HomeMy WebLinkAboutBld-20-003561 (2) i Office Use Only
Permit#
., , y Amount, c3S--''' e
a ,. Permit expires 180 days from
1 issue date
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EXPRESS BUILDING PERMIT APPLICATION i F 13 E
TOWN`OF YARMOUTH _ '- _'- . -.. -,--
Yarmouth Building Department € ? ZG19
1146 Route 28 f 1
South Yarmouth,MA 02664 ijii.r,-, t„,,,*, .
(508) 398-2231 Ext. 1261 L_ -
CONSTRUCTION ADDRESS: q aC 'J...,�I '''ik_(-
ASSESSOR'S INFORMATION:
Map: 1 00 Parcel: Ls J e,
OWNERO...4 iti-1,--Vf Vet Y
vr
DAME P DRE `� `� 1T. #
CONTRACI`OR:N ef( t � ?i �'0 L77 a -7 O /')
i Residential 0 Commercial Est.Cost of Construction$ 43 II U
Home Improvement Contractor Lic.# I Q Construction Supervisor Lie.# IOS L!f
Workman's Compensation Insurance: (check one)-
0 I am the homeowner 0 I am the sole proprietor wave Worker's Compensation Insurance
Insurance Company Name: r Worker's Comp.Policy#JDC)e0 S''S& '
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 i
Old Kings Highway/Historic Dist, ( )Replacing Iike for like Pool fencing
*The debris will be disposed of at:159 ) (a it C,"i} '}t H � 'c
Locatian 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 d prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: 1 Dates / /i)O/( 1
J. r
Owners Signature(or attachment) Date:
V 11
Approved By: Date: �. "A�
Building Official(or designee) EMAIL ADDRESS:piq,71`f'f il" E t9 (°')
Zoning District:
Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes .. No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes ❑ No
R1SE
ENGINEERING'
OWNER AUTHORIZATION FORM
I, Christopher Crawford
(Owner's Name)
owner of the property located at:
428 North Main Street
(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.
42d141, 11
Owner's Signature
IC / VlabLY
Date
RISE Engineering, a Division of Thielsch Engineering, Inc.
5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926
www.RlSEengineering.com
,
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DclOrtOtotit,0fhatitstrieitylveidents
1 Catr
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liasfoit,MA 01144017
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l ® DATE(MM/DD/YYYY)
ACORD 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 CONTACTNAME: Rogers and Gray Processing
ROGERS&GRAY INSURANCE AGENCY INC (a/c°.No.EMI: (508)398-7980 FAX
(A/C,
MESS: 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.
ADDL SUER POUCY EFF POLICY EXP
LTR R LIMITS
INSR OF INSURANCE INSD WVD POUCY NUMBER (MM/DDIYYYY) (MM/DD/YYYY)
COMMERCIAL GENERAL UABILITY 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 PRO-
JECT LOC PRODUCTS-COMP/OP AGG $
$
OTHER: COMBINED SINGLE LIMIT $
AUTOMOBILE LIABIUTY (Ea accident)
BODILY INJURY(Per person) $
—
ANY AUTO ALL OWNED _SCHEDULED N/A BODILY INJURY(Per accident) $
AUTOS — N PROPERTY DAMAGE $
NON-OWNED HIRED AUTOS AUTOS (Per accident) $
UMBRELLA UAB _ OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $
DED RETENTION$
WORKERS COMPENSATION TAT
X ;MUTE OTH-
ER
AND EMPLOYERS'UABIUTY Y/N E.L.EACH ACCIDENT $ 1,000,000
W
ANYPROPRIETOR/PARTNER/EXECUTIVE
A OFFICER/MEMBEREXCLUDED? N/A N/A N/A VC10060153152019A 03/14/2019 03/14/202p E.L.DISEASE-EA EMPLOYEE $ 1,000,000
(Mandatory In NH)
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 If more space la 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
n CLS
Harwich MA 02645 Daniel M.Cr y,CPCU,Vice President—Residual Market—WCRIBMA
101988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD