HomeMy WebLinkAboutBLD-19-738 } 7/ !i/648'
'iONE & TWO FAMILY ONLY-BUILDING PERMIT
i.
Town of Yarmouth Building Department , `or 'y
1146 Route 28, South Yarmouth,MA 02664-4492 +
508-398-2231 ext. 1261 Fax 508-398-0836 t
Massachusetts State Building Code,780 CMR
Building Permit Application To Construct, Repair, Renovate Or Demolish
a One-or Two-Family Dwelling
ova
\Thiss Section For Official Use Only
BuildingPermitN/34 - /9-- 73W:' ,DateApph - • - .
•
Tom. Segs9 , .. . 8:�► 8
Building Official(Print Name) • Signature'. ,. . ' .. Date
• • .SECTION 1:Si lb INFORMATION • .
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
(43 W swoQk- PA-L,i IHSS 13 .
47 1.1a Is this an accepted street?yes ✓ no Map Number Parcel Number
1.kZ,q n gInformation: 1.4 Property Dimensions: �, R E C I V .
Zoning District Proposed Use Lot Ada(sq ft) Frontage(ft)
1.5 Building Setbacks(ft) I f' iii j1"
1 i
Front Yazd Side Yards Rear/ad rum at fr u
A;, I NIL U
Required Provided Required Provided j Required 'Provi --
ded __ ___
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: - 1.8 Sewage Disposal System:
Zone: `t. Outside Flood Zone?
Public a Private❑ Municipal❑ On site disposal systemc
Check if yes❑
' , • SECTION 21 PROPERTY OWNERSHIP. .:
2.1 Own'eri of Record:
-sv.a,-te� •r-FsW l).i. Ali\a4c4 k. o.=.,tn PAl ',o aci7S •
Name(Print) City,State,ZIP
a3 ll.);(\a wd Pte-- sar-Ysa-qoFS L+m,Au@&o-Q. or
No.and Street Telephone Email A dress
SECTION 3:.DESCRIPTION OF PROPOSED WORK2(check.ail that applq) "'
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s)_0 Additica..
Demolition ❑ Accessory Bldg.0 Number of Units_ Other ❑ Specify: i= (; E i V E 1) '
Brief Description of Proposed Work1: l,, ,
'i:_ mat�kd.›3 __s-_ .a.. e a . I .i
u'r4-- DroA',' n FHT .
. . : .. SECTION.4::ESTIhi IATED CONSTRUCTION COSTS:r :. i
Item Estimated Costs: r " .
(Labor and Materials) _ •-•.. - Off cial•TJse.Only,...; ..,'.
1.Building $ a-Ci) .1...Building Permit Fee:$ice.. Indicate how fe'e;isdetermined:
2.Electrical $ 0Al Standard City/TownApplicationFee ';'• : ' ;. '''-[
❑.Total Project Costa tg•¢jx�uitiplier... : • •s
3.Plumbing $ 2: Other.Fees: $ J.G(/
4.Mechanical (HVAC) List '
(QAC) $ .. .. ..: :. : .. ..:.:. .. , .. .. . . •
5.Mechanical (Fire
u..ression $ D Tata1 AIlFeesi$
Check NS;• - Check Amount - Cash-Amount - '
L....76. otal Project Cost: $ id'm Full !Outstanding g Balance Due: 1IS
( �� �Pa
•
•
•
' a SECTION 5:.CONSTRUCTION SERVICES
'J 5.1+� \ConstructioniSupervisor License(CSL) ��t (aSQ ff
1ib-i• .0` '4 \I 1pi a'on(7O t f
t
License Number cation Date
II Name of CSL Holder
£6—' 1► rN .�r"„- n List CSL Type(see below) R
No.and Sweet, /"� v—Y Type , .. Description
�V.4A t P1/4.0... inia 01 U Unrestricted(Buildings up to 35,000 cu.R)
Ciwn,State, R Restricted 1°u2 Family Dwelling
'�., M Masonry
RC Roofing Covering
WS Window and Siding
—'151-311 SF Solid Fuel Burning Appliances
:561.
Q Loc xletect`` rs-Cle,W'—'I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) "+ � 1 4� 1"4 �{l`�
�0.f`� 6, A` ��`Q �^ 0`��1 �Q` v HIC Registration Number Expuati�D�e
me oom,3tanyNameorHICRegistrantName '
i , fl.r� (t,ro-� p l.a c„r- Em ee. ' g-mo x �
.u •
—�Io,and Street $oc—' Em ' ddrdres�
)A&. °atop\ 73i-vilf —.
Ci own,Sta ,ZIP Telephone
SECTION 6:WORKERS' COMPENSATION INS TRANCE 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 0
SECTION 7a:OWNER AU THORIZATION TO BE COMPLE L ED WRRN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT .
I,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.
•
Print Owner's Name(Electronic Signature) Date
/ • • SECTION 7b: OWNER'.OR AU'hfORIZED AGENT DECLARATION
I/ By entering my name below,I hereby attest ander 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.
CA114116ter-Adi (Ij --- frr
t Owner's or Authorized A2t s Name(Electronic Signature) Date
. . 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(MC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 141k.Other important information on the EC Program can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dns
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
Nnmher 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"
Y Department of Industrialelccidents
e.. c tls= 1 Congress Street,Suite 100
a• Boston,MA 02114-2017
^.�.9 • www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Eledtricians/Plumbers,
TO BE FILED WITH THE PERMIL L LNG AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): �,� � Cit
Address: 551 A turfs,
SOA)
City/State/Zip: nt,N.t:5..o Phone#: 567-- 131 -'J 1
u
•
Are you an employer?Check the appropriate box:
-
Type of project(required):
1.91 am a employer with employees(full and/or part-time).*
7. 0 New construction
2. am a sole proprietor or partnership and have no employees working for me in
capacity. 8. emodeling
an •y aP ry•lNo workers'comp.insurance required]
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. 0 Demolition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
5.9 I am a general contactor and I have hired the sub-contractors listed on the attached sheet 12.0 Plumbing repairs or additions
These sub-contractors have employees and have workers'comp.insurances 13.❑Roof repairs
6.9 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other
152,§1(4),and we have no employees.[No workers'comp.insurance required]
'Any applicant that checks box NI must also fill out the section below showing theirwarkers'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 GT 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:AISOGt.hat
Policy#or Self-ins.Lie.4:10cc.. &o -ScJ I -.Q�)0 I o Ig) 1 hi. -
r'� Expiration Date:
Job Site Address: 0`3 win-st s,a,,ter City/State/Zip: c).2 G-75
Attach a copy of the workers' compensation policy declaration page(showing the policy niamber 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: ala I 1 C
Phone*: S - -151 -31 11
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#:
' craelacksTOWN OF YARMOUTH
wBUILDING DEPARTMENT
$ 1146 Route 28,South Yarmouth,MA 02664
o •
508-398-2231 ext. 1261 Fax 508-398-0836•
v
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
Pursuant to M.G.L. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section 1113,
I hereby certify that the debris resulting from the proposed
not
onto be
conducted at c W ( P6 Vp\r - p.!\ �^lk P
Work Address 1
Is to be disposed of at the following location: 0--% S i4c GCw.np Saar'
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
t btii � r�
/ ignature of Application Date
Permit No.
. ac, TOWN OF YARMOUT ECE, Th
1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451 WED
_ Telephone(508)398-2231 Ext. 1292-Fax(508)398-0836
SEP 222011
OLD KING'S HIGHWAY HISTORIC DISTRICT CO MITT� u
Mo
(S LD KINGS HJGHWAY
APPLICATION FOR
CERTIFICATE OF EXEMPTION
Application is hereby made for the issuance of a Certificate of Exemption under Sections 6 and 7 of Chapter 470 of •
Acts of 1973, as amended, for the proposed work as described below and on plans, drawings, or photographs
accompanying this application.
•
Type or orint legibly; �" n , Q Q ,gyp 1J y^
Address of proposed vvorrk p.a. 11WI t&b-W1\-A c. :ae—. Maptot iF 1 ` t , 13
Owner(s): - d, x.%-. '( rau.x14 3.\CiK\SG.: Phone d:SY S-0-Q o FS—
All applications must be submitted bynowner�,or accompanied by letter from owner approving submittal of application.
Mailing address: 1 I %)'.ic e.4. Qtis.A 1 \L 1Q/ eetr )1/4-i3 1 akar built 1 ill
Email: w•h\\G4Oy x Fx� e.o.tisiCk c> Preferred notifieation method: Phone CV- Email
AaenUConhacwr. 1st-4N. (3' ' .n & I ��'- , 6A.i.L9 F tuneft ,Sb Gr- 7 37-3717
Mailing Address: t? 0 pa o1� aa7 W t- \-\tro..M:s-o Ma 0"ato 7•a.
AA 1
Email: ill_b CR{Zt9GN 1(Li ^ .Ow- Preferred notification method: 1< Phone Email .
pescriptbn of Proposed Work(Additional Pages may be attached If necessary);
(JAW w. c-i -Rear\ - ‘ CRECEIVED
V SEP 252017
TOWN CLERK
(��f//p/1�
SOUTH YARMOUTH, MA
Signed(Owner or agent).� AliC3,1\
`J�`-- Date: 9`/&1r 7
> Ovmedcontractorfa M is aware that a point may be required from the Building Department.(Check other deparhn nts,also.)
> This certificate Is good for one year from approval date or upon date of expiration of Building Perri,whichever Ste shall be later. •
For Committee use only
Data: 9-rid--1 q ✓rem � � changes APP VED
Amount C90 Reason for denial:
•
Cas-a . 2y SEP 25 2017 •
Revd by: gil
YAKMOU I H •
�` �� OLD KING'S HIGHWAY
Date Signed: 9/L'/Or7 Signed:� ° `�d/1/�+yc.�. � ' p� �[ e
' �J APPLICATIONS: i!-E1.17 R
V52017
•
DANILON-01 AMAHLER
4CORo CERTIFICATE OF LIABILITY INSURANCE DATE 07/30IDD/YYYY)
o7/3onols _
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: M the certificate holder Is an ADDITIONAL INSURED,the poiicy(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 endorsemeM(s).
PRODUCEROOCONTACT
434 Rte&Gray Insurance Agency,Inc. HaplyPHONE
I tea,NJ_(877)816-2156
South Dennis,MA 02660 .ADDREas.mailerogersgray.com
INSURER(SLAFFORDING COVERAGE NAICS
INSURERA:Associated Employers Insurance Company 11104
INSURED INSURER B:
Daniel L O'Neill DBA Daniel L O'Neill Carpentry INSURER c:
351 Megan Road INSURER D:
Hyannis,MA 02601 —-
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 POUCY 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.
MSR TYPE OF INSURANCE ADOL'SUBR POLICY NUMBER POLICY EFF POLICY EXP
ITR INS° WYO IMMIDDITYYY1 IMMD%WYYYI Ups
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S
CWMS#1ADE I I OCCUR DAMAGE
R MISETO RENTED
S(EI ocWrnrcoL_$
MED EXP(Apy onepNeon) $
PERSONAL&ADV INJURY $
GENL AGGREGATE pLRIMpIT.APPLIES PER: GENERAL AGGREGATE $
HPOLICY 1 l JECT LOC PRODUCTS-COMP/OP AGO S _
OTHER S
AUTOMOBILE LIABILITY &MccKlenU SI LINT S —
ANY AUTO BOORT INJURY(Pereereon) $
OWNED SCHEDULED - - -
AUTOS ONLY _ AUTOS
BODILY INJURYPereccklenn $
AOS ONLY _ ANUyONND BerpERTY
OWd t) E S
$
UMBRELLA LIAR _ OCCUR EACH OCCURRENCE
EXCESS LAB CW MS-MADE AGGREGATE 3 _
DED RETENTIONS S
A WORKERS COMPENSATION I PER OTH-
PERTUTE ER_
ANO EMPLOYERS'LIABIUTY WCC50050162012018A 07/12/2018 07/12/2019 1,000,000
ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N EL EACH ACCIDENT $
QF�FlCERIMEM REXCLUDED? N NIA
(Mandatory In� ) 1,000,000
If
yes describe under EL.DISEASE_EA EMPLOYER;
DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 1'000'000
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additlonsl Remarks WIN'S.,nay be attached If men space N required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE
Town of Herwith THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
732 Main Street
Harwich,MA 02645
AUTHORIZED REPRESENTATIVE
7,16411.-----------
ACORD 25(2016/03) 01988.2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
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; t :100 11/11;t111 tit dt••••4441C t 4€ 114, Nit. a ,E0 we 1 44 lidget _.1., 0..1 1,4.,* , •4,1e,,,,, a .4,,,.
idtgAti, $44141ps AZ414°,1tAilei 4.1;16,11..: .44^-':gta4C .446,1s fddr:j' *t4c- le 4461
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Office of Consumer Affairs & Business Regulation ;
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Wlif. . M HOME IMPROVEMENT CONTRACTOR
TYPE..
Individual
Registration Expiration
•st. ,t h,c,
x - : 168722- 05/14/2019
,__, .....,
-,-, •.,
DANIEL O'NEILLiTz--- \--.‘ " \-. -
--- --:, -,-., _
,
D/B/A DAN L. O'NEILL CARPENTRY
-, ,, ,_ ‘.. , „, -Ty:: _ ;,. ? •
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DANIEL O'NEILL (.... ,€,,cc...Get.......- ,r:
, .:-... - - - -,
351 MEGAN RD ' ,1--, - tr. -- ,
HYANNIS, MA 02601
Undersecretar ri‘
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Commonwealth of Massachusetts .,
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9 Division of Professional Licensure H
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Board of Building Regulations and Standards il
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Construction,Supervioc1 & 2 Family .sh4,
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Expires : 10/23/2019 „
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CSFA-105994
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DANIEL O'NEILL
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351 MEGAN ROAD .....:- ,; 4„ t
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HYANNIS MA 02601 ,,,iC f tills k
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A'aersen ,Act a.5
R.0• - 2.5)3":. X l 1G// TOWN OF YARMOUTH
Ji"fe- roof' 104 REVIEWED FOR BUILDING AND ZONING CODE COMPLI-
enr $1�e.N•¢ b.. tN,.4 R 0.524 +0co.le. ANCE. ERRORS OR OM FISSIONS DO NOT RELIEVE THE
APPLICANT FROM THE RESPONSIBILITY OF'AS BUILT'
poubl�. w«,.Icn.! b�1( plut"S COMPLIANCE.
DATE 'IS'I8
•
BUILDING 0 FICIAL
rrta. -, FILE COPY
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