HomeMy WebLinkAboutBLD-19-001470 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 508-398-0836 ` 44/
�'E
Massachusetts State Building Code,780 CMR
Building Permit Application To Construct, Repair, Renovate Or Demolish
a One-or Two-Family Dwelling
• . . t This Section For Official Use Only R E G V E
Building Permit Number: . . ' .1 Date Applied: Mt p Oz I_
S - s 2018'B /� � ;
'Building Official '.
gn:' .- • - Bin i'i
na' RTMENT
SECTION 1:SITE INFORMATION by:
Mpip
1.1 Property Address:25 Ow
etc' ,I h n a 1.2 Assessors arcel Numbers .2211.1 a Is this an accepted street?yes_ no_I�_ 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❑ Private 0 Zone: _ Outside Flood Zone? Municipal❑ On site disposal system 0
Check if yes❑
_ SECTION 2: PROPERTY OWNERSHIP[
2.1 Owner'ofRecord:
'M ll.t ?Isom rel OM. Oacm
Name(Print) � 11 d� ull d A ?Isom
ZIP
.25 Irttmtes "fele.? /QOM ' Io1N9Sdireati70Q�NIAil.tein
No.and Street Telephone mail Addres
' SECTION 3:DESCRIPTION OF PROPOSED WORK;(chick all'that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.0 Number of Units_ Other yYSpecify: Rtt RN'
Brief Description of Proposed Work'':
5+rp I<BORIJ Jh1p'kf eNt 14- Ralf
/Ike, 4ce r11 of Wood shhljlef-sem^,
SECTION 4:ESTIMATED CONSTRUCTION COSTS..,
Item Estimated Costs: 'I Official Use Only
(Labor and Materials)
1.Building $ 1� 790 ^`1: Building Permit Fee:$ :` ' ..- ,Indicate how fee is determined:
2.Electrical ! El Standard Ctty/T. . .'. ee
❑Total Proje+ osis(It 0)x m p • X
3.Plumbing $ 2 OtherFee $
4.Mechanical (HVAC) $ .,,.f,...:_.
s
5.Mechanical (Fire
Suppression) $ Total All Fees:S •
'Check NO ; : Check Amourit:' - '. Cash Amount' '
6.Total Project Cost: $ /1 t'7 cp p Paid in Fall: ,", O Outstanding Balance Due: '
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor� License(CSL) Cf-/a
se
Joh Pt Gtg%i 1 k5 License Number Expirati n Date
Name of CSL Holder I ,
/6 , I _ / / __ _ List CSL Type(see below) V
No.and Street �d (^4�!« e Description
1 Z tiw n_Y{. 1114 0�7/ U Unrestricted(Buildings up to 35,000 cu.ft)
ty/I'own,State,ZIP t 7 R Restricted 1&2 Family Dwelling
M Masonry
47$ "I Qn /_/_!9 RC Roofing Covering
l Ll '( lF(Pl7 WS Window and Siding
SF Solid Fuel Burning Appliances
jehit CaPY4Ik0411ch'Vdtan 4)jAIR:I.c t% I Insulation
Telephone Email addres D Demolition
5.2 Registered Home Improvement Contractor(HIC) /43 73G • 7r/4ko/,
Caitvet/4A Cats1(wof-hm HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
/S NiarFSd(' 44414 . (Sat as abate)
No. // ,r^ 8907$' 175 qso GOO_ Email address
'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 ❑ 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 (,f44(Vit/Ijp &ftritt/LThin
to act on my behalf;in all matters relative to work authorized by this building permit application.
T/N I.r & All/
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 • a•I d accurate to the best of my knowledge and understanding.
30k1 CaR✓rtGw / (aunt- 5541f pet,
Print Owner's or Authorized A,ant's Name(Electronic Signature) Da4e
✓ 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.eov/oca Information on the Construction Supervisor License can be found at www.mass.aov/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
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
1p=sem gy Department oflndustrialAccidents
€,WSW1 1 Congress Street,Suite 100 .
• " l=_ A.
�t Boston,MA 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/Organization/Individual): C.Qth/a I lle Can s try
Address: 15 mend"
City/State/Zip:y, ro pot; /0 1,470. ' Phone#: 975 lift 6419
Are you an employer?Check the appropriate box:
' Type of project(required):
I.❑I am a employer with employees(MI and/or pan-time)." 7. 0 New construction
2.❑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. 1 am a homeowner doingall work myself. 9. ❑Demolition
❑ y [No workers'comp,insurance required.]t
4.0 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.❑Electrical repairs or additions
pprietors with no employees.
12eqa
.❑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 C.
14.❑Other
152,§1(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. 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: 4'cau/zt -ricurepv.e. Cowltaip
Policy#or Self-ins.Lic.#: RA if g f 30a71.5 Expiration Date: 51,100I�r'�7
Job Site Address: 25 Frgneu He& / City/State/Zip: yt*# P-4 iit4 pact-75
Attach a copy of the workers'compensation policy declaration page(showing the policy nfimber 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 cer
!• der thr aiinss and penalties of perjury that the information provided above is true and correct
Sivnature: /���y"� l �va r%� t.4h t.wa(✓A rho Date: c,t ' 41 At l i
Phone#: V 979 If fa & if
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#:
/amal LCTCONS-01 MINTERS
A`ORn� CERTIFICATE OF LIABILITY INSURANCE DATE 06/13/201 YY)
06/13/2018
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(les)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 tights to the certificate holder In lieu of such endorsement(s).
PRODUCER 12 ACT -
30
TRU insurance
St Agency,Inc. ;HONE FAX No):
E-MAIL
No,Ext):(781)281-9688
ADDRESS:
Ashland,MA 01721
INSURER(S)AFFORDING COVERAGE NAIC 0
INSURER A:Kinsales Insurance
INSURED INSURER B:Acadia Insurance Company
LCT Construction and Service Inc INSURER C:
4 Evergreen Lane INSURERD:
Hopedale,MA 01747
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 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 OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADDL SUBR POLICY EFF POLICY EXP
LIR TYPE OF INSURANCE IVSD WVD POLICY NUMBER IMMIDDIYYYYI IMMIDDNYVY) LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE _3 1,000,000
CLAIMS-MADE ❑X OCCUR 0100058934-0 11/21/2017 11/21/2016 PR h119EsieeEocaTErece) $ 100,000
—
MED EXP(Any one person) E _
—
PERSONALS ADV INJURY $ 1,000,000
GEN.AGGREGATE LIMIT PER: GENERAL AGGREGATE $ 2,000,000
HPOLICY I I Pa j LOC PRODUCTS-COMP/OP AGG $ 2,000,000
OTHER'
$
AUTOMOBILE LIABILITY ,EBMtlaccentSINGLE LIMIT $
— ANY AUTO BODILY INJURY(Per person) E _
AUTOS ONLY _ AUUT�OSSWULNEEDD pBOODILY INJURY(Per accident) $
— AUTOS ONLY — AUTOS ONLY (Perr acC tOAMAGE
$ -
$
UMBRELLA UAB _ OCCUR EACH OCCURRENCE $
EXCESS UAB CLAIMS-MADE AGGREGATE $
DED RETENTIONS $
B AND EMPLOYERS'11ABWUTY VIN X STATUTE FORH-
MAARP302765 05/02/2018 05/02/2019 E L.EACH ACCIDENT
AA�NFFFICCPER,MAEMMBEERREEXCLUDED?ECUTIVE NIA $
1,000,000
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1'000'000
N yea describe under
DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 1'000'000
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLESORD 101,Addldonel Remark.Schedule ma attached mospace required)
WORKER'S COMPENSATION INSURANCE COVERAGEACAPLIES TO THE WORKER'S be If n b COMPENSATION LAWS FOR THAT STATE OF MA.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Carvalho Construction THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
15 Newfield Lane ACCORDANCE WITH THE POLICY PROVISIONS.
Yarmouth Port,MA 02675
AUTHORIZED REPRESENTATIVE
1 t1 U
ACORD 25(2016/03) m 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
og'Ygk TOWN OF YARMOUTH
oZ`. o BUILDING DEPARTMENT
.s� 4 y 1146 Route 28,South Yarmouth,MA 02664
`�e€3 6'9 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 25 fiwhc�si MAI gre
Work Address
Is to be disposed of at the following location: 1/4004 ...6, 9esei Alga_
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A. •
Ati
* 1 _!ur 4 9e/6
S'�ature of A. on Date
•
Permit No.
•
ropo�aY Page# of pages\
<, �0 7`b (2.ctrt'✓4 lite (,�inSr rvG'of �k.et-
' 15- PALM& 1...an Can'
Y,,ionoa 4o Arra a;675
PROPOSAL SUBMITTED TO: . - ^ JOB NAME • JOB#
l 074 (Jici-it.
JOB LOCATION
ADDRESS 25 f ✓ 'Vimi 4( .t.,.
tq / jJ ..� �} DATE DATE OF PLANS
Ilit, ,/i SI re, Aye/ Lf) '�% ARCHITECT
PHONE# !I
If
Nbky
%e hereby submit specifica%ons and estimates for. ____ _,_-- L— ` e'& '
•
t �%� r
t5 in 1& Al
/tap 07 _G4�lr re a. all-4
.kcrJ T, + / a 44+ re_ flt '
' T ''. -=t9C�4 if`1,R�,�_/_�_��5._ ii627`7 -iufr.0% /
ot. / /
r r •
;CIS rpt ! fai'n�4atc, _na, A/094:-
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v_.t.:- _ _
i 76
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,( � D' . „Ice' n
.1-1_,E4_,..1 f 14t — o tt i� -------
Z,.;rTu? N,u,) _✓wys j bice _ _ ____
%e propose hereby to furnish material and labor-complete in accordance with the above specifications for the sum of `r/r 140 ep
$ "if iD ,,1 1 / Dollars
with payments to be made as follows: J—ZS S/T /i I .! 7c1✓ I, ,4( 4 7`94'{ (el. 14 3! 0w, trti i f.( a f.a (47,;,<.;
4/1 4'1
Any atteratlon o'deviation from above specifications involving extra costs Respectfully /4/-4yt.(A
will be executed only upon written order,and will become an extra charge submitted "- ' k " ��""'�'
over and above the estimate. All agreements contingent upon stokes, �/ l
accidents,or delays beyond our control. Not this proposal may be withdrawn by us if not accepted within 0 days.
Rcceptance of Vropooal
The above prices,specifications and conditions are satisfactory and are -
hereby accepted. You are authorized to do the work as specified. Signature ,�.
Payments will be made as outlined above. j
Date of Acceptanced ' 51; AWS Signature /--- ---
A-1103819/14950 0941 /.--- '
c+Te - +
Wornmonrr mom/teal
Office of Consumer Affairs&Business Regulation I
Wit,` 1 HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only 1
rE . , TYPE:Individual before the expiration date. If found return to: '
�� Aeolstratioq Expiration
_ - -_ Office of Consumer Affairs and Business Regulation
- I .. 163736 07/16/2019 10 Park Plaza-Suite 5170
HN CARVACHO`-i-i'1 =%- ;i- Boston,MA 02116
• _
D/B/A CARVALripC(JN TRUCTION
VI
ig ,,
JOHN CARVALHO -. ,7
d-cce
15 NEWFIELD LANE;.
YARMOUTHPORT,MA 02675 Undersecretary Not valid with• ' . • -
Commonwealth of Massachusetts
of Professional�wensuredards
( Mations and Stan
Division
It Board Of Budding iIs�neryis0r
Cons`k Tires:0810412020
CS-101942 :7 -- S ,,f.. i±e �.'
_ JOHNMCARGN-HE:; �,.:; '; T • .
15 MENNElanpO4:f0 tak 0267 3s i �'
YARMOl1TH R1-ivoi%;-0l
Commissioner
(92eT ,,em'nee,Plr/CA o/bfllrstrach etti -. - .
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
Er
TYPE:Individual before the expiration date. If found return to:
-Feaistration Expiration Office of Consumer Affairs and Business Regulation
1-_"f�"". 163738 07/16/2019
f.., _ 10 Park Plaza•Suite 5170
HN CARVALHO-5:i -1l Boston,MA 02116
e
D/B/A CARVALHO CbN RUCTION .�
0:_; , lI
JOHN CARVALHO =yttc' Ey r-C( n-_,15 NEWFIELD LANE,.•_ '-""�PYARMOUTHPORT,MA 02675 Undersecretary
diet
ot valid with. . •- - I -
usetts
Con+rnonwealth of on_„Massa%wensure
of
Profess'
ons and Standards
�C Division ._.tl�i$11pejNlsor
! Board of Building``''
Const; 77 �ires:0810412020
aiF`i i,
7 i.,,, 71,1';',7 L
CS-1019a
• 1s NEt1,1F1-1:, R''N Mp.u.. , .
YARMOUTH PP�D�Wy��Aloicti.i:\V-'
cjiv
COM
La;Id%^J°
°F Y_ C TOWN OF YARMOUTH RECEIVED
ems1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451
. SEP 7 2018
Nor
Telephone(508)398-2231 Ext. 1292-Fax(508)398-0836 YARMOUTH
OLD KING'S HIGHWAY HISTORIC DISTRICT COMMI QLDKING'SHIGHWAY
APPLICATION FOR EE
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 print legibly:
& ,
Address of proposed work: 0�7 /��/j1 /'Osdyal^I Map/Lot# I a 5/a
Owne s): —77,..., Cr; _ Phone#:
All applications must be submitted by owner ora accompanied by letter from owner approving submittal of application.
Mailing fa�ddress: 25.. fr` pi teS He kii / yt tnoe4V1i &tr. Year built 19 7/
Email:1�1okr1/Sd5Cej`f797d ( •i97cgpit I (�T Preferred notification method: Phone etC
1/1
/Email
Agent/Contractor. C.avq.1 CeHs'fric OEM Phone#: 971 lira 67lI
Mailing Address: /6 Pow-F CG( tem)
r
Email: jk
Oq CerVQ 1rt0 cens veh ytA;(.Calf Preferred notification method: Phone Emailisi
Description of Proposed Work(Additional pages may be attached if necessary):
Sfip 45/0424roi.pAy sit , Cehor< Grey
Xtri4 Na) CifJan-t Ard:kat b tact 54 , Co fez. % c '
Ai
Signed(Owner or agent): : Date: S & De/f
➢ Owner/contractor/agent Is aware that a permit may be required front the Building Department(Check other departments,also.)
> This certificate is good for one year from approval date or upon date of expiration of Building Permit,whichever date shall be later.
For Committee use only:
Date:_- / Approved RECiEIV�AUProved cath c - •es--- d
Amount a d Reason for denial: II I 1 AP
Cas Or (omaSEP 1 (1 2018
Vti'N G!
TO .iv:
Rcvd by: ./ - _' ' "' MOUTH, MA ,i•UTH
OLD KING'S HIG rt ' "
Date Signed: /3/4 en- Signed: 67. 69,7174-.—volts
, i:..ti 8 � E 0 9 5
APPLICATION#:1
vs.2nn