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BLD-19-922 a OY'9R Permit# / IC Fee S • �OI - i•d Permit expires 6 months from . \*..41!(Y (issue date sxggit 131b1-1q47(0 )-1 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH R i_ C I V f_ 0 Yarmouth Building Department 1 1146 Route 28 AUG 15 2018 a South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 - Euu03 CONSTRUCTION ADDRESS:_lig Rocaccat / n. nL_ ASSESSOR'S INFORMATION: I Map: I c9c Parcel: l S7 nnpp _ � Ott / It OWNER: t i ■;t : l 1 r�� i�►1__•_1! .. ^w.J�,'�l]n" m O 7 . AME PRES T ADDRESS TEL # - 77y 837-0910 CONTRACTO•,t• . ..:it L•. ..� ,k I e► 40-. ' I. ' lis NAME i .p1Rtne.!:'SS m 4 •: et 14 , TEL.ti �,/'� esidential 0 Commercial e? ����� O Est.Cost of Construction s COI �-/e) Home Improvement Contractor tic.# 1(r O p'S4 Construction Supervisor Lit.# I OS-1U Workman's Compensation Insurance: (check one) 0 I am the homeowner �/I 0 I am the sole proprietor - have Worker's Compensation Lnsurance Insurance Company Name: !t-c4'- f Y IV Worker's Comp.PolicjOO^(cOl l S a0WA • JJJ ��` WORK TO BE PERFORMED 0 Tent (Fire Retardant Certificate attached) 0 Wood Stove Shed 7 Siding: #of Squares 0 Replacement windows:# 0 Replacement doors: # . 0 Re-roof #of Squares I ion ()Stripping old shingles" ()gang over layers of existing roof 0 Old Kings Highway/Historic Dismct Roofing/Siding(Like for Like) 'The debris will be disposed of at: AP lea •� I •►' ,! �a _ I .. ♦LJt Ii 0Sa Location o acdity 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 f m 'cense and for prosecution under M.O.L Ch.268,Section 1. x- � Applicant's Sigmture: Date__VMS Owren Signature(or attachment) �4a4 4 �� Date: Approved By: Date: Building Official(or designee) Zoning District: _._ Historical District: 0 Yes C No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes O No O Yes 0• No 3/01 I RISE ENGINEERING' OWNER AUTHORIZATION FORM I, Cynthia Shick (Owner's Name) owner of the property located at: 108 Freeboard Lane (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. „cec,j( (Own s Signature 'x/ Zo �g ' `Date RISE Engineering, a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com • "`Z... 1 he(iurininno-ealdt of Ma;swell ii rttr `'1. :::` ' Department of Industrial Accidents ++ il_ I {"nn;rn'J Sveel, ,Suite OM yi= r7 �'.'!cj' r 1! 9 't i—t Bort) .)1:10_114-. 11 4c-tic–J.- \\'nel:.•rt' t'umpen.nllnu 1nrur occ 1 ffid.isit: I3ulldei,lunuaclon,f.leeh'miana;l'hon In n e 1:1111 IIIFtt\\lllil'IIF P1H VIII W. \1111ln4115 \pnhganv Infnrm.loi,nt'Ir:nr 'l.IJt Is, NArrie ll{,:,m<,,i., .a1.lau,w In i. La: fP . ,.. r .:., r.!14- �._ LIt.-�',(if�n -1 ''\...• Addle" ' C. t h r"1 Cioi$latelin- ,171-)I;LQ." mA ,.'.. 1: . 1 Pi ne ;: _I.1'1 • _ ' • FLIP'. i. I Arc rum rurnlplerer'riled.h hr a pin girl lot �__,_. _.. .., ._ __. __.... r.;t/ Type of pruiecl Ii muire01 i I DI um atnpLrye...m !O_..n:pi.n«c(h.Il.1Jln na,l'n1 ' III � hlea cn'L.ruAu.n 1 :Jl nm ll”l<P'oprrtm l.•pana•.thbtp and 4a.:m.rel Lr.e:,.oar: f lr tar .' i! S J Remodel.114 Jon ccpack, :`:1 w,.lin\ ,,,,rt, raa ln:e rc;n.':' 1 9 0 Dcmolil,on ;O:rim ai'a•euu Au,:.IYIw,IAI:IAll1N...ndrit'4rg 41.enI1.:rry4.419I• .0 0 Lit.dd:ng add:lion J J..n,ahn.na.we: l , .Jtie l:irr 4 ci nv,cf,I.0 AO'Iu.I u.n,y' Ill,.rngnnr 1w11 tAV.w nm:e '.4141 r..li•1111^••I r w.;.r•' ;,.mrer.m ,i rlaur:e n 1114 V IC I 0 F.Ct'rIC01 rppai(S Or ad(1'1.100 I ). IQ I'!cI:o.au Ie,:alrs u: aC,IC:,+^.v , iJlan.4 AVIV ti.nr:1444 .:e1••. :11_ct,A`.,:v.1:KI: t'a,tclhu II i..r.a r...: I it 11<?nl LJ ^vr, luta ianinn:ry ion N.r: -•'n.'• •a rte-:.••...•.•. L_.. • ,I r�/ in'Arrer.rvn,Va,.m'v,a,.,.r". v.IIhe c.„I .. . u. , .. .a:n rrrr'u'it ! 1 uIN!..11 :•i < ' v 11: 11(I: -ri 'I.... 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(. c ct + � l,Ib Sue r\ddre:; (' n'".!a:c•.'l.Ip \tl: ia x yup\ u, the wancan' ompelntloot pmol Y,irclnl.11nto page 1\IIT\log the policy flu her and elpirtion tl i 7c Y a.,.re to acute Oivel Age 0 teymr^.d uadet ,bit ii.: I4:.;r2$A.4 o crenmai violaonn pontaha•,a by a fine op to SI 500 QO / ) "Indica une.y eV; 14009:00l14: 1' 0 W'I ;:cr.0 IVn1.11:4'...the fon',.4i S my(.1.Curti ORDER and a Inc of up to S259 OPa tar agony.!iht-to•!aiot Ar 0.ito."'Jteturl."•11, hit."t. :rdcli 10 we Oft.:o 'hi'.c:n_.Ils.^8 Of 010 DIA far nmuranoe WrrIilite\er111cat l.n _ __ I 110 hrrehr crrnft under the paint at wt un ill prq.'r tmrryfire b';'•r.nnhoto p• .Jill titer.e t s 'ra;al nen• . • ti IF.P3t:•'r____..._7_•11 �^�� \y1 t1 . _._ _ ._ '.):p.' }� 1_I��� hryPn L_ _ 7711 ..—D.37 7-O`•' .2.2.2..2._., .._ .__/ .., :IYC)/ /oicy lln/1 Pei a:I.l me to lilt'wen. co he 1'amplell'll hr ray Jr(awn tiffi•Int' II 1 ( lt II(Town l.suing Authority(circle one': I. Board of Health 2. tiulidnri!kV/intro', 3Fib'Ins-il lick 4 I'ir.wit al l or prrl ill Z. I'lumInn?I osperlua G,Other_ •....«._,__. ,.__,__,_,._._., , IrI uouct Person. Phone:1' ( ' ., .-2...2,22._ 222.2__._ • f Construction Supervise Specialty Cnnonwealth Jl:dassathuXns Restricted Ice o Drvsion of Professional Lcensure CSSLJC-Insulation Connecta ® Board o.Suiting Regulations anti Standards CSSL-105941 Eap•tes 02:172020 Cit FRANCIS HRDHAN s k 5 42 ARWICRD 3 BREWSTER MMA 02671 a� +i FailureBuil possess Cod as came for revulMe Massachusetts kZ State Building Code o is cause for revocation se this license. For information27420or about this license Call(617)7274200 or visit mvw.mass.gov/dp Commissioner • _ Offitc of Con.umcr.tffa.rs&Business Regulation License or registration valid for individual use only • • HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: s Y - Registration: 160854 Type: _ Office of Consumer Affairs and Business Regulation Expiration: 9'8:2018 LLC lO Park Plaza-Suite 51 70 Boston,NIA 02116 FRONTIER ENERGY SOLUTIONS FRANCIS SHEEHAN 502 FAR4ti1CH RD / BREWSTER,MA C2631 1 ndcrvcartarr Niecl ithou ignalure t . , • A�® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 04/30/2018 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 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 PH E E&8 : (508)398-7980 FAX Nq1: EMAIL maro ADDRESS: il ersra @ 9g ycom • 434 ROUTE 134 INSURER)AFFORDING COVERAGE_ _ NAICN SOUTH DENNIS MA 02660 INSURER A_ AIM MUTUAL INS CO __- 33758 INSURED , INSURER 8: _ FRONTIER ENERGY SOLUTIONS INC INSURER C: .__,. _ r ' INSURER D___ 502 HARWICH ROAD INSURER E: __ _ I BREWSTER MA 02631 INSURER F' 1 __ __ COVERAGES CERTIFICATE NUMBER: 263414 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 _____ _______ 1ITRI TYPE OF INSURANCE )ADDL SUER MMDCYEPP POLICY EXP LIMITS INSTBWVD POLICY NUMBER �JMMIDDO'1'YF 1-PO ICYEXYT COMMERCIAL GENERAL LIABILITY I I EACH OCCURRENCE _ E _ __ I -DAMAGE TO RnTEO CLAIMS-MADE LJ OCCUR PREMISES(Ea occurrence) _S_______ _ _ FMED EXP(Any one person) I S N/A I PERSONAL&ADV INJURY 1 S ____ __ GEIN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE S _ _ POLICY l_J jEC LOC PRODUCTS.COMP/OP AGO 5 ._1 OTHER S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1$ ,LEa accidenij __ 1_ ANY AUTO BODILY INJURY(Per person) I S ALL OWNED SCHEDULEDI BODILY INJURY(Per acadenil f autos AUTOS N/A r I NON-OWNED [PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident)_ -- ----- - IS UMBRELLA LIAR OCCUR EACH OCCURRENCE S _ —.— EXCESS LIAB CLAIMS.MADE N/A AGGREGATE S _ DED RETENTIONS X S WORKERS COMPENSATION MUTESTµ AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTNE YIN E L.EACH ACCIDENT S 1,000,00.0 A OFFICER/MEMBER EXCLUDED? N/A NIA N/A VWC1006015315201 BA 03/14/2018 03/14/2019 — - '— I (Mandatory lnNHl EL DISEASE•EAEMPLOYEEIL!51,000,000 If yes. DESCRIPTION OF OPERATIONS below descnbe under II E L DISEASE POLICY LIMIT I f 1,000,000 I N/A I DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If mora 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 stales 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/lwd/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 Rd Unit 6 AUTHORIZEDREPRESENTATIVE --, Aas.s Harwich MA 02645 " ` \'' Daniel M.Crowley,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