HomeMy WebLinkAboutBLD-19-001421 +Office Use Only
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*" 4e Permite
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,Permit expires 180 days from t,
'•: :�` "issue date f.
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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth,MA 02664
(508)398-2231 Ext 1261 1 / p
CONSTRUCTION ADDRESS: 7.1- jc.r e..3 Drive A. %�(._„,A l� , f • ��� "{/�
qASSESSOR'S INFORMATION: /
Map: Parcel:
OWNER: &a) Citiey 7 I Pa—r 3 06w 3.‘1,1_,.„-,, 4,Cigif orz&by (4n-97Py-5N/(
NAME 1 PRESENT ADDRESS TEL it
CONTRACTOR:f if id4cr RuiI�Q;.� LCC '� RE3MAIL GD/1 oI ft �,,� g. 1�e✓40 rn az 74/7 lh741/27C)- 11/0
.gidential ❑Commercial Est.
[� 'Q Cost of Construction$ /7 CID ' Y
Home Improvement Contractor Lic.# I co c 7 q i( ll'i Construction Supervisor Lic.# �5- c) oc
I
Workman's Compensation Insurance: (check one)
0 I am the homeowner 0 I am the soleproprietor Xi have Worker's Compensation Insurance
i7-9,44./
Insurance Company Name: e C ..vi{✓re-.n(St Worker's Comp.Policy# U QwC 75?97/
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 y/�� , D L� Pool fencing
*The debris will be disposed of at /p 56 p))Pas�,I )'7 t. , r�`Cst,OU✓d� �
Location of Facility
1 declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. 1 understand that any false answers)
will be just cause for denial revocation of my license and or prosecution under M.G.L Ch.268,Section I. �)
Applicant's Signature: # _di% %a Date: 5?-/I0iY
Owners Signature(or attacbment) aik, (� Date:
Approved By: ✓� Date: 9-1C)—i 8
Building Offici (or designee) EMAIL ADDRESS:,/4
Zoning District: C
Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No �4Jl o-' (Hjfl'w*-ttO�29
Water Resource Protection District: Within 100 ft.of Wetlands: 9 B
iilUbbEititi0199999W91-39fLMs9 98$94t95:F3135Eoblie ?gO$paiti .Aar bP bsirti3tzth 9
%„,I EFFIBUI-01 HWOODS
An CERTIFICATE OF LIABILITY INSURANCE DATE 08/3112018
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 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 ACT
Rogers&Gray Insurance Agency,Inc. PHONE FAX '-
434 Rte 134 (AIC,Mist
Ext}: I(NC,Iq:(877)816-2156
ADDR
South Dennis,MA 02660 Ess;mail@rogersgray.com
INSURER(S)AFFORDING COVERAGE NAIC N
INSURER A:Employers Mutual Casualty Company 21415
INSURED INSURER e:National Liability&Fire Insurance Company 20052
Efficient Buildings LLC INSURER C:
PO Box 248 INSURER D:
Bridgewater,MA 02324
INSURER E:
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 CONDITION OF ANY CONTRACT OR OTHER DOCUMENT IMTH 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 POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE VD I
ADDL SUER POLICY.NUMBER POLICY EFF POLICY EXP LIMITS '
1 TRINN WMMMINYYYYI IMMIDDNYYYI
A X COMMERCIAL GENERALUAMU1Y EACH OCCURRENCE $ 1,000,000
MAIMS-MADE ElOCCUR 5D1803119 09/01/2018 0970112019 DREAMAGETORopaarerKel $ENTED 5og,006
PMLSES(Ee
MED EXP(Any one demon) S 10,000
— PERSONAL&ADV INJURY S 1,000,000
G�EIN'L AGGREGATE UNIT APPLIES PER: GENERAL AGGREGATE S 2'000'000
I POLICY ri j ( X LCC PRODUCTS-COMPX)P AGG S 2,000,000
I OTHER: S
A AUTOMOBILE LIABILITY OMcudeM1 LE LIMIT S 1,000,000
— ANY AUTO 521803119 09/01/2018 09/01/2019 BODILY INJURY(Per person) S _
OWNED X SCHEDULED
AUTOSEE�� ONLY AAUUTTOSSyM.�Ep tree
INJURY(Pe sudden& S
X 'ARA ONLY X MOWS (Per emdeWU mAGE S -
S
A X UMBRELLA UAS X OCCUR EACH OCCURRENCE S 2,000,000
EXCESS UAB CLAIMS-MADE 5J1803119 09/01/2018 09/01/2019 AGGREGATE 2,000,000
DEO I X RETENTIONS 10,000 S
B AND EMPLOYERS'LIABILITY
X STATUTE 0TH.
ANYp� CPROPREIETgOER/PARTNERIEXECUTIVE Y� V9WC9589T1 03/02/2018 03/02/2019 E.L.EACH ACCIDENT S 500,000
OFFICdEPJMEMBER)EXCLUDED? I I NIA 500,000
I'Ae EL.DISEASE-EA EMPLOYEE S
N yes,describe under 500,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMB S -
DESCRIPTION OP OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,AddiSenai Remarks SeAMA&may be aaaeMd V mere space N 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 ACCORDANCE WITH THE POLICY PROVISIONS.
5 Dupont Ave
South Yarmouth,MA 02664 - - --
AUTNORQED REPRESENTATIVE
I �earteil L/ V
7
ACORD 25(2016/03) ®1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
Page l or 1
Customer Name:Tho as Casey CONTRACT
-- ----- --- ---- Email:tomcasey12@earthanknet
\‘‘b1(/ Phone:61 7-78 4 5 41 1
RISE Premise Address:21 ar 3 Ddve,South Yarmouth,MA 02664
Date:A Ig.13,20118
Date:Aug.13,2018
ENGINEERING
EthicirncyLnrrrircd.
RISE Engineering
5 Dupont Avenue,Sulfa 2
South Yarmouth,MA,02664
Job Description
• Measure Description'.- • , Quantity.,'-' Unit Total Cost''..""r . ' . Customer Cost ,=
WEATHERSTRIP DOOR&ADD SWEEP 1 each I $80.00 $0.00
INSULATE BULKHEAD DOOR 1 each $110.00 $27.50
BASEMENT SILLS:R19 FG BATT 106 SF $232.14 $58.04
Duct Sealing-8 Hours(insulated,up to 200') 1 each $874.56 $0.00
AIR SEALING 3 hr $240.00 $0.00
I Total: $1,336.70
Program Incentive: -$1,251.16
Customer Total: $65.54
WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPE i FICATIONS.FOR THE SUM OF
"'Eighty-Five And 54/100 Dollars $85.54
UPON RECEIPT OF YOUR RISE ENGINEERING INVOICE,CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL.IEREST OF 1%WILL BE CHARGED MONTHLY ON
ANY UNPAID BALANCE AFTER 30 DAYS.SEE REVERSE FOR IMPORTANT FORMATION ON GUARANTEES,RIGHT H
OF RECISION,SCHEDULING,AND
CONTRACTOR REGISTRATION.
joONoTsi__Co
• ACTIFTHEREA BLAN S
- g:
-E Represents va
I
Customer Signature
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 SATlSFACTO Y TO US AND ARE HEREBY ACCEPTED.YOU ARE
AUTHORIZED TO DO THE WORAS SPECIFIED.PAYMENT WILL BE MADE AS
OUTLINED ABOVE
•
•
Commonwealth of Massachusetts n '• Construction Supervisor �.
��
Orvieto rt Unre iricted-BuildingsofanyusegroupwhichcoMein
Board of Building Regulations and Standards •
less than 35,000 cubic feet(991 cubic meters)of enclosed -
Conatrct tori Silpervlsor space.
•CS-096581 Expires:06/12/2020
•• .
WW
IAM CALLAHAN--;'`i; - !-
176 QUINCY Siam DR-:.
• 681
QUINCY MA 02'P7.1. - •
•.. ... - ..4,y��: Faliuretopossessacurrentedttlono?MeMassaq�uselts
" _- lute Building ealli caese:Mon oentlofthis t= -. •
For information about this license
Commissioner V"`^' 1 .. .. `ti Call(817)7274200 orvisit www,rassgov/dpi
•
•
• W4WYmruntoitata ciP daCktztei•
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 Lit . Expiration: 08/18/2019
P.O.BOX 246
BRIDGEWATER,MA-02324•
'
•
Update Address and Return Card.
SCA 1 0 1311.1-0SR
�eMCow,ar /azjJnrhnRegulation
ce
er
ness
HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
TYPE:Supplement Card before the expiration date. If found return to:
Registration Expiration Office of CbnsumerAffairs and Business Regulation
169944 081182019 One Ashburton Place-Suite 1301 .
EFFICIENT BUILDINGS LLC Boston,onMA 02108
WBLAMCALLAHAN �,p,_. ( i 1_4.
300 ELM ST („) _ e �tJ
BRIDGEWATER,MA 02324 Undersecretary Not valid without signature
•
� .
. The Commonwealth of Massachusetts
Department ofIndustrial Accidents
It LEP=_ �_— i 1 Congress 0
Boston,MA 02119-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
} militant Information rA
n A Please Print Legibly
Name(Business/Organization/Individual): C I(A {el* 1Jl/I 7 L L.0
Address: 47 3 )j 12,0�. U
City/State/Zip:{I,9(r4 ,,0. t 1114A 6174/7 Phone#: (50V2,31' — 0l/0
Are you an employer?Check the appropriate box: Type of project(required):
I.gl am a employer with 1 3 employees(full and/or part-time).* 7. ❑New construction
2.01 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 workmyself t 9. ❑Demolition
❑ [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 ❑Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.0 I am a general contractor and I have hind the sub-contractors listed on the attached sheet 13.❑Roof repairs
These subcontractors have employees and have workers'camp.insurance.:
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14�Other Zit fV l iCT 1
152,11(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: (7--
� C. 2 its
Policy it or Self-ins.Lic.#: /�V I tiC f rF (1/ Expiration Date::' -7/-i/�//r / , L
Job Site Address: Z-7- 0" a r 3 Ort Ve- City/State/Zip:J, in4 Yl/SI b Z`G 7
Attach a copy of the workers'compensation policy declaration page(showing the policy num er and expirattion 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 and eno1l les of perjury that the information provided above�ovis true and correct
Signature:C/1.4 Pr"' �=�/�//lam— Date: 6 /3�J��J
Phone#: (5-0V Z 7 S l I / (,>
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
V@nA`g 2a a2i9Vg9A392?9$3991119D19A4i94§§9:-IVD6p teviercu9vv9Divn*.s05V■ 9t*OCMOVT41.4
ontac Persvon: Phone#:
I_it,a � Permit Authorization
mass save Form
4�+••� e^e^dy.«ta.r<a
Site ID: 3447236 Customer. Thoas Casey
aCSS e
,owner of the property located at:
(Owner's Name printed)
21 Par 3 Drive South Yarmouth, MA 02664
(Property Street Address) I (City)
hereby authorize the Mass Save Home Energy Services Program assigned Pirticipating Contractor listed
below to act on my behalf and obtai a but •ing permit to perform in lata and/or weatherization
work on my property.
Owner's Signature:
Date: e^
4e6841160 e69)08466 eeai******4 4.4111rnaltai010 4141**1.44 40 *4044440*44444a@4
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participa ing Contractor to the
above referenced project:
MICI:eA:± .5LADiA-16 1/13 ii"
Participating Contractor Date
Name: RISE Engineering
Phone: 401-784-3700
Email:
For Mice Use Only
Rev.102015