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Home My WebLink AboutBLD-19-002421 4Office Use Only r of 1' t 4 4‘t, o. 1 Pennitl t; Ntptet 'Amount f Permit expires 180 days from e - -�" issue date . ISL l(4-, N EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department C et ' s 1146 Route 28 22 2018 South Yarmouth,MA 02664 OCT (508)n398-2231 Ext. 1261 CONSTRUCTION ADDRESS: cJv (J y( i4'7 2, Or s, Va,�OJ� I\ )� BUILD NO a PARTMENT t ( , ASSESSOR'S INFORMATION: !! ,/� ' lett') y� .'A Map: p ((Pl1arcel: q OWNER: �elett IVATh/O��t'IN SL. CDvPRESHNTADVIb Vr cW4I4..4'( vkii9 o261SS i TEL y (0F)33o-7s r N'AMECONTRACTOR;(. (+'cit..4- 60IA:yr 971 iuufd Rd 14.D4r mod 1'hA029Y7 (9))271.--///0 NAME MAILING ADDRESS ) TEL# esidential 0 Commercial / , Est.Cost of Construction S S6 60 Home Improvement Contractor LiaI # / (0 S r 7 7 Construction Supervisor Lia N C.3--65,-reP I Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 04 have Worker's Compensation Insurance q Insurance Company Name: £MC 7NT.."t- 'c C Worker's Comp.Policy,/ ✓i WC 1 n 7�s 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 11Pool fencing �� [/ *The debris will be disposed of at: MC Ol'f'0)'U 9li , /3 zee/ X•�(.�/,L(�yUtl/y/rA 627 % 7 Lots s of Facility I declare under penalties of perjury that the statements b in containedrrr000are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denialyr revoca' of my licen, d or pL.on under M.G. Ch.268,Section 1. Applicant's Signature:(/ /"/// M'_ ii' it Date: /6 71 6 / Owners Signature(or a hment) 41. 1rn(.�.e.K Date: Approved By: Date: l m—-Z 5—r— riding Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 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 1♦ • /mmwm, EFFIBUI-01 HWOODS ACO v CERTIFICATE OF LIABILITY INSURANCE 05131 8 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(les)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 N2MEACT Rogers&Gray Insurance Agency,Inc. PHONE FAX 4 d Rte 134 (AIC,No,EMI: I IAIc,Nel:(877)816-2156 South Dennis,MA 02660 - Rt lbs:mail@rogersgray.com • I INSURERS)AFFORDING COVERAGE NAIC E • INSURER A:Employers Mutual Casualty Company 21415 INSURED INSURER e:National Liability&Fire insurance Company 20052 . ' Efficient Buildings LLC INSURER C: PO Box 246 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 WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO AU.THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADM SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INED WVD POLICY NUMBER IMMUDDryyyyl IMM/DDIYYYYI • LRAM A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 1 CLAIMS-MADE n OCCUR 501801119 0910112018 09/01/2019 pMAGE EFhE TEnnance1 f 500,006 MED EXP(Am one person) $ 10,000 • PERSONAL S ADV INJURY 3 1.000,006 CECIL AGGREGATEppL'T UR�MpR.APPIJES PER: GENERAL AGGREGATE .__$ $000,0R00 ..POLICY❑X JEQ we PRODUCTS-COMP/OP AGG f 2,000,006 OTHER • S COMA summonsWeILIrr lEaa INED oderel SINGLE LIMIT S 1,660,000 ANY AUTO - 5Z1803119 09/0112018 09/01/2019 homy INfJRY(Per parson) $ — • OWNED SCHEDULED AUTOS��pONLY X AUUTOpSA.r.ED BODILY INJURY(Petsomand S - X ALTOS ONLY X AUTOS ONLY (P&gid) GE $ — $ A X UMBRELLA WB X OCCUR EACH OCCURRENCE $ 2,000,000 EXCESS WB CLAIMS-MADE 5.11803119 09/01/2018 09/01/2019 AGGREGATE f 2,000,000 DEO X RETENTIONS 10,000pp f B WORKERS COMPENSATION X I PEAnitf FRS AND EMPLOYERS'LIABILITY ANY PROPRIErORIPARTNER,EXECUTNE yl SNI V9WC958971 03/02/2018 03107/2019 EL EACH ACCIDENT - $ 500.000 OpFFFICERAIeMDER EXCLUDED? i I NIA (Mandatory InNH) E.L DISEASE-EA EMPLOYEE $ 560,000 K yea,Desa+w under • 500,000 DESCRIPTION OF OPERATORS below EL DISEASE-POLICY OMIT $ DESCRIPTOR OF OPERATIONS I LOCATORS I VEHICLES(ACORD 101,AddINona Remelts Schedule,may M aWehed Woww spam Is rpWred) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE RISE Engineering THE EXPIRATION DATE TUEREOA, NOTICE WILL BE DELIVERED IN 9 ACCORDANCE WITH THE POLICY PROVISIONS. 5 Dupont Ave South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE I L' 17,44.."--..-------- ACORD 25(2016/03) ®1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD t Page 1 of 2 Customer Name:Megan Anthony CONTRACT Email:mlanthony@gmall.com \\:I .c..,,'" Phone:518-330-7565 RISE Premise Address:52 Country Club Drive,South Yarmouth,MA 02664 ate: ID.3 Date:Project ID.30,201860 ENGINEERING E f fit ency Energized. RISE Engineering 5 Dupont Avenue,Suite 2 South Yarmouth,MA,02664 Job Description Measure Description<' '- (°'It - Quantity ' i` - Unit '' : 'Total Cost ; Customer Cost . PULL-DOWN STAIR:THERMADOME,BUILT-UP 1 each $237.65 $59.41 ATTIC HATCH:SEAL&INSULATE 1 each $60.00 $15.00 AIR SEALING 8 hr $640.00 $0.00 WEATHERSTRIP DOOR&ADD SWEEP 1 each $80.00 $0.00 INSULATE BULKHEAD DOOR I 1 each $110.00 $27.50 OVERHANG 8"DENSE R-28 CELLULOSE 24 SF $47.52 $11.88 REMOVE EXISTING INSULATION-INCENTIVIZED 80 • SF $77.60 $19.40 BASEMENT SILLS:R19 FG BATT 166 SF $363.54 $90.88 ATTIC DAMMING-R-38 FIBERGLASS 115 SF $282.90 $70.72 KITCHEN EXHAUST-ELECTRIC ONLY 1 each $175.00 $43.75 4"x 16"SOFFIT VENTS 12 each $346.92 $86.73 VENT BATH FAN THRU ROOF 1 each $118.75 $29.69 VENTILATION CHUTES 84 each $293.16 $73.29 ATTIC FLAT-12"OPEN R-42 CELLULOSE 1303 SF $2,189.04 $547.27 Total: $5,022.08 Program Incentive: -$3,946.56 Customer Total: $1,075.52 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF "'One Thousand And Seventy-Five And 52/100 Dollars $1,075.52 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. 0 NOT SIGN THIS CONTRACT IF THER A• ANY BLANK SiS 6V ' /!fir Representative /I Customer S' na `Sign Date • • • Commonwealth of Massachusetts - • Construction Supervisor �� Division of Professional ticertsuro Unrettricted-Buildings of any use group which contain Board of Building Regulations and Standards - less than 35,000 cubic feet(991 cubic metas)of enclosed Constrncioa Sapervisor ` space.• • - • CS-095551 Expires:05/12/2020 WIWAM CALLAHAN.:;".::;' - <e .• • 1175 QUINCY SHORL DR srleff4t. Bili - QUINCY MA 02171 �"*, - Fauretopossessacurrent edition ofthe MassachuL State Building Code is cause for revocation of this license, . /� .: For infomMtionabout this license Commissioner Vt- Ca➢(6.17)727.3200orvlsitwryw•massgov/dpi • • Office of Consumer Affairs and Business Regulation • One Ashburton Place-Suite 1301 • - -•• Boston, Massachusetts 02108 Home Improvement Contractor Regisltation ,. • Type: Supplement Card EFFICIENT BUILD W GS LLC' Registration: 169944 P.O.BOX 246 F_tcpira➢ore 06!18!2019 BRIDGEWATER,MA-02324 - Update Address and Return Card. SCAt a 20?s-0snT r�y�yi.c nuam naww4 cPC�(o rr�nx((,- 6ffinfComamrAftahs86ustrtesaRe9alon -_-_ '—`--'-- -_ . HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE Supplement Card before the expiration date. If found return to: Registration. Tmiretloi Office of Consumer Affairs and Business Regulation 169944 08118/2019 Ono Ashburton Place-Suite 1301 • EFFICIENT BUILDINGS 11C - Boston,MA 02108 WILLIAM CALLAHAN 300 ELM ST C� `�`�.� "`�-_ .-/ `'v`.�'C'(Y BRIDGEWATER,MA 02324 Und Not valid without signature ersecretary e t 1 - . �—a— . The Commonwealth of Massachusetts t"_..-=& Department of Industrial Accidents =.iii=:: • _4i1E 1 Boston, 100s Street,Suite MA02114-2017 t,�,s•• 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): E cc•c:-•..4^4- Kv. 1 A.1 s LL c Address: ch 3 As.). ft,,,r^A City/State/Zip:V1-0/a-heau.d l yifA 1214 1 Phone#: (5-001-7 S - ( (i 0 Are you/ as employer?Cheek the appropriate box: Type of project(required):I am a employer with 1 4 employees(MI and/or part-time).* 2..�li7. EI New construction am a sole proprietor or partnership and have no employees working for me in $. 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. ❑Demolition 4.0 1 am a homeowner and will be hiring contractors to conduct all work on my pi warty. 1 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 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance.: 13.❑Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL e. 14. Other 1:4-17v iG 4-7141 h 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 end 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. if Insurance Company Name: EC /bl-S✓✓t..hi CA .LOAI P 4.11 t Policy#or Self-ins.Lic.#: V I'LAC 5''51 511 txpu c ion Date: 3/2-/ 2.G 177 Job Site Address: 57 Cn✓A-17-1 Club Oril&c CitylStatelZip: Cie,rvo✓'lIVLUq OZL6y 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 certify under the pal rndd enalties of perjury that the information provided above is true and correct Si¢nature/ .j1 as"- fit 1' Date: 1 o/,`l/t Phone#: 060275^ ///t) 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#: "its- � ,d. o Permit Authorization .ir mass save Form s.,k.g[1'vewr energy OMency- Site ID: 3447332 Customer. Megan Anthony I, a ( \ v 1\ Ake.- 0 V‘0,,owner of the property located at: (Owner's Name,printed) 52 Country Clu rive --- I South Yarmouth, MA 02664 (Property Street Address) (CnY) 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: / . / EPe. ►-,fiNle Date: ri 3 Semrlease+eetteed+saaaseaetae0*00304$0.ws40a.aeaeekelenese.aeleme Leteas®scoe FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date Name: RISE Engineering Phone: 401-784-3700 Email: For Office Use Only Rev.102015