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Home My WebLink AboutBLD-19-4058 Office Use Only 01'"Y4,0 t 1 t Permit# -. 0 •azar • �: Amount . �a a. 1 Permit expires 180 days from t issue date 13Lb-19-4:6abs g GIG- IPJ7 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department [ JAN 1146 Route 28 10 2019 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT CONSTRUCTION ADDRESS: 5�+ 'HQ nile 6.NS On v 8? (/�\ ASSESSOR'S INFORMATION: Map: Parcel: OWNERL -�_Q/1t lU n,•ob f� Oh Cp1�-�1 (v -$1-i I Z N PRESENT ADDRESS TEL # CONTRACTOR:(" 11��n S� 1 / 1 _f� vlKta 'v l� ' i-• lY U( / �M��iAAAMMMEEE MAILING ADDRESS TEL tl i idential ❑Commercial Est.Cost of Construction$ 1 t,,/U (� C one Improvement Contractor Lie.# 1 t i Construction Supervisor Lic.12. J—6 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am e sole proprietor r� ve Worker's Compensation Insurrteen/ `/��( Insurance Company Name. `–t Worker's Comp.Policy# V t "� l 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. ( )Replacinglalike for like �j7 Pool fencing I{� ^ //M/ *The debris will be disposed of a.�7" I I V i l e • 7 rt.J2(d ��, 141 ` I) ,/ " " i1fon of Facility [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 revocation of my license and msec tion m er M.G.L.Ch.268,Section I. Applicant's Signature /r7"- M/ Date: Owners Signature(or attachment) I. ,4tAia`t°0 \ Date: 00, Approved By: iDate: / 77fBuilding Offi '.r"(4.esignee) L ADDRESS: Zoning District: Historical District: 0 /Yes ❑ No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No ❑ Yes 0 No AC EFFIBUI-01 HWOODS h........— CERTIFICATE OF LIABILITY INSURANCE DATE(MM DDYYYY) 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(Ies)must have ADDITIONAL 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 =gm" Rogers 8.Gray Insurance Agency,Inc. PHONE jac,Na):(877)816-2156 434 Rte 134 (AIC,No,Eat): South Dennis,MA 02660 gop bs,mall@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC s 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; Bridgewater,MA 02324 INSURER E; 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 ADDU SUBR ITR TYPE OF INSURANCE INSO MD POLICY NUMBER POLICY EFF POLICY EXP IMMIDDNYYYI IMMIDD,YYVYT YI LIMITS A X COMMERCWLOENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ri OCCUR 5D1803119 09/01/2018 09/01/2019 PREMISESIEaoocu,urenul $ 500+000 MED EXP(My one person) $ 10,000 — PERSONAL&ADV INJURY _ 5 1,000,000 GENU AGGREGATE pORM�R APPLIES PER: GENERAL AGGREGATE 5 2,000,006 POLICY a JECT n LOC • PRODUCTS-COMP/OP AGO 5 2,000,000 OTHER' $ A AUTOMOBILE LIABILITYCOMBINED SINGLE LIMIT 1,000,000 Ma=Menti $ _ — ANY AUTO 521803119 09101/2018 09/01/2019 BODILY INJURY(Per person) I OWNED SCHEDIAED AUTOSpEONLY X AUUpTNNO.ppSµ'NEp BODILY INJURYp (Per accident) $ X AUTOS ONLY X AUTOSONLV (Karr egpentRAMAGE I - 5 • —_ A X UMBRELLA LIAB 'X OCCUR EACH OCCURRENCE �5 2,000,00 EXCESSLIAB CLAIMS-MADE 5,31803119 09/01/2018 09/01/2019 AGGREGATE _.5 2,000,000 OED I X RETENTIONS 10,000 5 B WORKERS COMPENSATION X STATURE FR- AND EMPLOYERS'LIABILITY ANY PROPRIETORMARTNERIEXEDUTIVE YIN V9WC956971 03/02/2018 03/02/2019 E L.EACH ACCIDENT $ 500,000 ��FFFICER/MEMBER EXCLUDED? U N/A 500,000 IMantlalory In NH) EL.DISEASE-EA EMPLOYEES If yes,describe under500,000 DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMR 5 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may M attached 5 mon apace la 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 REnAve ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) 01988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD DocuSign e=nvelope ID:BCA311 D0-F9C9-4DAE-BB65-48CC06556C0D Page l ort Customer Name:Llsa Henderson CONTRACT Email:bhenderson@tpx.com #-11, Phone:617-816-5412 Premise Address:50 Hemeon Drive,West Yarmouth,MA 02673 Protect ID:3565524 Date:Oct.2,2018 ENGINEERING RISE Engineering 5 Dupont Avenue,Suite 2 South Yarmouth,MA,02664 Job Description Measure Description` Quantity ' : Unit P'Total Cost Customer Cost s • AIR SEALING 9 hr $720.00 $0.00 ATTIC FLAT-13"OPEN R-45 CELLULOSE 1104 SF $1,920.96 $480.24 ATTIC DAMMING-R-38 FIBERGLASS 20 SF $49.20 $12.30 ATTIC HATCH:SEAL&INSULATE 1 each $60.00 $15.00 VENT FUTURE BATH FAN TO ROOF 1 each $118.75 $29.69 VENTILATION CHUTES 70 each $244.30 $61.07 6"x 16"SOFFIT VENTS 8 each $231.28 $57.82 OVERHANG 9"DENSE R-32 CELLULOSE 80 SF $160.00 $40.00 CRAWLSPACE WALL R10 RIGID BOARD 60 SF $243.00 $60.75 • Total: $3,747.49 Program Incentive: -$2,990.62 Customer Total: $756.87 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WIN ABOVE SPECIFICATIONS.FOR THE SUM OF ***Seven Hundred And Fifty-Six And 87/100 Dollars $756.87 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. D.euSign.d by: DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES LAS& Docuelgned by: DLIA• WI-MtA RISE Representa ve Customer Signature 11/2/2018 I F4:09 PM EDT 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 • • 1Commonwealth of Massachusetts .Y ; Construction Supervisor Division of Professional Licensure UnreStrlcted-Buildings of any use group which contain I �` Board of Building Regulations and Standards • Tess than 35,000 cubic feet(991 cubic meters)of enclosed • Constniotlbn`Sapervisor I space.• • CS-095581 ^.- Expires:05/12/2020 .1:- WILLIAM CALLAHAN C DR: iy.14.:. 1 r i B81 OUINCYMA 02111 . n t� t....4..- Failure to possess a current ednon otthe Massachusetts ; . State Building Code Is cause for revocation of this license. /'+ ._-. For Infonnatlon about this license Commissioner V'*^^ Call(617)7273 w 200 or visit ww.mass goiddpi • • . P./.4,e Wpdnvg;tnuaea a t'lQi glZ(i��L(/J�GLd - 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: 08/18/2019 BRIDGEWATER,MA 02324 • • Update Address and Return Card. SCA+ 4 ZOMasnr ffeaf Oiof Consumerirrs3Business Regulation ^ HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Supplement Card before the expiration date. If found return to: Realstration Expiration Office of Consumer Affairs and Business Regulation 16994408/1812019 One Ashburton Place-Suite 1301 • EFFICIENT BUILDINGS LLC ' Boston,onMA 02108 WILLIAM CALLAHAN - p,�, Loan/ J�� (�C;4M W 300 ELM ST (,, - u `NLtYG BRIDGEWATER,MA 02324 N Undersecreta Not valid without signature • • The Commonwealth of Massachusetts 1 eilis 07 Department oflndustrialAccidents • •__:an_ 1 Congress Street,Suite 100 •_e!_E=i Boston,MA 02114-2017 �� •_�,e 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): 1.0 I am a employer with 16 employees(full and/or part-time).• 7. El 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.] 3.01 am a homeowner doing all work myself[No workers'comp.insurance required.]r 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 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.0 Rp oof repairs These sub-contractors 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.❑✓ 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. tContracton 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:50 Hemeon Drive City/State/Zip:West 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. Ido her y ce :fir unde t e pains and pen ens off eer�y ury tl at the information provided above is true and correct Signature: • Date: /' 2') C. Phone#:(5 8)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#: DocuSign Envelope ID:BCA311DO-F9C9-4DAE•BB6548CC06556COD • Permit Authorization mass save Form Sarson roman,eno.rf✓antics.,,, Site ID: 3565524 Customer: Lisa Henderson Lisa Henderson I, ,owner of the property located at: (Owner's Name,printed) 50 Hemeon Drive West Yarmouth, MA 02673 (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. Docusion•d by�:� '�" Owner's Signature: �Sa E�Lu cuvsDlA Date: 11/2/2018 I 4:09 PM EDT FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: CJ ) \,i ) 641 vz f fir ParticipatingContras`or i Date Name: RISE Engineering Phone: 401-784-3700 Email: For Office Use Only Rev.102015