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Home My WebLink Aboutbld-20-004470 • Office Use Only 0 l R`rp., 4, &"22" W7 O Ht+'I H ( Amount 0 '` y Permit expires 180 days from au, ~'' t issue date -1-‘ EPARTIviLN EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext(. 1261 CONSTRUCTION ADDRESS: I°3 4- U2--C1 S4 l 0 tl,/n ASSESSOR'S INFORMATION: (�_ Map: Parcel: ,r � OWNER: 9OnV- (C9VL'cL"-\ �03.4 21)� �1` so /crt �113" �30` 'y 3 NAME �T PRESENT ADDRESS '/ '" TEL. # CONTRACTOR: V-(GiS-� `0,154-t cob <3 � ektc,c oin M�. acy AAAcc4 - ( _ NAME MAILING ADDRESS TEL.# 'Residential 0 Commercial Est.Cost of Construction$ Home Improvement Contractor Lic.# 19-1 It Construction Supervisor Lic.# CS — OCI 16 6 y Workman's Compensation Insurance: (check one) I am the homeowner E I am the sole proprietor C I have Worker's Compensation Insurance Insurance Company Name: 4 1 V Worker's Comp.Policy# k✓C Oa L( �/� 0 113 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares -SFReplacement windows: # Replacement doors: # Roofing: #of Squares 23 ( Vemove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: DC)b41P5 k/ TC. `o c V` 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 my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's i a re. Date: a(12.I 9-0 Owner Signature(or attac en G Date: Approved By: Date: 1_' /1 2-() a Building 0 ic. r e EMAIL ADDRESS: Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: C' Yes No C. Yes ` No Initial: �'' fl-' Painting— Can be quoted but is not included unless otherwise specified. Possible Extra—Any rotted or otherwise deteriorated trim boards, plywood sheathing, lead flashing, or other carpentry needing replacement will be done and charged for as an extra at the rate of$75.00 per hour, plus 20% mark-up materials. FRASER CONSTRUCTION guarantees the labor for LIFETIME of roof. FRASER CONSTRUCTION guarantees the shingles against Blow-Offs for 15 years. Please note that all pricing is contingent upon current market pricing. If contract is not accepted within thirty days of date of proposal, change in price may occur due to deviation in material price. Any deviation or alteration from above specification will be executed upon written orders and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays are beyond our control. Owner should carry necessary insurance upon the above work. We, if not accepted within thirty days, may withdraw this proposal. Proposal prepared and written by Mike Gunn. Work Permit- I (,L/„_:fa(r /({J (Sign Name) give Fraser Construction the permission to ull)a permit for the work being done at Io3P(1� ,'Ltor Si �,,,�n�pc,Jw'4�, ( ddress) , MO- -'. (1 tf FRASER CONSTRUCTION, INC: Carries Workman's Compensation and Public Liability Insurance on the above work, certificate available upon request. DATE OF ACCEPTANCE: l\gyp a(O Homeowner Fraser Construction, Inc Zitik�\ l ttC rvt/Iutaut,NCtsiui AV LllssJJsss.IINJCIIJ t•=j s�/ Department of Industrial Accidents L 7 Office of Investigations -N 600 Washington Street ` _ Boston,MA 02111 .t''•''.,„6101+` www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 1 Please Print Legibly Name(Business/Organization/Individual): Fa.e r Cons/ru/'oil the . Address: 3/ .f30w do/rl /Qil/ City/State/Zip:/Y)U.3,j,Ge /lei. D. q Phone#: 49 988- of(99 Are y an employer?Check the appropriate box: Type of project(required): I. "I oy am a employer with /t) 4. I am a general contractor and I 6. New construction employees(full and/or part-time).* have hired the sub-contractors t. I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in anycapacity. employees and have workers' p �' 9. Building addition [No workers'comp.insurance comp.insurance.' required.] 5. We are a corporation and its 10. Electrical repairs or additions 1. 1 am a homeowner doing all work officers have exercised their 11. Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12. Roof repairs insurance required.]t c. 152,§1(4),and we have no employees.[No workers' 13. Other comp.insurance required.] kny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have nployees. If the sub-contractors have employees,they must provide their workers'comp.policy number. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site 'formation. isurance Company Name: �CLTi'//y5f lr r/7.561f`t2/I ee . .C/7G olicy#or Self-ins.Lic.#: fsv y/8//.302 Expiration Date: gic2671:33T2o96 ab Site Address: City/State/Zip: .ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK.ORDER and a fine f up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ivestigations o/the DIA for insurance coverage verification. do hereby ce ijy under the pa' . - -' o erjury that the information provided above is true and correct. ianature: k. '/ Date; hone#: 56 ' V -.at c 9 a Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/LIcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ' ----"'"N FRASCON-01 LLEMOP( AMMO' DATEPAIEDDNYY17 CERTIFICATE OF LIABILITY INSURANCE 10110/2018 — 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 INSURERS),AUTHORIZED. REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the pollcy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement.A etatMr..,t on this certificate does not confer rights to the certificate holder In Kau of such endorsement(s). PRODUCER %WC' Bearingstar Insurance,Inc. PHONE FA�X Commercial Insurance Center Na acre:( )888-9151 (AIC,Nol:(508)83T•8573 375 Airport Road ; Fall River,MA 02720 ►NSUR6 I5)AFFORDING COVERAGE NAIL! • INSURER A:A10 INSURED INSURER B: Fraser Construction LLC INSURER C: PO Box 1845 POURER D: Cotult,MA 02636 INSURER E: _ INSURER F: COVERAGES CERTIFICATE NUMBER: 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 WITH INDICATED. NOTWWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT 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. LTR TYPE OF INSURANCE JN D WM POLICY NUMBER MMID MYYY) (M EDDOIYYYIO UNITSICY CCP COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAMS.MADE OCCUR PPREMIBEegRENeV1 $ . MED EXP WV ono oereanl e PERSONAL a ADV INJURY ! •_Mat ADORE TEpLSUIITAPPLESPER OENERALA GREGATE $ POLICY I1 FIR ❑LOC PRODUCTS.COMP/OPAGO S — $ OTHER COMBe&NOLELMIT $ aAUTOMOBILE LABILITY NEE BOOILY INJURY MP'cononl e' _ANY AUTO _ gC�EIxAI� pBOOpDIILEYINJURYIPer=aeMMM $ AUTOS ONLY _ A�UpT�OSS D GE $ — TOE ONLY ems 1 EACH OGC% ENCE $ UMBRELLA LAB OCCUR — CtA1AB F1A0E AGGREGATE $ EXCESS UAB ppgg�� $ DED I I RETENTIONS 18TATLITE I I ER per. A AND EMPLOYERS COMPENSATION y�;04g181132 9/26/2019 9/2812020 E.L EACH ACCIDENT S 500,000 AND EMPLOYERS'LIAINLIETY 500,000 ANY PROPRIETORIPE%CUUD n NIA EL DISEASE•EAENPLOYEL S FI nigiti E.L DISEASE-POLICY LIMIT I 500,000 I soRIP deeathe uder ,nue•.w. nTION OF�E, OPERATIONS/ • 101,AdEI1Mn1RemerbSMod"maybe03001NOON�n M � Proof of Insurance083oRIPTION OF for pulling permits. NAG • CANCELLATION tat TE H D BEFORE ANY OF THE ABOVE DESCRIBED POLICIES BE CAM:ELM ACCORDANCE WITH DRAT POLICY PROVISIONS E 1MLL BE DELIVERED et Fraser Constructiob AUTHORIZED R PRESS/HAMM g' `6.. reserved. ®1088.2015 ACORD CORPORATION. AB right. ACORD 25(2015/03') name and logo are registered marks of ACORD The ACORD • Commonwealth of Massachusetts ®� Division of Professional Licensure Board of Building Regulations and Standards Construction Supervisor CS-097668 Expires:06/07/2021 DEAN C FRASER 704 TWINN VIEW LANE'. EA FALMOUTH MA 02536 i Commissioner �. /. -- aJ/!e Fag m('webteag2- o/ lentMaa4Meai Office of Consumer Affairs and Business Regulation 1000 Washington Street-Suite 710 Boston,Mns0achusetts 02118 Home Improvement_Uontractor Registration Type: Corporation .•--•.•:.•.:c;i. 11!.; .'S Registration: 194747 FRASER CONSTRUCTION COMPANY,INC1;•1;s ,iT','�!?: `F Expiration: 03105(2021 31 BOWDOIN ROAD '=�iK.."; I.—;Y FRASER CONSTRUCTION9. is MASHPEE.MA 02049-3008 S:, 1W41: t ,.SN • ,`''1 ' Update Address and Return Card. 8CA t A etageref n trrewoonteveno o3/e6nuern ate/4 Mc*of Consunsr Anoka&Busieao Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPOtpctoonillte before the expiration dale.If found r.turnlo: Reotst attoit EEnirallon Office of Consumer Affairs end Business Regulation 1B4T47•- 03/05/2021 One Ashburton Plan-Suite 1301 FRASER CONS( t(S( QkiPANY.INC. Boston,MA 0210E DEAN C.FRASEI1t = ri 41r.s....ea.pea.-s 31 BOWDOINROAi)' t.;• t Not valid w SI nfllUftl • Is ERASER CONSTRUCTIONerseu g MASHPEE.►A 02849.3008