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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth,MA 02664
C (508)398-2231 Ext. 1261 I
CONSTRUCTION ADDRESS: O ! O3f�ox4e-r ' ) '/& UC IC„fN( c i vl to ()Z.tU-73
ASSESSOR'S INFORMATION:
Map: a 7 Parcel:
OWNER: U*Ufl il( ))ln) 0e 46PC'1-tr y 4-1140t
2)� (IS" n n p 622v
NAME PRESENT DRESS
TEy #
CONTRACTOR:C. 13
GAN' ,%1 el 11 /1 7 a Yc� A,)1r 6,,A IS 4) 27 5- 1 I I D
NAME MAILING ADDRESS TEL#
�7
esiden[ial 0 Commercialpp(� Est.Cost of Construction$ 1 3 �G . "
Home Improvement Contractor Lie.S I-to l- /- Construction Supervisor Lie.# C S D 5 5 57
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Workman's Compensation Insurance: (check one)
❑ I am the homeowner 0 I am the sole proprietor CrOQhave Worker's Compensation Insurance
Insurance Company Name: E MC- 1".5%,r G✓ACp, ( . f&+t—) Worker's Comp.Policy# V 9 WC, 7 y s r /�7
WORK TOBE 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 Ili
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing pn
*The debris will be disposed of at: /, C� 1 15�0 05 ici. C 6---o- '1 14_04..0e 121 J1 V r`$
1 Location of Facili_ �f
I declare under penalties of perjury that the statements herein containedpare 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 my license for rose/cutt}'Pn under M.G.L.Ch.268,Section 1.
Applicant's Signature:,� (1/11., { ,� (/(,Gl�r^ Date: cf/f I
Owners Signature(or attachment) S-C.t /I,ft Date: r
Approved By: w* !.✓ Date: o p— - I P
Building Official(or desigdde) EMAIL ADDRESS:
Zoning District:
Historical District: ❑ Yes 0 No Flood Plain Zone: 0 Yes 0 No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes 0 No
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EFFIBUI-o1 oop. � " DATE,�,Dmryr ,�� CERTIFICATE OF LIABILITY' !ASSURANCE
03/02/2018
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS.
i BELOW.BC THIS CERTIFICATE OF INSURANCE DOES NOT CONSTIOR NEGATIVELY TUTE A CONTRAC OR ALTER
COVERAGE
ISISSUING INSURER( ),AUTHORIZED'
I REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT; If the certificate holder is an ADDITIONALINSURED,the poi/al/es)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 endorsements}
I PRODUCER I HTACr
•
i:Rogers&Gray Insurance Agency,Inc. ILrPH
;434 Rte 134 FAX . .. --
SouthDennigMA02660 f!'.x•N0.O -.• __ -.._ ----Not�iT/�.8II 155 •
• n :miierOgersgray.corn._
•• .. . i r MSURERtSi AF[RDMO COVERAGE _-- f•_...NAM 8
-- _......_ .
INSURER Mutual Casually-Company_ ---
INSURED .- -- _ X21415 :
msrmERe:Nationat L4bifity_8_Fire Insurance Company 120052__
• PO Box
LLC ) Rc, --- --_---_- —( .-
!I PO BoX 246 +•--- -__ _. --- _
Bridgewater,MA 112324 ..—,
C GES CFJ .. INSURER F: .. .._ . . ._.. . . ..—r_ _ ..
t11tICATE NUMBER: REVISION NUMBER:
1 THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD,
INDICATED. NOTMTHSTANDING ANY REOUIRDI4ENT, TERM OR CONDITION OF ANY CONIRACTOR OTHERDOCUMENT WRH RESPECT TO WHICH THIS!
1 CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
i EXCLUSIONS AND CONDTIONSOF SUCH POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
t•�ni II TYPE OFRISUItANCE �AODj,�SIjaR: ..__._._.. _- POLICE' __ _ .. .. . _. - __ .
.IN50.4^NU. POl1CYNUF.1eEq EFF f vbuer E11tP Z '��rtg
A I n i CO:rdERLTALGENERALLN8 maim,/ ndGVgDPNYVI.IT qm -.__ .
i• j CLAIDS..1A0'E 1 n i CCO,m i 1 •
" { EACH Oc"URRBICE_ 1,660.000
E : 567803118 • ,09101/20 101/20 8��°''irESLFa2'r* .
• 1709 i r500,090
j 'tlED E%PI necmr nt�-�s••. _ . - '0010,000
CEr,i'LAGi-,-R�'rGATE CIGRri3'PUSP-aT. 1 l I {-_—... Aw:r?Rmr •s.- _�— 1,000,000
FOOD?I p�p� (�? ! 1 1 GeT1ERACREfil1TE r 5 •• -2,060,006
r. • 111 I.G'T ,!�):.f1r f!
1 IOTHE7_ I •p,2oxi.IS-I:CLIIPF7ADD'S 2,000,000 ��
A IAuroaoeReweLrrr —_ i
AIO"AUTO I aatt211e1ER:EDo icditc6r_'S_ .. .1.000.000
O'•,yro !--y%?scH-DtA.ED I I �SZ1803N8 i 09/01/2017109!01/2018 Psron.rgww Par ._ _ •
AUTOS OtES ; 1 AUTOS I C. Pn's r.
' ^,Wes acv T .I rrr., nip .I t I ROCILY_ IA/Maisg s _
i_ .�wYO 0.\LY i PROPERTYOr.4.1A
Pyr..=eerdl
1 I t 1 i 1. s. _..
A X I unaRaia UAe ;X t-OCLIR I ' _T_ , i-S
CCESS USG_ = l CLAIMS_ ...,ADEI ' 1 �5J1803118 109/011201710910112018;,:GsREGti-" s --Z000 000
otXX,mtZCE
1 __ 1 r .. .. ... !;
' ! ICEOTX�r ,rtes 10,000 1 1 1
• s ;WORKEP 1 i I I ._--'_
s camPrT,sanoN
;AND EMPLOYERS'l,A61LILY ( 1 —
'n;PER i 1,iff:.(�
' ;Ann' RS'L rc �ri,� r rN t �WC958971 103/022678:03/0212019 FJ s0, .•
. •.." 1... _ _
�1=.+neaoryin NTqFrn L_I,N,A. , CEACIr RcclCgT-,r_ Jr - 600,0DDt
s e.Cd9 A p aver i ! i EL_vs=zsE-.EA aw_nv�S 500,000
'OE_St :PTONor oPEfL:Tror,5 Ce!r: 1 --IF
( - ._
.! l I i EL rnsEAse_Pc;r,^Lr.c•rr 5 500,000
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DESCRIPTION OROPBtpnONSt LOCATIONS '"- I
VEHICLES(ACOR0101,Additional Petrie salsa may be AlbLLtsed imemspace g,t d)
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CERTIFICATE HOLDER ... CANCELLATION
IRISE Engineering SHOULD ANT OF THE ABOVE DESCRIBED POLICIES BE CANCI3jED BE`-ORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELR/ERED IN
5 Dupont Ave ACCORDANCE MID THE POLICY PRL)VISIONS.
` SouthYarmouth,MA 02554 a -
AUTHORIZED
PEFREESSD ATNe .
ACORD 25(2016103) '
01983-2015 ACORD CORPORATION, All rights reserved.;
The ACORD name and logo are registered marks of ACORD
.
A 20Th Pagel of
JUL - ' Customer Name:Edwin Wright CONTRACT
' Email:Not provided
1 lam. Phone:781-999-0728
�D( C C,'i� ,,,,,c---,_.
j Premise Address:89 Baxter Avenue,Yarmouth,MA 02673
■ ` I J E ` T Date:July 17, 0 8Project ID: 8
ENGINEERING'
tl=,..::ry r r1„-I,<rf.
RISE Engineering
SDupont Avenue,Suite 2
South Yarmouth,MA,02664
Applicable Customer Required Actions: Notes:
• Storage Removal” "-- -
Homeowner to remove items In crawl space that would
be blocking the easy installation of weatherization work
in the crawl space.Removal must be done before
scheduled day of with
.Inh flncrriptinn
Measure Description - •- ,- -• • , Quantity , Unit , .. ' Total Cost . • Customer Cost l
ATTIC DAMMING-R-38 FIBERGLASS 18 SF $44.28 $11.071
FLIP/SLASH EXISTING INSULATION I SF $0.25 $0.251
ATTIC HATCH:SEAL 8 INSULATE 1 each $60.00 $15.00 I
INSULATED BATH EXHAUST HOSE 1 each $60.00 $15.001
4'x 16"SOFFIT VENTS 12 each $346.92 $86.73 I
VENTILATION CHUTES 49 each $171.01 $42.75'
CRAWLSPACE WALL R10 RIGID BOARD 270 SF $1,093.50 $273.37',
AIR SEALING 6 hr $480.00 $0.00
ATTIC FLAT-T OPEN R-33 CELLULOSE 745 SF $1,117.50 $279.38
Total: $3,373.46
Program Incentive: -$2,649.91
Customer Total:I $723.55
WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF
"'Seven Hundred And Twenty-Three And 55/100 Dollars I $723.55
UPON RECEIPT OF YOUR RISE ENGINEERING INVOICE,CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL INTEREST OF 1%WILL BE CHARGED MONTHLY ON
ANY UNPAID BALANCE AFTER 30 DAYS.SEE REVERSE FOR IMPORTANT INFORMATION ON GUARANTEES,RIGHTS OF RECISION,SCHEDULING,AND
CONTRACTOR REGISTRATION.
,
DO NOT SIGN THIS CONTRACT IF THERE AR BLANK SPACES
' 1 frkkJL.S. , 1
-i ... . . lye Customer Signature are '�"n(e,/
Sign Date /
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Coinmonweali:h of Massachusetts ' - .
i �� Division of lirbfessional Licensure
Board of Building Regulations and Standards
Constrtft -ori Supervisor : -
1
CS-095581 I ! : Expires:
.. _ 05/12/2020
• 1MLLOAM CALLAHA , --, "- ! .
175 QUINCY SHO UR • -? rat- ! -
i - BB1 1 - 4I -
• cannier mit 62171- • • • " •
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Commissioner �) I - - _
ts
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• I Construction SLpervisor I) .s• .
Unrettricted-Buildings of any hse group which contain
: less than 35,000 ruble feet(991 eubic meters)of enclosed
t I spas I '
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.
• ' Failure to possess a currentedionofthe Massachusetts
'
State Building Code is cause EMI revocation of this flcegse.
For information atioutthisflcense
``, Call(617)727-3200 or vis www.mass.gov/dpi
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�aie Wpo42VMOWatec ? II + I +ei6
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Office of Consumer Affairs and Business Regulation
• One Ashburton Place- Suite 1301
• _ Boston, Massachusetts 02108
Home Improvement Contractor Registration
Type: Supplement Card
_ Registration: 169944
EFFICIENT BUILDINGS LLC• - Expiration: 08/18/2019
P.O.BOX 246 -
BRIDGEWATER,MA 02324•
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Update Address and Return Card.
SCM 0 ZOM-05/117
1:54e Pommnnirnul/bn �`llnllveAnje✓a
Office of ConsumerAftairss Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:Supplement Card before the expiration date. If found return to:
Registration Fxoiratior Office of Consumer Affairs and Business Regulation
169944 _ 08/18/2019 One Ashburton Place-Suite 1301
EFFICIENT BUILDINGS LLC - Boston,MA 02108
WIWAMCALLAHAN - - \,� Cc)_ i at
300 ELM ST U
BRIDGEWATER,MA 02324 Undersecretary Not valid without signature
• '_� The Commonwealth of Massachusetts
AP, :=-4.---.—et Department of Industrial Accidents
S=1411=; P
I1i8 a 1 Congress Street,Suite 100
_?�{c � Boston, MA 02114-2017
* 2,?,,s• www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information _ Ey. Please Print Legibly
Name (Business/Organization/Individual): L.+ t it_t{•n �t tl ib i LL C
Address: / 7 3 r 4 )4) a
City/State/Zip: ,h. OWi A IVA 017 Y 7 Phone#: (5-0c) 2 71' -1 //V
Are you an employer?Check thereappropriate box: Type of project(required):
LAI am a employer with I ' employees(MI and/or pan-time).• 7. 0 New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling
any capacity.[No workers'comp.insurance required.]
3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. El Demolition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees. 12.0 Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0 Roof repairs
These sub-contractors have employees and have workers'comp.insurances
6.0 We are a corporation and its officers have exercised their right of exemption per MGL o. 14. Other /th U IC Ii 1
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 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 it providing workers'compensation insurance for my employees. Below is the policy and Job site
information //
Insurance Company Name: r .V1/4c.„/�—�- , ins 4„,e,-nice-
Policy#or Self-ins.Lic.#: V nj Wei ?5-7'7'7 1 Expiration Date: 7/ L p/ l /
Job Site Address: O 51 het X.1-e-4- I%,i- City/State/Zip: t f e_rr--a"t vtAI4 014'1 7
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine 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 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 c fir under the pains an
enalties� off perjury that the information provided
aab�is�and correct
Signature: r't'„/Y" ( ,oJ/411,N Date: U I /f
Phone#: S 5V, 2? S— /17)
Official use only. Do not write in this area,to be completed by city or town official
City or Town: PermitlLicense#
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#:
Permit Authorization
mass save Form
^tl^..1*pew, ..r•.f erC3
Site ID:3438576 Customer: Edwin Wright
Ir &taw ttLc,s7 ,owner ofthe property located at:
(Owner's Name,printed)
89 Baxter Avenue Yarmouth, MA 02673
(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 buil ing permit to perform insulation and/or weatherization
work on my property. buil
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Owner's Signature: h i� aa
/�
Date: .W 1 . r�v///
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
() c„ew �3,,�►fir SLG 71 id'jlk
Participating Contractor Date
Name: RISE Engineering
Phone: 401-784-3700
Email:
For Office Use Only
Rev.102015