'S INFORMATION: Parcel: OWNER ' - 1 PRES ADD S TEL. CONTRACTOR:, " i _cit. 7II %°c-// _ � NA" rY) "" TEE.# 1I�Residential 0 Commercial Est.Cost of Construction$ e Rome Improvement Contractor Lie.# (t/Q Construction Supervisor Lie.Of f o Li Workman's Compensation Insurance: (cheek one) O I am the homeowner 0 I am the sole proprietor lave Worker's Compensation Insurance ` Insurance Company Name il:ei Worker's Comp.Polia� J WORK TO BE PERFORMED Tent Duration (Fire RetardanttCertificate 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 15 el) (41 c.H ill A Lj 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 tri d 6uc„prosecution under M.0.L.Ch,268,Section 1. Applicant's Signature. Date: /(/ f9/9 V Owners Signature(or attachment) ® ' --1-'f 13\e( Date: /� 3 - ll0 Approved By: ,/ I Date: e� h � Building Official(or desigpe- EMAIL ADDRESS:m(t,)Ifit to>c1- , .. € a !'` • f}) Zoning District: (te Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes C No Water Resource Protection District Within 100 ft.of Wetlands: 0 Yes ❑ No 0 Yes 3 No Permit Authorization mass - Form Site ID: 3835875 Customer: Aaron Niederman I,1(\\I\k,c7)(10 ,V\m, 0„g,N ,owner of the property located at: (Owner's Name,printed) 112 Wimbledon Drive 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. Owner's Signature; A d Date: -- a� 19' .0400040.0•64itineinipl....tinfi)../400060•046000.0**00****0 snap se seinen, 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 U ly Rev.102015 .T C'r�r in wetaft cf ! M h stiItS • De; ar ont,Othlittotrial4cei ets ri I C as.Street,Suite 100 46,774tipr-4- " stitrt,"MR 01.0-2017 4;` t ri'YJVklitV Ct per ilriari'LOW-WAdc ititr.r tr-fl rsl tttrikl0 ico*lciat i "t►iitp tort. "r ci ;'FILE}wi"1 ti`Ill Illt Pkitiii4171ING A r}1ORrrY. ApplfcttptInfortna n w ,:,, t*iaaasttMid L,ealbly. 4 .N£tmc (ausinoSSPI'rgshi' 1uniitatliaioLiat'1" i - ��'' n ,,,,.l x eity% tateiGi t - ' r ' Phone'#: * a7-4 * ,, .. • t ,ireyuuior droployee G(t#rkOra&ppratt trl,rst 'pe of pri.*of'rcqufroo, t. T.a ttigaloyor lairs I(.11- aintitayetis rfiin war,ir 1t hurt?' ' 7. 0 New construction 4•.0.1an a sole pr*tar+r'ertn>~rs4ttit°ar tltavrnare,nployensawar:,ritt for,;,ein S. QRert'todelin8 any aapoP ey,PW'M 1 r1;41V.Conti),iti iirant requ tred.! 9. .O'D 010.1iOA ➢ 1apsa honiemwier doingralimataltittys tf,jinn wturketa co+atta ina,rr4tteerequired,J't to 0 8uilt4ittg addition 4 plot t3omeowner anti w ll bey iting pontainota,to mutuost=xlt woik on oeY luotorty. 1.will Ovattredwoll.eontrVorsett f°hove"W',rkers'co ponstttiOtiostitt+totor€ieao.c 11 0El tried1repairsoradditions proptiottotwalfooemployees. 12,01sittl2rtl4 repairs'or'additi41tvu Ent an a awr l zontra titre an i kriava snarl d the imo.t r t4at taws hated owe*attr,eftad atttet, t,r.0 Roirf'repaii yhdsryoti sititketors. 4' =tn jgtes have w .era Witty ruu y imaidi I0,0 We molt Yarporwtuu and AS terKe"ilily �xorcist�l they right of nxctnption ant MU c. I152 tttd.,and wehovecarsosnplo es workus comp Inatome squatd; *Any apµfivant that cAeottp 1tillt d 1 sirup ialso tt cut triae' tugs+Wow sttuw..t,0 their wortcorir crrtnpdrdstaon pima:inrwtnnitin n ki'qumeuwnet wit*uulatttt this4.0414vit iriattonti tliny weld g 41i wat4totti tsen auttido unnuuotottt fhasi aubmit ti new a1tdtwit indtGutin anvil. c.oninticfst&pi;cltt this rptm tt i1utt;ddtfhtitimtt OpautAtwellgrhouatt p7'1 sUktetatttt tartsm4$ie*lii.dte*cantpiqueentiticuhave atlptt;ygp*t,ti th, rcctatraet, vt, 1 *0 maatiatD 401 _i,ttrDlkt'te rI tr11.1 t►wttiE : , 7 n..prr+ t 41,yer t 4.40$1*i tit rkeee:co n•itt trrouce Po oti 1174,e s. -1Adow r ills- tk 0trt r9#41e" fir, cinch*rn. pi nt,, �r g tt Insurance Company Nanut .-. -ifoki•�:tt.«t•. ': .�y_ Espirtition.-mate �..,. 9 .J Policy fa+afSetf l ltf,i..icH. �3CJa-�� 1 ,�� � (iitv, Job SitC Address: CiY�lSttGi . k t e'' ttvr n tiff olio n er del attOn •ate). Attadtao tlfd .. ot`1 ; c tnflexrsa� fey rierlartktinnpa� t.$ policy P?' � ;.tr Lure i t.elturu etiveragc.aos required wider trl.CL t: i; ;.§25A is orinunal yid-tailor)puttishtr e hy-o fine up to$L,5ocLi U Vldttlf dire-you"linpriSonttt t,as Well ita,eaivil penal ticti in the 1oitt &a S'1'OP W'(IRK OIW W EIt•ai d a rate,of op-to'$ fl.00 a day against t ltittlatott A copy of lino statement May kit Rtr warded to the O-ffioe of Investigaa?a tit of the DIA for insurance ' corer c ve tka of . - 9; -_ " _ t ritr heiihy rertarrwn4er tf . 4 ettati is afpdr,Jury tiff ilie in,/britrrrt n,'pt v^fed'`s ye"ii rru ariircvfr`ec Dale:. , t►i9 : ' Officad sse. r(a, Po ri ta4ritibt tiffs aria,ti+treaetrrtptet ¢t; (Iwo,teawtr ofj ciafr City'ar Town:: .� Penult/License �. Issuing Auth+city(tile oaf "t t 1.Board of•tieafth 2,tliSltdirlg peparttttent 3.Cftvtt'owu Clerk 4;tnectrtcal Inspect-Or S.Pitt/riding Inspector 6.Other__ ..._ Contact +ctkn. - J?ilo d Construction;Supcn lsor Suety CominortwRatth of massacnuseus Reetrisaed to: 3aYssxirf of Proi,astorxati�ten;ura is JC•tr.entmwn t:aNtardu Board oi'.Ski stung Regul$iona and Standards 1 • ":^a.�Skr:<.:.ts n Su}4@�vtaz r Sw6CMIt: j CSSL.10694/ fxs:prres.02)17402e FRANCIS$StISEHAN setatiit9 HARittICN R@ : Ws R Mrial Faiblai as pailatas a curies easion or me Massesnusetts . . ± si rAuseu*COd4 004111110r4100C4000 aims setts. l°cr iafc+rsr Yrt oboutinis kerne• Ca'Rtpty} a ea dada at-nsissyarhip► Commissioner y to 6menonrewnaI%'c/ 44,1err i tt `r Office of Consumer Affairs&Business Regulation HOME IMPRO MENT CONTRACTOR Registration valid'for Individual use only Tlforooration before the expiration date. If found return to: Expiration Office of Consumer Affairs and Business Regulation N 09/07/2020 1000 Washington Street-Suite 710 FRONTIER E S Boston,MA 02118 1,4 FRANCIS SHEE � �.•- • ?502 HARWICH RD BREWSTER,MA 028 i Not valid , gnature Undersecretary • • ,4D® 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 CONTACT NAME; Rogers and Gray Processing ROGERS &GRAY INSURANCE AGENCY INC ,Pti"�"a, ); (508)398 7980 FAX No): E-MADDRESS: 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 INSURERC: 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. IPOUCY EFF POLICY EXP NSR INSD LTR INSD TYPE OF INSURANCE WVD ADDL SUB) POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE 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 JET 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 CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE OTH- ER AND EMPLOYERS'LIABILITY 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 es,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 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 Harwich MA 02645 Daniel M.Cr ev 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