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HomeMy WebLinkAboutBld-20-0934 , \• Office Use Only O�''YAR`r Penntt C 1 5 ! Amount J i�' yy�� 1 -, : 3 • Permit expires 180 days from •`{. fUTTA M [3[�•�i ;'6l TArftwo*9 cf. issue date 6 0-zglo--93Y EXPRESS BUILDING PERMIT APPLICATION R E C E I V E ' TOWN OF YARMOUTH Yarmouth Building Department FAU6 1. 6 201q 1146 Route 28 South Yarmouth,MA 02664 a ''' (508) 398-2231 Ext. 1261 IBY CON STRUCTION ADDRESS: -6 I Q ix.,A rl a-C-I 10K `as-vnv k I-) ASSESSOR'S INFORMATION: IMap: I Parcel: 1 OWNER: IVOIA . 1 S I0 Tcthe ha de 1f f'l tos- n'‘Ot /) 5JCA'`1-71 '(�1a NAME PRESENT ADDRESS TEL. # Z�W. C-I'eY1 l L I Ono,n Q"--/3 ,e...� TEL.# NAME 0 0. f► .0 I pH D4-1�/ Est.Cost of Construction S 4 0 0 0 ,PJ Residential 0 Commercial Home Improvement Contractor Lic.# «QCt 1144 Construction Supervisor Lic.# ©q,s 5 s I Workman's Compensation Insurance: (check one) 0 I am the homeowner 1 D. I am the sole proprietor 'I have Worker's Compensation Insurance /UQ hhr \ 1.--Ca bt ' t t`-t 4' l I-'e. .1.y`S IN-Ctn C Worker's Comp.Policy# V W CO 1 1(p-1 t/ P Insurance Company ame: 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 V Old Kings Highway/Historic Dist. ( )Replacing like for Iike Pool fencing *The debris will be disposed of at: -is Z.Q., `) b ckAi m O 0-1 , R 0 a-1 4-7 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. I understand that any false answer(s) will be just cause for denial or revocation of my license and for prosecution under e 'VM.G.L.Ch.268,Section 1. �j �j Applicant's Signature: W C�kC Date: D ' 1 \ ' 9 Owners Signature(or attachment) J T 1 ft C44 E_1 Date: Approved By: -4"7 Date: [, ��"/t Build* (or designee) MAIL ADDRESS: I L t 4 v1 U t 1(1 VYte65 fib'Y)"10.t t •C 001 Zoning District: Historical District: Yes T. No Flood Plain Zone: = Yes 2 No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No 2 Yes ' No • ^wwwiN EFFIBUI-01 CFOGARTY A�oRo CERTIFICATE OF LIABILITY INSURANCE DATE D/YYYY) 3/1/2019 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 Cf1CT Rogers&Gray Insurance Agency,Inc. PHONE A/C No,Eat) (800)553-1801 No):(877)816-2156 434 Rte 134 : South Dennis,MA 02660 ,, mall@rogemgray.com INSURERISI AFFORDING COVERAGE NAIC Y INSURER A:Employers Mutual Casualty Company 21415 INSURED INSURER B:National Lability 8 Fire Insurance Company 20052 Efficient Buildings LLC INSURER C: 873 Reed Road INSURER D: North Dartmouth,MA 02747 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 LTR TYPE OF INSURANCE plpr�sp SUBRWVD POLICY NUMBER POLICY EFF POLICY EXP A X COMMERCIAL GENERAL LIABILITY IMMIDD/YYYY) IMMIDDIYYYYI OMITS EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE n OCCUR 5D1803119 9/1/2018 9/1/2019 DRE�MISET(EaENo 1 $ 500,000 — MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEM_AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY n JE plc LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: A _ $ AUTOMOBILE LIAHIUTY (Ea COMBINE acciden()SINGLE UMR $ 1,000,000 — ANY AUTO 521803119 9/1/2018 9/1/2019 BODILY INJURY(Per person) $ AUTOS DONLY X SCHEDULED H�RE� 'Ogee BODILY INJURY(Per aoddenk $ X AUTOS ONLY X AUTO ONLY PROPERTY DAMAGE $ P acdEaM) $ A X UMBRELLA LIMB X OCCUR EACH OCCURRENCE $ 2,000,000 EXCESS LIAB CLAIMS-MADE 5J1803119 9/1/2018 9/1/2019 AGGREGATE $ 2,000,000 DED X RETENTION$ 10,000 $ B WORKERS COMPENSATION X STATUTE ER AND EMPLOYERS'LIABILITY OTH- ANYQFFl�PR�OR�P�RlEIETOR/PARTNERIEXECUTNE Y/N V9WC011676 3/212019 31212020 EL.EACH ACCIDENT $ 500,000 (Mandatory In BER EXCLUDED? n N/A lmanda NH) EL.DISEASE-EA EMPLOYEE $It yes, 500,000 describe under 500,000 DESCRIPTION OF OPERATIONS below EL DISEASE POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE RISE Engineering THE CCO DANCE WITH THE POLICY P OTION DATE VISIONS.NOTICE WILL BE DELIVERED IN 5 Dupont Ave South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE 4: :,---000ume2 I 7/ ACORD 25(2016/03) 421988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID:E8C193EA-2B53-4065-BDAE-F02DA5D41397 Customer Name:Nancy Risio CONTRACT Email:nwr523@cox.net Phone:508-771-6412 Premise Address:8 Tabernacle Park,West Yarmouth,MA 02673 RISE Mailing Address:8 Tabernacle Park,West Yarmouth,MA 02673 Project ID:3862014 Date:July 31,2019 ENGINEERING' RISE Engineering 5 Dupont Avenue,Suite 2 South Yarmouth,MA,02664 Applicable Customer Required Actions: Notes: • Storage Removal Crawl space Measure Description Location Quantity Unit Total Cost CuStonier Cost DUCT INSULATION 10 SF $40.00 $10.00 Duct Sealing-4 Hours(not insulated,up to 200') 1 each $337.28 $0.00 AIR SEALING 10 hr $800.00 $0.00 WEATHERSTRIP DOOR&ADD SWEEP 3 each $240.00 $0.00 COMMON WALL:2"RIGID BOARD 40 SF $154.00 $38.50 VENTILATION CHUTES 46 each $160.54 $40.13 SHEATHING ACCESS 1 each $35.00 $8.75 PULL-DOWN STAIR:THERMADOME,BUILT-UP 1 each $237.65 $59.41 INSULATED BATH EXHAUST HOSE 2 each $120.00 $30.00 CRAWLSPACE WALL R10 RIGID BOARD 238 SF $963.90 $240.98 REMOVE EXISTING INSULATION-CRAWLSPACE 80 SF $77.60 $77.60 INSULATE BULKHEAD DOOR 1 each $110.00 $27.50 Total: $3,275.97 Program Incentive: -$2,743.10 Customer Total: $532.87 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF ***Five Hundred And Thirty-Two And 87/100 Dollars $532.87 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. —Docusigned by: DO NOT SIGN THIS CONTRACT IF TTHERA,agegity BLANK SPACES R15E-�e l a1161 brisiyng3 7/31/7 1� 9 1 4:13 PM EDT Sign Date Page 1 of 2 • Commonwealth of Massachusetts Construction Suheryisor - Division of Professional Licensure _ Unre0(ricted-Buildings of any Board of Building Regulations and Standards less than 35,000 cubic feet(991 cubic group m ens)off enclosed yea ConstrtfCtt`ori'5upervisor r space, • i CS-095581 - xpires_05/12/2020 WILLIAM CARLAHAN , a I 'ITO QUINCY SHORE DR { B81 "t QUINCY MA 02111. - • Failure to T - I c,= `` possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. diaCommissioner For information about this license —_.�ssl. - v.: Call(917)72T3200 or visit ---_-- — www.mass govldpt • t_74 Ke-,,m2-40-/-4diey, 4- Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, M.A '.chusetts 02118 Home Improvem=a: 'iitractor Registration ' = Type: Supplement Card EFFICIENT BUILDINGS LLC 11 t , -� - -,j� f� Registration: 169944 973 REED ROAD r ,= . n t Expiration: 08/18/2021 NORTH DARMOUTH,MA 02747 i ;I }--7 i _ ; I r_. scA 1 0 20M-05/17 Update Address and Return Card. J/lP. �imnzae¢�/ 0�✓�2ri•J.J¢cZil - - - ---- _.-- Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE4.Supolement Card before the expiration date. If found return to: Repistiatlo Expiration Office of Consumer Affairs and Business Regulation x� 08/18/2021 eg ation r .- rN 1000 Washington Street -Suite 710 EFFICIENT e� " Boston,MA 02118 - t11 W ILLIAM CALLAhiAlC ^, ``wCX 973 REED ROAD a.i'/, ,k �./�J Q � NORTH DARMOUTH,MA 02747 Undersecretary Not valid without signature • The Commonwealth of Massachusetts 1 1._ Department of Industrial Accidents —e �- 1 Congress Street,Suite 100 a E 1 ' Boston,MA 02114-2017 I. 4....- www s mas 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 25 employees(full and/or part-time).' 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 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.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.CI I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0Roof 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.D 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:National Liability& Fire Insurance Company Policy#or Self-ins.Lic.#:V9WC011676 Expiration Date:03/02/2020 Job Site Address:8 Tabernacle Park City/State/Zip:W Yarmouth MA 02673 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 penaldes of erjury that the information provided above is true and correct. Signature: k .e.t ill a-44 1 Date: 6 (I ' I 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#: DocuSign Envelo•e ID:E8C193EA-2B53-4065-BDAE-F02DA5D41397 Permit Authorization mass SaVe Form Site ID: 3862014 Customer: Nancy Risio Nancy Risio ,owner of the property located at: (Owner's Name,printed) 8 Tabernacle Park 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. r—DocuSIgned by: Owner's Signature: 7/av — t't"4"r(71.2 �--U ioAstbtn4ba4a4... Date: 7/31/2019 I 4:13 PM EDT FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: fft.e.,t;e4/1' -�-- I)CLI -7 31 . r g Participating Contractor () Date Name: RISE Engineering Phone: 401-784-3700 Email: Page 1 of 1 RPV. 1 rvn1 S For Office Use Only 1 • I DEBRIS FORM In accordance with the provisions of MGL c.40,s.54,a condition solid waste disposal fis acility the debris resulting of Building Permit NumberY as defined by from this Work shall be disposed of in a properly licensed Ma C.211 s. t This Debris will be di , 150A. i disposed of in: 1 (LOCATION OF FACILITY) �v/� /� 06/ 7Lj 7 ‘ 4...L6'&#/—°—‘j Signature of Permit Applicant `'— 1 ! Date • IF®t1MpSTteR IS USED IN EXC SS THE FIRE DEPARTMENT# R OF SIX 6 CUBIC YARDS A PERMIT FROM T UtREp 1 FOR COMMERCIAL INDUSTRIAL INSTITUTIONAL AND MULTI-FAMILY RESIDENTIAL OVER 20 UNITS DEMO, RENOVATIONS OR ALTERATIONS OF THE EXISTING BUILDING: CIRCLE ONE *HAVE YOUSi1B!}ln7TED THE,q NOT !CATION TO THE ASSACHUSE7TS D P? ` YES NO