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HomeMy WebLinkAboutBLD-19-000691 •4 `i e9/i . . , . • • ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department 1146 Route 28, South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508-398-0836 �'_ �E . Massachusetts State Building Code,780 CMR Building Permit Application To Construct,Repair, Renovate Or Demolish _ a One-or Two-Family Dwelling '.L t; p E E yr E D a S tion For Official Use Only . (., Buil PeiiuitNuntber'LP-; / 09/ ;Date A" lied: = • I is: it." 11 � �. / ,/, : PP 2 2018 J l ., 4jSl f- w J 4�(f•P/4':. - "7: .. .. . . ,.{, NARTME NT Building QfficiaPrrin%Nam ,. ', • Sigoaturer^.:;.,. . y:1'.,;- �• -Date • ,SE, N 1:SITE INFORMATION::' 1.1 Property Address: „ Assessors Map&Parcel Numbers III NI(LAI Lnke.t Avt:. J'Y ax 1cI1 1.1a Is this an accepted street?yes V no_ Map Number Parcel Number R F C E ! V E D 1.3 Zoning Information: 1d Property Dimensions: 5177—b 17 l 2.2C Information: „_ 1.4 5ciIi3- /NIA ._'� Zoning District Proposed Use Lot Area(sq ft) . Frontage(ft) ( AUG 1.5 Building Setbacks(ft) 1 F`-„�„_4I,7ST i r 2018 Front Yard Side Yards Rear Yard ❑v --- -- v-- Required Provided Required Provided .. Required Provided - <I” lc/1 - '� — — 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Private❑ Zone: A Outside Flood Zone/ Municipal❑ On site : . �,: . Check if yes❑ P disposal system ;,,. ..r,:.: . il • .;�.. ' 'c::.::.'.`SECTION”2::RROPEBTIY;OIi'NERSItik 'r. `'•%.;',,^ ::...:::. . : :•,:.. : 2. Owner'of Record: SDaku.a CL�.L.VIO • 1?tM Ot , 1.0 0/LIiii Name(Print) C• ity,State,ZIP N 1+ 3rit,��tok. d'tYtet, Glh- M.; -n©Gl} N/A Telephone Email Address (3 S TS PR 5t URK-•,(.,-. il`tba' <..:,..' ,'?` -.,:.i: ;; '.;:;SE ON1)E CRIPTIO QR OIjO h)\'V 2 checTt;,4 t a�'aPk�Y) ,i 'Y` c';`;j,•:.:: i ` New Construction❑ Existing Building' Owner-Occupied 0 Repairs(s) 0 1 Alteration(s) Addition ❑ Demolition 0 Accessory Bldg.0 NumberofUnits_ Other ❑ Specify: • Brief Description of ProposedWorkz: Oen.......h.-1-•-- I,,.t-cL .A IA'Act! Col,i...-i_ t-, 74- ' 17.ccbv.r-iiiu+.. Ct6Sc-i-5, (re k-e- [x.44, iv 't,.- well tzr-1.,,_,-v., (t:,.Lcl e .. f 1g...h. ";" i.i t>';SEC OI!I;4IEST ED,CONS O COST Po-.+r=` ct' ,. , ,. . �? 11VTAT �Ttlf�. S`•Vii: -.cd Estimated Costs: yr .c„ip: .;:c1:._;t ` ".:e?.t ciU'r, r;.,•' '. . Item (Labor and Materials) ''„K;; ,,`'-;r. :qd ' r.. ...2):Ws...* '`:" r .;:'':`'':: ?`c _•' •;x`-EuteR:.Y;�:r::n'r.:,:.. f ..,:1;;;,,q,?.-ey'9':'I,.`d'1;.4r s: $ 5 tj 'ill?!BuhIding'Pe�dt`Fe_et$ Indicate'kOW, :fee4s'deteimined; 1.Building !� � O U � �;" i..z..,:.;:'-':..A; ._,:,. 2.Electrical cA,Stan'dazd'Gity/IorigtApplio ti2Elk.e6 •?`'' 6:.;'j'` °;I'' ':'''' -plrofal?ToJeot.cc,,,tem. %,it. ^e:: bkadiniiltiplien,'�;'r.;%•:; ,,.�; 3.Plumbing $ /r 51 0 :,2j`othb F.,heSt $'q" 1 ":'; :,n ;:J x' ' >.,.,> ,;,;s, `..: 4.Mechanical (HVAC) .a . t v, `;,r «,"•>r r.- . , 5.Mechanical (Fire �- p1,.yr'S `::•y.i :14'.?ti.5'i:: :1:. :t:: i;.41.[,'sf?_.Cis :'d:J::1iu:.: Suppression) $ :T'ota1A11Fees.,$:. .•,, "".. „ Nea''ii.i. .ChOckA oiin1 :`'':•.` 'Cashi,Anioun1.// ....."-- check 6.Total Project Cost: $ 44C.co 653 a 1,11 m Full'.±::::.--:-/:k•:-a. (iiii tandiag l#hlarie,Du'e`:> :' •:;; • SECTION 5: CONSTRUCTION SERVICESC 5.1 Construction Supervisor License(CSL) �,1'j (� �e I Q George. 3(.V i cr License Number Date Name of CS older 33 `�Dr+,k �auu ' rt�� List CSL Type(see below) () No.( and Street_C1�, /� ,Type .. - . Description k I O(Lt,L ,//A.r rA c 111 H 0.26 tp L{ U Unrestricted(Buildings up el 35,000 cu.ft) r ,l� 1, R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding • SF Solid Fuel Burning Appliances SOP-394-Oed c�dnvu.r cif.orgro,aA/LeIR:. r ll.) I Insulation Telephone EmS' address D Demolition 5.2 ,10 /nRegistered Home Improvement Contractor(HIC) ,' 0 Coh f L a tong e. c�(),V W' 17 h l:. HIC Registration Number ExpGabdn Date HIC y am rHICRe ' ant Nam ‘3J3 ort�t, oilvt, Ritrre,t r,dotritr Mfg* ria'iWr.CO(*, N . Street (. "�J Email address nor sin.n O2lalhr4. SAP-c3619-0PclI ity/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit Signed Affidavit Attached? Yes No ❑ • • SECTION 7a:OWNER AUTHORIZATION,TO BE COMPLETED WREN • • OWNER'S AGENT OR CONTRACTOR�mAPPIES FORFOBUILDING PERMIT I,as Owner of the subject property,hereby authorize l�CM r e, IlILV(„r, 1 Kt, to act on my behalf;in all matters relative to work authorized by this-building permit application. thanAa. et-t;l0 Pia iP • Print Owner's Name(Electronic Signature) D • • • SECTION 7b: OWNER"OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. GAJ vCVr5i Print Owner's or Authorized Agent's Name(Electronic Signature) I D e . :. NOTES: .,. . 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.aov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" •, ....og'YAR,� TOWN OF YARMOUTH Tt o BUILDING DEPARTMENT 1146 Route 28,South Yarmouth,MA 02664 ss3�:::. 508-398-2231 ext. 1261 Fax 508-398-0836 BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G.L.Chapter 40,Section 54 and 780 CMR,Chapter 1,Section 111.5, I hereby certify that the debris resulting from the proposed work/demolition to be conducted at III N(Lnt11,Ckit A v OW/C. Work Address Is to be disposed of at the following location: cl4 J£xc 0 Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. , „a - slab? Signature of Application Date Permit No. • e V'orninonnea/4( Jc f?aUacAeroe((1 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corporation before the expiration date. If found return to: pealstration Expiration Office of Consumer Affairs and Business Regulation 160164 ' 07/01/2020 One Ashburton Place•Suite 1301 GEORGE DAVIS,INC..• Boston,MA 02108 I i F. a'–""_ti_ 33 NORTH MAIN STREET SOUTH YARMOUTH,MA 02664 Undersecretary Not valid without signature • Massachusetts Department of Public Safety ; Board of Building Regulations and Standards • •• License: CS-056130 Construction Supervisor •• GEORGE F DAVIS ' ' 33N MAIN ST a , ,1 • S YARMOUTH MA 02664 • • szo-ta �rtrL*— Expiration: Commissioher 03/01/2019 . • • • yr /—•41 GEORDAV-01 'WELCHER ACORO' CERTIFICATE OF LIABILITY INSURANCE DATE(MM/ 44.-- 03/05/22018018 ) 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(les)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 Gwen VOSburgh Mason 8 Mason Insurance Agency,Inc. NAME: 458 South Ave. ja//°ciJo,Eat):(603)3564392 I FAX m3)4603)356-9290 Whitman,MA 02382 ADo"nlEss'gwen©mmins.com INSURER(S)AFFORDING COVERAGE NAIC R INSURER A:Western World 13196 INSURED INSURER B:NGM Insurance Company 14788 George Davis,Inc. INSURER C:Associated Industries Insuranc • 33 North Main St INSURER D: South Yarmouth,MA 02664-3437 INSURERE: 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 OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITSLTR MD )WD IMM/DDNYYYI IMM/DD/YYYYI A X COMMERCIAL GENERALDABILITY EACH OCCURRENCE __ 1'000'000 CLAIMS-MADE n OCCUR NPP1477087 01/12/2018 01/12/2019 IEeENToccurtence1 $ 100,000 MED EXP(Any one person) S 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEM.AGGREGATE LIMITq .APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY I In I I LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: S B AUTOMOBILE DAEIDry COMBINED SINGLE LIMIT 1,000,000 (Ea asides/ E — ANY AUTO _ M9M28491 10/26/2017 10/26/2018 BODILY INJURY(Per person) E _ AUpT�O�S ONLY X AUUpTNNO.qDUWUTNL.�EEEDpp BODILY INJURY(Per accident) E X AUTOS ONLY X ORM? PdtefOgoEpiRd ntrAGE $ $ UMBRELLA UAB OCCUR EACH OCCURRENCE __ E — EXCESS LIAB CLAIMS-MADE AGGREGATE E DED RETENTIONS E C WORKERS COMPENSATION X STATUTE EOTH AND EMPLOYER$'DABIDry WCC50050143902018A 03/05/2018 03/05/2019 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE YIN EL EACH ACCIDENT E O FICggil In NER EXCLUDED? N NIA en a ory 1n ) E L.DISEASE-EA EMPLOYEES 500,000 If yes describe under . 500,000 DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Office Copy CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE . George Davis,Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 ACCORDANCE WITH THE POLICY PROVISIONS. 33 North Main St. South Yarmouth,MA 02664-3437 AUTHORIZED REPRESENTATIVE I ' ACORD 25(2016/03) ©1988.2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD _ P The Commonwealth of Massachusetts En4l Department of Industrial Accidents • =:-•s= n= 1 Congress Street,Suite 100 Boston,MA 0211 4-2 01 7 .fr; www.snass.gov/dia \Yorkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information -�' Please Print Legibly Name(Business/Organization/Individual): (� t.LOr3 C (V av Ltis / 1 ./{1.C, Address: t33 Nov-Ek., t1L , IQ(4t. rett City/State/Zip:&la,rhLo(th.L, frA 0'a.anG y Phone#: O p-(111/' O/t?21 Are you an employer?Check the appropriate box: Type of project(required): 11 am a employer with I3 employees(full and/or part-time).' 7. ❑New construction 2.0I am a sole proprietor or partnership and have no employees working for me in $, emodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑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.❑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. ]3.❑ROOF repairs These sub-contractors have employees and have workers'comp.insurance.: 6.❑We are a coryoration and its officers have exercised their right of exemption per MOL c. 14.El OtheI 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. A Insurance Company Name: A AP oe iat�,W 'tin.d,a, r tri(IC! �'1k1k-CD). rU. to Policy#or Self-ins.Lic.#: a)CC s7 YO l JAO l i n "I O„Z O lit t Expiration Date: 3/th J I\`/7 Job Site Address: III �I . )1. iar.ICGt A y G (L ti City/State/Zip:j ii e Lt e rmr ni on±I I 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 fot insurance coverage verification. I do hereby certify under th ins and penalties of perjury that the information provided above is true and correct. Signature: p• Date: PIyZ �I Phone#: 6O7- 341{' O ft3Z • 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#: VI.Permit Authorization By signing below, the Owner(s) authorize George Davis, Inc., to act on Owner(s) behalf relative to the work to be performed at this address. Project Address: 111 Nantucket Avenue, South Yarmouth, MA My signature indicates that I have read, understand accept all provisions of this agreement Do not sign this contract If there are any blank spaces. Owner• _Jr Date 07457' { M. Contractor /Se Date 7/2/f Deborah Esborn, AKBD 7 �� ir George Davis, Inc. Initial Initial Page 9of9 RECEIVED • Jt:Y'9k TOWN OF YARMOUTH AUG 02 2018 51c HEALTH DEPARTMENT o y HEALTH DEPT. "�•`' PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEr,I To be completed by Applicant: Building Site Location: III Na.wt(A.0 k Ct VC KIL t MD I Ilk, Yarn 0 CLtly Proposed Improvement " • g . G . t I o !.,• I I . t Y&COh i Ur cLocrtts crca e o rµ (K.3U WAIL &week) kite '/l yf 5a.±ic.. Applicant C e oral C., WavLr, Thc. Te1. No.: 501 �3qi{-08,3,2 33 Norfl / IjaC� Jt. /+ � � Address: �I oU t�l YQ r Q fA t�l O n� �a O�{ Date Filed: e 02 s, **Ifyou would like e-mail notification of sign off please provide e-mail address: �b Owner Name: 0 K.,k(1, e l,t alt 0 Owner Address: Itt jj r l^Q kU h, Arc It Owner Tel. No.: C 1 1{ (9- ())31 �...cLl Jt...t . ttA OjQ...it RESIDENTIAL AND/OR COMMERCIAL BUILDING HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements For Septage Disposal and other Public Health Activities. Please submit three (3) copies of plans, to include: (1.) Site Plan showing existing buildings, water line location, and septic system location; (2.) Floor plan labeling ALL rooms within building (all existing and proposed)— . Note: roposed)— Note:Floor plans not required for decks,sheds, windows, roofing; (3.) If necessary, Title 5 application signed by licensed installer with fee. REVIEWED BY: DATE:e °7 7/ PLEASE NOTE COMMENTS/CONDITIONS TO n zvin ( c'/ �ct K Sr vc 4 . • � 1i m I I ISI I'�I - 1� II I K__ I [Standard Tub 2[59VV+ II I o N a 0 Li BEDROOM ILO- - _ _ _ o.' 45 0 BATH r m I I Noz I I ©0.0 IQ: I 1 / I I 1 2466 =_- -_ IL c_I = 0 O O N cs HALL N al -1, \3106/Nr— 2666 2866 1 d X r. ��3106 w 0 D 2 E 1 m 0 FIFILE COPY A- o ill 2dz LIVING BEDROOM z Co__ E Aud 02 tots Q z } TOWN OF YARMOUTH - 4_ REVIEWED FOR BUILDING AND ZONING CODE COMPLI• HEALTH DEPT. o ANCE. ERRORS OR OMMISSIONS DO NOT RELIEVE THE1----t: N APPLICANT FROM THE RESPONSIBILITY OF AS BUILT' COMPLIANC DATE: DATE: -�l� EXISTING • 8/1/2018 L // • SCALE: Imo— z:ILDIN OFFICIAL 2739DH 2739DHL.--7...-rri—D - SHEET: ® I Pg-1 M I C N ❑ Oq, 8 N 2 0 2 ( — co o NZ 0a`o l y l P tel, i c , Scope of Work: cz a • Renovate Kitchen l , �� • Install cabinet in Bathroom • Reconfigure closets in bedrooms BEDROOM ii ,� - KITCHEN • Create wall opening between kitchen & living room lP - __----=- t, ki � f Great opening in wag, N N -C 'natal new header as required '� C 33 tri r m rt. l 2 72' O O C • ID 3 . m N Enlarge closet on front bedroom(move separating wall) Non-structural wall utero opening is ecandinq 3 N Co C Q X o 8 _C [IL Y +-' 3 C 3 O BEDROOM LIVING a z _c r • r o t N 9 I DATE: S EEZEsOMED 8/1/2018 L 1 L D - PROPOSED • SCALE: AUG 0 2 2018 1/4" = 110" .1—— -- _ HEALTH DEPT. SHEET: Pg-2