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HomeMy WebLinkAboutBLD-19-640 P-14fail 1/747-- ONE & TWO FAMILY ONLY-BUILDING PERMIT • Town of Yarmouth Building Department "or"r- ' 1146 Route 28,South Yarmouth,MA 02664-4492 • 508-398-2231 ext. 1261 Fax 508-398-0836 Massachusetts State Building Code,780 CMR . Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only, Building Permit Number: pits /9 02'J)4y0'' Date Applied: 0 rAtifey .: • •�. 8r 7—/g uildmgOfficial(Print Neale) • / Signature , Date - • .SECTION 1:S11 E INFORMATION • • 1.1 Pro erty Address: )lap&Parcel Numbers ✓ /12 voila 9-.. S1.2 Assessors.\armou`Nr, 0 /19 1.1a Is this an accepted street?y _ no Map Number Parcel Number L3 Zoning Information: 1.4 Property Dimensions: r_ f'- Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) J{/,i F t.) 1.5 Building Setbacks(it) C e ' er Front Yard Side Yards Rea.Yazd AUG '- G 2018 I Required Provided Required Provided Required gi 159X Fd ETA-F-;AA LNT "r 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: • • 1.8 Sewage Disposal System: Public❑ Private 0 Zone:_ Outside Flood Zone? Check if yes❑ Municipal 0 On site disposal system 0 • ' . •SECTION 2i PROPERTY OWNER ' ' Own'err 'R1�� of R cor nrxd tic aod can S• &ifMc YWt MA ba(o(n4 Name(Print) City,State,ZIP LV" tla Pond S+Peet ' 14 4S1 g3 D �eanQ;cS�0.rdR o'>S ) Amail•Wr1 No.and Street Telephone Email Address V SECTION 3: .DESCRIPTION OF PROPOSED WORK=(cheek all that apply) ' ' New Construction 0 I Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 I Addition 0 Demolition 0 I Accessory Bldg.0 Number of Units_ Other 0 Specify: Brief Description of Proposed Work'-: _ , , c. a• . 4..A.,./. ,I. a ii• t • V OP/f , /14,141(It evp/ 30-1706 a sit . . . . • ., SECTION 4i ESTIMATED CONSTRUCTION COSTS.. .. . Item Estimated Costs: • • l (Labor and Materials) . _ officialise Ont..:: ':; .: ., 1.Building $ :•1:Build ne Persait Fee:$.r,rV Indicate how fee is determined: 2.Electrical $ • 0 Standard City/TownApglicatiotiVee `; %H..', ' .... • ! , <. 0 Total Project Costti(Ite n u multiplier... . x•• . . 3.Plumbing $ 2: Other:Fees: $ • 65" , 4.Mechanical List: ' 5.Mechanical (Fire Suppression) $ TotalAIlFees:$ 5"-' ClieckN6 • . Check Amount Cash.Amount// 6.Total Project Cost $ a�i �O oO ❑Paid bPull . . ' 0 Outstanding Baladce Due: r JUL 31 2018 i El1iLDING DEPARTMENT . SECTIONS:.CONSTRUCTION SERVICES . 5.1 Construction Supervisor License(CSL) CS� )Op ry�Q r'2$I u 1 I (J 7 ict , c hr i rm)phe f So t e s License Number Expiration Date • • Name of CSL older U • Q•19 9 Mas\ pet Nierk Ras List CSL Type(see below) MNo.and Street 1 n /'}, TT z .. Description CI , /V fl O\�.,b� - Unrestricted(Buildings up to 35,000 cu.R) R Restricted 1&.2 Family Dwelling City/Town, ate,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I • _ •. .conn I Insulation Telephone Email ad.. IF D Demolition 51 Registered Home Improvement Contractor(HIC) I$Coady Oar\ p� Snows HIC ORegistrationNumber xpiration ate CComppa�nyN eorHICRI�egisgqaanntNate \ti mo.sv c NQi1L (AC� Cttr.voperssoareS retrial. No,and Street V • a a - ' I e it y • �91t a37, 00532 Email address car.. . • City o State, A Telephone SECTION 6:WORKERS' COMPENSATION INSDRANCE AFFIDAVIT(11LG.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 Issuan of the building permit Signed Affidavit Attached? Yes No...........❑ SECTION 7a: OWNER AU THORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FORBIIILDING PERMIT I,as Owner of the subject property,hereby authorizerhf IS &( rCS to act on my behalf in all matters relative to work authorized by this building permit application. PeYp./ o P. TA.„ 7-301g Print Owner's Name(Electonic mature) Date • • 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 /Tined in this application is true and accurate to the best of my knowledge and understanding. 9 30 • 18 t waer's or orined Agent's Name 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(HIC)Program),will nor have access to the arbivation progam or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Progam can be found at www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.aov/des 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" t ___'- = t Department of Industrial Accidents p•=ill 1 Congress Street, Suite 100 ..'`_ • Boston, MI 02114-2017 '0.�.a'�� www.mass.;ov/iia Workers' Cbmpensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organiizaattion/Individual): , t(,,I,,In j ( ��eS Address: 9N I' Iashpee tieck }'Rei. ,/ City/State/Zip:inUe (11/4(11/4Q (D 4 9 Phone#: rill y 338' &532 Are yon an employer?Cheek the appropriate box: Type of project(required): I. am a employer with 3 employees(full and/or part-time).* 7. 0 New construction _.Q I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] 8• Remodeling 3.0 I am a homeowner doing all work myself.[No workers'camp.insurance required.)t 9. Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 5.0 1 am a general contractor and 1 have hired the sub-contactors listed on the attached sheet 12.❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.t 13.Q Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.g/ OtherCt&gyp Rip 152,§1(4),and we have no employees.[No workers'comp.insurance required.] -b / BR +Lit u tl "Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information1` t Homeowners who submit this a£idavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ?Contractors that check this box must atached an additional sheet showing the name df 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: 6)04'0. I nSufe...n ce CO Policy Si or Self-ins.Lic.#: CRC tea' `ja 1 Expiration Date: o2''LG. 19 Job SiteAddress:I; %M1'l?_P:� City/State/Zip:S i `IA(mtsuk\n Mt 0Z(p(Qy i t 7 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby tiij under the pains and penalties of perjury that the information provided above is true and correct Sicznature Acac.---- Date: 7' 30 '19 Phone-,#: . 7'lL/ *93'8 cos-- a— Official it- aOfficial use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City-frown Clerk 4.Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: OF.YgR TOWN OF YARMOUTH �_$ BUILDING DEPARTMENT C • • 1146 Route 28, South Yarmouth,MA 02664 508-398-2231 ext. 1261 • • HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: • DATE: JOB LOCATION: NAME STREET ADDRESS SE:110N OF TOWN "HOMEOWNER" NAME HOME PHONE WORK PHONE PRESENT MAILING ADDRESS CITY OR TOWN STATE ZIP CODE The current exemption for'Homeowner' was extended to include owner—occupied dwellines of one or two units and to allow such homeowners to engage an individual for hire who does not possess a license,provided that such homeowner shall act as supervisor. (State Building Code Section 110 85.1.3.1) Definition of Homeowner. Persons)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 attached or detached structure assessory 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;such"homeowner"shall submit to the building official,on a form acceptable to the building official,that he/she shall be responsible for all such work performed under the building permit.(Section 110 85.1.3.1) The undersigned `homeowner' assumes responsibility for compliance with the State Building Code and other applicable codes,by-laws,rules and regulations. The undersigned 'homeowner' certifies that he / she understands the Town of Yarmouth Building Department minimum inspection procedures and requirements and that he / she will comply with said procedures and requirements. HOMEOWNER"S SIGNATURE APPROVAL OF BUILDING OFFICIAL INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch.142. Yes No If you have checked ves• please indicate the type coverage by checking the appropriate box. A liability insurance policy Other type of indemnity Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent h:homeownrlicexemp • • Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral Cr written." An employer is defined as"an individual,partnership, association,corporation or other legal entity,or any two or more of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MOL chapter 152,§250(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contacting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s) of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial • Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accident. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant . Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit • The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. : 617-7274900 ext. 7406 or 1-377-MASS AFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/din _og'Y TOWN OF YARMOUTH •�' � _an a BUILDING DEPARTMENT . -aa` ''c -I1146 Route 28,South Yarmouth,MA 02664 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 1113, I hereby certifythat the debris resulting from the proposed work/demolition to be �y7 it conducted at I a tlp-(,,i L$-, Work Address Is to be disposed of at the following location: Rat occ - - ( Lsvd ) Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. et4111.,-- Signature of Application Date Permit No. ACORL! . CERTIFICATE OF LIABILITY INSURANCE DATE(MMI°DnYYY) • L �: 07/30/2018 • 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 policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the tertns 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 FIRESIDE INSURANCE AGENCY, INC. PHONE I FAX 36 Shank Painter Road #10 .MAIL LL ",' P.O. Box 760 ADDRESS Provincetown, MA 02657 INSURER(S)AFFORDING COVERAGE NAICS INSURER A: AmGUARD Insurance Company 42390 INSURED INSURER a: Christopher Soares Soares Home Improvement INSURER C: 214 Mashpee Neck Rd INSURER D: Mashpee, MA 02649-3619 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 POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE MSD Win POLCY NUMBER (MMIDO/YYYYI IMMIDDPfYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 5 1,000,000 DAMAGETO RENTED A X CLAIMS-MADE OCCUR py¢115ES IE SSMIEINI) 5 50,000 CHBP908542 02/26/2018 02/26/2019 MEDsop(Any onsImmo s 5,000 PERSONAL SADV INJURY s Included • GEM.AGGREGATE UMITAPPLIES PIM GENERAL AGGREGATE s 2,000,000 POLICY❑JaT n LOC PRODUCTS-COMP/OP AGO f 2.000,000 OTHER 7 f AUTOMOBILE LIABILITY COMBINEDSINGLE LIMIT f (Ea aagenD ANY AUTO BODILY INJURY(Pet person) f AS ONLY ED AUT SCHEDUO BODILY INJURY(Per accident/ 5 — HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY _ AUTOS ONLY (Per acddenO f UMBRELLA LIAR _ OCCUR • EACH OCCURRENCE f EXCESS LULB CLAIMS-MADE AGGREGATE f OED RETENTION WORKERS COMPENSATION PER OTH- AND EMPLOYERS LIABILITY Y/N STATUTE FR ANYPR PRiETORARTNEIEXECUTIVE UDED? NIA EL EACH ACCIDENTOFFIC (Mandatory In NH) EL DISEASE•EA EMPLOYEE $ M yyeeaa,�deaaibe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLCY LIMIT f • DESCRIPTION OF OPERATIONS ILOCATONSI VEHICLES(ACORD 101,Add Menai Remarks Schedule,may W attached V mon space Is raqulled) General Carpentry work. For work at property owned by: Richard Rexnord 72 Pond St. S.Yarmouth Ma 02664 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROViSIONS. 1146 Route 28 Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE ,/}0 • • 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD • A • CERTIFICATE OF LIABILITY INSURANCE DATE(MINDONYYY) 07/26/2018 • 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 rlgMs to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT FIRESIDE INSURANCE AGENCY, INC. PHONEHON• 36 Shank Painter Road #10 MAIL Iuc.Nox P.O. Box 760 ADDRESS Provincetown, MA 02657 INSURERS)AFFORDING COVERAGE MAIC• INSURER A AmGUARD Insurance Company INSURED INSURER is: NorGuard Ins.Co. Christopher Soares Soares Home Improvement INSURER C: 214 Mashpee Neck Rd INSURER D: Mashpee, MA 02649-3619 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 POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. SISR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE MSD vivo POLICY NUMBER IMMIDOIYYYYI (MMIDDSYYYY1 LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 A X CLAIMS-MADE n OCCUR CPRE ISESBIEioau e CLAIMS-MADErroe) S SO,O(L CHBP908542 02/26/2018 02!26/2019 MED EXP(Any ane person) s 5,000 PERSONAL a ADV INJURY $ Included GENT AGGREGATE UMIT APPLIES PER GENERAL AGGREGATE S 2,000,000 X POLICY I I!ECT I I LOC PRODUCTS.COMP/OP AGO $ 2,000,000 OTHER f AUTOMOBILE LIABILITY COMBINED SINGLE UMIT f (Ea eatlentl ANY AUTO BODILY INJURY(Per person)— S OWNED — SCHEDULED BODILY INJURY(Per aaldenD $ AUTOS ONLY AUTOS HIRED AUTOSO NON-OWNED PROPERTY DAMAGE AUTOS ONLY _ AUTOS ONLY JPeredentl _ $ UMBRELLA LMB OCCUR EACH OCCURRENCE f _ EXCESS LMB CLAIMS-MADE AGGREGATE DED RETENTIONS WORKERS COMPENSATION PER 0TH- ANO EMPLOYERS'UABILrfY STATUTE ER B OF IFCER EMMBOERRREXCLNUDEDYECUTIVE Ya NIA CHC928521 02/26/2018 02/26/2019 EL EACH ACCIDENT f 100,000 (Mandatory In NH) E L DISEASE•EA EMPLOYEE $ 100,000 IDESCRIPTIOONO OPERATIONS below EL DISEASE•POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Addatonel Remedre Schedule,may be efaMed I mare space Is required) General carpentry and roofing work CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN s ACCORDANCE WITH THE POLICY PROVISIONS. p n 17I BeenroCtoNBn AUTHORIZED REPRESENTATIVE Beumar-MA-02572 .Aid ..- • —T:... ®1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 4 YMasachusettsOey:.)-0%ntAtPubliCSafety Board of Building Rei..lations and Standards : ' License:CS-109708;; - • : } ae ConstructionSupervisor � g \ CHISTOPHERSOARES . :..i--t . • 214 MASHPEE NECK ROAD: - t' MASHPEE MA 02648 nn G' &piratlon; - Commissione.- ".', . - o6/28n01C ni�+b`.cw d'.4�.•�+.'L+-vx.,e1C!'>r^Y^.>Lay.F.a i,•-tw-a .w / Cl if+� b10/2018 Office of Consumer Affairs 8awjetstiioiyfsn•ew•afefseoosasvuespsduy Pack To Search `RSolsly punj Mue.reno pue uopeillgau maln osle ueo noA iuu11si6a1 sly ao;purioj muimdiuoo_oN Site Policies Contact Us —.___._.--------___ __-----___._.__-..--_---:----__... sllelaa sluleldwoa © 2012 Commonwealth of Massachusetts. Mass.Gov® is a registered service mark of the Commonwealth of Massachusetts. ale0 8103/T3/60 uogeJldxa dIz 6t7930 vvi 'aadysew alMS ''40 PH )loaN eadyse j vTZ ssaippt/ saJeos Jaydolspyo aweN saieos Jaydolsuyo luens!5eu P30981 uogealslbael slu!UIdWOO uo!wasi6au 3IH (bEiv°°) u o !IP I nbazi ssauisn9 pup saiIV aewnsuoo jo 3311.0 rn • . . • • f - hnpsJ/services.ocastate.ma.us/hicnicdaduMot4t 69t 8fdl +g shag v iawnsuoO;o as WO . ; .. .(ITU" • .. n .. ot.-Yqk TOWN OF YARMOUTH • *F .-'► r'..,-)c -tis ' _ HEALTH DEPARTMENT '"•:••%fix PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET To be completed by Applicant:p ^ p Building Site Location:9 3 2oNk 1/4.9v. S. ao cmoc4 RN 0240(914 •Proposed Improvement: 0.4.“C &f (%ku\• ' 4Z o..% • a- p• .1 Cs • V o0.-e\ G-..."& ‘-j• c • ApplicantC\\S e.( z)c. r€S `` Tel.No.: '�� P3 S' &c32.. Address:914 MaS\.pee. i3cClc.. 2.c& IA0.ShQ 02(,49 Date Filed: i- '1i1cc' "Ifyou would like e-mail notification of sign off please provide e-mail address: Owner Name: Regaocd Q:e-L&rck 3te...c, Owner Address:73 9J 9. S. ytcN.a•1' tvlA latt`f Owner Tel.No.:q94 tic I c 3Sc7 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:Floor plans not required for decks,sheds, windows, roofing; (3.) If necessary, Title 5 application signed by licensed installer with fee. REVIEWED BY: / ( ab s DATE: 7--41 7f' PLEASE NOTE COMMENTS/CONDITIONS: nth,c, ie t Ert a l- - ace/time/7r — /Alec? ; l '•, `�' , 2$,laiw di cam' s ti / '�cf r fr (,�,i s}fie r�,�Gyrht 1ar7 = Fele/ 4 PIA-a77 el MCA red 1.1-14," t/4i'r/ 7U' /p=7 7 1 • • a. • . • TOWN OF YARMOUTH _ e r : REVIEWED FOR BUILDING AND ZONING CODE COMPLI- : • iJ F G 0 PY APPLICANT FROM THRS OR OE RESPONSMMISSIONS IBILITY NOT OF ASVBUILT' COt.1PLiANC • DATE: dla —7�� '� IL ING OFFICIAL •? , ! Chti>113 • / •f -�•"- 1 d 5 1 reek- G3C GrLOMGD , . , • • ,)cry Heli k?(g-; . �� OCT 18 2017• HEALTH DEPT. • � — t ; l M'a • NEI ,/ t ; 7� Irl._.. ", / . , , , , ., . . , . a / _...._. ., : , . ! ,Y, ! :. i , .. ,, ' : : . . • ....,-- , , • , y . „ . ; •. ,- , , . . pcsnd . SA-- : i % t3ecr 2 L ". 'i pi-- ' 'i-clx_ . :ImarS oi'LD' t3tocf ;: �. S. ��G✓✓rtcnslN] : Ill . _.p )0L' Oil X'9Putcri t.1-7 X9 ,-1- �"h . I -I j- i...ir- .- i-- ! -: .,. I. 't r IT.I 1 1 i 1 1 i i I ,-C ! 1 11 c.- v, YVl ! Q • • -1_;17X9 I7 ' • ' ' -100C 4 u+cL3. Q ' ' I , ' `12_ p anal %.1- 5 , L/ Ay morvickt r� ► ecs b .. =•e 1 Ft V winglow 716X L17- "FroriT- OFroni- 1 ocic- 3 6 ►n rea_c_oc),,v, 1 O F-F x I - 1- A ro 6c+ x 1- -. Sew e,v, S Ink-) l o1•e)c- • ® 6 F - n to FA-- c lc te-+ G3GGrC SMC DD © tASkdake v,)oMS CZGatRS OCT 181011 HEALTH DEPT. -G 13o in I Wroclaw �•y 5.�' N 6FF ) ' ,28Xv8Y , Zink: 5 � • b CwF sr ow e✓ Is - � o '0 0t © - CY - -1-'Coot I 4 'tea ooc__, Co 'Ant /' 0 i41, . — �, I` r ro Li-4' ts-tall74e1 Seek,czn 6"' Fac s,t4 el0--- , che t s, 3'0 *el 6 P - F7AO1 •Sjcsf 1 G+ . A0 F{ . W etc 1 acsick • • • - • • r-._ ••v, ,v .,..NLL - L'✓- SOIL TEXTURAL CLASS - / EFFLUENT LOADING RATE - 0.74 GPD/SF • 440 GPD / 0.74 GPD/SF - 595 S.F. REOL • - PROVIDED: 2-500 GAL LEACHING GYAMB£RS W/4• STONE AROUND. A-606 S.F.• 606 S.F. x 0.74 - 448 G.P.D. SOIL TEST P T DATA • INDICATES V INDICATES 1 PERCOLATION = OBSERVED • 9�� �d� • TEST ? GROUNDWATER • OCT 8 2017 TP .I maw_ HORIZON TEXTURE COLOR HEALTH DEPT•• �' 96.8 1 96.7+ _ LOAMY IOYR _ • N. 1 �\ 4 SAND 3/3 \\I a� 12 — — 95.8 -• ^,., LOAMY IOYR 96.7SAND 4/6 — •Aq E 2-S00 GALLON 4.0 24 22 3• 2-500/NG mums MEDIUM IOYR — 94.8 62, 3 9 wig• STONE AROUND — C — N 13 +36.8 \g •-b°:-/N SAND 7/4 � pGE �� I! o-p 97.7 \ I-- , to• i _ ..••• / / 7.1 95.742' 14 _ CATCH BASIN ! 'IC* :'.:':.: • pY . _. - . // 9R�VE� d 9al tte SEPTIC500SLLONTANK .� 1''i� :iii: ::: -- ; — - •// PpYE997.0 !.`Ck. .i.. NO WATER / 5111.." I20- 86.8 /� c+� • , ::;;.i_ "' DATE: NOVEMBER /9. 2015 E • /// , R9d�• v 25 �woot �sjs / • TEST BY: STEPHEN HAAS �,w 97.3 WITNESSED BY: AMY VONHONE .�{ // • t',Y p'I1 BB. CORNER ON PERC RATE: ( 2 MIN/INCH V ,/ M \\\\\\\\ 6 A EL-97.70 E fESC Z f�P9 A \ 004 lir tt, • o• 00 97 g1 o tl Ni) D e Yarmouth Health Department CI c e 133• •A p 2_ 4J) P L 0 T 25A s 62� ��,os �c` 4APPR� ED \ff 10. 698± S.F. �, � ' /P C1rw G� '7= i7 4p ;4 / ame Date • 8 01.41ISEPTIC S Y •,--1, to , a 72 POND STREET . •I. f I• a = SECOND FLOOR PLAN SOUTH YA F d 3 Po ,�� . [ : ..... PREPA