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HomeMy WebLinkAboutBLD-19-001187 O .fl. •Office Use Only f. .01' rC Permit# k Sl Z $: �, 'Amount t3`5 i N ,, \ %:a'. ..::t-.Y,:.... d uePermitdate expires 180 days from BLb-t9-0o118-7 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 yY �X' (508)398-2231 Ext. 1261 /J '1 //,,• / CONSTRUCTION ADDRESS: {U 19)-(1L L✓0 O& �,�j, 2 J� WGrrvt p U 1 44 i/z6(/ 1( INFORMATION: I (Map: 1 '� ` Parcel:T1 'IJ 'tcoik (s-°V3 - s�"5U NAAAMMM��� .1- �7PRESENT ADIDRESSS O TEL # CONTRACTOR: -«,•r.,p-nt f'Ut)3+-is T-73 Haid. Til. fi3Oeftdrhovilel49/a 01147 toriz7c:-,110 NAME J MAILING ADDRESS TEL.# Residential 0 Commercial '` y Est.Cost of Construction$ 3/ y 01) ' Home Improvement Contractor Lied/ to // ia /e� e Construction Supervisor Lic.#....5 C)9 sr: / Workman's Compensation Insurance: (check one) &n ElI am the homeowner 0 I am the sole proprietor ( -'fhave Worker's Compensation Insurance Insurance Coman Name: ' //�/ 'p P r (`W`C Lyv lift.—CR �,tw�Gi,�l Worker's Comp.Policylt V '] W(, Il i 971 WORK TOIBE 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 1K i Old Kings Highway/Historic/ Dist. ( )Replacing/� like for like q1 y/.� Pool fencing *The debris will be disposed of at j'1r7�.. oil ins A-1 ► tttA t £ u (& 44 a I Location of Facility ) I declare under penalties of perjury that the statemen erein contained are true and correct to the best of my knowledge and belief. 1 understand that any false answer(s) will be just cause for denia or refoc i of my li and o r cution under M.G.L.Ch.268,Section 1. / Applicant's Signature: �( 14" a ` Date: Z o//7 Owners Signature(or attachment) a Set e.,ri-a, at Date: Approved By: /7 / Date: �j G i L — 8 B /ng ,11(or designee) E • ( ADDRESS'. , '% U ,. � f%/) ' (J/tel Zoning District /�: a' l� 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 ❑ Yes 0 No ' EyFFIBUI-01 O�S4ED- • DATE commterrm� CERTIFICATE OF LIABILITYIH .AA%CE 03102J2018 : ' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDEt THIS; I CERTIFICATE DOES NOT AFFIRMATIVEEXTEND OR ALTER THE COVERAGE AFFORDED BYTHE 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(les)must have ADDTTONAL INSURE—e If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certainpolicies provisions statementa eon' this certificate does not corder rights to the certificate holder in lieu of such endorsement(srequire an endorsement A on I PRODUCER _ 'Rogers&Dray Insurance Agency,Inc. WARCT NE - _---_ . 436 Rte 13b PHONE - _.._—________.__ South Dennis,MA 02880 [OM,xe.int___.-• _ _ __ V-__:el-No- 816-2156__ aoDRm maimroc�ersgray.com Yi _ - • hxsvRER!s7aPwxoetoeovr?cane---- NAhca -"— _ INSURER Mutual Casvaify Compo _ --_,-,.- [INSURED • — `21475 mS_UMERe:Nationai Liabifrt rug Fre Insurance mpann 1 0052 Efficient Buildings LLC PO Box 246 Bridgewater,MA 02324 R15VRER0: • ._.. . __�_...i-. COQ V RAGES .._ rt•7suRPst F: .___ . .._..__� CERTIFICATE NUMBER: 2REVISION 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS! CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS,: EXCLUSIONS AND CONOmONSO_FSUCH POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS p.i. _. TYPE OP INSURANCE .FODL�SOaR t .,NSD.wvo. POLICY NUMBER mY1,IMUUM A I X i C0301ERC,AL GENERAL WLSIUTY __.. gpp ...i.._ t IRPo i - LIMITS LLY __�CLa.IISd.L;CE ,X i Qxlar I ! ; FFdL.otIRrr..E T_ .1,000,000 5D1803113 ,09/0112017 0910'112018 Rm5DEs . s 500,000 • �__`_____ _..._ . I I - _ . _ • +� 7 F4fED EXPIA,�meemsv,]_ `5_ 100bD • I ca_r A,GREGAT�thcsrAPPLresP_Tr 1 ` 1 'r m_RSTI7WL dApyR.nmY 's _ . 1,000,000 Poucv • X� (< Loc I I I i • �GcNERA�R7GllF:,'yLTE •_ i 5 2,000,000 I iQTH_T+_ I I • I _ !_P?gxrrs.corrPCPa--s--... 2,000,_OOU �� A I Au-remotes Lemur? T , • I I L'ONMETED sxiallarsr LI1 a7fY AttrO Et)at^rmD _--_,_ 1,000,000 -1 oKvro I , SZ1803118 '09/01/2017 Boar MARVrer 8-" ,__,)AUT09 OFaY %X j yu'� I r• • , 091d1120ts �. T . n J•X i,t PBOp'1Y i_^. oS JNLY • I • I PODr,VNAR,_Y_[Perm MU 5 •. I... I •• i I I PROPERTY tDAtKG_ i AiXlrnrem.eups :X;oaam ! I • s. _.. I i cVJt_sitADEI • I EAraf/XXa7fS2_cT_.'C,E—_ s 2.000,000 I ISJt8031t809/011201T109/01/2018r- ��_„---- i--F MESS LIMB j., , ( , I"-uT^Tn-�ENTlc:ts tU,000� • I ,aG�RE;ar Is $000.000 i } - • B ILYORKERS COMPEISATION t ---- •ANDELIPLAYERSLNSILRY i i , S • • 1 X:PER ; !OTA. T�����_ ZANY PP.oPRIETOtIP Rn7EP�E.•!_sC,RIW fN! 11/9WC958971 03m2/2018.03/02I2019 ; m:-.ana'at ryin Np E4CWCEp. L_ Ii NEA, I LcACH ACCIL^r7- ,S _ SaD,DOD 1 !Ric,c:.-ra,�.:er I I ! , ! F�_rx-:- -- -- qv s_ -_- �500,0d0 O_s[aLPTyl_t OF OPERATIONS De `I _ I 7 i "-- ,et osrnsec r ietrrI.s _d0.000 I I I 4 I I i 1 I i ! ;DESCRIPTION OFOPERATIONS IWCATIQN5f VEHICLES(ACOROt AtINROAa ! Dt. Rm,arheSUMtEB Argy bo atbeAN amore spare Is req,bed) • • . 1 � ER7TFICATEHOLDER •-- ..._.__ _— - . CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BECANC I RISE Engineering THE EXPIRATION DATE THEREOF, NOTICE WILL D CANCELLED REFIRE S Dupont Ave ACCORDANCE SUDS THE POLICY PROVISIONS. I IN I South Yarmouth,MA 02664 - AUTHOR®REPPRRESSEEYTATNE '} ACORD 25(2016103) • '""" ©1988-2015 ACORD CORPORATION, All rights The ACORD name and logo are registered marks of ACORD I S . _ - Paoa i or 1 • Customer Name:Jim Welch CONTRACT Email:howiedoinn@yahoo.com Phone:508-394-5850 Witch wood Premise Address:48 wood Road,South Yarmouth,MA 02684 RisE �." Project ID:3444658 L1 Date:July 30,2018 ENGINEERING . ,c .atrrrs'3rf.:. . • RISE Englneertng 5 Dupont Avenue,Suite 2 South Yarmouth,MA,02864 Job Description Measure Description . _.. ._-, .- . . Quantity _ ._._. Unit .. _. .Total Cost' .•_ - Customer Cost -. AIR SEALING 12 hr $960.00 $0.00 WEATHERSTRIP DOOR&ADD SWEEP 1 each $80.00 $0.00 REPOSITION EXISTING INSUL - 300 SF. $75.00 $75.00 VENTILATION CHUTES 54 each $188.46 $0.00 KNEE WALL SLOPE:2"RIGID BOARD 489 SF $1,882.65 $0.00 BASEMENT SILLS:R19 FG BATT 120 SF $262.80 $0.00 I Total: $3,448.91 Program Incentive: -$3,373.91 , Customer Total: $75.00 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF *"Seventy-Flve And 00/100 Dollars j $75.00 UPON RECEIPT OF YOUR RISE ENGINEERING INVOICE,CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL.INTEREST OF I%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. jti DO NOT SIGN THIS CONTRACT IFTHER ARE ANY BLANK SPACES ' RISE Representative Cu- .F.rSignature • Sign Date 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 - , D C'CC OVI Auc - 3 2018 -J t� Commonwealth of Massachusetts • Construction Supervisor • • •f. Division of Professional Licensure Unrettricted-Buildings of any use group which contain Board of Building Regulations and Standards less than 35,000 cubic feet(991 cable meters)of enclosed Constr_ttcttofi Supervisor space. • • CS-095581 Expires:05/12/2020 WILLIAM CALLAHAN..t'- f, t -,. 176 QUINCY SHORE DR� N - • 881 r. - `'I3' t QUINCY MA o2h.y • .�;a �+.. Failure topossess acurrent edMonofthe MassachusEt[s •: State Building Code is cause for revocation of this license. • /n• For Information about this license Commissioner a— Call(617)7273200 orvisit www.massgov/dpi • • • &/-10 W0471 7 E etaPATZWaL�?"Z�%U1Yifil/J• Office of Consumer Affairs and Business Regulation • One Ashburton Place- Suite 1301 - " - Boston, Massachusetts 02108 Home Improvement Contractor Registration • • • Type: Supplement Card EFFICIENT BUILDINGS LLC'. Registration: 169944 P.O.BOX 246 Expiration: 08/18/2019 BRIDGEWATER,MA.02324 Update Address and Return Card. Salla mltosrr — — — --- — • giuneirsetd Office onsumerA Maksninneffraid Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Supplement Card before the expiration date. If found return to: Registration Expiration Office of Cbnsumer Affairs and Business Regulation 169944 08118/2019 One Ashburton Place-Suite 1301 • EFFICIENT BUILDINGS LIC - Boston,MA 02108 W IMAM CALIAHAN04,7 300 ELM ST ( `� ����/�^' , ado "'�" F'�r^� BRIDGEWATER,MA 02324 Undersecretary Not valid without signature , The Commonwealth of Massachusetts --a= t _6 177 - / Department oflndustrialAccidents Congress Suite 10 =` s. vii I Boston, MA 02114 -2017 0 s'�Lso 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): 1416„4,. .f- (64/1dAnr ( c C Address: 97 3 Rod la City/State/Zip: 14, 196-//141.41-1_41A ,AL1 `(7 Phone#: (SOO/ 17 q — / // 0 An you an employer?Check the appropriate box: Type of project(required): I./g i am a employer with /3 employees(full and/or part-time).• 7. ❑ New construction 2.0 1 am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall work myself 9. ❑Demolition ❑ toys [No workers'comp.insurance required.]t 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑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 5.0 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.* I 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.�Othei L n f U�W'(/ 152,41(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: 6Sic2 V t/rt' —4•t_. C!)y Policy#or Self-ins.Lie.#: ./ 1' C 5' (F� 1-7 ) 7 Expiration Date: 3/I-12-0/ IJob Site Address: y3" 01 h-rrl'w'c',1 Q City/State/Zip& v° 4/4 az6Gtl Attach a copy of the workers' compensation policy declaration page(showing the policy num er and expirati n 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 pen o perjury that the information provided above is true and correct Signature: 6J/ v % Date: fit G1iOV Phone#: (5D ) en S- 1 // O 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#: , 4 Permit Authorization ne mass save Form tse*un t' C&)?''+n'7.s r.r.CM, Site ID: 3413161 Customer: Jim Welch • is )f 0( 't% tv%_ ttiCXC.L V r ,owner of the property located at: (Owner's Name,printed) 48 Witchwood Road South Yarmouth, MA 02664 (Property Street Address) (qty) 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: 4. ft< - Lc).-t Date: -1( 0( t F FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: 6aall,f L (CC ti /;or► eY Participating Contractod Date Name: RISE Engineering Phone: 401-784-3700 Email: For Office Use Only Rev.102015