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Office Use Only
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£ �Permit Z ()10.32
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'�,<TM „•:.'d Permit expires 180 days from
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EXPRESS BUILDING PERMIT APPLICAT ! I.
TOWN OF YARMOUTH R 7 T,..
Yarmouth Building Department
1146 Route 28
APR 2 �
South Yarmouth, MA 02664 2013 ;,
(508) 398-2231 Ext. 1261 BUILDING DEPARTIV1rNT
Highland Street ---
CONSTRUCTION ADDRESS: 34 Hi g
ASSESSOR'S INFORMATION:
Map:28/ 117/ / / Parcel: 1400
OWNER: Ronald Mattes 34 Highland Street 774-994-2695
NAME PRESENT ADDRESS TEL. #
CONTRACTOR: Adam Glenn 235 Essex Street Whitman,MA 02382 781-205-4516
NAME MAILING ADDRESS TEL.#
0 Residential ❑Commercial Est.Cost of Construction$2000
Home Improvement Contractor Lie.# 181138 Construction Supervisor Lic.#CSSL—I 106148
Workman's Compensation Insurance: (check one)
I am the homeowner -) I am the sole proprietor 0 I have Worker's Compensation Insurance
Insurance Company Name: Federated Mutual Insurance Company Worker's Comp.Policy# 1847910
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 IV I
I ] Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
*The debris will be disposed of at: Not Applicable
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: Date: 4/24/2023
Owners Signature(or attachment)Federated Mutual Insurance Company Date:
Approved By:
Date:
Building Oiici or i e) EMA DRESS:
w�mermittina homeworksenergy.com
Zoning District:
Historical District: Yes No Flood Plain Zone: Yes No
Water Resource Protection District: Within 100 ft.of Wetlands:
Yes No Yes No
'r,,. The Commonwealth of Massachusetts
- Department of Industrial Accidents
# __. Office of Investigations
Lafayette City Center
N`,
2 Avenue de Lafayette, Boston,MA 02111-1750
x 4 www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Homeworks Energy _
Address: 235 Essex Street
City/State/Zip:Whitman, MA 02382 Phone #: 508-644-8197
Are you an employer? Check the appropriate box: Type of project(required):
1.Q I am a employer with 500+ 4. 0 I am a general contractor and I 6. ❑ New construction
employees (full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers' 9. Ej Building addition
[No workers' comp. insurance comp. insurance.:
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4),and we have no Weatherization
employees. [No workers' 13.11] Other
comp. insurance required.]
*My 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: Federated Mutual Insurance Company
Policy#or Self-ins. Lic. #:#1847910 Expiration Date: 1/1/2024
Job Site Address: 34 Highland Street City/State/Zip: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 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 and r the pains and pe es of perjury that the information provided above is true and correct.
Signature:
, Date: 4/24/2023
Phone#: 508-644-8197
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority(check one):
10Board of Health 20 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 5Elumbing
Inspector 6.0Other
Contact Person: Phone#:
A DATE�
CERTIFICATE OF LIABILITY INSURANCE
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 pollcy(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:CONTACT CLIENT CONTACT CENTER
FEDERATED MUTUAL INSURANCE COMPANY
HOME OFFICE:P.O.BOX 328 (A/CNNo,Est):888-333-4949 (A/C.No):507-446-4664
OWATONNA,MN 55060 E-MAILDDRESS:CLIENTCONTACTCENTER[aZFEDINS.COM
INSURER(S)AFFORDING COVERAGE NAIC#
INSURER A:FEDERATED MUTUAL INSURANCE COMPANY 13935
INSURED 419-899-0 INSURER B:
HOMEWORKS ENERGY,INC. INSURER C:
101 STATION LNDG
MEDFORD,MA 02155-5134 INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:0 REVISION NUMBER:1
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 SUBS POLICY NUMBER POLICY EFF POLICY EKE LIMITS
LTR INSR WVD IMM/DDIYYYY) (MMIDDIYYYY)
X COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE $1,000,000
CLAIMS•MADE I X I OCCUR DAMAGE (AGE RENTED $100,000
PREMISES EENcvRenml
MED EXP(My one person) EXCLUDED
A N N 1847909 01/01/2023 01/01/2024 PERSONAL&ADV INJURY $1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000
X POLICY I JECT LOC PRODUCTS-COMP/OP AGG $2,000,000
OTHER:
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1,000,000
IEa accident)
X ANY AUTO BODILY INJURY(Per person)
SCHEDULED
A OWNED AUTOS ONLY AUTOS N N 1847908 01/01/2023 01/01/2024 BODILY INJURY(Per accident)
NON-OWNED PROPERTY DAMAGE
HIRED AUTOS ONLY AUTOS ONLY (Per accident)
X UMBRELLA UAB X OCCUR EACH OCCURRENCE $1,000,000
A EXCESS LIAB CLAIMS-MADE N N 1847911 01/01/2023 01/01/2024 AGGREGATE $1,000,000
DED r !RETENTION
WORKERS COMPENSATION X PER STATUTE OTH-
ER
AND EMPLOYERS'LIABILITY Y/N
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500,000
A OFFICER/MEMBER EXCLUDED? NIA N 1847910 01/01/2023 01/01/2024 -- "-..__—
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $500,000
If yes,describe under E.L DISEASE-POLICY LIMIT $500,000
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACM)101,Additional RemerSe Schedule,may be attached i1 more space is required)
THIS COPY IS NOT TO BE REPRODUCED FOR ISSUANCE OF CERTIFICATES.
CERTIFICATE HOLDER CANCELLATION
01
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN
A CERTIFICATE HAS BEEN FILED WITH EACH OF YOUR CERTIFICATE ACCORDANCE WITH THE POUCY PROVISIONS,
HOLDERS. AUTHORIZED REPRESENTATIVE
O 1988-2015 ACORD CORPORATION.All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
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DEBRIS DISPOSAL AFFIDAVIT
In accordance with the provisions of M.G.L. c. 40, s. 54, Building Permit
# 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:
HomeWorks Energy
Name of Waste Facility
Not Applicable - No Debris
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. 111 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
Signature of Permit Applicant
4/24/2023
Date
Insulation/Air Sealing Permit Authorization
Specialist: Ryan Mgrdichian Company: HomeWorks Energy
Email: ryan.mgrdichian@homeworksenergy.cc Address: 101 Station Landing
Cell: 8603947804 Medford, Ma 02155
Phone: 781.305.3319
Customer: Ronald Mattes Address: 34 Highland Street
Email: closetman@comcast.net Yarmouth, MA,02673
Site ID: 4811292 Phone: 7749942695
I, 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.
In the event that a permit is pulled on your home for insulation and/or weatherization work, you may be required to
have a final inspection of the work scheduled and performed by the building inspector in your town. If required by the
town, you will be notified by Home Works Energy that an inspection is necessary with instructions on how to complete
this process to close out your permit.
Email: closetman@comcast.net
Customer _Ai�///
Signature: if 1 Date: 4/19/2023
Ronald Mattes
For Condo Owners:
If you have property oversight by a condo associationt, please have the association's authorized person(s) complete
and sign the section below. Please email this document to wxpermitting@homeworksenergy.com once completed.
We, being the duly authorized representatives of the association
Name of association or management companyt
or management company have reveiwed the plans and specifications for improvements to the address specified above.
We further acknowledge that the above listed owner has given notice that they intend to seek permits and to carry out
the proposed work.
Signature of representative Date
Print Name
t Other unit owners may sign when there is no association.
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PLAN VIEW
z Name:�oy%.4i . AA4Finished Sq. Ft: 1519
3 S Site ID: Sf 1 i Z 1 Z.
o Phone {i1i-t)t"1gy,—Z.GgS Year of House: 19 t2.( Electric Acct#.: t`t31 O ooto �'
,�jd,!dress: ' u fi� t a,�rt St #of Floors: t Gas Acct#: 05`t 1 Z`t 1 Cx 40`'(
W.TAI# Jlttll ttZtr2 Unit I: #Occupants: Z Housing Type? 42+`/ctt
DUCTWORK INSPECTION Ducts insulated?f
*act Linear Ft.
Duct Square Ft. 0//S 1.Ce (T Z. ( /4r
Duct Air Seating Hours T --- _
Duct Insulation V �?� .' STit''r"' `('
„,
Duct Insulation Removal m
z BASEMENT INSPECTION ` z
Existing Spec'ing Ln/Sq.Ft. r.
cc Bsmt Wall AG .' .-- ,
Crawl Ceiling - * i (h Z.
Crawl Rim Joist
Bsmt RJw/Sill 1--16t A-fS (b rr ,
Bsmt RI NO Sill ` .,,� '
Vapor Barrier! ----' sqft. Bsmt Door' 9-
Y/N Blower Door? WALLS&GARAGE Drill Location?
Siding Cell.Height Existing Spec'ing Sq.Ft. ,�Framin
Exterior Wall 1 InJe4dC (�tcip 1,5 t —t 3 -" ' Tmm.. 0w x 1l{ Baboon/H�ctlf9r..ol
Exterior Wail 2 r , x x Balloon/Platform
Overhang x x
Garage Wall -- x x Ba oon P a orm
Garage Ceiling '
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n Removal
Insulation
. t ,"-..
Sweeps: '...--
WX Stripping:
WORK SPEC'D BUT NOT CONTRACTED AD BLOCKS PRESEN MANDATORY)
Attic Basement/Crawlspace Other: K&T Y/ Moisture Y/N 1Combustion Sfty Y/i'
Kneewall Overhang/Garage Asbestos Y N Mold>100 sq.ft Y 'CON Detector Missing Y
Ductwork Exterior Walls Vermiculite Y/ Structl Concerns Y J Other:
Notes for Lead Vendor/Work Not Contracted:
KW WALL AND KW FLOOR Blind Spec? ._ -4 - OR ---»''' KW SLOPE AND GABLE END Blind Spec? 0
hi? Why?..."
-\EJIAVING Fltl 'lNG SPeC i4G 59 . i
` S FR . :ING EXISTING SPEC ING 5 .*•
WALL x\ Xi‘j"' p k, SLOPE X
FLOOR X e' r GABLE X x
cot
a CESS X
TRANS X X v a
RAMS x x t ATTIC - a-
•TTIC SLOPE x X7,1 `
'_OPE x x N`s..'' EXISTING VENTING? N,,,' o.
pp
su _
13'
2 EXISTING VENTING? EXISTING PIPES? Y l N r"
ON ve v a Ve.,t 5s HP Nose Nmr:ung St'ta,kerg beans :ena Access, kW tuI to & e`�4ptiA ceu
ex ,';':...'"-1
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t^:u'ar'e Wall '3 X Fred L t?B 'ns"ticse 8x Vent BF rA:lF` Cn n C4 t D3,r,,,rtg _2 i-: VR.i'2 1R 13A=J vol: x .0058
A"Handier�E Teru3 A.;ess'=Pug Dews ' :• Natty E :kW:Hazi "ice cot^,/ a-Ras'Veit'`P 1i'...'
� 0 191: or,l
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xi+"ox({o ATTIC 1 Blind Spec? 0 x x ATTIC 2 Blind Spec? x is.<rzuo'r,)
z Existing Spec'ing Sga3.stasont
ft Existing Spec`ing
a Multipliers
Unfloored JtKM to-t4 An `13?2.. Unfloored _ Tru - C'assBarnng
a Floored .e+ aa, Duct Work
Floored
a$�(..a. vone
z Cath Slope r _ Cath Slope `` Air Sealing Hours
Walls Walls
Access tiCtr 17" OL"C t to Access 1 1—
A ,
Venting Propav_nts Vent BF BF Hose Damming Veneng Pp vents Ve F BF F'o a Damming
no, jh4 ig �(� *` ,,„: -, ViEfF ,,�r...., .
. { v E -[ { I '-" •J 1y i TerT,# ce _,,.
'err 1 1 - a Sheathing Ai ess:w4^
R.L.Corers`
-u /30,7- _(Ex.st-AA>,c.^^;t- sT,e t Sc.C:I AYJ- (_•:ft 73rk.v:ndn41= 1P:cgdcd Roof,Aver,„) YPe:
Existing r.F� r: Existing Venting?
.a.
Venting.
Page 1 of 1
HomeWorks 101 Station Landing Ste 110,
n (l mass save Medford,MA 02155
Energy PARTNER (781)305-3319
Customer Name:Ronald Mattes
Email:Not provided
Phone:774-994-2695
Premise Address:34 Highland St,Yarmouth,MA 02673
Mailing Address:34 Highland St,Yarmouth,MA 02673
Project ID:4817422
Date:April 19,2023
Job Description
Measure Description Location Quantity Unit Total Cost Customer Cost
AIR SEALING Other 14 hr $1,320.62 $0.00
PULL DOWN: THERMADOME 100% Other 1 each $253.21 $0.00
6" - VENT BATH FAN TO ROOF OR ALTERNATIVE Other 1 each $156.75 $39.19
Recessed Light Enclosure -Cost Other 4 each $200.00 $200.00
Project Total $1,930.58
Weatherization incentive ($117.56)
Air sealing incentive ($1,573.83)
Total Program Incentive -$1,691.39
Customer Total $239.19
Total Contractor Price and Payment Schedule
HomeWorks Energy, Inc.agrees to perform the above described work,furnishing the material and labor specified for the listed total
price. Payment of the balance of the customer contribution Is expected upon completion of the work.
Customer Signature: Date:
Customer Phone:
Specialist Signature: Date:
LIMITED TIME OFFER:
The prices and incentives in this contract are subject to change in accordance with the sponsoring utility MassSave Home Services Program offers.
Proposals eon be sent to:Inbox@HorneWorksEnergy.com