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HomeMy WebLinkAboutBld-20-003558 (2) .i!Office Use Only 'IikPeN - . Permit# -1Arnount tOa 4*.,0011.001:4. Permit expires 180 days from ,BCA)--( 0-355 :lissuedate EXPRESS BUILDING PERMIT APPLICATION F !: ‘, ED TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 DEC .;) 2019 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 ‘t, CONSTRUCTION ADDRESS: 1-1I ASSESSOR'S INTORVIA"FION' Map: lar-S Parcel: 1 OWNER: NAME ADDRESS TEL. # CONTRACTOR:fent1/441&—k— Ott.C., '7'7 tif ocll o NAME MARIKaMS ()4 0404 cc TEL.# Residential L.-Commercial Est.Cost of Construction$ cC14,3 Home Improvement Contractor Lic.# Construction Supervisor Lic.# /OS it Workman's Compensation Insurance: (check one) L I am the homeowner 2 I am the sole proprietor lil,1#1<aVe Worker's Compensation Insurance Insurance Company Name& Mk01 Worker's('omp.Policy 4 OC)(40(1 3 I Ca kilt 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:i Guee,0 Al.Akat,„ cfri thici Ca.(4444‹: 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 in nd for prosecution under M.G.L.Ch.268,Section I. Applicant's Signature Date' iPPOI Owners Signature(or attachment) Date: • Date. 4- ? 49 Approved Building Official or designee, "."itAilL ADDRESS (.1101, A --Afejalctiva4 jey) Zoning District: Historical District: C Yes C No Flood Plain Zone: C Yes cl2 No Water Resource Protection District: Within 10C ft.of Wetlands: Yes No Yes 2 No RisE ENGINEERING* OWNER AUTHORIZATION FORM I, KEITH TORREY (Owner's Name) owner of the property located at: 43 Pine Street (Property Address) Yarmouthport, MA 02675 (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. t't -Or Owner's Signature Date RISE Engineering, a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com The cantorotwdoth of 1t ostoc�t i 24 :t Conpas Prot)site 100 _ • " Z1 401rt 47",eh i tti€ietyart a&gr t+!' i1'orke 'Coinpentittion Insttrrt ee;Alll vie 1}tiers/.Conte totattiec leis /Plu ers, ,} TOt3t',,}":}I.,i=ri1'r'LTL1'€'}l PV.fla'liT ic;At:r)toRrrv. Applicant 1nitirma4n Please Print Leeib}tr x s ?i ftirIC routines'Crpaf i tiopili tiiviticatil �`l t AIL,. CityStateal Phanelt; t.. .«, Art ra.ace employee Clerk the Opiarprists him Type of project((required): 3 1. ten a employer with , employees tfu;l rott•ae otitr erred." 7 U New CCtnt€til t4til7 20 Rasa sole PrOprtoterorpetteli5hipOWL hmtvisreo eillieoyeus Wilrkutg Ter rite an 8. 0 Remodeling eity;speedy.piervinrkwV comp.inaurai rec{rnteei.i 9,. j t3t�}11t 3:tat amnhwne notrdoing,�all work mutt JNo-worked'comp rna.tc l regartft, ' Idirig addition 4,0tamleboinonenerandwitibettirintontrantem to c lr 41 a*rk ofrfItY lallaPOY, }will ensure.dtata winttireore efi*eihgv v rkere"c nipensetira insritlra ;or solo i 1,C)tiltetrical repines or additions pirltptietroswtatrta eniptisyees. 12,0 Numbing repairs or additions 5 Otani sgensrel 000ttMor anti kditrvc,+hrool thee ricrocrors eaten cox rhe ermelwit slaw 1:3- t 0LJ r 8u$ Thefo-itt.,tonfreeta.halfOvoVIOYoesarnYNye-vomi.ereo:slop Laurence: 1 ,► e.C.3 N?e art;s,,orportutott and its etricerstowe osercswsl Owe+ti thr otsse nptnarpot!wear c. t$Z,jl(or,wed we rase rur employees es 4l workers comp vomit.*it..*wquitcd} i !May apylivanttket k-lt r'pt urutjt AOOO' ti OM auotr{trt b aebo ae titcinelAtne tOn�tieo OW)tnfccoellt �` Homeowners tvtip su1>t�this gidavii ttilttirahttg,'tlSrsF a�rilotng"gtll work, Owl*otitsrrira'cpntrtictora utusi submit alto*a •rt 8ndiiat" Srn;h: ;ctorsolors,itsch ihtt.to05,most,OpoOeskoweitiritiiinel Iiiiietebowintthe,il On*Stib;c011040t0MnikdW Merits >vtt++tbrokeentitieshese ainirtoyce Stcha c r Stem,theyma iruriee1 r ikeise9t'itl pthli¢yn i sue 2 rem on obiployet*iris prol'itfn, woken'covens rft;axrrttice for irr.}t employers. Mow Le Me policy ret7tl job site . trrlt'ai tTrit#ian. 4 1rtsuiatiee'omply Narne �Lb.. '_w ` :, Policy 4'tlfSelf-axis,I..it-#4f 'fOQ": I5 ` 3iSc ) _/ A. ExpirationPate,.,. iq,) ` _ _ _ __ Job 5�ififrldtl`t�a .�(�itytStateiGI : .� Attach:r r,+py;pfit 'wee tfo� ;deelarltion page' hoti$it}.&rile pof l 1r f#aer a 4 ee$4rat or ate). ft •s c�i�} pulley Faust!to secure coverage as reqii iresi under atO L,u. 1i2,1125A,is a criminal violation Tpitriilta h hytt tine at)to$l..000G a'nd or one-year imprisonment,as well asrtivil penalfkt in the"form of II S'rc7P '•01'tK O1WE1.arid a titre Oi op to:2=5O O11 a day*Mist the'violator,A copy of this atateMent array ot'rfort.earded to the Office of Investigations&the DIA for insurance coverage veri a mill i c I ltr herrtry relit-vitae `.ttr€4 )copies p fperr,itt;y Mot Ilse.information provided it owe is W e and coi.reety • Gt)vied use mrta „tr not write Or this arca,tit be-completed by city or tawtr o f Ciat" Ceti or Town Perinifit ieense k .. _ __ , Issuing t#c . i � 1 Board ofealll 2 Buildin&- Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector fi.Other Contact Person: Phone#1_ ,,,. � ,..,.,m- n� — Q..z 1 it c I I ii I ).4E 0 = I R {{ C y .. ' III L a dv1 Z cc,sua8 ),r i o E tt to 4 4 , ,: „ =0, ., : , 411 S'; tiq • hilL t h n , ii % vt C 2 k. X ter Q y =or Z Um11J N A D® CERTIFICATE OF LIABILITY INSURANCE , DATE(MM/DDIYYYY) 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). CONTACT Rogers and GrayProcessing NAME: o9 ROGERS &GRAY INSURANCE AGENCY INC (arc No.Extl: (508)398-7980 FAX No): E-MADDRESS: mail@rogersgray.COm 434 ROUTE 134 INSURER(S)AFFORDING COVERAGE NAIC# 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 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. ADDL SUBR POLICY EFF POLICY EXP LTR R LIMITS INSR OF INSURANCE INSD WVD POLICY NUMBER • (MM/DD/YYYY) (MMIDD/YYYYl COMMERCIAL GENERAL UABIUTY 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- CT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY (Ea accident) BODILY INJURY(Per person) $ _ ANY AUTO ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS — AUTOS N/APROPERTY DAMAGE $ NON-OWNED (Per accident) HIRED AUTOS AUTOS $ 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 E.L.EACH ACCIDENT $ 1,000,000 ANYPROPRIETOR/PARTNER/EXECUTIVE A OFFICER/MEMBEREXCLUDED? N/A N/A N/A VWC10060153152019A 03/14/2019 03/14/2020 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 I 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 L.../ fi t .. Harwich MA 02645I Daniel M.Cradelley,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