HomeMy WebLinkAboutBLD-19-2983 0
1"Y 3 Office Use Only
.� .'
ONi .' 3Amowt I'
,
��'"•1O N` Permit expires 180 days from f
--�•;:::.. • tissue date
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH .
Yarmouth Building Department
1146 Route 28
South Yarmouth,MA 02664
(508)1398-2231
Ext. 1261
CONSTRUCTION ADDRESS: , 3 I PIej&ani- St S. t/G.rnrio. ,l% V'\ OZ 6 `I
ASSESSOR'S INFORMATION:
Map: 57 Parcel: 3Z
OWNER: 14t0•••131/43.1 o per 13 ) pi etSi- 514 rr.o4', rua 61.4111 177:1)35-7- GZ1�'
NAME PRESENT ADSS I TEL
CONTRACTOR. 6 c-F-rc;4M- 13v:IP Pts 113 Atte' ICI 4.06,,,,1oA11
HAA 0277 61)02 '1
751lO
1.1stME MAILING Oikgsidential 0 Commercial Est.Cost of Construction S /OOO t
Home Improvement Contractor Lie.i. .1 to 55 Y y Construction Supervisor Lie.# C.S.— O 7 Q 5-51
I
Workman's Compensation Insurance: (check one)
❑ I am the homeowner 0 I am the sole proprietor Shave Worker's Compensation Insurance 4
Insurance Company Name: F VIA( 7...,174.1 ,.ftWy Worker's Comp.Policy# V9 LAX 9 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 pc
Old Kings Highway/Historic� Dist. ( )Replacing like for like/ .Pool/� fencing
*The debris will be disposed of at A ` 01 CP)/4 I AG 6e(/ 4tQ `�l t 140
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. I understand that any false answer(s)
will be just cause for denial or revocatio of my limn��''}p^�d for@�sy�ution under M.(3 1..Ch.268,Section 1.
Applicant's Signature:blase/ tom.. ( __ GGL L/-� Date: /i/ 7//f
Owners Signature(or chment) r Q, 4j 4Date:
Approved By: Date: //•' may--/CC
uilding Official(or designee) EMAIL ADDRESS:
Zoning District: /�n 1
Historical District: 0 Yes 0 No Flood Plain Zone: ❑ Yes ❑ No y�ti l�.Y`� ;"
L C as
Water Resource Protection District: Within 100 ft.of Wetlands: I . LI DING O,-F�a1iTt. eiT
❑ Yes ❑ No ❑ Yes 0 No
• - Lv r3
BUILDIN .' i ,-
i-,
BY:-
%— EFFIBUI-01 HWOODS
ACORn CERTIFICATE OF LIABILITY INSURANCE 08//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 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 polirypes)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 CICO per
Rogers 8 Gray Insurance Agency,Inc PHONNEPAX
434 Rte 134 INC.No,Eat): I(A/c,No):(877)816-2156
South Dennis,MA 02660 =tbs.mail@rogersgray.com
I)
INSURER:SI AFFORDING COVERAGE - HAIG V •
INSURER A:Employers Mutual Casualty Company 21415
INSURED INSURER a:National Liability&Fire Insurance Company 20052
Efficient Buildings LLC INSURER C: -
POBox 248 INSURER D:
ry. % Bridgewater,MA 02324
INSURER E:
INSURER P:
COVERAGE CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE USTED 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 TOALLTHE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ITR TYPE OF INSURANCE DAD MT POLICY NUMBER POLICYEFF PO[.IC'IEr LIMITS
A X COMMERCIALGENERALLMBILnY - Mmwnmm IMMIDDM/YYI 1,000,000
EACH OCCURRENCE 3
I CWMSMAOE a OCCUR SD1803119 09/01/2018 09101/2019 psas TO RENTED 500,000
PREMI$);1 fEeomrtemRt E
, MED EXP(Any one Demon) 5 10,000
PERSONAL 3 ADV INJURY 3 1,000,000
—
r=EWLAGGR ATE ye El
PER: GENERAL AGGREGATE _,S 2,000,000
Poi.cr X JECT a LOC PRODUCTS-COMP/OPAGO 3 2,000,000
OTHER' - S
COMBINED SINGLE UNIT
A AUTOMOBILE wimpy, (Fa Imm a $ 1,000,000
_ ANY AUTO _ 5Z1803119 09/01/2018 09/0112019 BOCILYINJJRY Tor person) $
_ AU EOEOpS ONLY X A ��SWANEEOU FBODILY INJURY(Per acadenl) 5
X A�RTOS ONLY X AUTO OS ONLY (Perameryem) GE $
$
A X UMBRELLA WIe 1.21 OCCUR EACH OCCURRENCE _ $ 2,000,000
EXCESS LIAR CLAMS-MADE 5.11803119 09/01/2018 09101/2019 AGGREGATE $ 2,000,000
DED I X RETENTIONS 10,000 E
B WORKERS COMPENSATION X I PESERTLTIE I I FR
ANDD EMPLOYERS'LABILITY V9WC958971 03/0212018 0310212019 500,000
ANY PROPRIETOR/PARTNERIEXECUTNE 0 EI EACH ACtlOENT 3
DFFICER/MF,M9.�T E[CWDErn N/A
en aory nn) EL DISEASE-EA EMPLOYEES 500,000
s
2ICIPT1ON OFOPERATIONS beim - EL d$EASE-POLICY LIMIT E 500,000
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 1a1,Additional Ramada SeIaNINN,maybe beaded Nmon span Is n quinti)
•
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
RISE En lneerin THE EXPIRATION DATE THEREOF% NOTICE WILL BE DELIVERED IN
9 g ACCORDANCE WITH THE POLICY PROVISIONS.
5 Dupont Ave •
South Yarmouth,MA 02664
AUTHORED REPRESENTATIVE7
ACORD 25(2016103) 01988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
•
•
Page 1 of I
Customer Name:Ilmberly A Cooper CONTRACT
EmaB:kymtooper@comcest.net
C C\tt tile/
f/ Phone:774-353-8238
Premise
Date:t ID 346012.5
gAddress: 31 Pleasant Street,South Yarmouth,MA 02684
Aug
ENGINEERING-
RISE
NGINEERINGRISE Engineering
S Dupont Avenue,Suite 2
South Yarmouth,MA,02664
Applicable Customer Required Actions: Notes:
• Storage Removal Homeowner to remove the items in the crawl space
blocking the installation of weatherization work to the
crawl space walls.Removal must occur prior to
scheduled day of work.
.Inh Oocrriptlnn
Measure Description . Quantity Unit . Total Cost Customer Cost
WEATHERSTRIP DOOR&ADD SWEEP 2 each $160.00 $0.00
CRAWLSPACE WALL RIO RIGID BOARD 233 SF $943.65 $235.91
DUCT INSULATION 156 SF $624.00 $156.00
INSULATE BULKHEAD DOOR 2 each $220.00 $55.00
REMOVE EXISTING INSULATION-CRAWLSPACE 56 SF $54.32 $54.32
Total: $2,001.97
Program Incentive: -$1,500.74
Customer Total: $501.23
WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF
'Five Hundred And One And 23/100 Dollars $501.23
UPON RECEIPT OF YOUR RISE ENGINEERING INVOICE,CUSTOMER AGREES TO REMIT AMOUNT DUE IN FURL 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.
DO NOT SIGN THIS CONTRACT IF THERE ARE
ANY BLANK SPACES
RISE Representative Customergignature
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
EtEllvE
SEP 172013 0
•
•
! - Co •
mmonwealth of Massachusetts • �'
• . . - Division of Proressionai Ucensure - UreStritYed-Buldi X01 group which comate •.
Board of Building Regulatons and Standards iris than 35,000 cubic feet(991 cubic meters)of enclosed
• i Consirt tgti Supervisor : spate.
CS39ss81 Expires:0512/2020
WILLIAM CAaAHArJ•._'
1f5QUINCYSPOREDR-,' r -
r • BB/
r. - � ` §p.
QUINCYMA 02131 "'b:;
_<;;: -�`; ,ya - A
SI tabs�topossessaumenteditionoftheMassadmsefts '
Building Coders cause Mrrevocation of fhb license.
For information about this&eesa
Cotnrtssione•r Can(BIT)7273200 orvisitwww.mass govidpi
•
A
Office of Consumer Affairs and Business Regulation
• - One Ashburton Place-Suite 1301
- - • • Boston, Massachusetts 02108
Home Improvement Contractor Regish cation a
•
Type Supplement Card
EFFICIENTBUILDINGS LLC' - Registration: 169944
P.O.BOX 246 Expiration: 08/18/2019
BRIDGEWATER,MA.02324
•
Update Address and Return Card.
son a ,xiag`1r'
-7t Cnurswnnrnnv4i cfC�� rcPlf '
Rice of Consumerpttaas3 ttuslnene negulanon
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE Supplement Card benne the expiration date. Ifound return to:
Registration f3mtmdon Office of CbnsumerAffairs and Business Regulation
169944 08/1812D19 One Ashburton Place-Suite 1301
EFFICIENT BUILDINGS LLC Boston,MA 02108 '
•
W ILUAM CALLAHAN
300 ELM ST -�� ^' - --r aims,
BRIDGEWATER,MA 02324Undersecretary - Not valid without signature
•s
The Commonwealth of Massachusetts
v"i I Department of Industrial Accidents
_iEin_ v 1 Congress Street,Suite 100
Boston,MA 02114-2017
"leisM1 www mass.gov/dia
no
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):Efficient Buildings, LLC
Address:973 Reed Road
City/State/Zip:N. Dartmouth, MA 02747 Phone#:(508)279-1110
Are you an employer?Check the appropriate box: Type of project(required):
LQ 1 am a employer with 16 employees(full and/or pan-time).• 7. ❑New construction
2.0 1 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.]: 9. El Demolition
10 Building addition
4.0 l am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 1 I.❑Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
50 1 am a general contractor and Ihave hired the sub-contractors listed on the attached sheet.
13.0Roof 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 MOL c.
14.['Other insulation
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
'Any applicant that checks box NI must also fill out the section below showing their workers'compensation policy information.
1 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 andJob site
information.
Insurance Company Name:EMC Insurance Company
Policy#or Self-ins.Lic.#:V9WC958971 Expiration Date:03/02/2019
Job Site Address: 131 Pleasant Street City/State/Zip:S.Yarmouth, MA 02664
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 ins and penal ies f erj ry that the information provided above is true and correct.
Signature: �i ��(/ !.^'" !!/S��J`\ Date: ///7 hr
Phone (5° )8 279-1110
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#:
I
Permit Authorization
HT1 1 -
mass save Form
4M.:nxg'4UCm�Wnr:nitN•"r*ny
Site ID: 3455227 Customer: Kimberly A Cooper
I• k1 tM L✓I k// Ct?per ,owner of the property located at:
(Owne+'s Name,printed)
131 Pleasant Street South Yarmouth, 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 and/or weatherization
work on my property.
Owner's Signature:
Date:
02//K
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
L '/'Ue-tA .6vt M/� �c q/f Z //0
Participating ContracWr Date
Name: RISE Engineering
Phone: 401-784-3700
Email: •
For Office Use Only
Rev.102015