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Home My WebLink AboutBLD-19-001190 ONE &TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department o• 1146 Route 28,South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508-398-0836E- !'A Massachusetts State Building Code,780 CMR EuiidingPermit Application To Construct,RepaB;Remanent Or Demolish CtatCQ t B Lb-I q -ct( 'Q v a One-or Two-FamllyDwelling RECEIVED This Section For Official Use Only Building Permit Number: ' - Date Applied: MG 27 21118Ufliciil(PriotNsn �� DW to dhtikm- il S •. !�I" aY' 'SEM rINFORMATION �S� LI P7 erty4ddrr Address: no Li Assessors Map&Parcel Numbers 1.1a Is this an accepted street7 yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.01 c.40,f 54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Outside Flood Public El Private a Zone: Cheek Zone? Municipal El On site disposal system El SECTION 2: PROPERTY OWNERSHIP' 2.1 OwnerrofRecord: ri Cyan 6A1aor)o rr a/ o1, ! 4 o2( 64/ Name(Print) City,State,ZIP 97 Ru,4 P44) 01 No.and Street Telephone Email Address • SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction U ,Existing Building U Owner-Occupied a Repairs(s) U Altera ions) Cl I Addition U Demolition U Accessory Bldg.0 Number of Units_. _ I Ocher CI Specify: Brief Description of Proposed Wore: • SECTION 4e ESTIMATED CONSTRUCTION COSTS. EstItemi •mated Costs: ' ' 0lit;131Use 0a1,y - . (Labor and Materials) • 1.Building , $ 1. Building Permit Fee:S Indicate how fee is determined: /Electrical S U Standard City/Town Application Fee 0 Total Project Cost!(Item 6)x multiplier . • x 3.Plumbing $ 2. Other Fees: S - 4.Mechanical (I1VAC) 5 List: - .. ... • 5.Mechanical (Fire $ • .' • - Suppression) Total All Fees:S 6.Total Project Cost: $ 03e, Check No. Check Amount Cash Amorms ref.? is; . U Paid in Fust Cl Outstanding Balance Due:_ • , • SECTION Sr CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) -10 570TAA et-0 N�N)S `License Numbber y Expiration Name of CSL Holder j`Ra /.47:; /Co/ List CSL Type(see below) I) No.and Street Tae . 1 Dmatpttoa /24,,,c,‘,711 )47,14 62 31,0U Umesn ed(Buildingsupto31,000cu.ft) R Restricted l&2 Family Dwelling Cittifordn,Stare,221 M Masonry RC Roofing Covering WS Window and Siding /i SF Solid Fuel Burning Appliances 779-343^4146 /'7i kerei/i r e174hr„/t_CNt I Insulation Telephone Email addr D Demolition Si Registered Horne Improvement Contractor(BIC) Gor3skk1 e A0.) 1744 1S38o7 HIC Registration Number Exp• on Date HICGpmpany Fame ori YRegsttantNamc No /ands !S?t [Sure/ 3 �h 4 Mei ere P(o,tsk j;,+,coM M6.. ,GrL_A� ir, o23/02 reet , F.r,A, address City/fotvn,State,ire Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M G.L.c.I52.§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 the building permit Signed Affidavit Attached? Yes t No..... U • . SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize to act on my behag in an manus relive to work authorized by this btrabg permit appicnioa 6Cfy L7araC�',PO Print Owner's Ne(Electronic Signature) 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 contained in this application is true and accurate to the of my browl ge and understanding. m429Jei yarns �/�� ' 81240 Print Owner's or Authorized Agent's Name(Elect nic 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 Rome Improvement Contractor(MC)Program),will not have access to the arbitration program or guaranty find under M.O.L.c.MM.Other important information on the MC Program can be found at www,mass,goWoes Information on the Construction Supervisor License can be found at www,mass.i ov/dna 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.R) 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 Costs s 3)000 o1 4R'S • TOWN OF YARMOUTH { BUILDING DEPARTMENT -r.�z moi\a x 1146 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 111.5, I hereby certify that the debris resulting from the proposed work/demolition/ to be conducted at 97 M.&t Pn,4� Ped !�tpinc./A Work Address Is to be disposed of at the following location: 18G SaLill P1ec aw Qc Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. Signature of Application Date Permit No. • 09/06/2010 09127 4016215603 IELFHSF PAGE 02/02 • Permit Authorization mass saw Form Site ID:)415021 Customer: Gary Ga Wane Gary Occt a-let .owner ofthe property locatedat coma non owe* 97 Run Pond Road South Yarmouth,MA 02664 Oaevrtysnv nPedn) Favi herebyauthortte the Mass Save Home Energy Services Program assigned Paracme Contractor listed below to act on my behalf and obtain a MADE • to . - • tnsudatlar and/or+ wrkonmyproperty. / Otvrta1,Denatures < / Dates A P-t/"• naw lid, FOR OFFICE USE ONLY We have assigned the fotbveng Mass Save Kane Enemy Services Pertldpating erm:torts the above referenced protect: AD / et9 PardcmatL+glbntraaor . NPlaamesnt RI401-784-370SE Ermtneed0ng Email: Oar Mini ui.owh • • / . II The Commonwealth of Massachusetts p Department ofIndustrial Accidents `.is f= „ ' 1 Congress Street,Suite 100 • i~_ += ,y • Boston,MA 02114--2017 ' _I= " www.mass.govidia _ :. .�' r Workers'CompensationOBE PILED wail THE Insurance Affidavit:ERMIBp ING AUTHORITY. dans/Phim ors TPlease Print Leen* Applicant / _ J 7 ' Name(Business/Organistionllndrvidnel): P°1b// t6 Itasu445) i G Address: P a Piox fo 413 'City/StatefZip: tf Is • , _ Phone#: 776"2t9.-0002 • Are yon a ployert Ch -the appropriate box: Type of project(required): r, am a employerwith 10 employees(fun end/or part-time).* 7. Q New construction 2-01 em a sole proprietor or partnership end have no employees working for me in 8. Q Remodeling try a rte'xr.(NO workers*comp.insurance requital 9: Q Demolition 3.01 sinahmneownerdoing ell work myself jNoworkers'comp.Insolence requiredJr IO[]Building addition 4.0 I em a homeowner end will be taking contractors to conduct all work on my property I win 11.0 Electrical ie ilio Di addition9 ensure that all contractors either have workers'compensation insurance or am sole 12 ❑Elumbing repairs or additions proprietors with no employees. • • 5.01 am a general contactor and I have hired the sub-contractors listed on the attached sheet 13.1:119 (repairs it These cub-conoaatora have employees and have workers'comp.insurance.: 14. �N'f er hl4.7rohl 6.p We am acorporation and its officers have exercised theimight of exemption perMOL e. Id2 r1+ e.dwehavenoemployee.(Novo:hers'comp.insurencetequhsdl •Any applicant that checks box#1 must also fill out the section below showing 8.dn wean*eempentation policy arfonaation. f Homeowners who submit this affidavit indicating they are doing all work end then hire outside contractors must submit a new affidavit Indicating such. • acontectors that cheek tis box must attached an additiom�heeet showing the name of the sub-contactorsand state whether or not those entities have , employees.If the subcontractors have employees,They provide their workers'comp.policy I inn an employer that is providing work'compensation insurance for my employees. Below Is the policy andJob site InureM Insurance Company Name: �•�M I 't t"71t"i' / Policy IorSelf-ins.tic.#: VIDE-11,6 e)1937ti2017 Expiration Date: 7//'r0tS� lob Site Address: 9? ILIA Pnrsei RJ city/statelZip: Ye,rrroe,ij Mit ozsey Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MOE a 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 veS1t3 lion. I do hereby certify un•- the pa . , • ener es of perjury that the information provided above is true and correct. . // ��. D ate: •.. e r r ... „AO • Off!ete use only. Do not write In this area,to be completed by dry or town officiaL • , City or Town: Issuing Authority(circle one): 1.Board of Health 2.Budding Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact,Person: Phone it: • • Cee 'm,nw,ntieaxfz4 ii014000•0Atae42s Office of Consumer Affairs and Business Regulation One Ashburton Place-Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Type Corporation Registraliorr 183807 MON CONSTRUCTION INC. Expiration 11/15/2019 PO BOX 6413 PLYMOUTH,MA 02362 Update Address and Return Card. SCA I O 20M-05/1T r57..'fr-ewrrr en ar 9417. ftea oift Office of Consumer Marrs rf Bashress Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only • TYPE:Conioration before the expiration date. If found return to: Reab. ioninkertton Office of Consumer Affairs and Business Regulation 183807 11/15/2019 10 Pant Ptaza-Suite 5170 MOH CONSTRUCTION INC. Boston,MA 02118 eirar MATTHEW HARRIS 98A,ESTA RD r PLYMOUTH,MA 02360 �� ,:r r • Wiilfrsignature • Convnonwealth of tlassact'usttts Division of Professional Locensoue Board of Budding R.epaations and Standards Construction Supervisor • CS-105879 EXsnires:11/0712019 • MATTHEW 0 WW2= - - 98AESTAROAD - • :,� - •-.. PLYMOUTH MA 02360 • • Cornmissioner 0 • CERTIFICATE OF LIABILITY INSURANCE DATE fMM ODrcYYY) nc 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 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._ Christo her Jordan -.p Professional Insurance&Risk Brokerage,LLC PROAE Amy M E:T (781)826-7475 __FAX BRI.01LBz6-T484 _- 31 Schoosett St.Suite 309EaaAIL a ordan 1rbinsurance.eom ADDREssL._ j GAP - ---_-.- ----'--- ----_— Pembroke MA 02359 INSVRERISLAFFORDING COVERAGE _-, NAIL 0_ IN QRER A_AIM MUTUAL _ 3375E INSURED wsphER a• The Main Street America Group __ 14768 MOH Construction,Inc. INSURER C:Penn America Insurance Co 32859 PO Box 6413 INSURER 0• Scottsdale Insurance Co 41297 Plymouth MA 02362 MSURERL_-___._,__-_._ 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 IAAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OR SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS ___ _�___- INSR -----------_- _ AODLSUBR—�"-----� POLICYEFF POLICYEXP LTR TYPE OF INSURANCE ASO MO POLICY NUMBER IMMIDDYYYYI IMM'DDllYYYI LIMITS X COMMERCIAL GENERAL LIABIUTY EACH OCCURRENCE S 1,000,00.0_ ^ C ._-.._ CLAS MADE X OCCUR _.PREMtSCSO IMEO=Gf a P) _ 5100,000 _, X ISO FORM CG0001 X X PAV0168733 05115/18 05/15119 ,LIED EXE An_Yte person_J s 5,000 X Contractual_Liability_ _ _ PERsos4..s CV nrJry___'0,090,000_ GE NL AGGREGATE LIMIT AP'LIE_S PEN CENERAL AGGREGATE 12,000,000 U^v'_ FiT _ PDX-_ o- L01 PRODUCTS AGG 52,000,000 OrNTR S AUTOMOBILE LIABILITY COMBINED S;NGLE uI.Cr 11 000 000 B --- ANY AUTO BOOKY INJURY(PM_ y1 , FBr3 ______- ___ •-- ALL O.YNEO X SCHEO,ri En X X M3F0206P 06/15/18 06/18/19 SOOX Y INJURY;Pr vs.Jen: S -_-'AUTOS SON-0p'NFO PROPERTY DAMAGE .S X_HIRF3 AUTOS X A,..Os ,_Pr' -.ndrat -__ _ X ISOCA0001 s X_UMBRP I A LSAB X Gcc t./ EACH OCCURRENCE S1,000,000_______ D • !EXCESS LAB __`CLAIMS.MADE' X X XBS0099982 05/15/18 05/15/19 AGGREGATE $1.000,000 __ DED 'X ' PFTENTTON$10.000 S WORKERS COMPENSATION X PER DTH- 'AND EMPLOYERSLIABIUTY _ _SNTE ___-_B_._.-._.__._ _ .. ___._.. ANY PROPRIETORPAPTNFR£YECUTAR Y/N• EL ACM ACCi:.?ENT �S500,000 A OFndEFUMELMER EXCLUDED' �N� NIA X VWC10060193752017A 09/04/17 09/04118 '- '—"— (Mandatory m NNS ,E L O)SEkg.fA EMPLOYEE $500,000 DSsGmcInON OwOP FHATOeA!sr. FL DISEASE.POLICY OW' (500,000 Comprehensive Ded 5500 B 'Auto Physical Damage M3F0206P 06/18/18 06/18/19 Collision Deductible 5500 DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES IACORD 101,Add,nonal Remarks Schedule,may be attached R mora space)s required) CERTIFICATE HOLDER CANCELLATION SHOULD MY OF THE MOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE4. <DA> • 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD