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HomeMy WebLinkAboutBLD-23-005798 in as l e&L --,. Office Usc Only * O Permit ____16 z 3 4. �'�1 AmountJ3_. AT iA St- ", .n..t,„ • Permit expires 180 days from �cJ issue date 5 Li) - 3 - 605-lc's EXPRESS BUILDING PERMIT APPLICK ! D TOWN OF Y.AR.MOUTH ---------- Yarmouth Building Department APR 19 2023 1146 Route 28 South Yarmouth, MA.02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT BY _ --___ CONSTRUCTION ADDRESS: +1Q1J - ASSESSOR'S INFORMATION: Map: 33 Parcel:/7d, OWNER: -- `v!r J t itilljt. —K dU- -- / E P ESEN D : S ,, TEL. l"��J�/�� CON"IRACTOR:- 'eg - �� ao Mir di __'7 2 7 9 w 9 Residential ❑Commercial Est.Cost of Construction$ Home Improvement Contractor Lic.# I tL 0 — ! l - Construction Supervisor Lie.# i Cy5 ( ' Workman's Compensation Insurance: (check one) 0 I am the homeowner . 0 1 am the sole proprietor�Q have Worker's Compensation Insurance a ,�. Insurance Company Nam . t�13 1 \. Worker's Conrp.Folic} L i'L'� WORK TO BE PERFORMED Tent n Duration (Fire Retardant Certificate attached?) Wood Stove 111 Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares (❑)Remove existing*(max.2 layers) Insulation_ Ei nOld Kings Highway/Historic Dist. Replacing like for like Pool fencing In *The debris will he disposed of at: I ,;'/!-. _ --b '0 — -- r ocation of Fac • 1 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 lic r prosecution under M.G.L.Ch.268,Section 1. VA' j��Applicent's Signature: -___ --. -------- Date: --- ` Date; Owners Signature(or attachment) V` /�_� Date: ` Building 0 icia r designee) h 1 ADDRESS: Zoning District:____ Historical District: L t Yes 11 No Flood Plain Zone: _, Yes !::-. No Water Resource Protection District: Within 100 ft.of Wetlands: Yes I.:: No I'. Yes LI No Permit Authorization i 1 mass .ve Form Site ID: 4612448 Customer: Dave Manning I' OqUe Man(Vrl ,owner of the property located at: (Owner's Name,print 64 Holly Lane Bass River, MA 02664 (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 • • .'orm i•..ulation and/or weatherization work on my property. / / A Owner's Signature: I I. hill , di rt!,P1-4 to al Date: I /-- - j 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: 508-568-1926 Email: Page 1 of 1 For Offits Use enly Rev.in7ois Construction Supervisor Specialty commonwealth of MassaChusrtti Chvtcton ?OccYrpatconai L censure, Rrashictsd to Board,t$trtidir: Ri°eau# tic tis a r.St it r4arc9ti CSSL-ic•Insulation Contraclar CSSL 105941 t:13.pireS. ; ,17 2024 FRANCIS S StiEEHAN 602 HARWICH RD BREWSTER lojA. 02031 tr , W1V Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Commissioner for information about this license Call(617)727-3200 or visit www.nass.govidpl THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE:Corporation Office of Consumer Affairs and Business Regulation Re 160854 t glion 1000 Washington Street •Suite 710 O9/0712024 Boston,MA 02118 FRONTIER ENERGY SOLUTIONS FRANCIS SHEEHANi • 502 HARWICH RD BREWSTER,MA 02631 Undersecretary Not valid wit out signature The Conunonwealth of Massachusetts x b j Depar�tntelit ofIndustrialAccidents L 1 Congress Street,Suite 100 ,tea 4a Boston, MA 02/14-2017 •' vwr+.mass.gov/ilia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): 1'—e_c_No'1'Ott.. C, ,1.)(7t y ( 10-10+o ^ri i :roe Address: )39 C =; 1,) ntjrac- D City/State/Zip: 4--)iA ii „.:)t( -( LA A- ( -(t, S—Phone#: '77L/ - ._:---2.--Cp -LI 0 Are you an employer?Check the appropriate box: Type of project(required): I.©I am a employer wilh-L..0 ____employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in S. Eil Remodeling any capacity.[No workers'comp.insurance required.] 3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition 10 ❑ Building addition 4.0I am a homeowner and will be Itiring contt actors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I i.❑Electrical repairs or additions proprietors with no employees. 12.Q 1.lutnbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ 13.n Roof repairs These sub-contractors have employees and have workers'comp.insurance. 14.❑Other 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. — ------ 152,j 1(4),and we have no employees.[No workers'comp.insurance required.] "Any applicant that cheeks box Ill must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance,for my employees. Below is the policy and job site information.Insurance Company Name: Ai �l t3 qq Ii 1 1 t"t 1�}-�_- r- 5 .. ,1,,,1 C o _____Policy#or Self-ins. Lic.#: V OC-71 DD(p 01 ,3)S Expiration Date: `74/y l 2-9 Job Site Address: CtalL4&- jcJjCity/State/Zip: y(✓K.Attach a copy of the wor.kers' compsation policy declaration page(showing the policy nt 1 er and expiration date). Failure to secure coverage as required under MOL c. 152, §25A is a criminal violation punish )le by a tine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form o1'a STOP WORK.ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of investigations of the DIA for insurance coverage verification. I do hereby certify under the pains" .penalties of'perjury that the information provided. bov is true and correct. Si nature: : }� Date: 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ,ac RD® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 03/14/2023 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 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 statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Mariana Sousa BALDWIN KRYSTYN SHERMAN PARTNERS LLC (A/CC.No.Extt: (508)619-4545 No): E-MAIL ADDRESS: msousa©rogersgray.com 4211 West Boy Scout Blvd Suite 800 INSURER(S)AFFORDING COVERAGE NAIC# Tampa FL 33607 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 INSURERF: COVERAGES CERTIFICATE NUMBER: 870573 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY 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: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ AWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS ) HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PERTUTE OTH AND EMPLOYERS'LIABILITY Y/NER ANYPROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBEREXCLUDEDT N/A N/A N/A VWC10060153152023A 03/14/2023 03/14/2024 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 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/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.Croy,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD