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HomeMy WebLinkAboutBld-20-003683 Office UseOnly Permiat 3c— ituthte.imisodays flag issuo.4ate EXPRESS BUILDING FERMI APPLICATION TOWN OF YARMOU Yarmouth Building 0-- •• eat • 1146 Route 28 South Yannouth,MA 024 • C,Ka(( a (508)398-2231 Ext. 12:1 CONSTRUCTION ADDRESS: , 11Kr P.0-1-4 w . OA 03-4 73 ASSESSOR'S INFORMATION: Map: Parcel: OWNER: S tiS C cbt/ 15 KPt 1,../ NAME PRESENT ADDRESS TEL. # CONTRACTOR: P.01 and ( 2-ttrIn (110 Corzfve_ Q've.. IAA 5Dr-SID 7-6 7 NAME MAILING ADDRESS TEL.# pesirleMial 0 Commercial Est •• of Construction$ 7 •5—D- Home Improvement Contractor Lk.# 1 "7(1-7 Supervisor Lk.# Workman's Compensation Insurance: (check one) am the homeowner 0 I am the sole proprietor /).(I have Worker's .. -I. • Insurance Insurance Company Name L1 t447tl Wl worker' Comp.policy,/ Xi.J.S. St*LI,g7 WORK TO BE PERF rD Tent Duration (Fire Retardant Certificate attached. Wood Stove Siding: #of Squares ReplarPnvet windows:# Replacement doom: # Roofing: #of Squares ( )Remove existing*(max.2 layers) insulation 2( Old Kings Righway/Historic Dist ( )Replacing like for like Pool fencing *The debris will be disposed of at: 1080 A;re- Feli ,ref ilA 0)-77-c) don of Facifity I declare under penalties of perjury that the statements herein contained are true and comsct.to the best• my knowledge and belief I understand that my false auswer(s) will be just cause for denial orrevocation of morseeirid 'on under M.G.L.Ch.268,S I. Applicant's Signature: Date: )-0/I Owners Signature(or attachment) Date 2-0/1 Approved By: Date: /— —.20- Building* ) EMAIL : Zoning District: Historical District 0 Yes 0 No Flood Plain* e: 0 Yes C No Water Resource Protection.District: Within 100 of Wetlands: C Yes 0 No C Y No The Commonwealth of Massachusetts it.INV ME et Department of Industrial Accidents .,..:—All.....- 0 1 Congress Street,Suite 100 t Tiiiiiiiir 1 Boston, MA 02114-2017 www.mass.gov/dkt 'ZillmeNA Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legiblv Name(Business/Organization/Individual); Insulate2Save Inc. Address:410 Grove Street City/State/Zip: Fall River MA 02720 Phone#: 508-567-6706 Are you an employer?Check the appropriate box: Type of project(required): 1,D I am a employer with 20 employees(full and/or pare-time).' 7. 0 New construction 2.0 t 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. El Demolition 30 I am a homeowner doing all work myself.(No workers'comp.insurance required.]' 10 El Building addition 4,0 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. 12.0 Plumbing repairs or additions 5 0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.; .s. El6.0 We arc 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. i.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: Liberty Mutual Insurance Policy#or Self-ins, Lic.#: XWS 56418741 Expiration Date: 12/10/2020 r Job Site Address: Is- kft's-k...-' P,A City/State/Zip: 0 le '.lit rvi 0)4 7 3 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the s ,' ianp e ' s of perjury that the information provided above is true and correct. fill Signature: Date: I V-.)-4f)//9 Phone#: 508-567-6706 — — Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: DEBRIS FORM In accordance with the provisions of MGL c.40,s.54,a condition of Building Permit Number is that the debris resulting from this work shall be • of Ina properly ilce+sed solid waste disposal facility as defined by MGL c.111,s. 150A. This Debris will be disposed of in: Republic Services Dumpster: 1080 Airport Rd Fall River, MA 02720 (LOCATION OF FACILITY) /11 / Signature of Permit Applicant 12-/2-0/iq Date IF DUMPSTER IS USED IN Exq OF SIX §Z CUBIC YARDS A SIR - IL FIRE DEPARTMENT IS REQUIRED FOR COMMERCIAL INDUSTRIAL INSTITUTIONAL AND MULTI-FAMILY RESIDENTIAL OVER 20 UNITS DEMO, RENOVATIONS OR ALTERATIONS OF THE EXISTING BUILDING: CIRCLE ONE •r NAVE YOU SWATTED THE A406 NOTIFICATION isumk MASSACHUSETTS DEP? YES NO .//'fi t' r Z✓ - �G ' ' 1/,— Office of con$umer � $ tt 1 -Sum 710 ab Boston, 4 • µA�� 02118 f 1# RTC nSAVE �r ,5 114 x.«... � +ems ton 24StJL"S i G S , L/. £ , :.a=,°.i .A o a` 1 i F�+A�A1,,;t' +��+ Ryy MA 3', LLfFI'ir 4.7 fie s ter° c... Office Cf. t 40112812Uid 1W •Sidi*rffi INSULATE 2 SA Behr►,MA Cells iM CY‘CC;Q*.r" 0111:1 17 *t- FAUMIVERt3 �t„ r �'�02.720 tftt virnd A stoode!/1* p ' n ay A G Ef CERTIFICATE OF LIABILITY INSURANCE DAT M/DD/YYY) 12/13/19 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 CON]ACT NAME: Anthony F.Cordeiro Insurance PHONE F�08-677-0407 FAX 171 Pleasant Street ° � (ac,No): 508-677-0409 Fall River,MA treat ADDRESS: hsou�cordeiroinsurance.com INSURER(S)AFFORDING COVERAGE NAIC#I INSURER A: Liberty Mutual Insurance INSURED INSURER B: Insulate 2 Save,Inc. INSURER C: 410 Grove St. INSURER D Fall River,MA 02720 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 POUCY 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.UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AIA,CoUbet POLICY EFF POLICY EXP LTR TYPE OF INSURANCE LSD WVD POLICY NUMBER (MWDD/YYYY) (MWDD/YYYY) UMITS X COMMERCIAL GENERAL UABIL.ITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE El OCCUR DAMAGE TO-RENTED PREMISES(Ea occurrence) $ 300,000 MED EXP(Any one person) $ 5,000 A — Y Y BKS 56418741 12/10/19 12/10/20 PERSONAL&ADV INJURY $ 1,000,000 GCE(N'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY C',WI- n LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER AUTOMOBILE LIABILITY (Ea SINGLE LIMIT $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ A OWN SCHEDULED AUTOEDONLY x AUTOSS Y Y BAA 56418741 12/10/19 12/10/20 BODILY INJURY(Per accident) $ x HIRED x NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ $ X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 2,000,000 A EXCESS LIAR CLAIMS-MADE Y Y USO 56418741 12/10/19 12/10/20 AGGREGATE $ 10,000 DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N XI EA lJlE ER ANY PROPRIETOR/PARTNER/EXECUTIVEn Y XWS 56418741 12/10/19 12/1 O/2O EL EACH ACCIDENT $ 500,000 A OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POUCY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Proof of Insurance • CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth,MA 02664 AUTHORIZED /:fi �r �� 'r, ""* I ©19 ; 2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID:13467776-7C13-4023-93EB-2C2CF526454F Customer Name:Susan Ciulla CONTRACT Email:cottagepk38@comcast.net Phone:508-694-7856 Premise Address:15 Kristin Path,West Yarmouth,MA 02673 R i E 4"i Mailing Address:15 Kristin Path,West Yarmouth,MA 02673 Project ID:3924474 Date:Nov.5,2019 ENGINEERING off =esl<yE,ergized. R1SE Engineering 5 Dupont Avenue,Suite 2 South Yarmouth,MA,02664 Applicable Customer Required Actions: Notes: • Storage Removal Please remove loose flooring and cover the storage in • Flooring Removal the attic. .Inh llrscrrirtinn WEATHERSTRIP DOOR&ADD SWEEP 3 each $240.00 $0.00 ATTIC FLAT-10"OPEN R-37 CELLULOSE 888 SF $1,385.28 $346.33 VENTILATION CHUTES 84 each $293.16 $73.29 ATTIC DAMMING-R-38 FIBERGLASS 115 SF $282.90 $70.72 ATTIC HATCH:SEAL&INSULATE 2 each $120.00 $30.00 INSULATED BATH EXHAUST HOSE 2 each $120.00 $30.00 COMMON WALL:2"RIGID BOARD 72 SF $277.20 $69.30 AIR SEALING 15 hr $1,200.00 $0.00 4"x 16"SOFFIT VENTS 10 each $289.10 $72.27 ATTIC FLAT-6"OPEN R-22 CELLULOSE 384 SF $506.88 $126.72 Total: $4,714.52 Program Incentive: -$3,895.89 Customer Total: $818.63 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF ***Eight Hundred And Eighteen And 63/100 Dollars $818.63 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. T—Doousipned DO NOT SIGN THIS CONTRACT IF THE NK SPACES �tvUd OC.oivt, S SAAA, CitillA `—,3n5789BC7AFUR7 R6FAFFCCRR4C45d RISE Representative Customer Signature 11/7/2019 ( 2:40 PM PST Sign Date Page 1 of 2 DocuSign Envelo.- ID:13467776-7C13-4023-93EB-2C2CF526454F Permit Authorization maw " i Form swomoSite ID:3783680 Customer Susan Ciulla I, 5vs G (/29 ,owner of the property located at: (Owner's Name,prirted) 15 Kristin Path West Yarmouth, MA 02673 (Property Street Address) KO) 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 oowsIgned by: Owner's Signature: ttiSaan, arnrcocoonmE.4 11/7/2019 12:40 PM PST Date: * a a s o e s *a,a+ a as a * as c a c aa FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project s4,1>4e2satti •t. f z/b//'' Participating Contractor Date Name: RISE Engineering Phone: 401-784-3700 Email: Page 1 of 1 For Office Use Only Rev.102015 ." The Commonwealth of Massachusetts COLLECTOR COPY Town of Yarmouth Fiscal Year 2020 Real Estate Tax Bill Office of Collector of Taxes Jaye Anne Kesten: Town Collector Assessed Owner BM No. Based on assessments as of January 1,2019.Your Real Estate tax for the CIULLA SUSAN C 2966 fiscal year beginning July 1,2019 and ending June 30,2020 on the parcel of real estate described below is as follows: _ Tax Rate Residential Commercial Industrial Real Estate Values Per $1000 10.00 10.00 10.00 Residential -Land 125,000 CPA $103.47 Property Description and Location -Building 219,900 RE TAX $3,449.00 Parcel: 076.110 Commercial -Land -Building Deed Book/Page: 27634/0238 Residential Exemption Location: 15 KRISTIN PATH Total Taxable Value 344,900 Class: 1010Betterments& Liens: $.00 Lot Size: 8,712 SQFT Special Assessments Exemptions/Deferrals/Abatements: $-.00 Interest at the rate of 14%per annum will accrue on overdue Total Due FY 2020: $3,552.47 balances from the issue date until payment is made. 1st Payment Due 11/01/2019: $1,776.24 2nd Payment Due 05/01/2020: $1,776.23 Interest Due as of 12/27/2019 Interest: $.00 Demand: $.00 CIULLA SUSAN C Payments: $-1,776.24 15 KRISTIN PATH Due by71/01/2019 $.00 WEST YARMOUTH MA 02673 18002082020600002966000000000000 Fiscal Year begins July 1,2019 and ends June 30,2020 Payment Information: Abatement Information: Prior Balance information: Please return the top portion of this bill and Abatement Applications should be sent to: Our records indicate that your account has make checks payable to"TOWN OF Town of Yarmouth a prior year balance due in the following YARMOUTH."and mail to: Assessor's Office year(s): 1146 Rt 28 Town of Yarmouth South Yarmouth,MA 02664 Tax Collector's Office 1146 Rt 28 Abatement applications are due by 11/01/2019. South Yarmouth,MA 02664 For abatement related questions, For payment related questions, please call 508-398-2231 x 1222 Please contact the Tax Collectors Office at please call 508-398-2231 x 1233 508-398-2231 x 1233 for more information. Your Exemptions/Deferrals/Abatements Town Hall Hours: M-F 8:30 -4:30 The Commonwealth of Massachusetts TAXPAYER COPY Town of Yarmouth I Office of Collector of Taxes Fiscal Year 2020 Real Estate Tax Bill' Jaye Anne Kesten: Town Collector Assessed Owner Bill No. Based on assessments as of January 1,2019.Your Real Estate tax for the CIULLA SUSAN C 2966 fiscal year beginning July 1,2019 and ending June 30,2020 on the parcel of real estate described below is as follows: Tax Rate Residential " Commercial Industrial Real Estate Values 1 Per $1000 10.00 10.00 10.00 Residential -Land 125,000 CPA $103.47 Property Description and Location -Building 219,900 RE TAX $3,449.00 Parcel: 076.110 Commercial -Land Deed Book/Page: 27634/0238 -Building Residential Exemption Location: 15 KRISTIN PATH Total Taxable Value Class: 1010 344,900 Betterments &Liens: $.00 Lot Size: 8,712 SQFT Special Assessments Exemptions/Deferrals/Abatements: $-.00 Interest at the rate of 14%per annum will accrue on overdue Total Due FY 2020: $3,552.47 balances from the issue date until payment is made. 1st Payment Due 11/01/2019: $1,776.24 2nd Payment Due 05/01/2020: $1,776.23 Interest Due as of 12/27/2019 Interest: $.00 Demand: $.00 CIULLA SUSAN C Payments: $-1,776.24 15 KRISTIN PATH Due b 1 t/01/2009 $.00 WEST YARMOUTH MA 02673 Y 18002082020600002966000000000000