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Home My WebLink AboutBLD-19-001422 M I Office Use Only tYJ1 .�Z RSC Penniti �y 0 HH: Amount JSP rw�l . 4 �,�....• ,(31: Permit expires 180 days from t issue date ticD -lit— bojtla)-. EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 /'� (508)8)398-2231 Ext. 1261 `�1 y� '/�^ CONSTRUCTION ADDRESS: I Z I l p /1+Mx" tce-A ^ jL,0i[ J+"n 'f r ins` '"� OAS `S ASSESSOR'S INFORMATION: 1^ Map: Parcel: OWNER: Vinrt ^ hAt\ AN) k2An IZ C.Ap Ln (5 ?) 77cr os-63 3 NAMPRESENPAbD TEL # CONTRACTORNC c &sac g 17) OIIIIPVIA r — ilb JMAILING ADDRESSTEL# ccsidential 0 Commercial [' gyp Est.Cost of Construction$ 3C,6 0 Home Improvement Contractor Lia# ! C I I(/ I Construction Supervisor Lic.# C S — 0 ci 5 50c Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor rkhave Worker's Compensation Insurance Insurance Company Name: el. MC, vre.nCV. Worker's Comp.Policy# V9t-e95a5'7) 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. ( )Replacing like for like Pool fencing *The debris will be disposed ofat A ,J G 111/5 pp d.1 �lr^rovtvi 0o..& bedA/1 AAA Location of Facility U I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. !understand that any false answer(s) will be just cause for denial orArevocation of my licensepand for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature:. 1' 2 C(1 vtV) L-/�v[4 Y4 Date: FA 0,)0 Owners Signature(or attachment)�'6 c ,A Date: p Approved By: (/ Date: -10 /A Building Official(or des e) EMAIL ADDRESS: r Zoning District: it L Historical District: 0 Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No �1, EFFIBUI-01 HWOODS AGORO' CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDIYYYY) 4.1.—/ 06/31/2018 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 POUCIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: H the certificate holder Ls 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 90NTI1CT Rogers&Gray Insurance Agency,Inc. PHONE 434 Rte 134 1 e,Est): II FAS,Ax Ne1�( 816-2156 South Dennis,MA 02660 ass:mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC I INSURER A:Employers Mutuat Casualty Company 21415 INSURED INSURER B:National Liability&Fire Insurance Company 20052 Efficient Buildings LLC INSURER C: PO Box 246 INSURER D: Bridgewater,MA 02324 ' INSURERS: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 CONDmON 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 ADDLSUBR POLICY NUMBER POUCYEFF POLICY EXP IJNfIB LTRINSD WVDIMM/DDNYYYI IMM/DDNYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1.000,000 CLAIMS-MADE ill OCCUR 5D1803119 09/01/2018 09/01/2019 PREMLSESIEeE Hence) $ 500,000 — MED EXP one enm 10.000 _ PERSONAL AADV INJURY 1.000.000 GENT AGGREGATE SM APPLIES PER: GENERAL AGGREGATE 2.000'000 RPOLICY n JECT X LOC PRODl1CTS-COMP/OP AGG 2.000.000 OTHER: f A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 ANY AUTO 521803119 09/01/2018 09/01/2019 BODILY INJURY person) $ — _ _ AUTOSAp�� ONLY X SCHEDULED PBPOOpDILY INJURYTypg (Per accident) $ X AUTOS ONLY X AUTOS ONLY (PeOr g0er0) mAGE $ _ — — i A X UMBRELLA LIAO X OCCUR EACH OCCURRENCE $ 2.000,000 EXCESS LAB CLAIMS-MADE 5J1803119 09/01/2018 09/01/2019 AGGREGATE $ 2,000,000 DED X RETENTIONS 10,000 $ B WOR KERS COMPENSATION XPERTUTE I ETH- AAND EMPLOYERS'IAINIIIV Y/N V9WC958971 03/02/2018 03/02/2019 500,000 ANYpN� PROPRIETOR/PARTNEEEXECUTIVE n E L.EACH ACCIDENT $ aggr(MandatoryInNH)EXCLUDED? NIA o/ply=In NNNN) EL DISEASE•EA EMPLOYEE $ 500.000 Ifyes,describe under 500,000 DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ DESCRIPTION OP OPERATIONS/LOCATIONS I VEHICLES IACORD 101,Additional Remarks Schedule,may he attached I men pace M required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE RISE Engineering THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 g ACCORDANCE WITH THE POLICY PROVISIONS. 5 Dupont Ave South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE I f ACORD 25(2016/03) 01986-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD • Page 1 of 1 Customer Name:Mary n Mulhem CONTRACT Email:maryannmulhemt)gmail,com \y Phone:506-776-0563 • i` Premise Address:121Captain Bacon Road,South Yarmouth,MA 02064 R ' JC E Project ID:3436149 Date:July 11,2018 ENGINEERING' RISE Engineering S Dupont Avenue,Suite 2 South Yarmouth,MA,02664 Job Description Measure Description Quantity. .,;;. Unit . , = ToLl Cost ;, . Customer Cost WEATHERSTRIP DOOR&ADD SWEEP 3 each $240.00 $0.00 AIR SEALING 10 hr $800.00 $0.00 ATTIC FLAT-10"OPEN R-37 CELLULOSE 840 SF $1;310.40 $327.60 4"x 16"SOFFIT VENTS 12 each $346.92 $86.73 18'X 24"ALUM GABLE VENT 1 each $123.50 $30.87 ATTIC DAMMING-R-38 FIBERGLASS 220 SF $541.20 $135.30 VENTILATION CHUTES 68 each $237.32 $59.33 Total: $3,599.34 Program Incentive: -$2,959.51 Customer Total: $639.83 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF "'Six Hundred And Thirty-Nine And 83/100 Dollars $639.83 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 ao DAYS.SEE REVERSE FOR IMPORTANT INFORMATION ON GUARANTEES,RIGHTS QF RECISION,SCHEDULING,AND CONTRACTOR REGISTRATION. BUNK I DO OT SIGN THIS CONTRACT IF THERE ARE ANY SPICES Ate r .- Loa RISE Representative _ Customer Signature / a,//i - Sign Date NOTE:THIS CONTRACT MAY BE WITHDRAWN BY US IF NOT EXECUTED WITHIN, ACCEPTANCE OF CONTRACT'Th ABOVE PRICES,SPECIFICATIONS AND 30 DAYS CONDITIONS ARE SATISFACTORY O US AND ARE HEREBY ACCEPTED.YOU ARE AUTHORIZEDTO DO THE WORK A SPECFIED.PAYMENT WILL BE MADE AS OUTLINED ABOVE 2. Commonwealth of Massachusetts �• Construction Supervisor •• Division of Professional Licensure UnreSblced-Buildings of any use group which contain - Board of Building Regulations and Standards • less than 55,000 cubic feet(991 cable meters)of enclosed Constra ori Supervisor • space. • • I CS-095581 Expires:05/12/2020 WILLIAM CALLAHAN. 11 = e{_,; 170 QUINCY SHORE DR' ,.ii;" . 1307 QUINCY MA 0217.1. " �".+� I ";i_t:,:es' . ;`.: Failure to possess acummtedition of the Massachusetts State Building Code Is cause for revocation of this license. For Information about this license Commissioner Cal(017)T2T32o0orvisnvnvw.massgov/dpi . • • V fti W0427//'/w eGlifil/1•Fi 01 PAZdoacAttoeitiLll• Office of Consumer Affairs and Business Regulation • One Ashburton Place-Suite 1301 • Boston, Massachusetts 02108 Home Improvement Contractor Registration • Type: Supplement Card EFFICIENT BUd DINGS LLC • Registration: 169944 P.O.BOX 246 Expiration: 08118/2019 BRIDGEWATER,MA•02324 Update Address and Return Card. SCAt 0 201.1-01/IT ViZefCmnHB18 (lnrd Aa6uslRegulation HOME IMPROVEMENT CONTRACTOR Registration sand for Individual use only TYPE Simolemelt Card before the expiration date. If found return to: Registration Expiration Office of CbnsumerAffairs and Business Regulation 169944 0811812019 One Ashburton Place-SuRe 1301 • EFFICIENT BUILDINGS LLC Boston,MA 02108 W LI AM CALLAHAN 00jjyy �Jg/J 300 ELM ST �.�/�"-- ""/ lZt�✓` BRIDGEWATER,MA 02324 Not valid without signature Undersecretary _� The Commonwealth of Massachusetts - 1 Department oflndustrialAccidents eF/d= f: 1 Congress Street,Suite 100 _`ti�_ Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information n / Please Print Legibly Name(Business/Organization/Individual): c.6/6;ej e-- - -v u I �l t✓�a Address: 4 7 7 tors ars A J UJ 0 City/State/Zip:f t Qj',,}me u4, j /1f 617 y 7 Phone#: Oa).) 275' — I i I U Are you au employer?Check the appropriate box: Type of project(required): 1.01 am a employer with i 3 employees(full and/or part-time).* 7. 0 New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. Q Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]: 9. El Demolition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I w71 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 1 have hired the sub-contractors listed on the attached sheet 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 14.0 Other 6.Q We area corporation and its officers have exercised their right of exemption per MGL e. �l�rrv�ti4' 152,11(4),end we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they ere 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, p,1 �7^ Insurance Company Name: /6/14 C. YYtSv ro,,,t ct Policy#or Self-ins.Lie.#: t/�&/C. ?�d'/ 7 I Expiration Date: `'/ / �" 07‘6(7 / // Job Site Address: / 2 I ( Apmin h6+�Wr fr/46-1, City/State/Zip• oJ{ %%r i e'-`1h/mu 07b6(1 Attach a copy of the worker'compensation policy declaration page(showing the policy number Ind 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 certrti/fy funder the pains an eennal 'e/s of perjury that the information provided above is true and correct Signature:G� " titvi /s2�//�P — Date: c/56 Phone#: (fes d,7-7 7 - /1/) 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 I11L P f 4,i+<t 4001 44101n11t60-0160041x0 Aottak-Las thata T.Phone#: Contact Person: ti1-.WE str Permit Authorization mass save Form -.w.'n.rres.go,.^,t3''e,rn:y Site ID: 3432527 Customer: Mary nn Mulhem 4 5( /6J�!/ �04) ,l / bate �(/ ,owner of the prclperty located at: J (Owner's Name,printed) 121 Captain Bacon Road South Ya-mouth, 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 to perform insulation nd/or weatherization work on my property. Owner's Signature: tXfif /wk.. Lths Date: )( ;per FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: fiC14f Pwla;^fri Participating Contract r Date Name: RISE Engineering Phone: 401-784-3700 Email: For Office Usa Only Rev.102015