HomeMy WebLinkAboutBLD-19-001184 •
of'YAR `office Use Only•
4O Permit#
O 3S
O
tti Amount �U
M�
�""""�S c�� Permit expires 180 days from it
. ;. ' issue date
Bib—tat—DU i c-
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth,MA 02664
i
(508)
�398-2231/4).Ext. 1261 ^�
CONSTRUCTION ADDRESS: 17 )4AAL4tSi( 8�L[l� ) . /o_rrhot ) �J` o2(J 0 13
ASSESSOR'S INFORMATION:
Map: '/� Parcel: / ( p q
OWNER: AAj1k(i2 ��(�evrjh)i�n �2 /'PRESENT
ILO (A),( .tra)utn C(H1711d"o " 041 I
yyA (/�{[�� 31;1)
�p� ✓J 17/7?
PPREySE�NT AADD/DfRES�SS /� l T�EJL # y Q �//I
CONTRACTOR: l' 41.c-i4- i ) t11f / 7 AX,IJ NAmE MAILINGp )sO 4 07�/Ls(7UdJ1/7-ii
ti esidential 0 Commercial � Est.Cost of Construction S 5o y aCr?
Home Improvement Contractor Lic.# / to' /�) J"it1 Construction Supervisor Lie.#e S` 01 S✓ /
Workman's Compensation Insurance: (check one)
❑ I am the homeowner
t._❑ I am the sole proprietor - I h e Worker's Compensation Insurance
Insurance Company Name: f" /t' .. ANSA a et,,,n,/�,� Worker's Comp.Policy# 1/1)4)C151.17/
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. ( )Replacingalike for like I Poolfencing
*me debris will be disposed of an A 6C' jQ Apt//1 - / t-t-i 4-Y` )
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 deni or oc o f my lic an forfor ecution under M.O.L.Ch.268,Section 1. /7
Applicant's Signature: Jil" /13.1j �/ Date: 1C /2 //I7'
Owners Signature(or attachment) .t -ffyt((� Date:
Approved By: !�! Date: (92�/r O
ldi %:ttici:a (or designee) EMAILADDRESS: /it -r
Zoning District: �/ �y
Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes 0 No
Water Resource Protection District Within 100 ft.of Wetlands:
0Yes 0No 0Yes 0 No
•
gi
• • ®ROT EFFIBUI Di HWOQ
�-- CERTIFICATE OF LIABILITY INSURANCE °^'�"—�°°^* :
' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATEBIS:
I 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•
I REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER
•
_ORT
IMPORTANT: If the certificate holder is an ADDMONAL INSURED,the pofcy(les)must have ADDITIONAL INSURED provisions or be endorsed;
; If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,
this certificate does not confer rights to The certificate holder r in lieu of such endorsement(s).o6cies may require an endorsement A statement on'
,PRODUCER -
;Rogers 8 Only Insurance Agency,Inc. :A �• ._.. •�_
:434 Rte 134 I PHONE
_ __._�_�__—__.___._..r.F _ ._ _ _ _
;South Dennis,MA 02660 I/NC. 9. • -+y.- hap,r etara816-2156_ -
'Iabprof ;,/nail ropers ray.cam—�
.. . f MSURER AFFOROMB GOVOE_ r T - NAID9 '
-
-. ._-.• •_ MSUREI{A:EmpIOyBrs Mfrtual CaSiIBI'(�/COTTIPa _. _.
INSURED - .._ _
• OY .__'21_415
• e suera e:National Liab16ty_&Fire Insurance Comparry 120052_�
Efficient Buildings LLC
. PO Box 246 - !vsuitvtFi__._..._._•_ __�.._..__- .--
' Bridgewater,MA 02324 -•- .L--' •---
I INSURER P: V_ . . ..
CERTIFICATE NUMBER: —�
COVERAGES
THIS IS TO CERTIFY THAT REVISION NUMBER:
INDICATED. NOTiMTH THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
STANDING ANMAYY REQUIREMENT, TERM OR C ON OF ANY POLICIESCTOR OTHER DOCUMENT WITH RESPECTTO WHICH THIS;
CERTIFICATE MAY BE ISSUED OR PERTAIN, THE INSURANCE AFFORDED BY THE BYPADESCRIBED HEREIN IS SUBJECTTO AND CONDITIONSO_F SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAD)CLAIMS ALL THE TERMS.i
rN j. TYPE OFa79URANCE :MK::' 7
�t1 PfILIL^f EFF f FOLrLY EXP
,,y „ � PDUCYN07.16ER nnLVDOrYYYY7,Ranre@W9Y1�.• - _. __LQ1n5 ._ _ __.
IniCO:.1LiEROALGENERAL LWsLRY j _..
CLAtM&7,tn0'c X i C:.CUR I I t Iu OcOCCURRE -�_ 1,000,000
1 5D1e03114 ;09/0172017�asrot/zota R SE TO RIDDED
L : • 500.1360
_. --
„REV!.AGGRcr._.ATe A( PVt.� '� 1 !.. I 'x_asnuaLagwawr:r -_s_ - 1,000.000
INn7cY .. { I - 'GnEmA,GGRFr,ATE 7 S ---!,660,066
'...IDIRca ! I 1 • I CCL7 PAC _5 _
-
A �Atnn aoe s tme urT 1 —..i- l t_._--T__,
I COVERED D SAIC.ETnm •
AIA'AUTO X521803118 ? - EODDILY ---• �_ •_ _00(1:000
L
/YAWED TSCH-DULED i I 09/01/Y017I 091d1/2078 enonrrwrr P,r __
-... ;MOW
MET iX (TCS I e C. 'i�S ... .... ._ _ ..
n ;MOW .n I iRF: A : .1 RO IL .Y C7Il7,T(LPa a..G1,�.t�S
... s__.( O_QYL 1 j PRO JtIY DAre _
I ! I I • ; Lpetaat talitl S
A _n I ULtSRPt.e LU16 ' n�OQ:UR I 1 . ._ I S
is iddatiti
r__+IXCESS UAB I cL7,Rs ' i I EAn!cx:a7RI e; s 2,000,000
1 Sa:AD= �J18031t8 I 09101t2017I W/01(2018 - _ --- ••
I I FED 1..."T RETENTIONS 10,000; • i• 1 ! AG REGar
: B !WORKERS COMPENSATION -� , v:Fa .i; _ .__..
;AND EMPLOYERC ualls.nY I 7 X i i 'OrH•
• Ik^I'IrppoPRPactfoeRR.E:hxEranwE I/N j kWC958971 03/02/2018 03/0272019
I !Ltwnaaiorylo NHj EICWCEO: I••
,�N/A. L cACHACCIC'tc rr S.. _ 500,0.DO
, !ares,CesyTa weer I• I - _
FLvASE.EA>IP-s '50°,600
'PESCR;PTu)Nn_oPER;,T7ows Reis • .1 I 1 t --
1 , � I eL otscAse:• rniurr s b60,060
_ II
�i ; • I ; •
,DESCRIPTION OFOPf7tAT10775f LOCAIIQ SIVEHICLES(ACORDI01.ACe1DOR➢I ReNurbS
Cttedute.may be attached V MOS space is mRihed)
•
•
•
_ •
CERTIFICATE HOLDER
CANCE_LLI3TIQN_
1 LD .
RISE Engineering
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE cAN�•--BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
5 Dupont Ave ACCORDANCE WITH THE POLICY PROVISIONS.
1 Sopth Yarmouth,MA 02664
• AU RORQED REPRESEYTATNE •__,
ACORD 25(2016103) `"" � � �—
The ACORD name and logo are registered marks of ACORD
CORPORA7TON, All right,reserved:
•
Page 1 of 1
' Customer Name:Ann Marie McLaughlin CONTRACT
Email:ammd184@hotmail.com
Phone:617-388-0479
RISE / Premise Address:17 Anastasia Road,West Yamouth,MA 02673
Project 0:3446572
Date:Aug.3,2018
ENGINEERING"
Efficiency Energized.
RISE Engineering
5 Dupont Avenue,Suite 2
South Yarmouth,MA,02664
Job Description
Measure Description Quantity.. ..- Unit ' ' Total Cost • ' . Customer Cost •
CRAWLSPACE:10 MIL GROUND COVER 575 SF $557.75 $0.00
CRAWLSPACE WALL RIO RIGID BOARD 350 SF $1,417.50 $354.37
AIR SEALING 10 hr $800.00 $0.00
ATTIC FLAT-9"OPEN R-33 CELLULOSE 1140 SF $1,710.00 $427.52
PULL-DOWN STAIR:THERMADOME,BUILT-UP 1 each $237.65 $59.41
ATTIC DAMMING-R-38 FIBERGLASS 110 SF $270.60 $67.65
VENTILATION CHUTES 74 each $258.26 $64.56
Duct Sealing-8 Hours(Insulated,up to 200') 1 each $674.56 $0.00
COMMON WALL:FG BATT+2'RIGID 53 SF $278.25 $69.56
VENT BATH FAN THRU ROOF 2 each $237.50 $59.37
Total: $6,442.07
Program Incentive: -$5,339.63
Customer Total: $1,102.44
WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF
"'One Thousand,One Hundred And Two And 44/100 Dollars $1,102.44
UPON RECEIPT OF YOUR RISE ENGINEERING INVOICE,CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL.INTEREST OF 1X 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 RE ANY FjLANK ES
11,
t//ter//✓/ (�r�LY�/'`�
RISE •epresentative Customs Sign re
ait
Sys/ /
NOTE:THIS CONTRACT MAY BE WITHDRAWN BY US IF NOT EXECUTED WITHIN ACCEPTANCE OF CONTRACT-THE ABOVE PRICES,SPECIFICATIONS AND
30 DAYS CONDITIONS ARE SATISFACTORY TO US AND ARE HEREBY ACCEPTED.YOU ARE
AUTHORIZED TO DO THE WORK AS SPECIFIED.PAYMENT WILL BE MADE AS
OUTLINED ABOVE
•
I'
Commonwealth of Massachusetts �• Construction Supevisor •
®� Division of Professional Licensure • Unre*tricted-Buildings of any use group which contain
Board of Building Regulations and Standards less than 35,000 cubic feet(991 cubic meters)of enclosed
Constrticttori Supervisor •! space
•
CS-095581 Enpires:05/1212020
WIWAM CALLAHAN_;.z`>' 57.: 74-->
175QUINCYSHOREDR'<' .%
r . 981- . +r' »-v
QUINCY MA 02171y •
' Fanura poess cause edmon ofthe Massaehu
State Building
ssCodea is cause for revocation of this license, .
/'�//� For Information about this license
Commissioner v""' • ._ `. Can(617)7274200 orvisiwww,nnessgov/dpi
•
•
Office of Consumer Affairs and Business Regulation
• One Ashburton Place- Suite 1301
ri - ' Boston, Massachusetts 02108
Home Improvement Contractor Registration
• i
Type: Supplement Card
EFflCIENTBUILDINGS LLC'. Registration 169944
P.O.BOX 246 Expiration 08/18!2019
BRIDGEWATER,MA•02324
Update Address and Return Card.
SCAT C 2OM-05/17 - --, -- -----
arrantmanan-off/j%/^-lln:nniitatte
Office onsumer Afloat&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
TYPE:Supplement Cbrd before the expiration date. If found return to:
Registration Expiration. Office of Mummer Affairs and Business Regulation
169944 08/1812019 One Ashburton Place-Suite 1301 •
EFFICIENT BUILDINGS LLC Boston,MA 02108
•
WIWAM CALLAHAN ///�J,Q�yy/ s®Q�
300 ELM ST �J�J�^' ` ('�`^ J'CaVa
BRIDGEWATER,MA 02324 Undersecretary Not valid without signature
• __ The Commonwealth of Massachusetts
Department oflndustrialAccidents
TtiTifilEj 1 Congress Street,Suite 0
Boston, MA 02114-2017
`•' .fie., www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): �, H?t/fid- 4;)1); L,C„,
s/
Address: / 73 '/i p pA } r
City/State/Zip:11. LiCd r)a i/lI$ pt71- 'I Phone#: C5n0 7-"?T- i" /J
Are you an employer?Check the appropriate box: " Type of project(required):
It)am a employer with / 3 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 8. 0 Remodeling
any capacity.[No workers'comp.insurance requited.]
3. I am a homeowner doingall work t 9. ❑Demolition
❑ myself[No workers'comp.insurance required.]
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.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance
6.0 We are a corporation and its officers have exercised their right of exemption per MGI.c. I4.�Othei L�r I vie A"+rte
152,ii 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 is providing workers'compensation insurance for my employees. Below is the policy and job site
information. �}�
Insurance Company Name: G_ � 0 Takt tete Ce - J q
Policy#or Self-ins.Lie.It: V9i-✓C' g�d' // / Expiration Date: i/Z/ L d l j
Job Site Address: /7 471,-1,176CIC City/Stateizip:jv t.ai vt1 1 /7)2 02671
Attach a copy of the workers' compensation policy declaration page(showing the policy numiSer 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 certify under the pains a ,pe f perjury that the information provided above is true and correct.
Signature:Z�74 - es Date: elle ///t7
Phone#: (IL& 2-7
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#:
Y „re Permit Authorization
mass save Form
$++nts tteet 7e enemy r ,Many
Site ID: 3441953 Customer. Ann Marie McLaughlin
I, AAA. ►MG.{It VrILLa4/SL ,ownerofthepropertylocatedat:
(Owner's Name,primed)
17 Anastasia Road West Yamouth, MA 02673
(Property Street Address) (Ory)
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: CL.9141,911.
Date: g/; (IT
63Aitle** Q04.06$4$0cRSf Ita4s7fi#4etee;oa6$4*WpoPiSM40,*(st*84Pdr.ACMSZ*04 t040A44*t
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
Participating Contractof Date
Name: RISE Engineering
Phone: 401-784-3700
Email:
For Office Use Only
Rev.102015