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Home My WebLink AboutBLD-19-003966 ! Y ice Use Only - AA e rc 7O /9-i9 3 .� S' aA! 4 e C ...era - $ 1 Amount l N ..-1 atg �,"' O s' ' - f Permit expires 180 days from 1 tissue date 9 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 M (508)398-2231 Exti1261N yf CONSTRUCTION ADDRESS:2 of U S C Qs ± 11V Al t v. Ormtaf I ASSESSOR'S INFORMATION: Map: _ 9/ Parcel: 93 OWNER •N:1 NllhmlA6i\) 2 C1A^QSS Pa KI+ Wl,1,y s iil1 ;cis-3 CONTRACTOR: NAME ` (4 gb I Ill inr ( P 1?3 J(1 6 I .AES ENT ADDRESS ... �, fi LLLhhLL..... ass..a, 9. Ill o MAILING DRESS II esidential ❑Commercial `j1)(`� �"r V Est Cost of Construction S y33 I Home Improvement Contractor Lie.# I GO J '7 Construction Supervisor Lie.#os 09 V)&-I Workman's Compensation Insurance: (check one) ❑ I am the homeowner/yam 0 I am the sole proprietor ave Worker's Compensation Insurance/� /� Insurance Company Name:V ' `vC I t Sire- C9 CO N'f70`"� Worker's Comp.Policy# v"I UC"I CS-97 WORK TO BEV 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 att C �, Rill SIn t l/ 73 ,(-,Qa.a . N. ir`I`C( "�l Locatto acility 71-1 7 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 den' ati/nn of my license r prosecution under M.O.L.Ch.268,Section 1. `� /— Applicant's Signature: �`C '�— ��J�, Date: Z•�V ' (� Owners Signature(or attachment) all-4 C Date: Q Approved By: ..L.1 Date: I .. 6 '1 1 . Buil g Official(or desi ce) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No EFFIBUI-01 HWOODS ACD ii,.......--- CERTIFICATE OF LIABILITY INSURANCE DATE IMM DOM YY) 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 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 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 CONTACT Rogers 8 Gray Insurance Agency,Inc. PHONE I FAX No):(877)816.2156 434 Rte 134 (AIC,No,Ext): South Dennis,MA 02660 Miss:mallerogersgray.com INSURER(S)AFFORDING COVERAGE NAIC It 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 0: Bridgewater,MA 02324 - INSURER!: 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 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 ADM SUER POLICY EFF POUCY EXP ITR TYPE OF INSURANCE INRs MD POLICY NUMBER [MM/DOM'Yh fMMIDDIriYY) OMITS A X COMMERCIAL GENERAL UA91D1Y EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE n OCCUR 5D1803119 09/01/2018 09/01/2019 p^EREM SgS((Eaoacmrcnce) $ 500,000 MED EXP(Any mut person) $ 10,000 PERSONAL S ADV INJURY $ 1,000,000 GENL AGGREGATE pURNIT APPLIES PER: GENERAL AGGREGATE 2,000.000 1 POLICY❑X JECTpa LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: A AUTOMOBILE LIABILITY /E COMBINEDINE1,000,000 ISINGLE LIMIT = — ANY AUTO _ 521803119 09/01/2018 09/01/2019 BODILY INJURY(Per Demon/ $ AUTOS ONLY X SCHEDULED kVA XUT ppNN..pp EEpp BODILY INJURY M(Per aaiden0 S AUTOSONLY X AUTOSONLY (Pero cin GE $ S A X UMBRELLA LIAR X OCCUR EACH 2,000,000 EXCESS LUIS CLAIMS-MADE 541803119 09/01/2018 09/01/2019 OCCURRENCE AGGREGATE 2,000,000 DED X RETENTIONS 10,000 $ • B WORKERS D EMPLOYERS COMPENSATION X STATUTE ERµ ANY PROPRIETOR/PARTNERIEXECUTVE Y/N V9WC956971 03102/2018 03/02/2019 E.L.EACH ACCIDENT 500,000 p}FFICE(UM�njER EXCLUDED? NIAS 500,000 1 antla NNN�) E.L.DISEASE-EA EMPLOYEE $ If yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more apace le required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE RISE EngineeringTHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 5 Dupont Ave ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE 117,414....".'---- ACORD _ACORD 25(2018/03) ®1988.2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Page 1 of 1 Customer Name:Cheryl Hohmann CONTRACT `- "---""-- Email:hohmannefq@yahoo.com °.1y{,{r Phone:413-478-1983 R ' F Promise Address:2 Cypress Point Way,South Yarmouth,MA 02664 Project ID:3579927 "`- Date:Oct.22,2018 ENGINEERING' RISE Engineering 5 Dupont Avenue,Suite 2 South Yarmouth,MA,02664 Job Description Measure Description Quantity Unit Total Cost Customer Cost . . WEATHERSTRIP DOOR&ADD SWEEP 4 each $320.00 $0.00 PULL DOWN STAIR:THERMADOME 1 each $230.19 $57.55 AIR SEALING 15 hr $1,200.00 $0.00 ATTIC FLAT-8"OPEN R-30 CELLULOSE 1156 SF $1,664.64 $416.16 ATTIC DAMMING-R-38 FIBERGLASS 100 SF $246.00 $61.50 BASEMENT SILLS:R19 FG BATT 172 SF $376.68 $94.17 8"ROOF VENT 2 each $174.30 $43.57 INSULATED BATH EXHAUST HOSE 2 each $120.00 $30.00 Total: $4,331.81 Program Incentive: -$3,628.86 Customer Total: $702.95 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF "'Seven Hundred And Two And 95/100 Dollars $702.95 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. DO NOT SIGN THIS CONTRACT IF THERE ARE/1 NY BLANK SPACES^ RI E Representative Customer Signature (' -. 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 tConstruction Supervisor 1 • Commonwealth of Massachusetts ` Unrehtrfcled-Buildings of any use group which contain } �� Division of Professional Licenc feet• Licensure . leas than 38,000 cubic (991 cubic meters)of enclosed Board of Building Regulations and Standards • apace. ConstrUctran'Supervisor• - CS-095581 . . E-ypfres:051122020 WILLIAM CALLAHANT•11 = a: 175 QUINCY SHORE DR: .- I • B91 QWNCYMA 0211.1. .` orst - :� • • Failure to possess a current edition of the Massachusetts ' • '`� •• State Building Coders cause for revocation of this license. •. y2 ; For Information about this license Commissioner Cog(81T)MTJ20llorvisttwww.massgoy/dp1 wpm Office of Consumer Affairs and Business Regulation • . One Ashburton Place-Suite 1301 • - ' • Boston, Massachusetts 02108 Home Improvement Contractor Registration • Type: Supplement Card EFFICIENT BUILDINGS LLC . • Registration: 169944 P.O.BOX 246 Expiration 08/10/2019 BRIDGEWATER,MA 02324 • Update Address and Return Card. SO:c a mssost Rice of Consumer Affairs Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Supplement Card beforethe expiration date. iffound return to: Realstratiott Expiration Office of Consumer Affairs and Business Regulation 189941 08/18/2919 One Ashburton Place-Suite 1301 • EFFICIENT BUILDINGS LLC Boston,MA 02108 • WILLIAM C - \p r�0 _. p ( / l WI ELM CALLAHAN U u BRIDGEWATER,MA 02324' Not valid without signature Undersecretary The Commonwealth of Massachusetts _10I t Department of Industrial Accidents 1 Congress Street,Suite 100 • • = �_1l= Boston,M4 02114-2017 b,,„;��, 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.S I am a employer with 16 employees(full and/or part-timer - - - - - - - 7.- 0 New construction 2 1 am a sole proprietor or partnership and have no employees working forme in 8. El Remodeling any capacity.[No workers'comp.insurance required.] 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9• ❑Demolition 10 Q 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 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof airs These sub-contractors have employees and have workers'comp.insurance.t ❑ repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.mother 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-iris.Lic.#:V9WC958971 Expiration Date:03/02/2019 Job Site Address:2 Cypress Point Way 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. I do hereb and r th pains and p e Ities pe jury that the information provided above istrueand correct Signatures/t' Date: /7 76 'a 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 II: Permit Authorization mass save Form `Sav '8f thrown energy en c.ency Site ID: 3566405 Customer: Cheryl Hohmann I, OH 1 Flo 11 owner of the property located at: (Owner's Name,printed) 2 Cypress Point 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: Date: II .3 'y FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: SCCie/c-4cke1c� 11 F Participating Contractor Date Name: RISE Engineering Phone: 401-784-3700 Email: For Office Use Only Rev.102015