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HomeMy WebLinkAboutBld-20-000155 , 0 ce Use 0nlyai 0`O ao OF7'.9R mu l, C Amount li . � Permit expires 180 days from "� M�q x`��_� issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 vr, ADDRESS: 1, L/ i n Cl Yv es- L n S . Ack c-oo k CONSTRUCTIONJ 1/4 ASSESSOR'S INFORMATION: �� IMap: 77 I Parcel: n� P 1 OWNER: ,'1, 1����-11 Ma. r f-2g L31 n d m Yl'�.er `-nTEL.q + (3-(a3�. 131a`�NAMEI 1- ` PRESENT AA�DDRESS CONTRACTOR:W 1)1 10.Yr\ Ca 16( 1'1C*Vi Ch 3 .ee. Z a N baA mAA/AA A & 'a '1 110 . NAME MAILING ADDRESS TEL.# esidential 0 Commercial Est.Cost of Construction$ i' �C Home Improvement Contractor Lie.# le I t 9-4 Construction Supervisor Lie.# C6-`^i 8 I Workman's Compensation Insurance: (check one) 13 I am the homeowner I am the sole proprietor I have Worker's Compensation Insurance (� � ce' Mx+ot�y.I (-tQb►1 t+.4 4'Ct r'e SnSoRanc Worker's Comp.Policy V 1 (i ten to Insurance Company Name: WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # 1 / Remove existing*(max.2 layers)Roofing: #of Squares ( ) y ) Insulation ✓ Old Kings Highway/Historic Dist. ( )Replacing like for Iike Pool fencing OSQ T ) R�Z d 1\) INAA. wi r4 r 1 �7 *The debris will be disposed of at: 1)1,5f 1 T r 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 der M.G.L.Ch.268,Section 1.J Applicant's Signature: a Y\ W C .A C(..� Date: '21' I G Owners Signature(or attachment) �.� C 1 1 f-b Date: Approved By: Date: Building O i•a!(, ..'si_ 0EMAIL AD S: Zoning District: Historical District: 5 Yes 2 No Flood Plain Zone: Yes - No Water Resource Protection District: Within 100 ft.of Wetlands: Yes _! No 2 Yes IT No • ____.,.......NN EFFIBUI-01 CFOGARTY A`��- CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/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). PRROODUCER COaIEACT R434 Rte 1�34ray Insurance Agency,Inc. PHONE I FAX No):(877)816-2156 (NC,No,Ext):(800)553-1801 South Dennis,MA 02660 n Rss:mail@rogersgray.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: 973 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 TYPE OF INSURANCE ADDL SUBR POUCY NUMBER POUCY EFF POUCY EXP LIMITS LTRINSD MD_ ,(MMIDD/YYYY) (MMIDOIYYYY) A X COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR i 5D1803119 9/1/2018 9/1/2019 DAMAGE TO RENTED 500,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X JECT X LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY (EOaMBINEent)SINGLE LIMIT $ 1,000,000 — ANY AUTO 5Z1803119 9/1/2018 9/1/2019 BODILY INJURY(Per person) $ OWNED AUTOS E��DONLY X SCHEDULED SWULNEDp BODILYO INJURY(Per accident) $ . Ma ONLY X AUTOi ONLY (Perr acadentDAMAGE $ $ A X UMBRELLA LIAB 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 PER OTH- ERAND EMPLOYERS'UABIUTY Y/N X STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE V9WC011676 3/2/2019 3/2/2020 500,000 FFICER/MEEXCLUDED? NIA E.L.EACH ACCIDENT $ (Mandatory�ltag 500,000 E.L.DISEASE-EA EMPLOYEE $ If yes,desc ibe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I 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 EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 5 Dupont Ave ACCORDANCE WITH THE POUCY PROVISIONS. South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Customer Name:Mitchell Mazur CONTRACT Email:terimarinello@charter.net Phone:413-636-1312 R I S E Premise Address:28 Windjammer Lane,South Yarmouth,MA 02664 Mailing Address:28 Windjammer Lane,South Yarmouth,MA 02664 Project ID:3841569 Date:June 20,2019 ENGINEERING' RISE Engineering 5 Dupont Avenue,Suite 2 South Yarmouth,MA,02664 Job Description Measure Description Location Quantity Unit Total Cost Customer Cost AIR SEALING 2 hr $160.00 $0.00 REMOVE EXISTING INSULATION-CRAWLSPACE 224 SF $217.28 $217.28 CRAWLSPACE WALL R10 RIGID BOARD 130 SF $526.50 $131.62 CRAWLSPACE:INSULATE DOOR 1 each $60.00 $15.00 CRAWLSPACE:10 MIL GROUND COVER 246 SF $238.62 $0.00 Total: $1,202.40 Program Incentive: -$838.50 Customer Total: $363.90 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF ***Three Hundred And Sixty-Three And 90/100 Dollars $363.90 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 TH PA 1 � RISE Re• :live us er Signature Sign Date fted° e ? NOTE:THIS CONTRACT MAY BE WITH. N 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 Page 1 of 1 Commonwealth of Massachusetts Construction Supervisor •�. Division of Professional Licensure Unre§tricted-Buildings of any use group which contain less than 35,000 cubic feet(991 cubic meters)of enclosed Board of Building Regulations and Standards Construction-Supervisor space. • CS-095581 Expires:05/12/2020 WILLiAM CALLAHAN 175 QUINCY SHORE DR 1 B81 1 QUINCY MA 02171 ''� � f Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation • CALy1'! os of this license. �dr,<< `�J For information aboutthis license Commissioner Cali(617)727�200 or Visitwww,mass.govldpl Q-/Xe W04211/FiteXii,WeCtia ?P_ATZdaeibtaeea 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 1 O 2Qti-05117 ''i%nrmn„raid r. ^flazar/asel --- Office of Consumer/Affairs Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Supplement Card before the expiration date. if found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 169944 08/18/2019 One Ashburton Place-Suite 1301 EFFICIENT BUILDINGS LLC Boston,MA 02108 W ILLIAM CALLAHAN ( t$ 7 BRIDGEWATER,MA 02324 Undersecreta Not valid without signature ry The Commonwealth of Massachusetts 1.iDepartment of Industrial Accidents =i,l_ 1 Congress Street, Suite 100 i11E_ __ 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): I.0 I am a employer with 25 employees(full and/or part-time).* 7. D 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 3.1=I I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Q Building addition 4.El 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 repairs These sub-contractors have employees and have workers'comp.insurance.I 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.1:pOther 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 s- LI f lc:0" iWIR Job Site Address: as t►r1& o V)'► vt�e r �-n City/State/Zip: p (4,Q,14 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 undery the pains and penalties of perjury that the information provided above is true and correct. Signature: L Qi?.L;,,,,, C X( ct iCL 4'1 Date: CP/c 7 ) 19 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 i mass save Form ' Site ID: 3837699 Customer: Mitchell Mazur I, in )4,ewe( 4 m imitge ,owner of the property located at: (Owner's Name,printed) 28 Windjammer Lane 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 obt-'• a building permit to perform ins nand/or weatherization work on my property. Joe Owner's Signature. L _ �. Date: ` • j r /pp FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: l TiA,Ccre-, _ 1304 1)CIA;1 6 -1° t9 Participating Contractor U Date Name: RISE Engineering Phone: 401-784-3700 Email: Page 1 of 1 For Office Use Only Rev. 102015