HomeMy WebLinkAboutBLD-19-001192 •
ONE &TWO FAMILY ONLY-BUILDING PERMIT
Town of Yarmouth Building Department or text
I146 Route 28,South Yarmouth,MA 02664-4492 '
508-398-2231 ext.1261 Fax 508-398-0836 1E
ni
Massachusetts State Building Code,780 CMR kkYI(y (
ltuiallfrig PenrL4 atian To Canso Repair,Renovate Or Demolish
aOne-orTsa-FamilYDwelling RECEIVE !:
f3O-lq-00llg2-
This Section For Official Use Only 1 •
Building Permit Number: • Date Applied s 27 2018
/I� F7 to .1?et t, ,�� r. " (/ ,,,� Rr� TMc 11
Building officiai(Print faiS) igatuce - BY: _ _.
SECTION 1:SITE TNFOSMATION �t`
1.1 P rfy,El nress:I>J2 Q�1 .2 Assessors Map&Parcel Numbers l
Isla Is this an accepted street?yesno Map Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(ft)
1.5 Building Setbacks(RE)
Front Yard _ Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,154) 1.? Flood Zone Information: LS Sewage Disposal System:
Public f] Private D Zone. _ Outside flood Zone? Municipal D On site disposal system D
Check if yuD
SECIIoN2: PROP'ERTYOWNERSSiP'
2.1 Owner}of Record: ,
m;epicI Pere tr4 Wes71letm0lll1Ma 02673
Name(Print) City,Stare,ZIP
9 She/hcswe a .SoF-26yloy85.
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Coastuction f] ExistingReiding D Owner-Occupied D Repairs(s) Alteration(s) 11 1 Addition D
Demolition D Accessory Bldg.0 Number of Units_ ( Other /Specify: Z '5' 41;0 r
Brief Description of Proposed Work . . - /c.. /.. - "p ./aTis, o,J o Wye 4M•G
• SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated stimaadCosra • ' . ::OfTitialUseOW
(Labor and Materials) .
1.Building $ 1.Building Permit Fee.S Indicate how fee is determined:
2 Electrical $ D Standard City/Town Application Fee
D Total Project Costa(Item 6)x multiplies . x •
3.Plumbing $ 2. Other Fees: S •
4.Mechanical (HVAC) S List .
5.Mechanical (Fire -$ TotatARFeet S
Saw.c.u:oml) ' -•
CheckNo. Check Amomit Cash Amount
6.Total Project Cost: 3 37cc A Paid in Ful I]Outstanding Balance Doe
" SECTIONS: CONSTRUCTIONSERVIt"RS
St Costnctlon Supervisor License(CSL) Li /O5-(p7y II ��/9
MG 1 eiii it s 5 UcenseNumber •on Date
Name of CSL Holder nn
Yet �StI K� List ESL Type(see below) V
No.and Street `.. TYPe Desmptron
p / /�,, U Unrestricted(Buildings up to 35,000 as it)
/ 'R 6 2 3/00 R Restricted t&2 Family Dwelling
City/Town,State,ZIP/ M Masonry
RC Roofing CoverMf
WS Window and Siding
SF Solid Fuel Burning Appliances
?79-3c4-1/660 Mtke INrti4te7Cf m Y, c6M I Insulation
Telephone J Email address D Demolition
5.2 Registered Horne Improvement Contractor(HIC) 193190, 5
#41 Q I' Loess tie.CT,bti J.-t L nue Registration Number Expiration ate
HRC Company Name or HIC Registrant Name
f a faux brf/3 P1keaA,ere /ticl/,topidn-clO 1.4507
No.and Street
'14 62362 72Y-249-406Z
Email address
City/Town,ifi=et ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.152.§ISC(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 t7
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 behalf,in all matters relative to work authorized by this building permit application.
•
Print Owner's Name(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 best of my knowledge and understanding.
lj
1 - 9A SAC('
14 14(
Print Owner's or Authorized Agent's one(Electronic Signature) Date
•
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hues an unregistered contractor
(not registered in the Home Improvement Contractor(WC)Program),will ggi have access to the arbitration
program or guaranty find under MGL e. 142A.Other important information on the HIC Program can be found at
www.mass.aov/ocq Information on the Construction Supervisor License can be found at www.mass.¢ov/dos
2. When substantial work is plamted,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 ofbalfibaths
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" cif 3 2d0
of 'r` TOWN OF YARMOUTH
�" i 0 BUILDING DEPARTMENT
o H .s
� ..�.i�;m $Y 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 I,Section 1113,
I hereby certify that the debris/ resulting front the proposed work/demolition to be
conducted at `7 SL e/be ,,ue Li
Work Address
Is to be disposed of at the following location: (Plc S•o }4 f ec,Jow ,en)
Pry,"okfA I mei
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
a' 6) ch 8
Signature of Application Date
Permit No.
li-
•
'it • . i
The Commonwealth of Massachusetts
,� Department ofIndustriialAccidents
1-.1.;01r--.! ° .1 Con-r asStreet,.Salle100 • '
a = ;5 • Boston,MA 021142017
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-y`..�'✓tG' www.maSS.gOVidta
• Workers'Compensation Insurance Affidavit:Builders/Ctrade dancelumbers.
TO BE FILEDWITHTHEPERMITTING AUTHORITY.
Please Print Lettibly
ApplicantInformation
Name(gusiness/Orgeniaation/Individual): m D H- AS tip t .411,. bit) 7/4 G
Address: Pa 13/ax (04/3
'City/State/Zip: '1 s,_ __ Phone#: 7744-269e-0002 •
An you ployert Cie the appropriate box: Type of project(required):
I. am a employer with IO employees(MI and/or parttime)! 7. 0 New construction
201 am a Bole proprietor or partnership and have no employees working forme In 8. 0r Remodeling
try madly.Ye workers'comp.imaanee required') • 4. tl Demolition
3.01am ahomeowner doing air work myse)r.No workers'comp.insurance require1r 10{]Building additioa
4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will 1 I.[�Electrical repairs or additions
ensure that en contractors either have workers'compensation insurance or am sole
proprietors with no employees. • 12.0 Plumbing repairs or additions
• 5.01 am a Roast contractor and!have hired the sutfreontrectors listed on the arched sheet 13.09ofrepairs Ia
Tbwecub-conhsctoraluwemployesmdhave warlten'tamp.imuranca•t 14. Other fN'fhl4tM/J
6.0 We area corporation and it:officers have exercised their right of exemption per14132 o.
I;;,11(1),and we have no employees.¢do workers'compoinsurance
'Any applicant that cheeks box#1 must also fill out the section below atiow%ng teals workers cmtmensationyoliey information.
t Homeowners who submit this en.davit Indicating they era doing all work and then hire outside contractors must submit a new affidavit indicating such. •
?contractors that check this box must attached an additionallsshe���ngth� policy
lc wors and state whether or not those entities have
. employees. lithe sub-contractors have employees,they
I am an employer that is providing
workers'compensation insurance for my employees. Below is the policy andJob site
Information. . firm Mt1Taa /
Insurance Company Name:
policy fforSelf-ins.Lie.it: Pitt t 'seer/9375201-7F3 Expratienllate: ,f7.��
Yob e Address:_j
�7 ihe/bt rr Re City/statelzip:JtrrloJIt Mat 02 673
Attachtha copy of theworkers'compensation policy declaration page(showing the policy number and expihrion date).
Failure to secure coverage as required under MOX.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
eoverageveriEcation
Ida hereby certify un!, the pal, •en. es of perjury,that the information provinod above is true and correct
a ate'
• o
,-e •
.
Official use only. Do not write in this area,to be completed by city or town official
• o a•rrait/Fkeense#
• City or Town: '__
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other .
Phone ti:
Contact Person: mmr ..—
DocuSign Envelope ID:8FEFEEDD-886D-4C137-932B30137B865BEC
Permit Authorization
1
mass save Form
Site ID: 3362408 Customer. Miguel Pereira.
I, Miguel Perei ra ,owner of the property located at:
(Owner's Name,printed)
9 Shelburne Road West Yarmouth, MA 02673
(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.
DoouSgned by:
Owner's Signature: CAc -
c369204353414BE...
Date: 4/1/2018 I 9:53 PM EDT
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
01 D 60g57letteAo,-) e/.5/,S)
Participating Contractor Date
Name: RISE Engineering
Phone: 401-784-3700
Email:
for ORrte Use Orly
Rev.102015
•140 &o'mnwntuetrfai o/G acAuoet2
• Office of Consumer Affairs and Business Regulation
One Ashburton Place-Suite 1301
Boston, Massachusetts 02108
Home Improvement Contractor Registration
Types Corporation
Registration 183807
MOH CONSTRUCTION INC. fpiratiort: 11/15/2019
PO BOX 6413 -
PLYMOUTH,MA 02362
Update Address and Return Card
SCA 1 A 20M-05/17
kcaPaptientrid
Moe of Consumer Mains£Brstoen Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:Corporation before the expiration date. If found return to:
Braistuditaa €xairalon Office of Consumer Affairs and Business Regulation
183807 11/152019 10 Park Plaza-Suite 5170
MDH CONSTRUCTION INC. Boston,MA 02118
MATTHEW HARRIS Ara,98AESTA RD
PLYMOUTH.MA 02360 Undersecretary
rirwith signature
•
•
® Camwneeafts of Massachusetts
Orison of Professional Licensor*
Board of Budding Regulations and Standards
ConstructlDn Supervisor
CS-105579 f"risires:11/0712019
MATTHEW UHARRIS -
9S A ESTA ROAD • - -• :.F "
PLYMOUTH MA 02350
• Commissioner aft
nco CERTIFICATE OF LIABILITY INSURANCE DATE(MM OD'YYYY)
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. It SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy.certain policies may require an endorsement A statement on this certificate don not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CN.AOog CT Christopher Jordan_
Professional Insurance&Risk Brokerage,LLCd E,lj181)826.7475 __,_ihiNSS.Lf!26-7484_
31 Schoosett St Suite 309 ERIA4 ordan Irbinsurance.com
ADDRESS.__ 1 @P
Pembroke MA02359 INSVREfes)_AFFORDIN'G covERAGE..____. NALC F__
_. — ._____ —._--IN�QRER AAIM MUTUAL __ ____ .__�__ 33758
INSURED MSUR€R e, The Main Street America Group _ -_14788_ _
MOH Construction,Inc. esuRER c:Penn America Insurance Co 32859_'_
PO Box 6413 INSURER 0: Scottsdale Insurance Co ___—___ 41297
Plymouth MA 02362 ,AsuRERE: '
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 OE D SUCH POL ICIFS LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
INSR A TYPE OF INSURANCE ADD/SUER PODGY NUMBER iMMTDWYYI IMM'DDM•WI LIMITS
POLICY EFF POLICY EXP •
4Tft MSD YlYD
X COMMERCIAL GENERAL UABIu Y EACH OCCURRENCE $1,000,000
C _ MAIMS MADE X OCCUR DAMAGE RENTED
_PRE.MISESCIFe ozc.Cters I S:100000
X ISO FORM CG0001 _ X X PAV0168733 05115/18 05/15/19 MED EXPXI/m pe•s._J._,S 5,000_
X_ Contractual Liability ,,PERSONAL 5 CV IMr-Y 's 1,000,000
GE ML AGGREGATE LIMIT APPLIES PEN GENERAL AGGREGATE .s 2,000,000
POLICY X PEP ! LOC , PRODUCTS_COMP/OP AGG 52,000000
0 DI_R S
AUTOMOBILE LIABILITY DeA M D SINGLE LIMIT =1000000
B ANY AUTO 820K V INJURY'Pe_Fenn: 5 .. .,
' ALL ONWE'D SCH''J.ED art INJURY:Pei tm.lea , S
_;AUTCF .. AUTOS X X M3F0206P 06l18M8 06!18119
NON-OWNED PROPERTY DAMAGE i S
X I MIRED AUTOS •_X WEDS _Xs,acnrtrnn
X ISOCA0001 .5
X_UMBRELLA UAB _X OCCUR EACH OCDURRENCE ' 51,000,000
D ` EXCESS LIAR CLAIMS-MADE'X X XBS0099982 05/15/18 05115/19 .AGGREGATE $1.000,000 _
DED 'X PFTFNTKIN510.ODO S
WORKERS COMPENSATION X PER 0TH-
'ANDEMPLOYERSLIABILITY -_-S�S:VTE...__.__R .__._ _. _____
ANY PROPRIETOR--PARTNEREXECUTiVE YEN NIAEL EACHACCiDENT ' S500,000
A 'orrICEOrvEMBER EXCLUDED'/ LN X VWC10060193752017A 09104/17 09/04/15 -'--"E'- "-"
.(Mandatory in MC ,EL DISEASE EA EMPLOYEE 5SUU,000
r yyea a:acroe sxel
DESCH1P'ION CµOPERATIONS eerzw E L DISEASE..POLICY LIMIT 5500,000
Comprehensive Ded $500
B Auto Physical Damage M3F0206P 06/18118 06118/19 ;Collision Deductible 5500
DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES (ACORO 101,Additional RenM%a Schedule,may be attached If mora space Is rennred)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVS cDA>
•
C
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