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HomeMy WebLinkAboutBLD-23-005943 CEIVED n'lajlrI/ g•Yq - p Office Use Only ' Wit; � � rAPR262023 I�� Permit# y�l�� O I y irk _ _ Amount 3 ;.� , O " �.;:";d$ Jr-- LDING DEPARTMENT ' _- ----- Permit expires 180 days from issue date —N5q14.3 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: I I CAPTAIN DORE ROAD ASSESSOR'S INFORMATION: Map: 67 Parcel: 175 OWNER: LOUISE LAFONTAINE I I CAPTAIN DORE ROAD,YARMOUTH,MA.02664 508-694-6757 NAME PRESENT ADDRESS TEL. # CONTRACTOR: MATTHEW RUSSELL- 3820 DIAMOND HILL ROAD,CUMBERLAND,RI 02864. 401-651-0003 NAME MAILING ADDRESS TEL.# ®Residential 0 Commercial Est.Cost of Construction$ 5,619.86 Home Improvement Contractor Lic.# I95309 (EXP.04/18/2025) Construction Supervisor Lie.# 106162(EXP..04/26/2025) Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor Ei I have Worker's Compensation Insurance Insurance Company Name: ARGONAUT INSURANCE CO Worker's Comp.Policy# WC928938765994 WORK TO BE PERFORMED Tent D Duration (Fire Retardant Certificate attached?) Wood Stove ri Siding: #of Squares Replacement windows:# Replacement doors: # Roofing:� #of Squares (❑ " )Remove existing*(max.2 layers) Insulation II I ' Old Kings Highway/Historic Dist. CT Replacing like for like Pool fencing 1i *The debris will be disposed of at: 5C ENERGY,330VICTOR ROAD,ATTLEBORO,MA.02703 Location of Facility I declare under penalties .: ��+ Date: 4/21/23 that the statements herein contained are true and correct to the best of myknowledge and belief. I understand that any false answer(s) will be just cause for d / : ocatio my license and for prosecution under M.G.L.Ch.268,Section 1. g Applicant's Signature: ` PLEASE SEE ATTACHED OWNER IZATION&CONTRACT Owners Signature(or attachment) Date: ' '`�Approved By: Date: ' �c� 5 Building Offic' (or Igne ) EMAIL RESS: MARYANN@SCENERGYINC.COM Zoning District: Historical District: 1 1 Yes No Flood Plain Zone: Yes r No Water Resource Protection District: Within 100 ft.of Wetlands: Yes i No Yes No The Commonwealth of Massachusetts ►'* t Department of Industrial Accidents =3e/118 1 Congress Street,Suite 100 90 Boston,MA 02114-2017 ��� 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):5C Energy, Inc Address:330 Victor Rd. Bldg A City/State/Zip:Attleboro, MA 02703 Phone#:774-203-3704 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. Remodeling any capacity.[No workers'comp.insurance required.] 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. 0 Demolition 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 11.0 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.: 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0✓ 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: ARGONAUT INSURANCE COMPANY Policy#or Self-ins.Lic.#: WC928038765994 Expiration Date:12/27/2023 I I CAPTAIN DORE ROAD City/State/Zip: YARMOUTH,MA.02664 X Job Site Address: 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 certi u er the p ins and penalties of perjury that the information provided above is true and correct. Signature: Date: 4/21/23 Phone: 774-203-3704 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#: ® ACG DD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 12/28/2022 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 Rosalynn Davila Loiselle Insurance Agency PHONE AIC No.Ext): (401)723-8510 (A/C,No): (401)728-1820 279 Dexter Street IL rosal nn ra loiselleinsunce.com ADDRESS: Y P.O.Box 1148 INSURER(S)AFFORDING COVERAGE NAIC# Pawtucket RI 02862-1148 INSURER A: Employers Mutual Casualty Co 21415 INSURED INSURER B: EMC Prop&Cas Ins Co 25186 5C ENERGY,INC. INSURER C: Argonaut Insurance Co ARGO 330 VICTOR RD-BUILDING A INSURER D: RISCO RISCO INSURER E: ATTLEBORO MA 02703-6294 INSURER F: COVERAGES CERTIFICATE NUMBER: Master:2022 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. INBR ADUL SUM( POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DDIYYYY) (MMIDDIYYYY) UMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR DAMAGElO RENTED 500,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 A 5D98024 12/27/2022 12/27/2023 1,000,000 PERSONAL&ADV INJURY $ GEN'LAGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000 POLICY JET LOC PRODUCTS-COMP/OP AGG $ 2,°O- CO00 OTHER: AUTOMOBILE UABILITY COMBINED SINGLE LIMIT $ 1,000,000 ANY AUTO (Ea accident) BODILY INJURY(Per person) $ 20,000 B OWNED x SCHEDULED 5Z98024 AUTOS ONLY AUTOS 12/27/2022 12/27/2023 BODILY INJURY(Per accident) $ 40,000 X AUTOS HIRED NON-OWNED PROPERTY DAMAGE ONLY X AUTOS ONLY (Per accident) $ 5,000 Uninsured motorist BI $ 1,000,000 X UMBRELLA UAB OCCUR r" 3 000, ,000 - EACHH OCCURRENCE $ A EXCESS UAB CLAIMS-MADE 5J98024 12/27/2022 12/27/2023 $ , ,3000000 AGGREGATE DED XI RETENTION$ 10,000 WORKERS COMPENSATION $ AND EMPLOYERS'UABILITY Y I N X STATUTE ERH C ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? Y N/A WC928938765994 12/27/2022 12/27/2023 (Mandatory In NH) 1000,000 If yes,describe under E.L.DISEASE-EA EMPLOYEE $ , DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 D Contractors Pollution Liability CPLMOL107038 06/16/2021 06/16/2023 Aggregate $250,000 Eeach Occurrence $500,000 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 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts Division of Occupational Licensiare Board of Building R 4' ins and Standards Cctnstnicti I r Specialty CSSL-100162 f40. •*--* eoires: 0412612025 1111An1._ t_tip 4a* 3620 bmAis 'am ***4 CuilitEraMO *4 1 47: 11111 dit * 410. SI*44' t. 4; 443 44 '3.7S -411V4111 ‘C% Commissioner d Cat.r Construction Supervisor Specialty Itestriated MSLigle Insulation Centraster Fakirs to proem a come*edllon elite Marsactiusatts $tale likiltlisq Code is cause*sr ravisicalari this Scensc For kikweation about this 111;ense 4:411(1117)rites:so or vomit vravAimassolioviv I I i R 1° i i t i_ list. I 1 122cti All , 1111 § x te liii • li i cl-og(3, ° I is: t".) ti;m flU]0 1 o AP"g i' l 8 Az g Ili II 21 be• I - pie_ ii III 41 i til a u ggli h 111 f i I I/ 1 lil 8 .. . ... . . . . _ I O 4.0 lbL 71 c o, �a I I b it 1 S L Si €i9 ' � � ��11 Jil ,... iii A . . ;.ram ,f 1 " 1 k """�- :.xis ! '` i--- iill 6 .v F it.:.:,,,, 1,, ,..; :,_>i.. „ ,-,g-- re_ i ei li W ME gg 1 i ji m 2TC ^ w ` h 3 , 1111 i51 fi , • a hIiq W 3 NO DEBRIS INSULATION ONLY DEBRIS DISPOSAL AFFIDAVIT In accordance with the provisions of M.G.L. c. 40, s. 54, Building Permit # n/a was issued with the condition that all debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by M.G.L c. 111, s. 150A. The debris will be disposed of in: 5C Energy, Inc. Name of Waste Facility 330 Victor Road,Attleboro, MA 02703 Address of Waste Facility 111.5 Debris: As a condition of issuing a permit for the demolition, renovation, rehabilitation or other alteration of a building or structure, M.G.L. c. 40 s. 54 requires that the debris resulting therefrom shall be disposed of in a properly licensed solid waste disposal facility as defined by M.G.L.c. 11 l s. 150 A.Signature of the permit applicant, date and number of the building permit to be issued shall be indicated on a form provided by the Building Department and attached to the office copy of the building permit retained by the Building Department. If the debris will not be disposed of as indicated, the holder of the permit shall notify the building official,in writing,as to the location where the debris will be disposed. 780 CMR—6th Edition t/l/ 611 64401-11— Signature of Permit Applicant 4/2 I/23 Date R E C E P v E D cLi ''l Office Use Only ;' o APR 26 2023 Permit# H. i Amount, S, OD ._1 0 - tee+ - H; _� A ..; BUILDING DEPARTMENT yy Permit expires 180 days from _.ram;.-• — issue date 8 UD—a & —N59y3 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: I I CAPTAIN DORE ROAD ASSESSOR'S INFORMATION: Map: 67 Parcel: 175 OWNER: LOUISE LAFONTAINE 11 CAPTAIN DORE ROAD,YARMOUTH,MA.02664 508-694-6757 NAME PRESENT ADDRESS TEL. # CONTRACTOR: MATTHEW RUSSELL- 3820 DIAMOND HILL ROAD,CUMBERLAND,RI 02864. 401-651-0003 NAME MAILING ADDRESS TEL.# ®Residential 0 Commercial Est.Cost of Construction$ 5,619.86 Home Improvement Contractor Lic.# 195309(EXP.04/18/2025) Construction Supervisor Lic.# 106162(EXP.04/26/2025) Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor El I have Worker's Compensation Insurance Insurance Company Name: ARGONAUT INSURANCE CO Worker's Comp.Policy# WC928938765994 WORK TO BE PERFORMED Tent U Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares (❑)Remove existing*(max.2 layers) Insulation I I 1 Old Kings Highway/Historic Dist. 0)Replacing like for like Pool fencing 1-1 *The debris will be disposed of at: 5C ENERGY,330 VICTOR ROAD,ATTLEBORO,MA.02703 Location of Facility I declare under penalties : .> 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 d� e : ocatio my license and for prosecution under M.G.L.Ch.268,Section 1. AI+ Applicant's Signature: Date: 4/2 I/23 PLEASE SEE ATTACHED OWNERA IZATION&CONTRACT Owners Signature(or attachment) Date: �j -7-- �'`� Approved By: Date: / Building Offid (or ghee) EMAIL RESS: MARYANN@5CENERGYINC.COM Zoning District: Historical District: Yes No Flood Plain Zone: Yes L No Water Resource Protection District: Within 100 ft.of Wetlands: ?. Yes No Yes No I . + .`♦w* 4 ++,' M. , ,...«. .. sir-> ' .w i.'."„` T t c w "4. , 1' Signature Certificate ' Reference number:KYVVU-DFMWO-QJJBE-FARWE f - 1 "r vt, ,,. ..., ,..,,m. . ....., , ,,,,,ti. w f g Si ner Timestamp Signature ' e Louise Lafontaine I 5 Email:loulafnh©yahoo.com r I Sent: 13 Apr 2023 13:57:56 UTC Viewed: 13 Apr 2023 18:D8:48 UTC eJ Lout"' `����I '''r va ice. t `, .444 • Signed: 13 Apr 2023 18:10:10 UTC 1 %.. Recipient Verification: IP address:66.31.191.53 NA ✓Email verified 13Apr 2023 18:08:48 UTC Location:South Yarmouth,United States f i'wtr r r.4.F "' Document completed by all parties on: ,m' i'; 13 Apr:2023 18:1010 UTC- - - Page 1 of 1 :140'":11.11:ifti AV Iit H li �r I s ` il« 4 I i i Nri4 Iii r ,r ;; +i, r e. -.f. 1 El.,:vt''''liii: ' 4.4v,. � i raVitk s Signed with PandaDoc El. e' • _„, •r ,, t , Panda Doc is a document workflow and certified e$ignature ,,- T. +;:, solution trustedby 40,000+companies worldwide. 1 ,0— 4 r; ,t ,r4 i 4. it.' I t: x Customer Name:Louise Lafontaine CONTRACT Email:loulafnh@yahoo.com Phone:508-694-6757 Premise Address:11 Captain Dore Rd,Yarmouth,MA 02664 RI S Meiling Address:11 Captain Dore Rd,Yarmouth,MA 02664 Project ID:4811274 Date:April 12,2023 ENGINEERING` RISE Engineering 765Attucks Lanny, Hyannis,MA,02601 Job Description _b 'x^"�r, �, n ,fi r€ `. ');'.'"‘;',-:"-'7 , ,.: E.w < @ P 8 '' t 3 1 `� IA Ai` >✓e m�6+1 Yy rf '�d� '�' fix° �' k ,*i'' � 6 rm'J 8.d >,« 'h '9 ,i� `N 1 S BASEMENT SILLS:R19 FG BATT 100 SF $237.00 $59.25 AIR SEALING 16 hr $1,509.28 $0.00 INSULATE BULKHEAD DOOR 1 each $68.83 $17.21 CRAWLSPACE WALL R10 RIGID BOARD 84 SF $384.72 $96.18 WEATHERSTRIP DOOR&ADD SWEEP 3 each $173.76 $0.00 ATTIC FLAT-7"OPEN R-26 CELLULOSE 1274 SF $2,038.40 $509.60 VENTILATION CHUTES 10 each $34.90 $8.72 ATTIC DAMMING-R-38 FIBERGLASS 100 SF $242.00 $60.50 4"x 16"SOFFIT VENTS 6 each $185.10 $46.27 8"x 16"SOFFIT VENTS 4 each $123.40 $30.85 Recessed Light Enclosure 4 each $200.00 $0.00 4"-VENT BATH FAN TO ROOF OR ALTERNATIVE 1 each $130.63 $32.66 WALLS-INTERIOR DRILL&PLUG CELLULOSE 128 SF $291.84 $72.96 Total: $5,619.86 Program Incentive: -$4,685.66 Customer Total: $934.20 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF ***Nine Hundred And Thirty-Four And 20/100 Dollars $034.20 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 SPACES Dame/41Cv a Lou re lafordaifte RISE Representative Customer Signature 2023-04-13 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 Documont Ref KYVVU-DFMWO-QJJ6B-FARWE Page 1 of , w +ir p i£b tt 4�b : Yet .: Signaturenature Certificate lift , Reference number:KYVVU-DFMWO-QJJ6E-FARWE ? ' ;:r.: M. Of * Signer Timestamp Signature Email:docoin eiseen neenn .co„_ _.__,._ ._ ._, ', i , 4 Daniel O'Coin i �. .�_ , , �_._ g g m 40 Co c 1 44,, i Sent: 13 Apr 2023 13:57:56 UTC Signed: 13 Apr 2023 13:57:57 UTC +_._.__._ , IP address 71.235.0 143 "I :Ater Location:South Yarmouth,United States r4 Louise Lafontaine tiV ��:0 Email:loulafnh yahoo.com i ' Sent: 13 Apr 2023 13:57:56 UTC a // //'(� /�`/ /� h y Viewed: 13 Apr 2023 18:08:48 UTC ! ""'" "�"'� '.c� U�� ~ q' 444 Signed: 13Apr 2023 18:10:10 UTC l Recipient Verification: IP address 66.31.191.53 1') Email verified 13Apr 2023 18:08:48 UTC Location:South Yarmouth,United States , I e* + Document completed by all parties on: k. .- 13 Apr 202318:10:10 UTC .r r: 4 IL Page1of1 let t iv b. 410♦ i ' is ;�. r e At 4: « ; i a Signed with PandaDoc 1,44 :' ; ,e..4.1.t.: I ..,.:.,,,--,,..--.., :,. :,-2,„ Panda Doc is a document workflow and certified eSignature �, - {' ;t ", solution trusted by 40,000+companies worldwide. D I To— i 'i ;4; ..' ' i ;,.,.. .:„ r :r 4 r" Permit Authorization mass saw Form SgMnits.00"tt ifooqy Oft:RIMY Site ID: 4795482 Customer: Louise Lafontaine Louise Lafontaine ,owner of the property located at: (Owner's Name,printed) 11 Captain Dore Rd 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. attg:re Letfcgdatft e Owner's Signature: Date: 2023-04-13 FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above rirennr.s3Avt:444tc: 5C ENERGY INC. 4/21/23 Participating Contractor Date Name: RISE Engineering Phone: 508-568-1926 Email: Page 1 of 1 For Office Use Only