HomeMy WebLinkAboutBLD-19-003399 O ce Use Only
4.` Y"R' RECEIVEC'•1 1> (t�-Fii 3
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' DEC 031018 Permit expires 180 days from
tissue date t:
BUILDING DEPARTMENT
EXPRESS BUILDING PERM APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth,MA 02664
(508) 398-2231 Ext. 1261 /-
CONSTRUCTION ADDRESS: I C V e-A11Q* Or S. Yar oV , win QZ‘'/ tj
ASSESSOR'S INFORMATION:
Map: X'7 Parcel: /9y
OWNER: Ckn'sdist Srk.t Is Ysr/tu. S. OZ64v (ca)0fv- 7335
NAME PRESENT ADDRESS / TEL #
CONTRACTOR: E •cc.."1" &Vitt u-C 1723 n2Pl /[dt i ct3i to #1:1 1127 '141.40Ll c-/Il ()
NAME MAILING ADDRESS TEL#
Residential ❑Commercial Est.Cost of Construction S Ic Ci
Home Improvement Contractor Lie.# I 4, 1e�9r7,I�I` Construction Supervisor Lic.# C 3- Ory Ls?/
Workman's Compensation Insurance: (check one)
❑ I am the homeowner /�0 I am the sole proprietor Q�I have Worker's Compensation Insurance '7
Insurance Company Name: C,MC `/t3✓/R.�sUI ' v Worker's Comp.Policy# V 7 W e 95 7 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 /1'
Old Kings Highway/Historic Dist. ( )Replacing like for like laze
n Pool fencing
*The debris will be disposed of at: A/3C I/1�pea... 1 1ek., /fed l ze
Location 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 bejust cause for denial.or revocati of my license and for prosecutionn under M.G.L Ch.268,Section 1.
Applicant's Signature:,/V• , jA...., 1�,�,-% Date: I i/Fooy
Owners Signature(o achme Date: c
Approved By: �i(-a.r'1 Date: '�- 3- IO
Building Official(or designee EMAIL ADDRESS:
Zoning District:
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
A`oRv CERTIFICATE OF LIABILITY INSURANCE °08/31`/20°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 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 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 CMTI1CT
Rogers&Grey Insurance Agency,Inc. PHONEPAX
434 Rte 134 (AIC,Na Eat): I INC,No):(877)816-2156
South Dennis,MA 02660 - mks.. .
i.
INSURER/SI AFFORDING COVERAGE - NAIC 5 •
INSURER A:Employers Mutual Casualty Company 21415
INSURED INSURER B:National Liability&Fire Insurance Company 20052
Efficient Buildings LLC INSURER C:
PO Box 246 INSURER D:
v .. Bridgewater,MA 02324
INSURER E:
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 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 IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH PO�UC�IES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR R13DJ ww POLICY NUMBER IPMMU�DIYE%FYYI IINMIDDNYTYY1 LIMITS
LTR TYPE OFINSUIGMCE
A X COMMERCIAL GENERAL LIABILITY - EACH OCCURRENCE 3 1,000,000
CLNMSJJADE Li OCCUR 501803119 09/01/2018 09/01/2019 MNAGE TO RENTED 500,0011
PREMISES/EepmprslK) S _
• MED EXP(Am ons penanl $ 10,000
PERSONAL S ADPINXRY 5 1,000,000
SOL AGGR ATE UMITAPPUES PER _GENERAL AGGREGATE $ 2,000,000
2,000,000 N.
POLICY X JpRp.EST X LOC PRODUCTS-COMP/OP AGG S
OTHER: . $
A AUTOMOBILE LIABILITY :Farce SINGLE UNIT 5 1,000,000
— ANY AUTO. _ 5Z1803119 09/0112018 09/01/2019 BODILY IN.ARYR"erpenon) s
—
A EOEppS ONLY wseo X AUTOS�� •
I Peg
BRODILY INJURY IPerartldeil S
X ALRTOS ONLY X AVIV?
ONLY p&a�wn�enU G E $
_S
A X UMBRELLA MB X OCCUR EACH OCCURRENCE _ $ 2,000,000
EXCESSLIAB CWMEMADE 5.31803119 09/01/2018 0910112019 AGGREGATE S 2,000,006
DED X RETEMION5 10,000 5
B WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY X I TAME I IOFB
AANNYCPR�OPRIIETTOORRUPARTNER)EXECUTIVE Y� V9WC9569TI 03/0212018 03102/2019 EL EacH AcODENY s 500,000
(Menaa:OTY In NHU ETICWDEr" NIA
EL DISEASE-EA EMPLOYEE 5 500,000
I7yn,de$QWe OFF • 500,000
DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMB 5
DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES(ACORD 101,AddManal Rendu SebedW,maybe se:whsd P men span Ta ngldnd)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
RISE En Inee.a THE EXPIRATION DATE TUJEREOIS NOTICE WILL BE DELIVERED IN
9 g ACCORDANCE WITH THE POLICY PROVISIONS.
6 Dupont Ave
South Yarmouth,MA 02604
AUTHORED REPRESENTATIVE r
ACORD 25(2016/03) CI 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
•
Pape/oft
Customer Name:Christopher Small CONTRACT
Emelt:odameh0139@yahoo0om
Phone:508.894-7335
RISE Pres Address:15 Yankee Dabs,South Yarmouth,MA 02884
Project ID:3407203
Data:May 1,2018
ENGINEERING
RISE Englneerinp
S Dupont Avenue,Sults2
South Yemrourh,MA,0266
Roadblocks: Notes:
• Combustion safety-spillage or draft test fall HOTER HEATER HAS POOR DRAFT
Inh TTecrrIptInn
Measure Description Quantity Unit - Total Cost - - Customer Cost
AIR SEALING 4 hr $320.00 $0.00
ATTIC FLAT-14"OPEN R-49 CELLULOSE 42 SF $75.60 $18.90
BASEMENT SILLS:R19 FG BATT 136 SF $297.84 $74-46
CRAWLSPACE WALL R10 RIGID BOARD 220 SF $891.00 $222.75
Total: $1,584.44
Program Incentive: -$1,268.33
Weaterizatlon Garner Incentive: -$0.01
Customer Total: $318.10
WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF
***Three Hundred And Sixteen And 10/100 Dollars $316.10
UPON FINAL INSPECTION MID APPROVAL BY RISE ENGINEERING.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. •
DO NOT SIGN THIS CONTRACT IF THER RE LAN SPA
n
RISE Representative Customer SIgnatur
Sign Date
NOTE:THIS CONTRACT MAY BE WITHDRAWN BY US IF NOT ACCEPTANCE OF CONTRACT•THE ABOVE PRICES,
EXECUTED WITHIN 30 DAYS SPECIFICATIONS AND CONDRIONS ARE SATISFACTORY TO US
AND ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED TO DO THE
WORK AS SPECIFIED.PAYMENT WILL BE MADE AS OUTLINED
ABOVE
6 — P�c( fo Ose.
SCPA,
[ - • '. Construction Supervisor ,
Commonwealth of Massachusetts •
Unrestricted.Buildings of any use
} �i Division of Professional Lkensure group which contain
Board of Building Regulations and Standards less than 35,000 cubic feet(991 cubic meters)of enclosed
spa
ConatructiOni Supervisor •
ce' •
•
•
CS-095561 Expires:06/12/2020
•
WIWAM CALLAHAN 1)7?- c •A
175 QUINCY SHORE DR
681- r ` ?I-re
QUINCY MA 02171
t-• ' Failure to possess a current edl0on ofthe Mas2rhusetis
' ,... State BugdMg Code is cause for revocation of this gcense.
CL � For information about this license
.. Commissianer. <<. Call(917)727-3200orvisit wwwmassgov/dpl
•
•
Office of Consumer Affairs and Business Regulation
• One Ashburton Place-Suite 1301
='. - Boston, Massachusetts 02108
• •• Home Improvement Contractor Registration
•
Type: Supplement Card
Registration: 169944
EFFICIENT BUILDINGS LLC•. Expiration: 08/18/2019
P.O.BOX 246
BRIDGEWATER,MA 02324 .
Update Address and Return Card.
seat a zarx.pmtr
"37e F'ammnnmra//A cfr'/6annirraen+
Office of ConsumerAltairc Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
TYPE:Supplement Card before the expiration date. If found return to:
Reoistratioq gxplratioq Office of CbnsumerAffairs and Business Regulation
169944. -. 061182019 One Ashburton Placee-Suite 1301 .
EFFICIENT BUILDINGS LLC Boston,MA 02108
WILLIAM CALLAHAN tD _f>.'pr� _, �)J�� t�C e
300 ELM ST - : (, r
BRIDGEWATER,MA 02324 Undersecretary Not valid without signature
-
.
•
• _� The Commonwealth of Massachusetts
—y=gid, Department of Industrial Accidents
E eirti 1 Congress Street,Suite 100
MILL=et Boston,MA 02114-2017
.4 www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Lesibly
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 boa: Type of project(required):
1.01 am a employer with 17 employees(full and/or part-time).* 7. 0 New construction
2.01 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. CI Demolition
10 0 Building addition
4.0 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.
12.0 Plumbing repairs or additions
5.0 i am a general contractor and I have hired the subcontractors listed on the attached sheet 13.0 Roof repairs
These subcontractors have employees and have workers'comp.insurance.:
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c.
14.EI Other Insulation
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
'Any applicant that checks box 41 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 subcontractors 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:15 Yankee Lane 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.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature: /24 h £7JI4 Date: ///7E//0
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
mass save Form
Site ID:3404340 Customer. Christopher Smith
CAnr SAvpLev-- Sm t 441 ,owner of the property located at:
(Owners Name,printed)
15 Yankee Drive South Yarmouth.MA 02664
• (Property5treetAdress) (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: 4-
in 7417 ��
:.Date: /0/5740•
/x!
• FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced protect
60Ft;,,i- I 'ii iff GLC / 61)/
Participating Contractor ate
Name: RISE Engineering
Phone:401-784-3700
Email:
For OfficeUlf Only
• Rev.102015 _.