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Home My WebLink AboutBLD-19-002422 U1"Ygk I Office Use Only **4 So. Permit/ 4. Itoli' 4 C 354. I € Amount -# Permit expires I80 days from issue date 13 �, LLb ` ` EXPRESS BUILDING PERMIT APPLICATIO R j V TOWN OF YARMOUTH C Yarmouth Building Department erg= E 13 1146 Route 28 OCT 22 2018 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 ByUiLDING DEPgRTM ` t� ENT CONSTRUCTION ADDRESS: Ii 0 Ei /e-f,h S'1-- yeir ,^di 1-7-ft" `_��'' ASSESSOR'S INFORMATION: Map: Parcel: OWNER: V e/UN Co. g✓fnfiF4c.. Ho cc.ii eA.. 5i— yec.rw.o.rirt-g44/ )36 D -29(14' NAME Q tt PRESENT ADDRESS i //TEL pp& CONTRACTOR:CNcE'c..u.. J)t ?J: y CLC Q 73 h ant ADDRESS TEL M. eb suoc itis (SOG)tic- in iD - // h'' 3 700. O' by sidential 0 Commercial`�r t, Est.Cost of Construction S VVVHome Improvement Contractor Lie.# i 1 1 ' -i Construction Supervisor Lie.# CS--U 5' • " I Workman's Compensation Insurance: (check one) 0 I am the homeowner/ 0 I am the sole proprietor 41,- / have Worker's Compensation Insurance Insurance Company Name: (. f/4‘c .t/1f`#'a L..r,C t 4 f ti,el Worker's Comp,Policy# ✓ 9 el Lae 5-6,7 2 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 a„„ Old Kings Highway/HistoricisDist. ( )Replacing like for like (� Pool fenci�ng/ [� 'The debris will be disposed of at: �4 R C pir7' I COMt N••I / 7? go/K(1 �s �Q•/ ✓tt in42210 {/1 �^ Location of Facility J 427 / 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 denial or revocaattioonnj�f my lice and for prosecution under M.O.L Ch.268,Section 1. / ry Applicant's Signature: .CAi. /_.6C. Date: / # IO/I/ Owners Signature(or a Went) 4 Q t74.0 .-Cd Date: Approved By: - Date: !o —a.30.—/R uil ing Official(or designee) EMAIL ADDRESS: It Zoning District: C 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 EFFIBUI-01 HWOODS ACO o CERTIFICATE OF LIABILITY INSURANCE °08/3v'""'018 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: 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 NAINTACT Rogers 8 Gray Insurance Agency,Inc. PRONE FAX 434 Rte 134 IND,Miss, Esq: i(AIC,No):(877)816-2156 ADDR South Dennis,MA 02660 Ess,mail@rogersgray.com INSURERISI AFFORDING COVERAGE NAIC a 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 ALL THE TERMS, EXCLUSIONS AND CONDmONS OF SUCH POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POUCYEFF POUCYEXP JR-D MND IMMIDOIYYYY) IMM/DDNYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACHOCCURRENCE $ 1,000,000 CLAIMS-MADE n OCCUR 5D1803119 09/01/2018 09101/2019 pR rM SES ffeENT °xKel $ 500,000 MED EXP(Any one person) S 10,000 PERSONAL IIADV INJURY $ 1.000,000 GENT AGGREGATE pLIRMITAPPLIES PER: GENERAL AGGREGATE $ 2.000,000 POLICY n JE& X LOC PRODUCTS•COMP/OP AGG $ 2,000,000 OTHER' $ A AUTOMOBILE UABIUTY IfEeecadentSINGLE LIMIT $ 1,000,000 ANY AUTO 511803119 09101/2018 09101/2019 BODILY INJURY(Per $ _ — AAUTO�S ONLY X AUUTT.�OWA.TL.�EEDo BODILYppINJURY(Per sodden!) $ X AUTOS ONLY X AUTOONLY (Pa R1Y?AMAGE $ $ A X UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 2,000,000 EXCESS MB CLAIMS-MADE 5J1803119 09101/2018 09/01/2019 AGGREGATE S 2,000,000 DED X RETENTION$ 10,000 $ B WORKERS ND EMPLOYERS LIABILITY X STATUTE ERS V9WC958971 03/02/2018 03/02/2019 EL EACH ACCIDENT $ ANY PROPRIETOR, RIEXECUTIVE500,000 OFFICE �A EXCLUDED? n NIA E.L.DISEASE-EA EMPLOYEE $ 500,000 an at TJFF�j nyee,descme alder 500,000 DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ DESCRIPTOR OF OPERATORS I LOCATORS I VEHICLES(ACORD 101,Additional Remarks Schacht,may be Beached Puma spa Is repand) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Engineering THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN RISE 5 EM Ave g ACCORDANCE WITH THE POLICY PROVISIONS. DuSouth Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE I �_v 7�� ACORD 25(2016/03) ®1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID:D8F3520D3E52-4214-A818382940791740 Page 1 of 1 Customer Name:Veronica Burnette CONTRACT Email:rental02675@gmail.com „,:I I,� Phone:508-360-2448 R Promise Address:110 Eileen Street,Ya mouthp0n.MA 02675 Project emise 3457230 Date:Aug.22,2018 ENGINEERING' RISE Engineering 5 Dupont Avenue,Suite 2 South Yarmouth,MA,02664 Job Description Measure Description Quantity Unit _ T Total Cost Customer Cost'' BASEMENT SILLS:R19 FG BATT 145 SF $317.55 $31.75 AIR SEALING 10 hr $800.00 $0.00 WEATHERSTRIP DOOR&ADD SWEEP 2 each $160.00 $0.00 ATTIC FLAT-10"OPEN R-37 CELLULOSE 1100 SF $1,716.00 $171.61 VENTILATION CHUTES 58 each $202.42 $20.24 VENT BATH FAN THRU ROOF 2 each $237.50 $23.75 ATTIC DAMMING-R-38 FIBERGLASS 90 SF $221.40 $22.14 FINISHED CEILING ACCESS 1 each $135.00 $13.50 Total: $3,789.87 Program Incentive: -$3,506.88 Customer Total: $282.99 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF "`Two Hundred And Eighty-Two And 99/100 Dollars $282.99 UPON RECEIPT OF YOUR RISE ENGINEERING INVOICE,CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL INTEREST OF 1%WILL BE CHARGED MONTHLY ON ANY UNPAID BALANCE AFTER 30 DAYS.SEE REVERSE FOR IMPORTANT INFORMATION ON GUARANTEES,RIGHTS OF RECISION,SCHEDULING,AND CONTRACTOR REGISTRATION. EDoeaSbna4 DO NOT SIGN THIS CONTRACT IF THE I WWLANK SPACES bstiti.J 3CA;„ , auReprebailltitAEaabL RISE Representative Cus oma rm'- 8/31/2018 1 1:00 PM EDT Sign Date NOTE:THIS CONTRACT MAY BE WITHDRAWN BY US IF NOT EXECUTED WITHIN ACCEPTANCE OF CONTRACT-THE ABOVE PRICES,SPECIFICATIONS AND 30 DAYS CONDITIONS ARE SATISFACTORY TO US AND ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED TO DO THE WORK AS SPECIFIED.PAYMENT WILL BE MADE AS OUTLINED ABOVE Commonwealth or Massachusetts ', Construction supervisor .®� Comma wealtesstonssachnsure - Un�mded-Buddingsofany use group which contain • Board of Building Regulations and Standards . . less than 35,000 cubic feet(991 cubic meters)of enclosed Constrt(eti'oa Supervisor Space' CS-095551 .. Expires:0511212020 W911AM CALLAHAN ''• _ .i ;.. 175 aunty SHORE DR r • B91 I - I QUINCYMA 02111 "ter �x,� . t : l� ay ' Fadumtopossessacurrentedtionofthe MassadteUs State Budding Code ius s cause ire revocation of this license. � /+ For Information about this Beals. t_ Commissioner Cit • :-- Call(617)727-3200or visit www•massgov/dpl • • die CelOgR z:oluetea otab/ uur Office of Consumer Affairs and Business Regulation • - - One Ashburton Place-Suite 1301 - - ' - Boston, Massachusetts 02108 • •• Home Improvement Contractor Registration ,. • Type: Supplement Card EFFICIENTBUILDWGS LLC. Registration: 169944 P.O.BOX 246 ExPi2tfore 08/18/2019 • BRIDGEWATER,MA-02324 - - Update Address and Return Card. scat ss n-oscr 3?e�fap nasrolA,.Pc ienscrlrrarin Office MConaumerAftairs$Businesa Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE Supplement Card before The expiration data If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 169944. 08/18/2019 One Ashburton Place-Suite 1301 • EFFICIENT BUILDINGS LLC Boston,MA 02108 / ®Q� ,, W 01JAM CAU.AHAN \2.G ¢-- 63.4itejt��",.dept 300 ELM ST t, BRIOGEWATER,MA 02324 UndersecretaryNot valid without signature 4 a 1 a The Commonwealth of Massachusetts ih. 1t_ / Department oflndustrialAccidents 1 Congress 100 Boston, MA 02114-2017 tt„ www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. ,4aalicant Information Please Print Legibly Name(Business/Organization/Individual): st Address: c 79 kap la City/State/Zip:{1.O6trhnwAR(jvp, 01141 Phone#: 6-0/Z7 S - P I 1 Are you an employer?Cheek the appropriate box: Type of project(required): Lig!am a employer with 1 1 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. ❑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 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.; 1, 6.0 We are a corporation and its officers have exercised their right of exemption per MGL a 14.NOther T�?$,//C/'(Jn 152,11(4),and we have no employees.[No workers'comp.insurance required.] 'Any applicant that checks box MI 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: ('Wi C j '5wc...c* q.eai u Policy#or Self-ins.Lic.#: /.vI wC ysa-E7/ /Expiration Date: 3// Z-/i 5' Job Site Address: 1 10 L• :i e,, .St City/State/Zip:�kr.uifirt 44/Q QZg'7 fJ 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. 1 do hereby certify under the pains . •d penalties of perjury that the information provided above is true and correct Si•nature: _ A . Qilif/fi Date: /OhJ& Phone#: ET& 17r — t 1 / 0 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#: DoeuSgn Envelope ID:D8F3520D-3E52-4214-A818-382940791740 're Permit Authorization mass save Form �eoq rnr ur ncs Site ID: 3448454 Customer: Veronica Bumette —72..3o.n Ater ,ownerofthepropertylocatedat: (Owner's Name,printed) 110 Eileen Street Yarmouthport, MA 02675 (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 and/or weatherization work on my property. nocusinea b,: Th Owner's Signature: C�1SeIn 7 .rnet rnngwcn Date: 8/31/2018 I 1:00 PM EDT 4'. n1 uonv,v t-cs ,6' fit sq.A'n r . ,.. a m.:;w`Fa e^ . t.„t r ^ > >.?i^... FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: 11r LSC F/r/ /it Participating Contractor Date Name: RISE Engineering Phone: 401-784-3700 Email: For Office Use Only Rev.102015