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HomeMy WebLinkAboutBld-20-000039 Office Use Only Permit# Q Amount } "�+*w,�•"�,Ca?. Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 I Ira hh 14 D�co(Q CONSTRUCTION ADDRESS: IQ+f1�. TC�� �• —L Q.C'h't.O l ASSESSOR'S INFORMATION: Map: Parcel: OWNER: Q)Qr \ Ciro btane. UR Scid' 3Qg •07158 NAME �rPRES ADDRESS A' TEL CONTRACTOR: tarn CA. (1 t&rt 8t,t 1(Itv c. 410 ReedJ)4. 3b8•819.111!7 NAME MAILM ADDRESS TEL.# Residential 0 CommercialEst.Cost of Construction$ 31 C)0O Home Improvement Contractor Lic.# I( Q u (,f0 j -1 'i 1 Construction Supervisor Lic.# (.S' ag55g' Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor I have Worker's Compensation Insurance Na �o � L\o kit IA-4 �r‘,r�=.nsuro.r%C.€ L� p V W L0 116-1�o Insuran om Name: Worker's Comp.Policy# 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 1 Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: ry U C M.)t s ec&1 4-13 ,Q.e_l1 qRd. N b.fi nbook W pi4 & 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 prosecutions� under M.G.L.Ch.268,Section 1. Applicant's Signature: �, o/ 0-11•(.A' Date: �// QP • I V• 19 Owners Signature(or attachment) te/I' 6 -G__9-ci0 Date: Approved By: / y / Date: J ` 1 C Building Official(or designee EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes G No Flood Plain Zone: ❑ Yes G No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes ❑ No 0 Yes 0 No • EFFIBUI-01 CFOGARTY '`��Rom- CERTIFICATE OF LIABILITY INSURANCE DATE 3/1/0119 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 POUCIES 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 NAM ACT 434ere Gray Insurance Agency,Inc. PHONE FAx (ac,No,Ert):(800)553-1801 �(ac,No):(877)816-2156 134 South Dennis,MA 02660 Mks;mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Employers Mutual Casualty Company 21415 INSURED INSURER 13: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 POUCY EXP I TYPE OF INSURANCE NSD y�yy�p POLICY NUMBER INDI POLICY (SILVDDNYTY1 LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 5D1803119 9/1/2018 9/1/2019 DMGO EoNscTuEnDe $ 500,000 _ 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 FM: X LOC PRODUCTS-COMP/OP AGG $ 2,000,000 I OTHER: $ A AUTOMOBILE LIABILITY ICOMBINEDaccident) SINGLE LIMIT $ 1,000,000 ANY AUTO 5Z1803119 9/1/2018 9/1/2019 BODILY INJURY(Per person) $ OWNEDSCHEDULED AUTOSRE� ONLY v AUTOS y�N p BODILY INJURY(Per accident) $ X AUTOS ONLY X AUTOS ONLY (Pe0®ERTY DAMAGE )) 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 X STATUTE ER AND EMPLOYERS'UABIUTY Y/N V9WC011676 3/2/2019 3/2/2020 500,000 ANY PRRO/PRIIETgO�R�/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ (MMandatory�In NH)EXCLUDED? N/A 500,000 E.L.DISEASE-EA EMPLOYEE,$ If yes,describe 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 POUCIES BE CANCELLED BEFORE THE NOTIC RISE Engineering ACCORDANCE WITH THE POLICY PRODATE VISIONS.E WILL BE DELIVERED IN 5 Dupont Ave 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:Barbara Petrie CONTRACT Email:petrieb@gmail.com Phone:508-398-2158 Premise Address:182 Diane Avenue,South Yarmouth,MA 02664 RISE Mailing Address:182 Diane Avenue,South Yarmouth,MA 02664 Project ID:3833136 Date:June 7.2019 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 7 hr $560.00 $0.00 WEATHERSTRIP DOOR&ADD SWEEP 1 each $80.00 $0.00 ATTIC DAMMING-R-38 FIBERGLASS 65 SF $159.90 $39.97 ATTIC FLAT-7"OPEN R-26 CELLULOSE 930 SF $1,283.40 $320.86 COMMON WALL:2"RIGID BOARD 16 SF $61.60 $15.40 VENTILATION CHUTES 54 each $188.46 $47.11 Total: $2,333.36 Program Incentive: -$1,910.02 Customer Total: $423.34 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF ***Four Hundred And Twenty-Three And 34/100 Dollars $423.34 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 ANY BLANK SPACE RIS epresen tive 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 Page 1 of 1 ` Commonwealth of Massachusetts �, Construction Supervisor '. Division of Professional Licensure Unrestricted-Buildings of any use group which contain less than 36,000 cubic feet(991 cubic meters)of enclosed Board of Building Regulations and Standards i • COnstntctibri Supervisor space. CS-095581 Empires:05/12/2020 WILUAM CALLAHAN - ,. I 175 QUINCY Sli ORE DR _ ` B81 ) QUINCY MA 02171, '" ` Failure to possess a current edition of the Massachusetts . (I State Building Code is cause for revocation of this license, 4.CAL „--- For information about this license Commissioner Cali(617)727-3200 or visitwww,mass.govldpt Q9L `620/~toziutie /t1 orgiicedelackaea 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: 08l18/2019 • BRIDGEWATER,MA 02324 Update Address and Return Card. SCAI C: 20M-0511: /VinsPAiiriJRelOffcce of Coumerffaais 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 ILUAM CALLAHAN e-P- 300 ELM ST �R"� — (JL/ ai4540., BRIDGEWATER,MA 02324 Undersecreta Not valid without signature ry The Commonwealth of Massachusetts ` 1, Department of Industrial Accidents 1Ni sitimi•Ni1- 1 Congress Street,Suite 100 . _ Boston,MA 02114-2017 ' '. www mass goy/dia IMP 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. 0 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.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El 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.❑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. 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.ID 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: 182 Diane Avenue 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 hereby1 certify' under the pains and�penalties of perjury that the information provided above is true� correct.and L/' rf'S��Signature: `— C Ca /►r\ Date: (0' ( " • 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#: Permit Authorization mass save Form Site ID: 3695769 Customer: Barbara Petrie to r L A ru re; CC ,owner of the property located at: (owner's Name,printed) 182 Diane Avenue 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: go4,40140....& Date: V 7 1 / FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: gu_LO.Ln' 1/1 Participating Contractor Date Name: RISE Engineering Phone: 401-784-3700 Email: Page 1 of 1 For Office Use Cnly Rev.102015