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Bld-20-005001 •• ice Use Only Y14 66emi diots J f t. 'r O . yi H � Amount I ruTi n v._ �,"`^�••�•" Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICA1 ION: � „ ._.c TOWN OF YARMOUTH Yarmouth Building Department YIAR 1146 Route 28 South Yarmouth, MA 02664 R (508) 398-2231 Ext. 1261 v , 2,97,"1 CONSTRUCTION ADDRESS: 110 Captains Small Road ASSESSOR'S INFORMATION: Map: Parcel: OWNER: Cheryl Keane 110 Captains Small Road 617-842-7735 NAME PRESENT ADDRESS TEL. # CONTRACTOR: Scott Veggeberg 101 Station I anding Medford MA NAME MAILING ADDRESS TEL.# 'Residential ❑Commercial Est.Cost of Construction$ 4940 Home Improvement Contractor Lic.# 181138 Construction Supervisor Lic.# 103832 Workman's Compensation Insurance: (check one) 1 am the homeowner I am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: NH Employers Insurance Company Worker's Comp.Policy# 4001017 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. ( )Replacing like for like Pool fencing *The debris will be disposed of at: 2510 B Cranberry Highway Wareham Location of Facility 1 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 vocation o my lice se and for prosecution under M.G.I.,.Ch.268,Section 1. Applicant's Signature: At Date: Y6-7?..._c.) Owners Signature(or attachment) C � kxeti Date: Approved By: am' Date: — kb Building Official(or de nee EMAIL ADDRESS: Zoning District:_ Historical District: Yes . No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No . Yes No The Commonwealth of Massachusetts Department of Industrial Accidents t h Office of Investigations 600 Washington Street Boston, MA 02111 ' `, www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Homeworks Energy Address: 101 Station Landing Ste 110 City/State/Zip:Medford MA 02155 Phone #:(781) 305-3319 x5007 Are you an employer?Check the appropriate box: Type of project(required): 1.❑■ I am a employer with 200 4. fl I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. El New construction listed on the attached sheet. 7. ❑ Remodeling 2.❑ l am a sole proprietor or partner- ship and have no employees These sub contractors have 8. ❑ Demolition working for me in anycapacity. employees and have workers' g p Y• 9. ❑ Building addition [No workers' comp. insurance comp. insurance.* required.] 5. ElWe are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 11.❑ Plumbing repairs or additions 3.El t am a homeowner doing all work myself. [No workers' comp. right of exemption per MGL 12.17 Roof repairs insurance required.] c. 152, §I(4),and we have no Weatherization employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information. ' 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: Safety Indemnity Insurance Company Policy#or Self-ins. Lic. #:4001017 Expiration Date:1/1/2021 Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that 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 penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#:(781) 305-3319 x5007 / wxpermitting@homeworksenergy.com 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#: -....^iN HOMEENE-01 LLARIVIERE ACORO CERTIFICATE OF LIABILITY INSURANCE DATE /DD/YYYY) �1...►-' 12/192/19/2019 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 CONTACT Lisa Lariviere NAME: Foster Sullivan Insurance Group,LLC PHONE FAX 163 Main Street (A/C,No,Ext):(978)686-2266 301 (A/C,No):(978)686-6410 North Andover,MA 01845 R-61 Ess:certificates@fostersullivangroup.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A_Homeland Insurance Company NY 34452 INSURED INSURER B:Safety Indemnity Insurance Company 33618 Homeworks Energy Inc. INSURER C:NH Employers Insurance Company 13083 Homeworks IIC LLC 101 Station Landing Suite 110 INSURERD: Medford,MA 02155 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 POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD, IMMIDD/YYYYI IMM/DDIYYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 7930060650002 4/1/2019 4/1/2020 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 JECOT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ ANY AUTO 6244378 4/1/2019 4/1/2020 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY X AUTOS BODILY BODILY INJURY(Per accident) $ X HIREDTOS ONLY X AUUTOS ONLDY (PerP accident DAMAGE $ $ A UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 X EXCESS LIAB CLAIMS-MADE 7930060660002 4/1/2019 4/1/2020 AGGREGATE $ 2,000,000 DED X RETENTIONS 0 i $ C WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY X STATUTE ER YIN ECC-600-4001017-2020A I 1/1/2020 1/1/2021 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE N N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Evidence Only CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Homeworks EnergyInc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 101Station Landing Ste 110 Medford,MA 02155 AUTHORIZED REPRESENTATIVE —i'—vL 4 ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD -77 I///' ' i'//I.ri�f'ti:J`irt/rl:. f'lt. ,/,/.!/.i-rfr`i i!i•s� fi•.% Office of Consumer Atlairs and Business Regulation 1000 Washington Street-Suite 713 Boston.Massachusetts 02118 Home Improvement Contractor Registration Typo C.rrporuri:-� Rgawtrjkon 1811:'fi HOVE b'CRkS ENERGY.!tiC. Ery;datrn U3'!i's. UU° :31 STA1!ONLANDiNG STE 41EDF=3RD.LIA 021`i5 Update Address and Return Cord. CXrice of C oeiui'1e!Atfahs 8 54.91,e4A ReOUIS:10n R 49'eltpn v0l d for Int-!dual y;a aMy SOME WI PP OU FM ENT-.'N�RACt ORenr TYPE: before the expootio n doe.If round return on ptcalstrater, radon Off=of Consumer Atf,n s and Business RegutMion 151 t3d 33+T YD'- loan Was hYlpf1 Street-Bulls 719 Boston,MN 9211 IE;Sr TQN u1 tit i;S-E.1 2 valid without signature -WEERr G 0.1;:G 55 11ndsrsfo n1nr) `. t^' C:oa nt.,r,w+>.11tr, ,t:nu;.1trs Construction Sup:. ,-;nr Specialty .rrn B n,4ry .r Rnr,Itt1,; IirOtt,ns 1,11 =:r.aty, ar,-i, RtStncted to.. CSSl--1C•Insulation Contractor C SSI 103832 Kxptres. 10,13;2021 SCOTT VEGGEBERG 8 COVINGTON ST#1 BOSTON MA 02127 W #f Failure to possess a ctr 'Mon of the Massachusetts State Building Code is r revocation of this license- 4 ,, tt•, „' For inlorrntt .,bout this license Call(617)727-3200 or visit www mass.govfdpl HOMEENE-01 LLARIVIERE ACCJRU CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) �. 12/19/2019 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 CONTACT Lisa Lariviere NAME: Foster Sullivan Insurance Group,LLC PHONE FAx 163 Main Street (A/c,No,Eat):(978)686-2266 301 (A/C,No):(978)686-6410 North Andover,MA 01845 E-MAILDSS:certificates@fostersullivangroup.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Homeland Insurance Company NY 34452 INSURED INSURER B:Safet(Indemnity Insurance Company 33618 Homeworks Energy Inc. INSURERC:NH Employers Insurance Company 13083 Homeworks IIC LLC 101 Station Landing Suite 110 INSURER D: Medford,MA 02155 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 POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTRINSR WVD (MM/DD/YYYYI IMM/DD/YYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 7930060650002 4/1/2019 4/1/2020 DAMAGE TO RENTED 500,000 PREMISES(Ea occurrence) $ MED EXP LAny one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 J PRO- JECT 2,000,000 POLICYLOC PRODUCTS-COMP/OP AGG _$ OTHER: $ COMBINED SINGLE LIMIT 1,000,000 B AUTOMOBILE LIABILITY (Ea accident) $ ANY AUTO 6244378 4/1/2019 4/1/2020 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY X AUTOS BODILY INJURY(Per accident) $ X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY ( ) $ A UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 X EXCESS LIAB CLAIMS-MADE 7930060660002 4/1/2019 4/1/2020 AGGREGATE S 2,000,000 DED XJ RETENTION$ 0 C WORKERS COMPENSATION )f PER X STATUTE EOTH AND EMPLOYERS'LIABILITY ECC-600-4001017-2020A 1/1/2020 1/1/2021 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE r N/A E.L.EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? I " (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Evidence Only CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Homeworks Energy Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 101Station Landing Ste 110 Medford,MA 02155 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Insulation/Air Sealing Permit Authorization Specialist: Ben Wollman Company: HomeWorks Energy Email: benjamin.wollman@homeworksenergy.com Address: 101 Station Landing Cell: (508)292-2630 Medford,Ma 02155 HotTleWorkS Phone: 781-305-3319 Customer: Cheryl Keane Address: 110 Captain Small Rd Email: 0 South Yarmouth,MA,02664 Site ID: 3927500 Phone: 617-842-7735 1,the owner of the property identified above hereby authorize HomeWorks Energy Inc.,or their Partner to act on my behalf in obtaining any building permit that maybe required to perform insulation and/or Weatherization work on my property and all matters related to the work authorized by said permit if one is obtained. Any related permit application cost will come at no additional charge provided that the agreed Weatherization work is completed. Customer Signature: _ Date: 11/16/2019 Cheryl Keane. Page 1 c HomeWoiks mass save EnverC`\;', Inc PARTNER 101 Station Landing Ste 110,Medford,MA 02155 (781)305-3319 ex:.120 Customer Name:Cheryl Keane Email:Not provided Phone:617-842-7735 Premise Address: 110 Captain Small Rd.Yarmouth,MA 02664 Mailing Address: 110 Captain Small Rd,Yarmouth,MA 02664 Project ID:3934481 Date:Nov. 16,2019 Job Description Measure Description Location Quantity Unit Total Cost Customer Cost AIR SEALING Other 6 hr $480.00 $0.00 INSULATE BULKHEAD DOOR Other 1 each $110.00 $27.50 WEATHERSTRIP DOOR & ADD SWEEP Other 4 each $320.00 $0.00 ATTIC FLAT- 8"OPEN R-30 CELLULOSE Other 730 SF $1,051.20 $262.80 ATTIC FLAT- 6" OPEN R-22 CELLULOSE Other 958 SF $1,264.56 $316.14 ATTIC FLAT- 10" FLOORED R-32 DENSE CELLULOSE Other 128 SF $276.48 $69.12 VENTILATION CHUTES Other 150 each $523.50 $130.87 VENT BATH FAN THRU ROOF Other 1 each $118.75 $29.69 INSULATED BATH EXHAUST HOSE Other 1 each $60.00 $15.00 ATTIC DAMMING- R-38 FIBERGLASS Other 180 SF $442.80 $110.70 Total Contractor Price and Payment Schedule IiomeWork.s Energy, Inc. agrees to perform the above described work,furnishing the material and labor specified for the listed tota price. Payment of the balance of the customer contribution is expected upon completion of the work. Customer Signature: Date: Customer Phone: Specia ist Signature: Date: LIMITED TIME OFFER: The orices and incentives in this contract are subject to change it accordance with the sponsoring utility MassSave Home Services Program offers. Proposals can be sent to:tnboxi HomeWorksEeergy.com Page 2c • 4#04i mass save Energy, Inc ft. PARTNER 101 Station Landing Ste 110,Medford,MA 02155 (781)305-3319 ext. 120 Customer Name:Cheryl Keane Email:Not provided Phone:617-842-7735 Premise Address: 110 Captain Small Rd,Yarmouth:MA 02664 Mailing Address: 110 Captain Small Rd,Yarmouth.MA 02664 Project ID:3934481 Date:Nov. 16,2019 Project Total $4,647.29 Weatherization incentive ($2.885.47) Pre-Weatherization barrier incentive ($107.52) Air sealing incentive ($800.00) Total Program Incentive -$3,792.99 Customer Total $854.30 Total Contractor Price and Payment Schedule HomeWorks Energy, Inc. ag"ees to perform the above described work,furnishing the material and labor specified for the listed tota price. Payment of the balance of the customer contribution is expected upon completion of the work. Customer Signature: (j -C_ ` Date: 1 1 t� � Z Customer Phone: � t T' � � _�1- 3 Specialist Signature: ,�G' �-�LI'` Date: V 4 Zal LIMITED TIME OFFER: The prices and incentives in this contract are subject to change it accordance with the sponsoring utility MasaSave Home Services Program of'ers. Proposals can he sent to:tnboxfa'HomeWorks£nergy.com