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Home My WebLink AboutBLD-19-003396 Aro Use Only of•YARe P r /9 , , �.f" oa ' ey � , ' F Amount _ 'Z tw."u t!!.' Permit expires 180 days from ), ►:;-:..- _ %issue date 1 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH ..-----.—.7RECEIVE Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 DEC 03 2018 . (508)398-2231 Ext. 1261 �_� Ci C I:t11tOiNG DE ARTMENT ! CONSTRUCTION ADDRESS i V lT &j( I�) '7yv w�44:t= ASSESSOR'S INFORMATION: �t ' p F/\�/ C }'.Mlap: l,( � C� �T� ( Parcel: �1 y OWNER: WN �*-'/�+e& I-1)U 11- �I `PII2ESENV,ftacriuFti. �. S. /rim L. #722 - c-S.�yS– CONTRACTOR: ill )CI1.14—g ;\1J(') 173 OneIC-OCA Dco1m(7❑1t- „"'-a,.9 t Ito NAME MAILING ADDRESS TEL./# — sidential 0 CommercialciiaEst Cost of Construction S COCO 3> _ Home Improvement Contractor Lic.# )(0- lq(LI Construction Supervisor Lie.#n— 0 q S��' I Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor r ❑ orker's Compensation Insurance Cc)n Insurance Company Name&\.\( I(`151X �`O Worker's Comp.Policy# v-` ) CE-42(-7I WORK TOO BF4RFORMED 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. ( )Replacing/) like�pforlike /� Pool fencing //(�y�j �j/�� *The debris will be disposed of at ci 7 5 r` e J fez"- /" " 0"" / /1 ' " 7-s-t7 Location of Facility / I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge aand belief. I understand that any false answer(s) will be just cause for de • revocation of my license an. • prosec/ under M.G.L.Ch.268,Section 1. Applicant'sSignatu'/��/` /� Date: II /7t//f- Owners Signature(or attachment ) a ire Date: Approved By: ,/ „(�., Date: 11,-3- 1(1 y 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 EFFIBUI-01 HWOODS ACQRO' DATE(MMmomYY) , `i CERTIFICATE OF LIABILITY INSURANCE 08/312018 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(les)must have ADDmONAL INSURED provisions or be endorsed. If SUBROGATION IS WANED, 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 N%MMg: Rogers&Gray Insurance Agency,Inc. PHONE o, 434 Rte 134 ANjuc,Noon)816-2156 IND No.Ea South Dennis,MA 02660 DDREss mall@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC R INSURER A:Employers Mutual Casualty Company 21415 INSURED INSURER B:National Liability&Fire Insurance Company 20052 Efficient Buildings LLC INSURER C: PO Box 248 INSURER D: 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 POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR EXP ITR TYPE OF INSURANCE NWT MD POLICY NUMBER IMM/DDY/YWYI M/DD/Y LIMITS A X COMMERCIAL GENERALLIABMY EACH OCCURRENCE 1,000,000 CLAIMS-MADE ri OCCUR 5/31803119 09/01/2018 0910112019 pPREM 8Es(Ea or i,mnce) $ 500,006 MED EXP(Mv one person) $ 10.000 PERSONAL AAOV INJURY _ $ 1,000,000 GEM AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,006 POLICY je& n LOC PRODUCTS-COMP/OP AGO S 2,000,000 OTHER: A AUTOMOBILE LWBILm' EOaMBINEDI SINGLE LIMIT $ 1,000,000 — ANY AUTO 5E1803119 09/012018 09/01/2019 BODILY INJURY(Per person) 5 AUTOES ONLY X 5.15710S1AED X ��p�� OATS pB�ODILY INJURYTypp (Per accident) $ AUTOS ONLY X AUT090S 1PaPa EttR10em1 MAGE S $ A X UMBRELLA LAB X OCCUR - EACH OCCURRENCE s 2,000,000 MESS UAB CLAIMS-MDE 5.11803119 09/012018 09/012019 AGGREGATE 3 2,000,000 DED X RETENTIONS 10,000 E B WORKERS COMPENSATION X STATUTE ER' AND EMPLOYERS'LIABILITY ANY r+aoPRlEroamARrNERnexEeTmvE YIN V9WC9589T1 03/02/2018 03/02/2019 E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? U NIA ands ory n ) E DISEASE-FA EMPLOYEES 500,000 R yea,describe under DESCRIPTION OF OPERATIONS below E.L.m$EASE-POLICY LIMIT $ 500,000 • DESCRIPTION OF OPERATIONSI LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if mom apace le required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE RISE Engineering THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 5 Dupont Ave South Yarmouth,MA 02664 AUTNORrcED REPRESENTATIVE 1 c_' 7/41.1444.---..----- --I�t*a'^.'--..----- -- ACORD 25(2016/03) ®1988.2015 ACORD CORPORATION. All righb reserved. The ACORD name and logo are registered marks of ACORD .. - 'T Page 11�of I Customer Name:Edward Smith CON 1 RAV 1 Email eddiecesey@aol.com Phoner727-845-5545 - R ' sE` Premise Address:744 Willow Street,South Yarmouth,MA 02664 - - ProJeq ID:3431327 Date:June 28,2018 ENGINEERING" RISE Engineering - -_ . . - .. $Dupont Avenue,Suite South Yarmouth,MA,02664 t r."----Roadblocks: Notes: ibustion safety-High CO BOILER HAS SPILLAGE AND HIGH CO bustion safety-spillage or draft test tail JohDeserlptlon a."„_. Measure Description .quantity s: Unit Total Cost Customer Cost WEATHERSTRIP DOOR&ADD SWEEP 3 each $240.00 $0.00 AIR SEALING 14 hr $1,120.00 $0.00 ATTIC FLAT-4'FLOORED R-13 DENSE CELLULOSE 392 SF $733.04 $183.26 PULL-DOWN STAIR:THERMAL TENT 1 each $226.65 $56.66 SLOPE 5"DENSE R-16 CELLULOSE 80 SF $157.60 $39.40 CRAWLSPACE:10 MIL GROUND COVER 1672 SF $1,621.84 $0.00 CRAWLSPACE WALL R10 RIGID BOARD. 626 SF $2,535.30 $633.83 Total: $6,634.43 Program Incentive: -$5,721.28 Weatherizatlon Barrier Incentive: -$0.01 Customer Total: $913.14 WE AGREE HEREBY TO FURNISH SERVICES•COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF 'Nine Hundred And Thirteen And 14/100 Dollars 5913.14 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 REGISTRATIOid N. - DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES RISE Representative _ Custo-rger Signature !sr/ ? 27 / 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 _ �c"" t' 5-e-frec 4o, Pf .7-1. • Construction Su 1 . Commonwealth of Massac lusetts Unrettrid ed.Buildingspe group row OivisionofPrafesslonaiCicensure of any • Board of Building Regulations and Standards less than 35,000 cubic feet(991 cubic meters)of enclosed Consfrt( oriiiupervisor Ce CS-095581 E-Icp(res:05/12/2020 . :.. WIWAM CALLAHAN,C1'� 178 QUINCY SHORE DR • 1 • 601' „g:-.• . !. QUINCY MA 02171; .., Failure to possess a current edition ofthe Massachusetts ' e. '• • a.. State Building Coders cause for revocation of Ibis license. i• . .: For Information about this license Commissioner H4. Call(017)727-0200 or visitwww.mass.gov/dpi • • Q/A0 ' 0/1724 wiuoea&i t 4 -i4. Office of Consumer Affairs and Business Regulation One Ashburton Place-Suite 1301 • - •. • •• Boston, Massachusetts 02108 • Home improvement Contractor Registration • Type: Supplement Card EFFICIENT BUILDINGS LW . Registration: 169944 P.O.BOX 246 Expiration: 06!16/2019 BRIDGEWATER,MA 02324 • • • • • Update Address and Return Card. SOU C 201.1473?tr • Hamnikriela Office of ConaumerAftairsB Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Suooiemelt card before the expiration date. Iffound return to: ReolstretioR. jcoilatiop Omcs of Consumer Affairs and Business Regulation 1809444 08/1812019 One Ashburton Plats-Sults 1301 EFFICIENT0 BUILDINGS LLC - Boston,MA ,02108 WILLIAM EAM CALLAHAN U ( , / WELM ST WJ BRIDGEWATER,MA 02324 - Undersecretary Not valid without signature The Commonwealth of Massachusetts !t Department of Industrial Accidents -itl- 1 Congress Street,Suite 100 • =_t Boston,IIIA 02114-2017 w _15,� wwmass.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 part-time).• 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. O Remodeling any capacity.[No workers'comp.insurance required.] El 3.0 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 5.Q 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. 6.❑We are a corporation and its officers have exercised their right of exemption per MGL C. Other Insulation 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 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:EMC Insurance Company Policy#or Self-ins.Lic.#:V9WC958971 Expiration Date:03/02/2019 Job Site Address:7`14 Willow St City/State/Zip:South Yarmouth, MA 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 pains and penalties of perjury that the information provided above is true and correct Signature: Date: 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 4 mass save Form szvrt^v.rvr:.e�eoc.•'.:v eHq+a:r..p Site ID: 3426699 Customer: Edward Smith l' A n:%✓/3-r?,) f• ..S / )7/ ,owner of the property located at: • (Owner's Name,printed) 744 Willow 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: 'C GC-13 /7_ , # FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: ar&1/4.Tt%j/ict,oA � ` Participating Contractor e ate Name: RISE Engineering Phone: 401-784-3700 Email: act Office Use Only Rev.102015