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Home My WebLink AboutBLD-23-005873 in Gj. 1 I y/2t#23 .y �-. ®/ ® Office Use Only o ``'' :lro. `_f _._ o-0_3-0o5 73 r'Y Amount o .. ,1 l APR 212023 35 "°.r ,�'�` 1 i� Permit expires 180 days from `' E_: 96-PARTMENT i issue date 't— EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 388 & 390 North Main St.South Yarmouth MA 02664. ASSESSOR'S INFORMATION: Map: Parcel: OWNER: Mary Jane Benoit 154 Winter St Hanover MA 02329 781-901-1938 titE E S TEL. # Energy 88 Arch gt AENTpt ffiaf iver 774-360-7658 CONTRACTOR: Services. LLC Ma 02724 NAME MAILING ADDRESS TEL.# Email: eliteenergyservicesllc@yahoo.com 4 154.99 IS Residential ❑Commercial Est.Cost of Construction$ 195944 Construction Supervisor Lic.# CS-113671 Rome Improvement Contractor Lic.# Workman's Compensation Insurance: (check one) C I am the homeowner 0 I am the sole proprietor ® I have Worker's Compensation Insurance Atlantic Charter Insurance Company Worker's Comp.Policy# WCV01488803 Insurance Company Name: WORK TO BE PERFORMED Tent E Duration (Fire Retardant Certificate attached?) Wood Stove El Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares (❑)Remove existing*(max.2 layers) Insulation I "I l l Old Kings Highway/Historic Dist. CT Replacing like for like Pool fencing I I *The debris will be disposed of at: New Bedford Waste Services 1245 Shawmut Ave New Bedford MA 02746 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 under M.G.L.Ch.268,Section 1.Applicant's Signature: /141(1-Z Date: Vi 3/ZO 23 Owners Signature(or attachment) Please see tt C form Date: Approved By: Date: 2.5 Building Official(or sign EMAIL ADD SS: Zoning District: Historical District: Yes No Flood Plain Zone: [ Yes I, No Water Resource Protection District: Within 100 ft.of Wetlands: Yes - No - Yes III No • . The Commonwealth of Massachusetts I _ 4ri Department of Industrial Accidents 1 Congress Street, Suite 100 C. V-911,,' i= ;` 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): Elite Energy Services, LLC Address: 88 Arch St Apt 3 City/State/Zip:Fall River MA 02724 Phone#: 774-360-7658 Are you an employer?Check the appropriate box: Type of project(required): 1.0I am a employer with 18 employees(full and/or part-time).* 7. El New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.01 am a homeowner doing all work myself.[No workers'comp_insurance required.]t 10❑Building addition 4.0I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.[�Electrcal repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12.0Plumbing repairs or additions 5.01 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.: 14.0Other Weatherization 6.0We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§I(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: Atlantic Charter Insurance Company WCV01488803 Expiration Date: 2/28/2023 Policy#or Self-ins.Lic.#: p Job Site Address: 388 & 390 North Main St City/State/Zip: South 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is)true and correct. Signature: � Date: Li/I$ l 20 2 2 Phone#: 774-360-7658 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: DocuSign Envelope ID:1AAC6222-E12A-45AC-A771-2A542BF2A037 Customer Name:Mary Jane Benoit CONTRACT Email:dunakin@verizon.net Phone:781-901-1938 Premix Address:388 North Main Street,South Yarmouth,MA 02664 Mailing Address:154 Winter Street,Hanover,MA 02329 7443 Date: t.28, 022 Date:Oct.28,2022 ENGINEERING` RISE Engineering 765 Attucks Lane, Hyannis,MA,02601 Roadblocks: Notes: • Combustion safety-High CO Due to the age and poor operating condition of the boiler&water heater,weatherization work must wait until these systems are replaced. .Inh r)acrwirtinn Measure Description Location Quantity Unit Total Cost Customer Cost AIR SEALING 5 hr $471.65 $0.00 ATTIC FLAT-14"OPEN R-49 CELLULOSE 498 SF $1,075.68 $268.93 ATTIC DAMMING-R-38 FIBERGLASS 25 SF $60.50 $15.12 BASEMENT SILLS: R19 FG BATT 53 SF $125.61 $31.40 4"FLAPPER KIT THROUGH GABLE 1 each $118.75 $29.69 VENTILATION CHUTES 14 each $48.86 $12.21 WEATHERSTRIP DOOR&ADD SWEEP 2 each $115.84 $0.00 Total: $2,016.89 Program Incentive: -$1,659.54 Weatherization Barrier Incentive: -$0.01 Customer Total: $357.34 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF ***Three Hundred And Fifty-Seven And 34/100 Dollars $357.34 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. DocuSigned by: DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES r—DocuSigned b : VGVAAVII M1 EF747CE1 D44A... 3E1 E�99D14F5.. RISE Representative Customer Signature 10/29/2022 1 1:03 PM PDT 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 Permit Authorization mass save Form Site ID: 4550938 Customer: Mary Jane Benoit I, Mary Zane Sena,* ,owner of the property located at: (Owners Name,punted) 388 North Main Street 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: 45.vv. 014401445b Date: g It- a), FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Elite Energy Services 4/14/2023 Participating Contractor Date Name: RISE Engineering Phone: 508-568-1926 Email: Page 1 of 1 For Office Use Only Rev.10201S Customer Name:Mary Jane Benoit CONTRACT Email:dunakin@verizon.net Phone:781-901-1938 Premise Address:390 North Main Street,South Yarmouth,MA 02664 Mailing Address:154 Winter Street,Hanover,MA 02329 Project45 7473 ate:Aug.31,2022 Date: g.31,2022 ENGINEERING" RISE Engineering 765 Attacks Lane, Hyannis,MA,02601 Applicable Customer Required Actions: Notes: • Other Weatherization cannot proceed until heating system has been replaced.Both sides to be insulated at the same time. .jnh Ilacrriptinn Location ' Quantity Unit Total Cost Customer Cost I 'Measure pescriptigrt! hr $471.65 $0.00 AIR SEALING 5 ATTIC HATCH:SEAL&INSULATE 1 each $60.00 $15.00 WEATHERSTRIP DOOR&ADD SWEEP 2 each $115.84 $0.00 ATTIC DAMMING-R-38 FIBERGLASS 30 SF $72.60 $18.15 ATTIC FLAT-14"OPEN R-49 CELLULOSE 486 SF $1,049.76 $262.43 BASEMENT SILLS:R19 FG BATT 35 SF $82.95 $20.74 INSULATE BULKHEAD DOOR 1 each $68.83 $17.21 4"FLAPPER KIT THROUGH GABLE 1 each $118.75 $29.69 VENTILATION CHUTES 28 each $97.72 $24.43 Total: $2,138.10 Program Incentive: -$1,750.45 Customer Total: $387.65 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF ***Three Hundred And Eighty-Seven And 65/100 Dollars $387.65 UPON RECEIPTFOFTE ENGINEERING INVOICE,CUSTOMER AGREES TO REMIT AMOUNTRIGHTS MONTHLY ON ANY UNPAID YOUR RISE DAYS.SEREVERSE OR IMPORTANT INFORMATION O G GUARANTEES, OF RECISION, CONTRACTOR REGISTRATION. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Customer Si to RIS &ttive QPN. 3J• a, Sign Date Page 1 of 2 Permit Authorization Sayer Form Site ID: 4550956 Customer: Mary Jane Benoit owner of the property located at: (Owner's Name,panted) 390 North Main Street 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: 9„1„4,4s,v,„„„8.4> Date: FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Elite Energy Services 4/14/2023 Participating Contractor Date Name: RISE Engineering Phone: 508-568-1926 Email: Page 1 of 1 Far Office Use Only Rev. 102015 t;e rnmonw with of MaSsachtiNefts Division of Professional Licensu+e Board of Budding Requtattons and Standards Construction Supervisor CS-113671 Expires:0610712023 STEVEN P HEBERT 226 SHOVE STREET APT 4 FALL RIVER MA 02724 c r Commissioner • <. """ ' ti L m t3 c bi 3 m cc N 13 0 W C 4' 4t is . "B. oo o � 0 2 in kl 1.NZ:: Law CD o00 Z C:20(I) 4 := + a � a) Tt t o :N -0 .. i' .� o �. C� as 2o `Nc 03 N o (71 -� U c co tU o L .r c < OCC° 6 .CE — o c 8.1h co U 0 to a"' o ._ 8 CD E `" 0 ° o o I wCC \ i —J U Cfi rU c N c U itQ — o v N N H L cv) Z W 0 mV UW (� Q *11Hr UJ CC as illWcc WW aW� — U Tr CV Z 0 > , rn > I,- 2 o wStC it — rn oW (!) J a to CC Q V JNQ W CD co�� (1JN11 �� W wwW _ > S= wZOC f_ ill W N N LL Ao D® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 03/08/2023 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 CONTACTNAME: Loretta Brown FBINSURE LLC (PHCNNo.Est): (508)824-8666 a,No): EMAIL loretta fbinsure.com ADDRESS: CG 128 DEAN ST INSURER(S)AFFORDING COVERAGE NAIC# TAUNTON MA 02780 INSURER A: ATLANTIC CHARTER INS CO 44326 INSURED INSURER B: ELITE ENERGY SERVICES LLC INSURERC: INSURER D: 88 ARCH STREET APT 3 INSURER E: _FALL RIVER MA 02724 INSURER F: COVERAGES CERTIFICATE NUMBER: 868837 REVISION NUMBER: THIS IS TO CERTIFY POLICIES OD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT ABOVE POLICY FOR THE OR OTHER DOCUMENT WITH RESPECT TO WHICH TIHIIS 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. ADDL SUBR POLICY EFF POLICY EXP LTR RLIMITS INSR OF INSURANCEINSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GENII AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO- PRODUCTS-COMP/OP AGG $ POLICY JECT LOC $ OTHER: COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS N/APROPERTY DAMAGE $ HIRED AUT (Per accident) AUTOS ONLY AUTOS OS ONLY $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ WORKERS COMPENSATION X STATUTE ERH AND EMPLOYERS'LIABIUTY Y/N E.L.EACH ACCIDENT $ 500,000 ANYPROPRIETOR/PARTNER/EXECUTIVE XCLUD 02/28/2023 02/28/2024 A (Mandatory In NH) CLUDED? N/A N/A N/A WCV01488803 E.L.DISEASE-EA EMPLOYEE $ 500,000 (Mandatory NH) If es,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) uant to dorsement WC 20 03 06 B,no authorization is claims for enefits to employees in s will be otherfd o thanMassachusetts achusetts employees the insured hires,or has nh hired those employees outside of Massachusetts.given to pay This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensation/investigations/. 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. Town of Yarmouth 1146 Route 28 AUTHORIZED REPRESENTATIVE Ct.t Daniel Yarmouth MA 02664 M.Cro, y,CPCU,Vice President—Residual Market—WCRIBMA 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ELITENE-01 LBROWN %�'"� DATE(MM/DD/YYYY) .a►`coRL7° CERTIFICATE OF LIABILITY INSURANCE 3/8/2023 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 NAME: C2NTACT Loretta Brown FAX FBinsure,LLC PHONE o,Ext):(508)8248666 (A/C,No):(508)880 0142 128 Dean Street ADDRESS:Ioretta@fbinsUre.com Taunton,MA 02780 INSURER(S)AFFORDING COVERAGE NAIL# INSURER A:Selective Insurance Company of South Carolina 19259 INSURED INSURER B:Commerce Insurance Company 34754 Elite Energy Services LLC INSURER C:Evanston Insurance Company 35378 225 Shove St Apt 4 INSURER D: Fall River,MA 02724 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. NOTWITHTANDING ANY REQUIREMENT, TERM OR CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, CONDITION OF ANY THE AFFFORD D 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 CY EFF CLYAIMS. LIMITS IN SR ADDL SUBR POLICY NUMBER IMM/DD/YYYYI IMM/DD/YYYYI TYPE OF INSURANCE INSD WVD 1,000,000 A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 212712023 212712024 PREM sES(EEoccu ence) $ 500,000 CLAIMS-MADE X OCCUR S2574612 15,000 X Blkt Waiver X Blkt Add'I Ins MED EXP(Any one person) $ 1,05,000 PERSONAL&ADV INJURY $ 12,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY X jpeT LOC $ OTHER: COMBINED SINGLE LIMIT $ 1,000,000 B AUTOMOBILE LIABILITY (Ea accident) ANY AUTO BDJH26 3/11/2023 3/11/2024 BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY X AUTOS PROPERTY DAMAGE RED -QWN D (Per accident) $ X AUTOS ONLY X AUTOS ONLY $ 27/2024 1,000,000 A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE S2574612 2/27/2023 2/ AGGREGATE $ DED X RETENTION$ 0 H $ STATUTE ER WORKERS COMPENSATION PER AND EMPLOYERS'LIABILITY Y/N E.L.EACH ACCIDENT $ ANY PROPRIETOR/PXCLUDEIEXECUTIVE I N/A E.L.DISEASE-EA EMPLOYEE $ QFFlCatory in ER EXCLUDED? (Mandatory in NH) If yes,describe under E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below CPLMOL107350 7/13/2021 7/13/2023 Per Occurrence C Pollution Liab DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Professional Insulation/Winterization Services Contractor.Pollution Liability coverage includes a$2,000,000 Aggregate and$1,000 Deductible. CERTIFICATE HOLDER CANCELLATION THESHOELLED U EXPIRATION F DATEE DA EVE THEREOF,ED NOTICEES BE WIILLCBEC BEFORE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD