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Home My WebLink AboutBLD-19-002981 • • - "ice Use Onlyr- oF'YAR• 1 G ' -r7 5a 1 /i€ cC 0 Amount @ t.Y Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 1 (508)1398-2231 Ext. 1261 ��A CONSTRUCTION ADDRESS: to CtF lit4jr00L 1.1 W.'f AfM0✓'f{.t MIS 62 b 2 3 ASSESSOR'S INFORMATION: �1 ,,•• L Map: / p� Parcel: (24, a(oy OWNER:Ckn$Tlak e&fflfk I 0c/di-you'.JJ tAt Ikfis•t'�h A0i.73 (�1)3t a -YG 5— NAME PRESENT ADDRESS i TEL. P CONTRACTOR:E.(61:64+ BJ;1ai�f 913 Lel li Ss)4thnthl1YIA 27Y7 (sys)z79-I11 A NAME sidential 0 Commercial Est Cost of Construction$ J q / 60 —_-- Home Improvement Contractor Lie.# 1 I I j 1/ Construction Supervisor Lie.# t2 S 05-157E I Workman's Compensation Insurance: (check one) 0 I ant the homeowner 0 I ant the sole proprietor fi(nn• A have Worker's Compensation Insurance 7�j r 7 j n Insurance Company Name: L W'L Zhtt,/GnCe 1 lxi{ Policy,' V /Worker's Comp.PolicybiC '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. (n ))(Replacing like for /like C Pool fencing *The debris will be disposed of at: A /3C P/y� L1-I YUt' 11i 4 , mA Location of Facility 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 revocation of my license for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: �( j�a� LL'�....�. Date: 11/7 Per Owners Signature(or hment) QS L.'�Gaf/ Date: • Approved By: Date: Y7.- /7,,, ilding Official(or desi EMAIL ADDRESS: S Zoning District: E -, , %E VFD Historical District: ❑ Yes 0 No Flood Plain Zone: ❑ Yes ❑ N lU1rt 10p Water Resource Protection District: Within 100 ft.of Wetlands: ` 13 20 lU ❑ Yes ❑ No ❑ Yes 0 No -- BU1L;-;:'iu DEPARTMENT • /'" EFFIBUI-01 HWOODS A`ORn 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 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 poiicy(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 suchppe■llndorsement(s). PRODUCER NAMEACT Rogers&Gray Insurance Agency,Inc. PHONE Fps( adgRte 134 IC,Ho,Eat): I(AID.Ne):(13n)816-2156 South Dennis,MA 02660 f^Al .mai l©rogersgray.com •. id MSURERISI AFFORDING COVERAQE NAILS • INSURER A:Employers Mutual Casualty Company 21415 . INSURED INSURER a:National Liability&Fire Insurance Company 20052 Efficient Buildings LLC INSURER C: PO Box 248 INSURER 0: Bridgewater,MA 02324 INSURER E: • INSURER P: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POUCIES 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN ISSUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDmONS OF SUCH POLICIES.OMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY ER; POLICY EX? LIMITS A X COMMERCIAL GENERAL LIABILITY mMIDO1YYYY1 RAWDDM/YY1 1,000,000 I� EACH OCCURRENCE 5 curds-woe l I OCCUR 5D1803119 09/01/2018 09/01/2019 PREMISESlFeDAMAGETORENTEommeOnSa) S 500,000 . — MED EXP(Any me person) 5 10,000 — PERSONAL aAwmJI/RY S 1,000,000 GEM.AGGR ATE pURM�IT,APPUS PER GENERAL AGGREGATE S 2,000,000 IPOLICY JECT Q LDC PRODUCTS-GOMP/OPAGO S 2.000,000 OTHER • 5 A AUTOMOBILE LIABILITY /Ea ac SINGLE LAM' S 1,000,000, _ ANY AUTO _ 521803119 09101/2018 09/012019 Boniv INJURY(Per wean) S OWNED SCHEDULED AUTOS • �EpONLY X �AUUTTOgSWN�p BODILY INJURY(Peraccident/ S X AUTOS ONLY X BOMB P��°amdgTe,U GE S S A X UMBRELLA LIAR X OCCUR EACH OCCURRENCE s 2,000,000 EXCESS LIAR CUUMS4MDE 531803119 09/01/2018 09/01/2019 AGGREGATE 5 2,000,000 DEO I X I RETENTIONS 10,000 $ B WORKERS COMPENSATION X I PER I IFR AND EMPLOYERS'LIABILITY ANYApNpPROPRIETOEEpBpRARTNER/ERECUTNE YQ V9WC958971 03/02/2018 03102/2019 EL EACH ACOOENT 5 500,000 Irnn°aaLoryFlornl R�°D x/w EL DISEASE-FA EMPLOYEE S 500.000 IDESCRIIPTTi N OF OPERATIONS below EL.DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS/LOCATORS I VEHICLES(ACORD 101,AddMenY Rameda Schedule,may be altaeMd!mere apses Is nydred) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE RISE En ineerin THE EXPIRATION DATE MEMOS{ NOTICE WILT. BE BE DELIVERED IN 9 g ACCORDANCE WITH THE POLICY PROVISIONS. 5 Dupont Ave South Yarmouth,MA 02664 AUTHORED REPRESENTATIVE ~/fjf ACORD 25(2016/03) ®1986-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD a Page 1 oft. Customer Name:Christina Perera CONTRACT..' Email:takota1970@outicok.com ` Phone:508.3604685 - R ■.\ .11f.r Premise Address:48 Clearbrook Road,West Yarmouth,MA 02673 Pro■ \I s ` +', Date:Sept.12,ct ID:3554169 2018 ENGINEERING', RISEEnglneering 3 Dupont Avenue,Sulfa 2 - -- South Yarmouth,MA,02664 " Job Description 4 'Measure Description:, ., :.ouantity 'f:Un8' _ `:Total Cost -_' Customer Cost ti -1 WEATHERSTRIP DOOR&ADD SWEEP 1 each $80.00 $0.00 PULL-DOWN STAIR:THERMADOME,BUILT-UP 1 each $237.65 $59.41 , AIR SEALING 10 hr $800.00 - $0,00 . ATTIC FLAT-8"OPEN R-30 CELLULOSE 788 SF $1,134.72 $283.68 ATTIC DAMMING-R-38 FIBERGLASS - -68 SF $167.28 $41.82 VENTILATION CHUTES 42 each $146.58 - $36.64 4"6 16"SOFFIT VENTS 12 each $346.92 $86.73 VENT FUTURE BATH FAN TO ROOF 1 each $11835 $29.69 INSULATE BULKHEAD DOOR 1 each - $110.00. $27.50 Total: $3,141.90 Program Incentive: -$2,576.43 - - - Customer Total: $565.47. WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF ***Five Hundred And Sixty-Five And 471100 Dollars $565.47 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 REGISTRATTIION. - ,. DO NOT SIGN THIS CONTRACT IF THERE ARE NY BUINKSPACES RISE Representative Customer Signature 97 A, 9./a/a' Sign Date NOTE:THIS CONTRACT MAY BE WITHDRAWN BY US IF NOT EXECUTED WITHIN ACCEPTANCE OF CONTRACT-THE ABOVE PRICES,SPECIFICATIONS AND 30 DAYS OONOmONS ARE SATISFACTORY TO US AND ME HEREBY ACCIt•1 eu.YOU ARE AUTHORIZED TO DO THE WORK AS SPECIFIED,PAYMENT WALL BE MADE AS OUTLINED ABOVE DEC EOMCE --i\ SEP 1 7 2013 J CoMrionwealth of Massachusetts - .' Coen Supervisor • U. DtvislonafProtessfortallieensurs _ Unnt.Buldhlgsofany use group which contain Board of Building Regulations end Standards I space.Tess than 35,000 cubic feet(991 cable meters)of enclosed - • I Constntgri Sifpervisor • • • CS-095581 _ Expires:05/12/2020 num CAl2AHAN-: == S4.,_t, its QUWCYSHOREDR . i ( - t . B81 :-. 4 I QUINCY MA 02171. 1,- f �: . ;r--�:=� #'=` • Failure to possess a current edlifon ofthe Massachusetts • • . .. State Building Code is cause for revocation of this license • /+ � y� For information about this license 'Comm[ssioner l u... _._. ` `. Call(617)727-32o0 or visit www,massgovidp_1 Office • • of Consumer Affairs and Business Regulation . --yr-- ; ., One Ashburton Place-Suite 1301 • • Boston, Massachusetts 02108 • •• Home Improvement Contractor Regisbation s • • Type: Supplement Card EFFICIENTBUILDWGSLLC - - Registration: 169944 • P.O.BOX 246 Expiratiorc 08/18/2019 BRIDGEWATER,MA.02324 • • Update Address and Return Card. scar a 2or.asir �itnmmnvo+ro�llcl(oac�t�unA: -..._.____ .—__�__ • office Consumer Arra S-&Business Regulation HOME IMPROVEMENT CONTRACTOR Registrationvalidfor Individual ime only TYPE Sul:anent Cord before the expiration data. If found return to Registration 6miratior Office of ConswnerAifairs and Business Regulation 169944 08/182019 One Ashburton Place-Suite 1301 _ EFFICIENT BUILDINGS LLC Boston,MA 02108 WIWAMCALLAFIAN - �p�,{L,i_ 300 ELM Sr a—""� BRIDGEWATER,MA 02324 UndersecretaryNot Valid without signature a • $ • _ • • e • The Commonwealth of Massachusetts Ia �_ el Department oflndustrialAccidents • =141= 1 Congress Street,Suite 100 e = �_1 � Boston,MA 02114-2017 ?t'-t, .44 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):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): I.Q I am a employer with 16 employees(full and/or pan-time).• 7. 0 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 p I am a homeowner doing all work myself.[No workers'comp.insurance required.]: 9. ❑Demolition 10❑Building addition 4.❑I 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 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions SEI I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑� Other Insulation 152,§I(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 am 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. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:EMC Insurance Company Policy#or Self-ins.Lic.#:V9WC958971 Expiration Date:03/02/2019 Job Site Address:48 Clearbrook Road City/State/Zip:WYarmouth, MA 02673 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 pains and penalties of perjury that the information provided above is true and correct �. / Signature: 1/_-. j44L— Date: /1 /7//f' Phone#:(508)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#: • ° ,� Permit Authorization *Sri r mass save Form •:..pro rs+x:,ri rr r+:minty Site ID: 3454651 Customer Christina Pereira I, 'L (iw1 s-Lgra_ ref-e:,{0— ,owner of the property located at: (Owner's Name,printed) 48 Clearbrook Road West Yarmouth, MA 02673 (Property Street Address) (CRY) 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. ` ��Jj Owner's Signature: �(?0,A, (/C. Date: C q/,7 / i g,t p,r,r✓c.-?ay i . -nM �! .iaa r _. .,a.@C . .+"Y ?=B C-`;v FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: EF6Uui- hw'414-1s GLC 94a47 Participating Contractor Date Name: RISE Engineering Phone: 401-784-3700 Email: For Office Use Only Rev.102015