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HomeMy WebLinkAboutBLD-19-003204 Office Use Only j : °EYq�o RECEIVED ;P C �t�D- 19-0� •o� o Amount— V N4 TT. y , NOV 26 2018 +..+o �. pPenult expires 180 days from .. ..:::. Tissue date DEPARTME6Z) By: --- EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508) 398-2231�� Ext. 1261 , �q CONSTRUCTION ADDRESS: Lir -iSlet. ci M GI. ///ofp-..J //�N7Y -62 &73 IN ASSESSOR'S FORMATION: 1, T Map: /'5 Parcel: 2y OWNER: nvesa R(nn lg 7-5164 ilA IP.y/ ritao IAA 07(al (1l7S)317- 1117 NAME PRESENT ADDRESS TEL. N CONTRACTOR:Fi'f't'c.t..i• jiplaint t& f'I312P A U 1'1 difr,hougt tzJV7 (51027c—lfeb ; NAME MAILING ADDRESS TEL N A&sidential 0 Commercial Est.Cost of Construction S 12.0t�Ti'!Home Improvement Contractor Lia tt i' (o / f'] Construction Supervisor Lie. 9 If CS - U p / Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor [codhave Worker's Compensation Insurance Insurance Company Name: EA,/C.. Zhs viu..rr $f/it(}f Worker's Comp.Policy# ✓41/.t/G93-(F 97/ 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 [t • Old Kings Highway/Historic Dist. ( )Replacing like for like J /�� Pool fencing 'The debris will be disposed of at: A(6C ,JIJQOJS1 UN &€I/it "/ 4Ylt Y 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 rev. ation of my licen d for pro ecution under M.G.L.Ch.268,Section I. J p, Applicant's Signature: t .� Date: I/II G/IO Owners Signature( attachmen Date: Approved By: E ADD Date: /I /� Building td or designee)) E ADDRESS: Zoning District: Historical District: ❑ Yes 0 No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No • 22.........„,„ EFFIBUI-131 MOODS AC R® CERTIFICATE OF LIABILITY INSURANCE 08/31" /2 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 WINE 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 CONVICT Rogers&Gray Insurance Agency,Inc. PHONEFAX 434 Rte 134 INC,Notes* I(Arc,Nog877)818-2156 South Dennis,MA 02660 $DorzxEw mail©rogersgray.com iii INSURER(SI AFFORDING COVERAGE I NAICC INSURER A:Employers Mutual Casualty Company 21415 INSURED INSURER a:National Liability&Fire Insurance Company 20052 Efficient Buildings LLC INSURER c: _ PO Box 246 - INSURERD: Bridgewater,MA 02324 msunERE • INSURER P: - 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 POUCY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POUCIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUER POLICY EFP POLICY EXP LTR TYPE OF INSURANCE INV, WVD POLICY NUMBER IMMIDDIYYYYI IAMIDDIYYYYI UMTT5 A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 5 1,000,000 CWMSJAADE �X OCCUR 5/31803119 09/01/2018 09/01/2019 PDREMISFS FLV„Dena,1 $ 500,000 . ._ m MED EXP/Am 5 10,000 PERSONAL S AWIR INAY 5 1,000,000 — 0 ItAGGREGATE UNIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY®SECT ID LOC - PRODUCTS-COMPIOPAGG S 2,000,000 % OTHER S A AUTOMOBILELIASLLRY rFaaMaccidentl DSINGLELIMR $ 1,000,000 _ ANY AUTO 521803119 09/012018 09101/2019 BODILY cam(pea seism) s • AaX SCHOED AUTOS BODILY INJURY(Per accident) s X �AUTOONLY X A G® pQmEDpAGE s —S A X UMBRELLA UAB tC1 X OCCUR EACH O7RRENCE 5 2,000,000 EXCESS LIAR CWMS4IADE 5.11803119 09/01/2018 09101)2019 AGGREGATE S 2,000,000 DEO X RETENTIONS 10,000 AER S B WORKERS NO EMPLCOMPENSATOR Y M.RS LISABILTIONITY X I STATUTE I I ER AAp�YPRgO�PR�IryE�rgO�RNIPARTNERIECECUTNE Y/❑N V9WC958971 03/0212018 03/02/2019 500,000 greSiRoryioeB EXCLUD®T NIA E.I..EAfat ACCOOENT $ 500,000 EL.DISEASE-EA EMPLOYEE S N TA deewwe under 500,000 DESCRIPTION OF OPERATIONS betaR EL DISEASE-POLICY uurr S — DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,maybe Meted Emcee weals Mulled) • CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE RISE Engineering ACCCCOREXPIRATION ANNCCE W TH TTHHE POLTE ICYYPPROVVISIONS. WB.L BE DELIVERED IN 5Dupont Ave -- --.. South Yarmouth,MA 02664 • AUTHORIZED /REPRESENTAVE ' , ACORD 25(2016/03) C 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD } l\ L..7! (•I �• � jj \ I. I ^� L. 'i! Pe9ela[i it SEP a 2018 Customer Name:Joanna Flynn CONTRACT _ Emelt:JIeynnl3@yahoo.com S__>i r , Phone:978-387-8117 � ' „.. Premise Address:29(stand Road,West Yarmouth,MA 02673 . - � .._-._-.._ ,, ProJeq ID:3961043 ".,_ . . Date:Aug.29,2018 ENGINEERING RISE Engineering S Dupont Avenue,Suite 2 South Yarmouth,AIA,02669 Job Description _—�----- - Measure Description '., - Quantity .....,.:Unit ,...:,Total Cost -,t >.Customer Cost_;_ PULL-DOWN STAIR:THERMADOME,BUILT-UP 1 each $237.65 $59.41 AIR SEALING 4 hr $320.00 $0.00 ATTIC FLAT-R-19 UNFACED FIBERGLASS 274 SF $465.80 $116.45 VENTILATION CHUTES 24 each $83.76 $20.94 4"x 16"SOFFIT VENTS 4 each $115.64 $28.91 Total: $1,22185 Program Incentive:. -$997.14 Customer Total: $225.71 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF ."-Two Hundred And Twenty-Flve And 711100 Dollars $225.71 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. i/ fr DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES RISE Representative stomer S re _ tiz 91i Sign Date NOTE:THIS CONTRACT MAY BE WITHDRAWN BY 1)5 IF NOT EXECUTED WITHIN ACCEPTANCE OF CONTRACT•THE ABOVE PRICES,SPECIFICATIONS AND 30 DAYS CONDmONS ARE SATISFACTORY TO US AND ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED TO DO THE WORK AS SPECIFIED.PAYMENT WILL BE MADE AS OUTLINED ABOVE ---.—_____------._.r----__ i ' Construcdon UUfl( DNisionorPtn�reoIllas n • li U -.luadingsofamr p whichcontay . -• Board of Bidding Regulationsless than 35,000 cable feet(991 cubic g and Standards i spate. meters)of enclosed . t. 1i Constc-,tea S pep,lsor .I CS-095561 _ ET,tram 05/12/2020 WILLIAM CA LAHAN_;'t ,.• 1T000WCySHOREOR' jr. e - e • RBI :-. 2 . QUINCYMA 02111. :2.~ :2 . .:y...,�a :;n.,� Fatiuretopossess acurrent ed onortha . .... State Building Code Is cause fur revocation(*this • . /'+ yA y� For information about this license ' ammL=siona CIL For information or vistwwerermagovfdpi • • • Q eOgnalW t Ci#4.46, ., . l Office of Consumer Affairs and Business Regulation ' • One Ashburton Place-Suite 1301 - • Boston, Massachusetts 02108 Home.Improvement Contractor Regis':anon a • Type: Supplement Card EFFICIENT BUILDINGS LW Regishation 169944 P.O.BOX 246 Expiration 08/1 51201 9 BRIDGEWATER,AAA-02324 • Updet Address and Return Cant. save a zw_tasw `��aaaenmv/!/rc({ecelra3--Y—_.....—. 0 •sect ConsumerrPaa4s Business Regulation HOME IMPROVEMENT CONTRACTOR Registration sand forladNidual use only TYPE SWptamt Card before the expiration date. Iffound return tx Registration Exnhafon Olike of a:foa nerAf airs and Business Regulation 189944 . 0511612019 One Ashburton Place-Suns 1301 • EFFICIENT BUILDINGS LLC Boston,MA 02108 30ert0 EL M CAL.L.AHAN - / e LLU' (��;AQJJ ST BRIDGEWATER,MA 02324 Undersecretary Not validwithout signatures R . e . • • _ \ The Commonwealth of Massachusetts Department oflndustrialAccidents -dae _t=pl= 1 Congress Street,Suite 100 Tir Boston MA 02114-2017 ..�. 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?Cheek the appropriate box: Type of project(required): LEI I am a employer with 16 employees(MI 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. ❑Remodeling any capacity.[No workers'comp.insurance required.] 30 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. CI Demolition 10 Building addition 4.0i 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 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.* ❑ 14.❑✓ other Insulation 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(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 Homeowner 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:EMC Insurance Company Policy#or Self-ins.Lic.#:V9WC958971 Expiration Date:03/02/2019 Job Site Address:28 Island Road City/State/Zip:W.Yarmouth,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 unde th pains and enal'es of perjury that the information provided aboveistrue and�ndcorrect Sienature:�� `40.° 2 _-. Date: ////9,e Phone#:( 08)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 all re mass save Form SVnAs r'-,rt oein,t" Site ID:3455894 Customer:Joanna Flynn *-. —17 F)rjo h) ,owner of the property located at: (bwnees Name,printed) 28 Island Road West Yarmouth, MA 02673 (Property Street Address) . 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 weatherizatlon work on my property. Owner's Signature:*— .7% Date:e* 9//P FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Ed-c.-÷ Bold* ac gh-fhP Participating ContraEtor Date Name: RISE Engineering Phone: 401-784-3700 Email: • Fcr Cfece Use Only Rev.102015