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'Ctoss-Ciiiitrotion-EInal:_--f.:7--Filial:.„--,,:----:--:----,---,--, ' , -: ---1.'- -'• --- '-..;'---,-:-.' - ---_--=--_.- '_ --;-_-1::-' ,;.-7,7_;,--,_-'---',-,:- ____-__:_„.--_. - - __•_,-,,,-,„ ,•_ --.136--aitr a f.Itealtti_.------.-,.--7 .-, 'E-911._ ,-,_ -_ _. -_ _ _ ; . , „- - Addition4 Comments! .--' - - ' -.-----'----= _ _-'.•---= ---- - • !_-. - - __-__ -It-- ---. • _ =--.-_- _----.:;. _-.____-_, - . -- _-___.:- - _ ,"---__-..-- • -„ ---J,-,-. __ ._•__-=,.. _ _ - .- - - . - _• .__ -- ---1"-----: - —----1 Planning Boaiil- _..•_.- - _ • ._ •„ _ „ . . - „ _, . , „_-,,-_,.-_, -_---,:.--, . — ---,---__ - - • _- -_ . _ -—_ - , —- -_ „, _ ___ ,,___ :___--__‘„,... ._ , Prior to issuance of COttilleate of Ozeeopancy/Canipletion,this-..srit-niiist be returnedto the Building Department with all_netetsary -- ---,---_-_- - , . _ „ _ ., _,..„_ inspectionssigned- off. Depart merit"phone numbers_are listed 64:tfiewhiti"fteitiiiied inspectioliS7 document provided with the-issuance of- .the-lhiiildifig permit. -----,-- . - ._ , . • ,_ -- = -_ -• :1---- ---' -- - - _POST CARD SO-IT IS VISIBLE:FROM-THE STREET. -.. _•,-,_ _ _- .,,,- - — . ... . _. . . • . TOWN OF DARTMOUTH1 BUILDING DEPARTMENT RECEIPT ° PHONE: 508-910-1820 FAX: 508-910-1838 Name: !- K `. Property Owner: -Date. Job Location: Description General Ledger#'s 105411111 Amount Building& Building Misc. 01000-44105 ca, L � F Electrical 01000-44106 Plumbing & Gas 01000-44107 o 7 Trench Safety 01000-44129 61-/00wi Other Department Revenue 01000-42420 White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received By, THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS RESIDENTIAL ❑ Phased Approval(R106.3.3)i , $25.00 APPLICATION FEE IS NON RE-FUNDABLE &NON-TRANSFERABLE OATH.� DATE RECEIVED ./'�--,"' "''• DARTMOUTH BUILDING DEPARTMENT Q rt �N; Ita 4 MI 36 r�" f It ni 400 Slocum Road, P.O. Box 79399 ., \-',. i . • Dartmouth, MA 02747 `°� 1664:.9 Phone: 508-910-1820 Fax: 508-910-1838 — www.town.dartmouth.ma.us APPLICATION TO CONSTRUCT, REPAI r RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING THIS TION FIR OFFICIAL USE ONLY RECEIVED BY: 1i BUILDING PERMIT NUMBER W DATE ISSUED: SIGNATURE: 447,7--esz___) 6.e/44_0_,64_--- DATE: f 2-/ Z)2--D Building Commissioner/Inspector of Buildings 0 Zoning District: Proposed Use: R Zone: X 0 B 0 A IDV Aquifer Zone: r THE FOLLOWING AGENCIES SHOULD BE NOTIFIED: ❑Board of 0 Board of 0 Cons. 0 Demo ❑DPW 0 Elec. 0 Energy Report Appeals Health Commission Affidavit Card Sent: Cut Off Follow-up* - ❑Fire 0 Gas 0 Planning 0 Sewer Card ❑Water Card ❑Zoning 0 Other Chief Cut Off Board Cut Off Cut Off .' *REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT. DEPARTMENTAL APPROVAL Board of Health: Signature: Date: 4 Conservation Commission: Signature: Date: Other: Signature: Date: Signature: Date: Signature: Date: i ID Brief description of work being performed, Tin 1/l � D n _ J� y� SECTION 1 -SITE INFORMATION 1.1 Property Address: 5 NA t A �s Ln • 1.2 Assessors Map&Lot Number: Lot Area (sf.) Frontage Map J -p t Lot lX - \ 2- Required Provided Front Yard 1.3 Historical District 0 Yes ❑ No Side Yard Rear Yard Year Built 0 Altering more than 25%per side of building 1.4 Water Supply(MGL c40 s54): 1.5 Sewage Disposal System: Has application been submitted to the Historic Commission? ,A ❑ Municipal 0 Private Well 0 Municipal 0 On Site Disposal System 0 Yes 0 No Date: Revised 10/11 ® CONSTRUCTION PLANS ❑ SITE PLAN 0 ENERGY REPORT RESIDENTIAL SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner Record: • Name(print) Contact Address (311,1 (hr er 2.2 Authorized Agent: 140 Point Judith Rd Unit A7,Narragansett,RI 02882 401-487-9922 Chris Saunders Name(print) Contact Address Phone Number SECTION 3-CONSTRUCTION SERVICES 3,1 Licensed Construction Supervisor/Specialty License: CSFA License Number: 106269 Company Name/Contractor Name: Chris Saunders 140 Point Judith Rd Unit A7,Narragansett,RI 02882 Address: Expiration Date: 3/25/20 Signature: Telephone:401-487-9922 3.2 Homeowner Exemption-One&Two Family Only Section 110,R5.1.3.1 Exception: FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT Exception: Any Homeowner performing work for which a Building Permit is required shall be exempt from the provisions of this section;provides that if a Homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor. For the purposes of this section only,a"Homeowner"is defined as follows: Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a Homeowner. If you are applying under this section sign below: Signature: SECTION 4-WORKER'S COMPENSATION INSURANCE AFFIDAVIT(MGL c 152§25) Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure t provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: Yes 0 No SECTION 5-DESCRIPTION OF PROPOSED WORK(Check all applicable) ❑ Deck 0 Pool ❑ Repairs VAiteration 0 Chimney/Fireplace 0 Woodstove/Pellet Stove ❑ New Construction* ❑ Accessory Bldg. 0 Roofing/Siding ❑Other (Energy report required) (Shed/Garage) (Specify below) ❑Addition ❑ Replacement window/door 0 Demolition (Energy report required) No. of windows Doors (Specify below) *If new construction, please complete the following: Single Family: No.of Bedrooms No. of Baths Two Family: No of Bedrooms Unit 1 No. of Baths Unit 1 No of Bedrooms Unit 2 No. of Baths Unit 2 ❑ Furnace(hot air)-fuel gas(natural or propane),fuel oil,electricity,other(specify): ❑ Boiler(heating)-fuel gas(natural or propane),fuel oil,electricity,other(specify): O HVAC(combined unit)-primary fuel,natural gas, propane,electricity,other(specify): 0 Air conditioning-(separate unit) ❑ None of the above to be provided 0 Hot Water: Gas Electric Fuel Oil Other ' SECTION 6-ESTIMATED CONSTRUCTION COST Item Estimated Cost($)to be completed by permit applicant 1. Building 0000 2. Electrical 3. Plumbing 4. Mechanical(HVAC) 5. Total=(1 +2+3+4) Li ) D 1--2 • SECTION 7A-OWNER AUTHORIZATION (to be completed when owner's agent or contractor applies for building permit) (Please Print) see attached authorization , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7B-OWNER/AUTHORIZED AGENT DECLARATION Chris Saunders I, , as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed der he pains and penalties of perjury. �1--, I f2f) / o Lo Signature of Owner/Authorized Agent Date SECTION 8-OFFICE/INSPECTOR'S NOTES Less Application Fee: $25.00 Remaining Balance: $ -.r—` Total Permit Fee: $ 73J Other$Amount$ Gross Area-New Construction total sq.ft. Gross Area-Alteration total sq. ft. , ) f� �� Permit Issued to: j0zkft_ cvir -7 r-.+ #� �'(. '.SL.. cam. SECTION 9-ADDITIONAL COMMENTS/SKETCHES z) Permit No. BP-94847 Project Location: 5 MEDEIROS LN Commonwe - -*fir sachusetts - 41111 TO i Z ' "? ' UTH M P#: 4175.00 ��4 1� ++il ., . . .. y , + �r A�i„' Lot: 0006 a�, •.. 1t i a�, to . Sublot: 0012 i Category: INSULATION • b 1,0, 111,, Pro ect# IF °_ J JS-2020-001767 T Est.Cost: $4000.00 w. i r ' 4. , Fee: $75.00 E Const.Class: i sr m Use Group: R3 maw e Contra d i . = e: one#. Lot Size(sq. ft.) 48287 CHRIS` I . ' SAU . 0626' ° f r )487-9922 Zoning: SR$ A uifer Zone: N/A Engineer. elPhone#: 9 a' ,.,, Flood Zone: ZONE X Applicant: 1 . 000" Phone#: New Const.: N/A SUPERIOR I .a ON - .. (401)487-9922 �* •�� Alt.Const.: N/A OWNER: *000,0,0® b.*.s AMARAL JUSTIN J n, DATE ISSUED: 1� ilikY TO PERFORM THE FOLLOWING WORK: Insulate attic floor with cellulose and install polyiso to knee walls,weatherization. DATE TIME TYPE OF INSPECTION&REMARKS INITIAL The Commonwealth of Massachusetts Department of Industrial Accidents 1` `+p= Office of Investigations p1� yl= 600 Washington Street 4� �SElrii t _'1,- Boston, MA 02111 ;.r00 � www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Superior Insulation LLC Address: 140 Point Judith Rd, Unit A7, City/State/Zip: Narragansett, RI 02882 Phone #: 401-487-9922 Are i u an employer? Check the appropriate box: Type of project(required): 1.i 7 I am a employer with 13 4. n I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub contractors listed on the attached sheet. 7. n Remodeling 2.1-1 I am a sole proprietor or partner- ship and have no employees These sub contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' 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 3.❑ I am a homeowner doing all work officers have exercised their 11.n Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ :oof repairs insurance required.] t . 152, §1(4),and we have no �� mployees. [No workers' 13. , Other Insulation ii ‘ V � '' omp, insurance required.] *Any applicant that checks box#1 lsd ou e section below showing their workers'compensation policy information. t Homeowners who submit this of L avil i dicating 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: Beacon Mutual Policy#or Self-ins. Lic. #: 67872 Expiration Date: 8/2/2020 Job Site Address: 3 VOJ LY\ City/State/Zip: ���T Y V l U LitH71 1144 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 cer ' u er the pains and penalties ofperjury that the information providedy above is true and correct Signature: c--- ,l6-- Date: z O Z D Phone#: 401-487-9922 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#: • ^.....„,,, SUPEINS-01 GARNOLD ,a`CORO' CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DO/YYYY) 7/31/2019 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 NAME: Mansfield Insurance Agency Inc. PHONE FAX 115 High Street ADDR(A/C,No,Ext):(401)596-2096 I 4 Westerly,RI 02891 E-MAILESS:info@mansfieldins.com (aa No){ 01)348-2060 INSURER(S)AFFORDING COVERAGE I NAIC# INSURER A:West American Insurance Company '44393 INSURED INSURERB:The Ohio Casualty Insurance Company 24074 Superior Insulation LLC INSURER C:Beacon Mutual Insurance Co. 30325 Michael O'Connor 140 Point Judith Road,Unit A7 INSURER D: Narragansett,RI 02882 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 SUER POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER (MM/DD/YYYY1 (MM/DD/YYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR X X BLW57941515 8/2/2019 8/2/2020 PREMISES Ea occcu ence) $ 100,000 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY I i PRO- JECT LOC I 2,000,000 PRODUCTS-COMP/OP AGG $ OTHER: $ COMBINED SINGLE LIMIT 1,000,000 A AUTOMOBILE LIABILITY _Ea accident) $ ANY AUTO BAW57941515 8/2/2019 8/2/2020 BODILY INJURY(Per person) $ X A OESDONLY AUTOSULED IED EE BODILY INJURY(Per accident) $ X ;A HURTOS ONLY X AI°TOs oNl° PROPERTY DAMAGE (Peraccident) $ $ B X UMBRELLALIAB X OCCUR EACH OCCURRENCE $ 5,000,000 EXCESS LIAR CLAIMS-MADE US057941515 8/2/2019 8/2/2020 AGGREGATE $ DED X RETENTION$ 10,000 5,000,000 C WORKERS COMPENSATION I PER TUTE 0T $ AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N 67872 8/2/2019 8/2/2020 E 500,000 OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ SOO,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under _ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Rerrarks Schedule,may be attached if more space is required) Insulation Contractor Insulation Contractor National Grid is listed as additional insured. Waiver of Subrogation in favor of National Grid;Liability is primary and non-contributory. CERTIFICATE HOLDER F . �r 1-:''' ''' CANCELLATION t SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE National Grid THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN j 40 Washington Street ACCORDANCE WITH THE POLICY PROVISIONS. Westborough,MA 01581 AUTHORIZED REPRESENTATIVE I - C- �� ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID:9829FEDE-0B8F-4B82-9C87-7532185D29A3 CLEAResult® CONTRACT FOR PRODUCTS/SERVICE WORK This service is brought to you through support from your local utility This Agreement is made by and among and Justin Amaral CLEAResult 5 Medeiros Ln Attn: HES Dartmouth,MA 02747 50 Washington Street, Suite 3000 Westborough,MA 01581 SA-32268_20191010 Federal ID No. 222457170 (Mail completed contract to address above) I. DESCRIPTION OF WORK TO BE PERFORMED Contractor will perform or cause to be performed the following work on these"Premises"in a professional manner and in accordance with the terms of this Contract,including the attached recommendations/work order describing the work in detail(the"Work")which are incorporated herein by reference: Description Quantity Location Estimated Cost Perform Air Sealing at Estimated 62.5 CFM50 Per Hour 10 $925.80 Damming 110 $262.90 Attic Floor Open Blow Cellulose 4" 996 $1,474.08 Install 2"Thermal Barrier Polyiso On Kneewall 214 $1,022.92 Cut and Finish Access 1 $124.53 Sub Total: $3,810.23 Program Weatherization Incentive: ($2,163.32) Program Air Sealing Incentive: ($925.80) Customer Contribution: $721.11 LI OPY,_, E II. PAYMENT Customer agrees to pay Contractor for the Work,the Customer Share of the Contract Price as follows:Payment#1:$ 0.00 as a Deposit payable to CLEAResult upon signing the Contract(not to exceed 1/3 of the total retail costs).Mail check&contract to CLEAResult,Attn:HES,50 Washington St., Ste. 3000,Westborough,MA 01581.Final Payment:$ 721.11 as the final payment for the Work shall be payable to the independent installation Contractor("TIC")upon satisfactory completion of the Work.Customer understands that he/she will not be required to pay the Utility Incentive Share of the Contract price in the amount of$ 3,089.12 .Changes to individual line items and/or previous incentives may increase or decrease the size of the Utility Incentive Share. III. DISPUTE RESOLUTION The IIC and Customer hereby mutually agree in advance that in the event that the IIC has a dispute concerning this Contract,the IIC may submit such dispute to a private arbitration service which has been approved by the Office ofConsumerAffairs and Business Regulation and Customer shall be required to submit to such arbitration as provided in M.G.L.c 142A. You may cancel this agreement if it has been signed by a party at a place other than an address of the seller,provided you notify the seller in writing by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement.DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. E1UaocuSigned by: ADS clIN antaral 1/8/2020 112:52 PM EST (OR) ha 6142iu sB$rg►IO.ture Date Indicate your selected IIC here,if applicable 4hitial here if you want the Program to assign a Matthew Francisco 10-10-2019 Matthew Francisco Participating Contractor CLEAResult Signature Date Name of CLEAResult Representative(Printed) TERMS AND CONDITIONS APPEAR ON THE REVERSE. 2200-12-R1.16 Page 1 of 2 Printed Date:October 10,2019 c •11$ w/1 Permit Authorization ,,� mass V+ Form �PARTICIPATING Pa� c CONTRACTOR Site ID: SA-32268 Customer: Justin Amaral i, Justin Amaral , owner of the property located at: (Owner's Name,printed) 5 Medeiros Ln Dartmouth (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. (-2--_ Owner's Signature: Date: 10-10-2019 FOR CLEAResult OFFICE USE ONLY CLEAResult has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date ts Ma CLEAResult•50 Washington Street,Suite 3000•Westborough,MA 01581• 1800-480-7472 .i y For Office Use Only /7?f)Z /?lGY'� G? ���%CZ�1.�11'C Zl.G1 / Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Supplement Card Registration: 175445 SUPERIOR INSULATION LLC. Expiration: 05/12/2021 140 POINT JUDITH RD UNIT A7 NARRAGANSETT, RI 02882 Update Address and Return Card. SCA 1 it 20M-05/17 .//,,r Vi'iii l,"t/ioriif✓'/( /49,i374i1ii7/4. Office of Consumer Affai Bus Hess Regulation HOME IMPROVEMENT CONTRA TOR Registration valid for individual use only TYPE:Sup ement Card before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 175445 05/12/2021 1000 Washington Street -Suite 710 SUPERIOR INSULATION LLC._ Boston,MA 02118 CHRIS SAUNDERS " C2/114/14— cr7:4±------' 140 POINT JUDITH RD UNIT A7 �/,w,-,,e(a t NARRAGANSETT,RI 02882 Not valid without signature Undersecretary n F, ,q 1 JJ. I . t PY r Massachusetts Department of Public Safety r Construction Supervisor 1 &2 Family " Board of Building Regulations and Standards Restricted to: , License: CSFA-106269 Construction Supervisor 1 & 2 Family CHRISTOPHER SAUNDERS ; „ 1742 MAIN STREET WEST WARWICK RI 02893 Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. ...Z. \ Expi rat! DPS Licensing information visit:WWW.MASS.GOVIDPS Commissioner 03/25/202 C