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HomeMy WebLinkAboutBLD-1-002755 Dt,,�.AR Office Use Only �O 3 Permit# i 0 t Amount 35— Y 4. `\e.4*'^"1O3`s '. - Permit expires 180 days from 4 �. :::.. �issue date atLi- lG-C( -i&5 RECEIVED EXPRESS BUILDING PERMIT APPLICATI 4 TOWN OF YARMOUTH NOV 05 2018 I Yarmouth Building Department 1146 Route 28 BulLttt�gfl3*9FNT South Yarmouth,MA 02664 BY: _�j1�� / -- (508)398-22312Ext. 1261 CONSTRUCTION ADDRESS: I U lC.& Af_at%,Se 4+ C'rcic ye.rn.o. roeI- )4419 02.6-2 2. ASSESSOR'S INFORMATION: Map: Parcel: OWNER: IL&I1.1ten C /DogAtr I0 Ktv.rx.-4e# G;rc.k 1arwu✓d,F CSLI,LSI- F3`1b NAME(' PRESENT p ADDRESSTEL. l 1.� �/ p TEL # CONTRACTOR: t r¢1'U t,.*+ L l d1"�' LLC 97? Sp nC I ht m 14i'i 60117 (r(m)z7 r-1 I I 0 NAME NI MAILING ADDRESS TEL.# Mesidential ❑Commerrtial [ EA.Cost of Construction S r 13 6 V e" Home Improvement Contractor Lie.# / Y 15' 7 i Construction Supervisor Lie.# CS - Oct J O Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor be..Thave Worker's Compensation Insurance Insurance Company Name:P.MC 'ft„S✓rc.v. (,t. Cowl/fr.-LT Worker's Camp.Policy# V7 VC9SPf7I 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 /x Old Kings Highway/HistoricicDist.(�( )Replacing like for like /� / Pool fencing �• *The debris will be disposed of at: /• l�c 0)S edit l {�Q,w Rett /+tel v e edit of Facility I 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 deni or revoc of my li ��a11n+f prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: j. d a-- Date: t/ /i /i et Owners Signature(or attachment) t S -e 4 LI'A-4 di - Date: Approved By: h-ell Date: //".-5---/g B ' mg ictal or designee) E ADDRESS: Zoning District: Historical District: ❑ Yes 0 No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No • /..="1 EFFIBUI-01 HWOODS A O CERTIFICATE OF LIABILITY INSURANCE 0112 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 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 endonsement(s). PRODUCER C�INTACT N ME: Rogers&Gray Insurance Agency,Inc. PHONE FAX 434 Rte 174 a� (MC,xek(671J 816-2156 South Dennis,MA 02660 .mail@rogersgray.com - . i INSUREMSI AFFORDING COVERAGE NAACP • INSURER A:Employers Mutual Casualty Company 21415 INSURED INSURERB:National Liability&Fireinsurance Company 20052 - - Efficient Buildings LW INSURER Cr PO Box 246 INSURER O: Bridgewater,MA 02324 INSURER!: 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 POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. jITR TYPE OF INSURANCE ADDL.MVO POLICY NUMBER PODGY POLICY EXP UNITS A X COMMERCIAL GENERALLIA®LLTY - EACH OCCURRENCE _S 1,000,000 CLAIMS-MADE n OCCUR 5D1803119 09/01/2018 09101/2019 pRMi SEFS atEam erKe1 $ 500,000 MED EXP(Am one Pelson) 3 10,0110 PERSONAL II ADV INJURY $ 1,000,000 — SNL AGGREGATE ppLIMIT.APPLIES PER: GENERAL AGGREGATE I 2,000,000 Mi POLICY�X JEOT a LOC PRODUCTS-C)MPIOPACT 3 2,000.000 OTHER 3 A AUTOMOBILE LIABILITYCOMBBIIde SINGLE LIMIT 3 1,000,000 — lEa ANY AUTO- _ 521803119 09/01/2018 09/012019 ROPILY INJURY(Per person) S — AUTOS ONLY X SCHEOIAEEDD pBRODILY�INJJRpYM((Per aaident) 3 X ATOS ONLY X VATS 1PxDPEamaeM) AGE 3 _ S A X UMBRELLA WB H OCCUR EACH OCCURRENCE _ S 2.000,000 EXCESBWN CLAMS-MADE 5.11803119 09/01/2018 09/012019 AGGREGATE S 2,000,000 DEO X I RETENTIONS 10,000 S B AND EMPLOYERS COMPENSATOR X STATVIE I I ER ANY PROPRIETORNARTNERIEXECUTIVE V9WC958971 031022018 03/01/2019 EL EACH AOODENT 3 500,000 QFFICEo i EXCLUDED? II�(ManOaINH) EL DISEASE-EA EMPLOYEE S 500,000 rues.deaate under r smogSCRIPTION OF OPERATIONS below E,.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATORS I LOCATIONS/VENICLES fACORD 101,AddNenai Remarks Sehmluh,may be attached I/mare apses h nqulnd) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE RISE Engineers THE SERRATION DATE T EREOK NOTICE WILL BE DELR/ERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 5 Dupont Ave South Yarmouth,MA 02664 AUTHORUED REPRESENTAIV7EE.[/�J�A. ACORD 25(2016/03) 01988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD i Page l oft Customer Nemo:Kathleen Cioulher CONTRACT Emelt:katydouther@gmall.tom {�'{ Phone:561-261-6348 Premise Address:10 Kencomsetl Grcle,Yarmouthpml,MA 02672 RISE ' SE Project At I .9,3449608 Date: ugg.9, ENGINEERING' • RISE Englnearing S Dupont Avenue,Suite 2 South Yarmouth,MA,02664 Job Description Measure Description Quantity , e,... ::UnB ..,. ° .:i;.. , ,,:rTotalCost Customer Cost INSULATE BULKHEAD DOOR 1 each $110.00 $27.50 AIR SEALING 12 hr $960.00 $0.00 WEATHERSTRIP DOOR&ADD SWEEP 2 each $160.00 $0.00 ATTIC FLAT-10'OPEN R-37 CELLULOSE 1350 SF $2,106.00 $526.50 VENTILATION CHUTES 72 each $251.28 $62.82 ATTIC DAMMING-R-38 FIBERGLASS 170 SF $41820 $104.55 VENT BATH FAN THRU ROOF 1 each $118.75 $29.69 ex 16'SOFFIT VENTS 4 each $115.64 $28.91 8'x 16-SOFFIT VENTS 4 each $115.64 $28.91 Total: $4,355.51 Program Incentive: -$3,546.63 Customer Total: $808.88 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF "'Eight Hundred And Eight And 881100 Dollars $808.88 UPON RECEIPT OF YOUR RISE ENGINEERING INVOICE.CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL INTEREST OF 1 TWILL BE CHARGED MONTHLY ON ANY UNPAID BALANCE AFTER 30 DAYS.SEE REVERSE FOR IMPORTANT INFORMATION ON GUARANTEES,RIGHTS OF RECISION,SCHEDULING,MID CONTRACTOR REGISTRATION. DO NOT SIGN THIS CONTRACT IF ERE ARE ANY BLANK SPACES RISE Representative Custoomee Sign lune } 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 illE© LEAVE \ SEII 1 0 2018 4 • • ----- t Co[mnonweatthofMassachusetts • \ ConstructionSUAe+irisor • •• v Division of Professional licensor° • - - Undued-Buubim�sota91cbicmetphigfw�a • Board of Building Regulations and Standards Iessthan 50,000 cubic feet(991 cudric/meters)of enclosed • tJ Con3trtftgi Supervisor I space. • I CS-095581 Expfret:0511212020 WILLIAM CALLAHAN•.:"•2; i 1T9 pUWCt 5HO1RE DR' "' "1_ ; . e I • 881 i. - c` :�f 1 QUINCY MA 027f1; y ^"" . • -,:c.--•::-....••-•, r;,,n Falluretopossessacurrent ed8fon°RhoMassaehuseOs . ` :- - State Building Code iscause far revocation ofthis license. C29.4°... �2 For infontreHon about!Ms license 'comnitsstaner ` L.4.` ;` Ca➢(01T)72T320DarWsjtwxtivmassgov/dpt • • • Office of Consumer Affairs and Business Regulation • •• - One Ashburton Place-Suite 1301 - _•. • • • Boston, Massachusetts 02108 • • Home improvement Contractor Registialion a ti - type Supplement Card EFFlCIENTBUODWGSLLC • - Regishation 169944 P.O.BOX 246 _ Expifation 08/18/2019 BRIDGEWATER,MA-02324 • Update Address and Return Card. SCAT 0 70.1;1R g� narmnnmm�/l c(�`llo..rr.�tcrA: of8a of ConsumerAffairsa Brats=Regulation HOME IMPROVEMENT CONTRACTOR Registration valid forindlVIduat use only TYPE:Suoplernalt C6rd before the expiration date. !Mend return to: Registration Exo refon Office of Cbnswmerp fairs and Business Regulation 169944 08/18/2019 One Ashburton Place-Suite 1301 • EFFICIENT BUILDINGS LLC Roston. MA 02108 / ®Q• 300 ELMVVILLIAM C 2te-- BRIDGEWATER,MA 02324 Not valid without signature . Undersecretary • •• ` i • y The Commonwealth of Massachusetts '� _c!/ Department oflndustrialAccidents _`TI�_ 1 1 100 ti Congress Street,Suite Boston,MA 02119-2017 ItikarLit www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information rf A. Please Print Legibly E }-A Name(Business/Organization/Individual): CI(A-I- 8,1;1 et;/,rcc c Address: C) ) 3 f .e k ne City/State/Zip: Vl, Q,rht.0JK.l yv141 62 41 Phone#: (T(*)2 1 5 - 1110 Are you an employer?Check therappropriate box: Type of project(required): I o19m a employer with ) ) employees(full and/or part-time).* 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required,] 3. I am a homeowner doingall work elft 9. El Demolition ❑ myself[No workers'comp.insurance required.) 4.0 l am a homeowner and will be hiring contractors to conduct all work on my property. I will 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.❑Plumbing repairs or additions 5.0 1 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; 6.0 We are a corporation and its officers have exercised their right of exemption per MGL a 14aOtllei 7 S f/!L' U^ 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: £MC. vyf.r d,..02- (0,4470A-1[^ • Policy#or Self-ins.Lic.#: V el W C. ' 61 S7 J Expiration Date: 3 / Z 71 4 Job Site Address:/6 ILthe0,4 .St'-4- Cie t_iG City/State/Zip:1/4.1.r.oJ9-1Pail', I4444 02672 Attach a copy of the workers'compensation policy declaration page(showing the policy number and exjliration 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 andel nettles of perjury that the information provided above is trueandcorrect �L Signature: i -- GJ�/�/�✓pe Date: /f /j//O Phone#: ( p) 271 -1 1/D 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#: 1� Permit Authorization el re mass save Form 54bas+tsmrow;es entry, cr.-y Site ID:3444648 Customer: Kathleen Clouther • 0,+11cel jij ,owner of the property located at: (Owner's Name,primed) 10 Kencomsett Circle Yarmouthport, MA 02672 (Property Street Address) (nty) 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: ,C atm ,e.Ltti� (U/�t t ' J Date: 1 / /W I ( FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: 6ch.c.<,,.fr f IJ, s 2/C 9/c/iy Participating Contractor Date Name: RISE Engineering Phone: 401-784-3700 Email: For Office Use Only Rev.102015