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HomeMy WebLinkAboutBLD-19-3607 eUseOnlyy p 0 �t 4 k 0 "SI�, 1'�,04 � I�n• I2I�Z/�(/ Amount i �""t• a Permit expires 180 days from -.4;/./6.... . - issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 /n (508) 398-2231 Ext. 1261 J1 - CONSTRUCTION ADDRESS: Z i 5/". Alf f<wt (9a) S. ` ti erK a ✓-Yt• � re � 6 4 V ASSESSOR'S INFORMATION: �(, I Map: ,�Ql r/' Parcel:lC 4 OWNER: ,NAMEe� Mc Ovillen zl 5+RE/3ENTADyyD�ls. b� ia.j fie/,y4CAU. (co3)L5-c7G7 SS TEL F CONTRACTOR: EF(tdt4' R✓;�.f:i 4'73 2�ttP a fl.(aaffru✓A,,M l/f`tJ /ruling -11 / 0 NAME MAILING ADDRESS TEL# )(Residential 0 CommercialEst.Cost of Construction S ita D 6 rHome Improvement Contractor Lie.# / le /4 l Y 4' Construction Supervisor Lie# CS-Oirci Workman's Compensation Insurance: (check one) �.(* ❑ I am the homeowner,r 0 I am the sole proprietor :have Worker's Compensation Insurance Insurance Company Name: Cft.%C-Ctnj✓r4.elf.. Worker's Comp.Policy# ii 1.4.<1.4.< IS,/p 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. ( )Replacing like for like , Pool fencing *The debris will be disposed of at: 14 6C P/ Ft 5 G' 4� &^lir/" /�"` r J�gr 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. 1 understand that any false answer(s) will be just cause for denial or revocation of my license and for p/y%ecution under M.G.L Ch.268,Section 1. y Applicant's Signature: t�.f�o-'. Com'/�'.� Date: 2/5 /�t7 Owners Signature(or t)t) Date: Approved By. G Date: /7 —/-2-�� . B mg Lela!(or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 it of Wetlands: 0 Yes 0 No 0 Yes 0 No i1 EFFIBUI-01 HWOODS AC p`O CERTIFICATE OF LIABILITY INSURANCE , os/ln001i8 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 BYTHE 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 state°nmton this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER itireCT Rogers&Gray Insurance Agency,Inc. PHONEFAX 434 Rte 134 INC,NI�o,E I INq e,*(877)816-2156 South Dennis,MA 02660 - PDGRESs,mall©rogersgray.com JJJ INSURER(5)AFFORDING COVERAGE ' NAICN • , INSURER A:Employers Mutual Casualty Company 21415 INSURED mSURERa:National Liability&Fire Insurance Company 20052 Efficient Buildings LLC INSURER C: PO Box 248 INSURER D: Bridgewater,MA 02324 msunER 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 RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTOALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LASTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD-SUER POLICY EFP POLICY EXP LTR TYPE OF INSURANCE IN% Wen POLICY NUMBER IMMIDORMI IMMIDDIYYYYI LIMNS A X COMMERCIAL GENERALUABNnY EACH OCCURRENCE S 1,000,000 CLAIMS-MADE in OCCUR 501803119 09101/2018 09/01/2019 Fit SEES ElSoma,°m,e) s 500,065 •• _ MED EXP(Aew e person) a 10,000 on — PERSONAL&ADV INJURY S 1,000,000 1GENEG NI.AGGREGATE pLIMIT APPLIES PEM RAL AGGREGATE 5 2,000,000 t POLICY I I JECT ®LAC PRODUCTS-COMP/OPAGYI S 2,000,000 OTHER- S A AUTOMOBILE IJABILITY COMeBmaED SINGLE LIMIT S 1,000,000 ANY AUTO 5Z1803119 09101/2018 09101/2019 BODRYINnraY(Parpewee) S _ • OAE AUTOSNLY X AUTOS BODILY INJURY(Pe *thden) S X .Al{71%ONLY X O0W0Nit? pgamgempg MAGE S - S A X MAMMA MAD X OCCUR EACH OCCURRENCE _ S 2,000,000 — EXCESS UAB CLAIMS-MADE 531803119 09101/2018 09/01/2019 AGGREGATE S 2,000,000 DED I X I RETENTONS 10,000 s B WORKERS COMPETES/MON X IANNE I I OFR AND EMPLOYERS LIABILITY ANY PROPRIETORA'ARTN@UEXECImVE Y/N V9WC9589T1 03102/2018 03102/2019 tA.EACH ACOOENT 5 500,000 DFFlCETIMEMNM)ExCu1D®'! U NIA EL DISEASE-CA EMPLOYEE S 500,000 1 FI Glory In �n11 Il yet,estate under r - 500,000 DESCRIPTION OF OPERATIONS below • EkD1SEJASE-POLICY LIMIT S DESCRIPTION OP OPERATIONS J LOCATIONS/VEHICLES IACORD 101,AddllIonal Ramada Schedule,may he eaaebed Einem slam Is reguIrS) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE RISE Engineering CCORDANNCCEWITH THETHDATE PROViSIo�� vntJ. DEUVERED IN • S Dupont Ave South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ''T � ACORD 25(2016103) 01958-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ` r • Page 1 of t fit) 4'''',1-1;":"2------ ,,, 1'I 71 Customer Name:MIc el McMullen CONTRACT 71 (ICI 1 �l e Email:kishdver@ao m C C�‘ II•,, , �C I 1 cO�a Phone: Pramtas Addreu:21 Sl Andews Way,South Yarmouth,MA 02884 ii Protect ID:9561802 1ty` ' Date:Sept.25,2018 ENGINEERING rr,eirncy E narri:^d, ."' RISE Engineering 5 Dupont Avenue,Sults 2 South Yarmouth,MA,02584 Job Description Measure Description Quantity . Unit Total Cost. ..s Customer Cost PULL-DOWN STAIR:THERMADOME,BUILT-UP 1 each $237.65 $59.41 AIR SEALING 8 hr $640.00 $0.00 ATTIC FLAT-10.OPEN R-37 CELLULOSE 1456 SF $2,271.36 $567.84 VENT BATH FAN THRU ROOF 1 each $118.75 $29.69 INSULATED BATH EXHAUST HOSE - 1 each $60.00 $15.00 VENTILATION CHUTES 63 each $219.87 $54.97 PERFORATED SOFFIT PANELS 12 each $312.00 $78.00 ATTIC DAMMING-R-38 FIBERGLASS 60 - SF $147.60 $36.90 Total: $4,007.23 Program Incentive: -$3,165.42 Customer Total: $841.81 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF "'Eight Hundred And Forty-One And 81/100 Dollars $841.81 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 90 DAYS,SEE REVERSE FOR IMPORTANT INFORMATION ON GUARANTEES,RIGHTS OF RECISION,SCHEDULING.AND CONTRACTOR REGISTRAT% i2rots CONTRACT IF THERE 7BLANKsPA7,j)y/ . RISE Representative Cume I_ /6 /// Sign Date NOTE:THIS CONTRACT MAY BE WITHDRAWN BY US IF NOT EXECUTEO 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 • t Commonwealth of Massachusetts • "•; ;. Construction Supervisor �• Division of Professional Licensure Division -Buildings of any use group which contain • • Board of Building Regulations and Standards , less than 35,000 cubic feet(991 cubic meters)of enclosed Constrltet?on-Supervisor ? • space. • I CS-095561 Expires:os/12)2020 WIWAM CALLAHAN'-+;;;<'* _ ;c_ 175 QUINCY SHORE DR r r • B81 'r - tip_ t 4;•T. QUINCY MA 02171 h , !,s...�� �:, Failure to possess a current edition of the Massachusetts '. ?7,*, State Building Code Is cause for revocation of this license. • C - For Information about this licensecommrssioner t`. Call(617)7273200orvisitvnnxmassgov/dpi • • • Q 2€ WQM/19-1041Zela 1Q/elad1 Q:eoeet Office of Consumer Affairs and Business Regulation • One Ashburton Place-Suite 1301 t. • .. Boston, Massachusetts 02108 Home Improvement.Contractor Registration • n . . Type: Supplement Card • EFFICIENT BUILDINGS LLC . Registration: 169944 P.O.BOX 246 Expiration 08/18/2019 BRIDGEWATER,MA..02324 - Update Address and Return Card. SCA1 0 2Mx ositr . '52 �ammanenroa r: C gerar/n e/d i Oma of Consumer AffairsBusiness Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Supplement Card before the expiration date. Iffound return to: Renlstraion Expiratlort Office of Consumer Affairs and Business Regulation 169944 08118/2019 One Ashburton Place-Suite 1301 • EFFICIENT BUILDINGS LLC Boston,MA 02108 • WILLIAM CAL A-IAN �A � � � - ^ ' j�r 64/4401. 300 ELM ST Not valid without t signatureBRIDGEWATER,MA 02324 Undersecretary <. s • r The Commonwealth of Massachusetts l�=._i-ft Department oflndustrialAccidents IPE: • 1 Congress Street,Suite 100 �'it Boston MA 02114-2017 .b.J-, .� 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 It:(508)279-1110 . Are you an employer?Check the appropriate box: Type of project(required): ICI I am a employer with 17 employees(full and/or part-time).• 7. 0 New construction 2.0 I ant a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp:insurance required.] 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]r 9. ❑Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. T will 10❑Building addition 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 3E11 am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.DRoof 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.El 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 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. 7 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:21 St Andrews Way 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and pe allies of perjury that the information provided above is true and correct Signature: b_U �(/ot Date: /2/5—//1- phone /5—/f t Phone#:(508)279-1110 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: •pi Permit Authorization mass save Form Site ID: 3453983 Customer. Michael McMullen I, )` /V I i G/-h i S L MC Mu &IV ,owner of the property located at: (Owner's Name,printed) 21 St Andrews Way South Yarmouth, MA 02664 (Property Street Address) - (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. Owner's Signature: k Date: ik /O/ii i$ 3000000i0ii0 i$i0iidi90Wi000.0400000009100000000004,0*90d90000009#000000 FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: � ,,��tt- LA LCC ) D //lIIS Participating Contractor Date Name: RISE Engineering Phone: 401-784-3700 Email: For Office Use Only Rev.102015 �..... _