HomeMy WebLinkAboutBLD-19-001384 ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department o► . r
1146 Route 28, South Yarmouth,MA 02664-4492
508-398-2231 ext. 1261 Fax 508-398-0836 �•-4.j't. i•
Massachusetts State Building Code,780 CMR ik
Building Permit Application To Construct,Repair,Renovate Or Demolish
a One-or Two-Family Dwelling
RECFIVED
This Secti n For Official Use Onl •
Building PermitNumber:'i q. 3R-y":.]:Date Appli . - pp 05 2018
C . _tb_- 37 b 2
9 r s--/F.
, BuildingOfficial(PrintName) - Sigoature�..,,, ',,':. BUIL E'ARTMENT
',SECTION 1:SITE INFORMATION • -. •
/ 1.1 P�ropggty Adtke�e c __). 1.2 Assessors Map&Parcel Numbers
✓ 1.1 a Is ythiss an aaccceeptted street?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.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yesCI
SECTION'2t PROPERTY OWNS
2.1 Pt wnertof cor
/ *liter +G'L50,r1
t v
/ Name(Print) City,State,ZIP
��V irLH `n41ry -9' 010-a/-O
No.and Street Telephone Email Address
. . - . SECTION 3:DESCRIPTION OF PROPOSED WORK;(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 AIteration(s) 0 Addition 0
Demolition li Accessory Bldg. 0 Number of Units / Other 0 Specify:
Brief Description of Proposed Work2: be v n 0 . LA/a ,Odor ,c i
Drt,. ux&lll cos et- ht
l cu 2i-�/t -•-
vni� 7II
- c,,,.. . ,.(SECTION 4;,ESTIMATED CONSTRUCTIQ.N COSTS::, ,;.!t= ' .:7'-s•4::;
Estimated Costs: :tr
Item '
(Labor and Materials) :.,:•,-:3•;•.,! `Offfc'�at Use'-'...1 -i-
1.Building $ ^•1 'Building Permit Feer$ Indicate how fee is determined;'
2.Electrical $ LOStandard CityttownApplicatiotll'ee -„t�:_x.°' .:.`N.-�i "
TotaIProject CostItem 6)x muitipliei x
3.Plumbing $ 2, Other Fees..$
4.Mechanical (HVAC) $ Listt '
5.Mechanical (Fire
Suppression) $
6.TotalProjectCost: $ '/ 440. 6v Checkist i•. Check Amount '. Cash Amount'..
7/ 6 Pmaid Full 'O Outstanding Balance Dili
SECTION 5:.CONSTRUCTION SERVICES . . .
5.1 Construction Supervisor License(CSL)
�^— IO�( 9 CS-Pdr?a9 / Ql 2.0-52.0-5GJ License Number Ex irati n Date
Name of CSL Holder �• "
me,s M. SGAIdifz, List CSL Type(see below) II
No.and Street ., Type • Description
ow IV(oNf0 0S�L l- f U Unrestricted(Buildings up to 35,000 cu.ft)
City/To State,ZIP 7/ LII. R Restricted 1&2 Family Dwelling
/ M Masonry
11:411 Ott I Aga.. Qz y y( RC Roofing Covering
WS Window and Siding
""�q�� 1 • ^� SF Solid Fuel Burning Appliances
//��
%�13 94/tO t�(1l.f3C(,,."he' h 1CLtlsc oM I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
Smes M. g�hd kr. /83939 1 en zoD9
HIC Registration Number iration Date
HIC Company Name or HIC Regispant Name
toy/ Mot/ rY sr Tinct?-f !3�•Iv�-mac., (NI
•con
No.and Street/1Email address
/T./144_ Fit. OaSeR 07/-791 -91417
City/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 0 No ❑
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:OWNER1 OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
J
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent'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(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.uov/oca Information on the Construction Supervisor License can be found at www.mass.ttov/dns
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basemenUattics,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"
. • The Commonwealth of Massachusetts
Department of Industrial Accidents
eeil►I_ 1 Congress Street,Suite 100
_t�_�= Boston,M4 02114-2017
„ .�,
www.mass.gov/dia •
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Org^anization/Individual); J{i/V �M
lcasttr .c, hc,ciort
Address: q F ,rJ R/k ,
City/State/Zip: ,Cj(,l 7 &Gt''v' DX‘'L Phone#: 7(f/"5'5c).7t
Are yo an employer?Check the appropriate box:
Type of project(required):
1. I am a employer with 4 ge employees(full and/or pan-time).' 7. 0 New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
3.01 am a homeowner doingall work myself. I
9. ❑Demolition
❑ y [No workers'comp.insurance required.]
4.❑I am a homeowner and will be hiring contractors to conduct all work on my 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.
12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp.insurance.: 13.❑Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL e. 14.❑Other
152,11(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. lithe 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. / / n n,
Insurance Company Name: y] Ii +7P h 14,1 &Sci U t tet/
Policy#or Self-ins.Lie.#: U 8 -SOt o P&Cc- i t Expiration Date: -3A/'20i/p
Job Site Address: City/State/Zip:
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.
I do hereby certify underee��the pains and of perjury that the information provided� above is true and correct
Signature: Piti, t/ Date: //30 /I6c
Phone#: 2S/ S7f 0)-71-d
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#:
og'Y9RMOUTH
t f; r e BUILDING DEPARTMENT
Nco"R"i ' 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 'H 9 {Nm Al A) t S. Yu A,,)y�
Work Address
Is to be disposed of at the following location: Seaviwrtist . sks- c'itun±. Mr?,
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111 ection 150A.
0
/ ! r Oa
Signature of Application Date
Permit No.
`"w t
SerViCeMASTERDisaster Restoration ServiceMaster South Shore Inc.
'Clean
Services 9 Ford Place,P.O,Box 399
Ay°W Scituate,MA 02066
Phone: 888/545-2700
781/545-2700
Fax: 781/545-7332
www.servicemastersouthshore.com
E-mail:info@servicemastersouthshore.com
18 Jan Sebastian Drive,Unit 6
Sandwich,MA 02563
Phone: 888/545-2700
508/833-8825
Fax: 781/545-7332
wwwservicemastersouthshore.com
E-mail:info@servicemastersouthshore.com
AUTHORIZATION FOR RESTORATION/CLEANING SERVICES AND PAYMENT
A Qua/Nr Restoration Vendor
Property Owner A N w e G, f�Q,Jpl(e_ro i✓
(- psl Property(Address 1WY Alcorn Cr S. y,4,040,7' ,yo Z, 0.1-'7
1'1 City J , )6(60074 State /14 Zip 01‘g.
Phone(home))0 Sib, `i /e,Zwork 4/92).2011 V7f6 '—
Insurance
Insu ance Company /IA big /Init./Deductible / Do O —
Adjuster 7/ IL Phone#
Policy# Claim/#
The undersigned pA/Q 17,,,VoeiJ eto✓ hereinafter referred to as Owner,authorizes
ServiceMaster South Shore,Inc.hereinafter referred to as ServiceMaster,to proceed with emergency
cleaning and/or restoration services required to restore the above listed property and/or contents from
damage caused by tVi f-?t
on '7—/Z- 1 (7
Owner understands that the total cost of cleaning and/or repairs shall be payable upon completion of work
and hereby authorizes and instructs that direct payment be made to ServiceMaster.Owner understands
that he/she is liable for payment of any deductible and for any and all charges not covered by Owner's or
Its insurance company.
Owner further understands that emergency services are necessary steps taken to prevent additional damage
to the building and/or contents and that restoration services may include cleaning,drying,repair,
resurfacing,refinishing and/or replacement of building materials and contents. ServiceMaster agrees to
perform emergency services and restoration services in a workmanlike manner using reasonable care to
restore the property and contents as nearly as possible to their pre-loss condition. With respect to items that
need to be restored at a remote location,ServiceMaster is hereby authorized to move those items.
ServiceMaster will prepare an inventory of hems removed from the property and Owner will be given an
opportunity to accept the inventory count and description before items are transferred.
Owner agrees that if any invoice for services shall not be paid when due,the balance due shall bear interest
of 18%per annum. The makers,endorsers,guarantors or sureties hereby jointly and severally agree to pay
• all costs of collection including reasonable attorney's fees,if any unpaid balance is referred to an attorney
for collection.
Date 112^/Z—he Property Owner ' •(l
Property Owner Email to I. y,/, d4 fob 411 J /)/ 0011
ServiceMaster South Shore,Inc.Representative -
A ServiceMASTER.
BRAND
AnRr i• CERTIFICATE OF LIABILITY INSURANCE I DATE(oMMIDDD'IYYYYI
TNLSCERTIFICATE 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 holler is an ADDITIONAL INSURED,the policy(les)must be endorsed. H SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require and endorsement A statement on this certificate does not confer rights to
the certificate holder In lieu of such endorsement(s).
PRODUCER CONTACT •
RAW
MCSWEENEY AND RICCI INS PRONE FAX
420 WASHINGTON STREET 5200 ( No,Ee): WC.NO:
EMAIL
BRAINTREE,MA 02184 ADDRESS;
26C9X INSURER(S)AFFORDING COVERAGE NAICS
INSURED INSURER A: CONTINENTAL CASUALTY COMPANY
SERVICE MASTER OF SOUTH SHORE INC INSURER 1:
INSURER C:
INSURER D:
9 FORD PLACE P O BOX 399 INSURER B
SCITUATE,MA 02066 INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMB Be:
THIS S TO CERTIFY TIM T THE POLICIES OF NSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE MSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REOUNB.BIT,TOM OR CONDITION OP ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH TMS CERTWCATE WET REISSUED OR WY PERTAIN.TK INSURANCE
AFFORDED BY THE POLICIES DESCRIBED MENEM B SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS DF SUCH POLICIES.LITS SHOWN MAY HAVE BEEN REDUCED BY
PAM CLAIMS
NM ADD SUB POLICY BF DATE POLICY EXP DATE
LTR TYPE OF INSURANCE L R POLICY MISER IWSDDAYYTY) IMMDmYYYY1 LITS
GENERAL LIABILITY EACH OCCURRENCE $
r COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED S
I CLAIMS MADE 0 CCCUR. PREMISES(Es occurrence)
— • MED DRP(Ary one person) S
PERSONAL a ADV INJURY S
GEM.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S
=PCUCY 0 PROJECT❑LOC PRODUCTS-COMP/OP AGO S
AUTOMOBILE U ABLIIY COMBINED SINGLE S
C ANY AUTO LIMIT(Ea ecckierq
ALL OWNED AUTOS BODILY INJURY •—,$
SOEOULE AUTOS (Per person)
HIRED AUTOS GODLY INJURY S
NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE S
(Per accident)
UMBRELLA11AB HOCCIdt EACH OCCURRENCE S
EXCESS LIAR CLAIMS-MADE AGGREGATE $
$
DEDUCTIBLE
RETENTIONS • S
A WORKER'S COMPENSATION AND x WC ITATUTCRV OFFER
EMPLOYEES LIABILITY YM UB5060P855-16 031D12018 03/01/2019 LIMITS
ANY PROf6xnIXtmAREVEROEGVrNE ID 7 N/A E.L EACH ACCIDENT S 1,000,000
CFFICERMEMEER EXCLUDED?
J
Mandatory In NH) . EL DISEASE-EA EMPLOYEE S 1,000,000
nyes.describe E.L DISEASE-POLICY LIMIT S
OESCRIPSCRIPr10N OF GF IXffRATION3IaleN1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE ROWER AFTECHNG WORKERS COMP COVERAGE
THE INSUREDS MA WORKERS COMPENSATION POLICY AND ITS LIMITED CIPHER STATES ENDORSEMENT AUTHORIZES THE PAYMENT OF BENEFITS FOR CLAIMS
MADE BY IREINSUREYS MA EMPLOYEES IN STATES OTNER THAN MA.NO AUDTORTZATION IS GIVEN TO PAY CLAIMS FOR BENEFITS INSTATES OTHER
THAN MA IF THE INSURED HIRES,OR HAS HIRED EMPLOYEES OUTSIDE OF MA.THIS POLICY DOES NOT PROVIDE COVERAGE FOR ANY STATE OTHER THAN MA.
CERTIFICATE HOLDER CANCELLATION
SERVICEMASTER RESIDENTIAL COMMERCIAL SVCS IP SHOULD ANY OF THE ABOVEDESCRIBED POLICIES BE CANCELLED
DBA SERVICEMASTER CLEAN
BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELNERED
IN ACCORDANCE WITH THE POLICY PROVISIONS.
PO BOX 751027
AUTHORIZED REPRESENTATIVE
MEMPHIS,TN 38175 ,0,7
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPOR)1RTION. All rights reserved.
•
Commonwealth of Massachusetts
V; Division of Professional Licensure
Board of Building Regulations and Standards
Co n strlfettM%Ope rviso r •
tJ
CS-103909 1, Expires: 12/01/2019
•}
JAMES M SCHULTZ ".11 1 = i
1041 MONPONSETT ST.! ;�
HANSON MA 02341 _',;
Commissioner v'"%
PY2e �ponunoazuweale% cialtalackman
Office of Consumer Affairs and Business Regulation
One Ashburton Place- Suite 1301
Boston, Massachusetts 02108
Home Improvement Contractor Registration
C _=
Type: Individual
1= " Registration: 183939
JAMES SCHULTZ - y J t„ peon: 12/01/2019
1041 MONPONSETTST
HANSON,MA 02341
'V ✓i.1' •
Update Address and Return Card.
SCM O 20M-05/17
rib rl/n Mande ti4
Office of Consumer Make&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
TYPE:IndMdual before the expiration date. If found return to:
Reotetration E>@iatian Office of Consumer Affairs and Business Regulation
183939 12/01/2019 10 Park Plaza-Sults 5170
JAMES SCHULTZ j. 3 Boston,MA 0211E
JAMES SCHULTZ ` 7
1041 MONPONSETTST 't/
HANSON,MA 02341 Undersecretary •
Not validrout S19T18tu B�
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