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HomeMy WebLinkAboutBld-20-003557 (2) Office Use Only ii P e nnit# •4 ) 1.3(..4) — 2-0--3S-51 Amount --- 4' ,...)7.:::: ste..,. Pisesnnueidtaetxpe expires 180 days from EXPRESS BUILDING PERMIT APPLICATI ,., - , „,-._ rt 1 1 Y TOWN OF YARMOUTH , _ . _ . .........._ ...... . ! Yarmouth Building Department r, i 1146 Route 28 i 0 70 9 ') 2019 1.) South Yarmouth, MA 02664 L.1 L. t6:4L,9w..._, (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: .. 0--ti1.-4--i-e, .)..c)._. go ASSESSOR'S INFORMATION: Map: .5- Parcel: k 9 OWNIERZ611\— D'H?„6.0,Q__, 51 kt Onf\-16.%%_Lk .us K)eaCiLA-4ANM,S- NA PRESENT ADD S TEL. g CONTRACTORifE,r9.:41 , e-.34.4E , 1;35 auesacy6-400,e4-ort-C-, 77 q az,7 OLI/o NAME -*--- MAkilkiCaRS tyl 4...c4ccit,i c; TEL.# t'Residential C Commercial Est.Cost of Construction$ -S I 00. i Home Improvement Contractor Lic.# ittiO '''')(7;(( Construction Supervisor Lic.# i OCir 9 f Workman's Compensation Insurance: (check one) • L I am the homeowner 2 I am the sole proprietor ii;-.4<ie Worker's Compensation Insurance , t Insurance Company Name. ' 44;.-It Worker's Comp.Policyg • laokiCkSclilPt- 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:IYI_C,, ,,,A2-0.-- ' ir-Ik t.---;4)-if(0 ijt-fit,,,LA 4 (-1-1 ih ii 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 m " - , d for prosecution under M.G.L.Ch.268,Section I. ,,---/, '- Applicant's Signature: ' Date. 12 /3 , ./p, IsC Owners Signature tor attachment) Date: ....---- Approved By__ Date' ,9Z -A 3 -11 Buildinv.Offictal(or deskmee) 7,m-s,- \DDRFSS - - '''' ' " iti.ak-Vi- — 4 A .ki--0 in Zoning District: Historical District: C Yes 0 No Flood Plain Zone: C Yes C No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No .] Yes 0 No Permit Authorization - Form Site ID: 3887761 Customer: Joan Heckel I, avi ueC 1c p I ,owner of the property located at: (owner's Name,printed) 30 Turtle Cove Road South Yarmouth, MA 02664 (Property Street Address) ( +) 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„ l Date: Q (3 60.00006........0.00•00.eoessee- 00 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 or office Use Only max, ...,ri., v ,. a... ,,,.,A Rev.102015 J i a I ; vg .g, e :- 4,13 g. ' cb •.,'*:,,,p, .1 ik: .,,, 1 1 i ..i. ...it—.-a— d- ts- ' + t 4 RR',. of j 'a Y �`' ' � . y Y+ t-- ac .o }}v s 11L % as h 3 r GC2 4 `c t". • 4u3 i ' t? C +" = e1 cLe:.'+ Q" wN ' ' _, u „ I a 4 41 a— a. Tom "to ti, �g ; a v� 4 n i l i t -, x- .� T .#,.* r: sue` H i. r Grp,,,�g» t �.„,,��/ w" + "� , 4 -, �- 7 ~ "' .Ny. ITi• .Lf 'c3+,b 4,i " -�j, ''y3. Z"S 4r. C�`, i 3, Ca !� ,"-, b, +.,, `,"y Q C ,�:al "�!SS Ali J �S', I +l ! f L 47 itflit1 ibik: zg t s cs IHIi1sflhIllI +gp .' 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S_ w,.-. `4: -1 E3 C+ Gad 0. t $a ' c "x'�",. . _.,. a3.'" 1 ty.. } S.� -r � l.�` ,„. ,r.. 4 -, ,o q4 ,f1 5 14i g O 't t=.. ` -1 i8i :fat a A Rielg GAn BIA piienION ' pun 1_£9Z0 WI'a31SM3t19 yr oa HOU1+ t/H ZAS! -x ��it '; ( I.133HS SIONb�t33 t is 81 iz0 VW`uaysog S'' 3 E 3I1NOs:ld § Oil a%PIS-3 3S uolBu14seM 0001 OZOZ/L0160- ' - ' '' 1 uopaln8 H ssoulang pus&gem iewnsuo3{o aoy o Uo ld :o3 uwn#at punoi 11 'aiep uoli®aidxa ate e,wleq uoge�oaoj' !�1 �Apo osn lenpinipul icy Ply+►uogs�slBaa t1013Vd1NO01N3W Otld WI 3WOH §§ i uoitetnEloti ssoultme e sgeuyJetunsuo0 W 3UJO fr /'/37f.1'Oc`('.� �1791iN//+frd/(nf/t.(ff) 1 `emu ' wow St � �. $*N U,W tottott:f it04 Ydh j r Ltd t.#t3&'eNtTe *cow I,to'ssd+d t76SQt-ISS3 /r .tto,aacts4ostovad-nsY.esk t!. suc,;; . s Aw c),PuelS true ttweµ,neaj autOP+'ll.a ix+eo8 acrt .1}ncsatsste#aa,t to tea...c !.. 1 xtt tMpta 14v tuolentooss@p;to totottmoottautto t -- ® DATE(MMIDD/YYYY) ACcARD 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.Extl: (508)3987980 FAX (A/C, mail@ 9 9 Y•ro ers ra com ADDRESS: 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 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. INSR ADM SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WWVD POLICY NUMBER. (MM/DDIYYYY) (MM/DDIYYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(My 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 AUTOMOBILE LIABILITY Ea accident) SINGLE LIMIT $ BODILY INJURY(Per person) $ _ ANY AUTO ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ NON-OWNED AUTOS AUTOS N/A PROPERTY DAMAGE $ (Per accident) HIRED AUTOS AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ -- EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE OTH- ER AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE EL.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBEREXCLUDED? NIA 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 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/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 Daniel M.Croy,CPCU,Vice President—Residual Market—WCRIBMA I ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD