HomeMy WebLinkAboutBLD-19-001463 i • -P,<,// 9/ / iif
• ONE & TWO FAMILY ONLY-BUILDING PERMIT
Town of Yarmouth Building Department • •or`r
1146 Route 28, South Yarmouth,MA 02664-449211111-
2664 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 R ��" ✓) VD
' This Section For Official Use Only 1 stP u 201• •
Building Permit Number i I-/ - 00 ;Date Ap • • •
BUI I Jti g_T,
• /fir- SeACS .. • , T• • S-o -I$ Y: • O�
Building Official(Print Name) • v ig iature• '. . Date
• • .SECTION 1:SILL INFORMATION •
1.RProperty wrp.nr.. %\. bits -hta , 9,r,1/41.2 Assessors Map ParcelNumber� �
�
1.1 a Is this7an accepted street?yes 1". no . Map Number / Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: F2 E C E VE
D
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft) r n Z018
Front Yard Side Yards Rear Yar•■4l♦,! 4
Required Provided Required Provided Required Ethi-h'BEI#N PAR
1.6 Water Supply:(M.G.L e.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Er Private CI Municipal_ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
' . • SECTION 21 PROPERTY OWNERS-
1 Owner'.of Record:
`uQ.ar C0.5tv.ou--o. Varectovk-h QUCh .
Name(Print) City State• ,ZL°
SI L4reooil 1IA- Stint n0 0`166 1S-0�orC'45�uw 7t3 tip • .Ccht
No.end Street Telephone Cam Email Address
SEGTION,3:.DESCRIPTION OF PROPOSED WORK2(check,alll that apply) • "'
New Construction❑ Existing Building 0 Owner-Occupied 0 Repairs(s) ❑ Alteration(s) EbtAddition n
Demolition 0 Accessory Bldg.0 Number of Units Other ❑ Specify:
Brief De ptionofProposr(d ork2: 7€1...ocu tad"-Ti- lo. 51rcs/ lltal_ 1e,se�
1 \tr w j c&..•.-JAw - .0.o,re ro.,r... w�.v• ^
o (0 g . . { k wi/ 4 , v. •.J • . , ,. 4Y as
. . . . . . .. SECTION 4::ESTBIATED CONSTRUCTIONCOSTS.. . , .....
Item Estimated Costs: .. r.
(Labor and Materials) . OfficialUse Only ',
1.Building $25'(ye e — 1:Building Peimit Feer$ I co. Indicate hOw fee is determined:
2.Electrical $ • • i!Standard City/I'own Application Fee't.''. :, ' •••••••••-:: ,.. •• .
TOO-'
❑.Total ProjectCost3(Item6)xmultiplier... ; : • ic•'
3.Plumbing S tr 2: Other.Fees: $ •✓J . . .
4.Mechanical (HVAC) $ /b-Dr List '
5.Mechanical
(Fire ii
Suppression) $ Total All 1 ens:$.
CheckNO: • • Check Ammmt: .C•.. Amount• '
6.Total Project Cost: S 'f d t0o0 --- p Paid in'FuE . . iB Outstanding Blan.e Duei {15
SECTION 5:.CONSTRUCTION SERVICES .
••• • Construction SupervisorLicense(CSL) •
Q(p$9SY Zq iota
�/�p� C^6C1 C ueJ1� • License Number E ira nDate
.Name of CSL Holder
N t %orel..
CSL Type(see below)
No.and Street' Type Description
'M Ar•SVPuS Yk.cc-5 41\0.55 p ler
Unrestricted(Buildings up to 35,000 Cu.R)
uz
City/Town,State,ZIP Restricted lea Family Dwelling
M Masonry
• RC Roofing Covering •
• WS Window and Siding •
p SF Solid Fuel Burning Appliances
j�jII1.59f2
TO K•Cvvi k✓b Any- LtAAm'S)-` I Insulation
Telephone Email address `"Jr D Demolition
5.2 Registered
reg stered Home Improvement Contractor(HIC) aarl�Y zi
Zak K Ct me HIC RegistrationNumbtt irati nDate
HIC Company Name gr HIC Registrant Name
o a( 1224S 1-04
nd Stre. f d) s C GhaN,rv-ku,.�(DCCA ACaD i KA+
g4'n—S ,tv t•L PA-0.5, Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(11YLG.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 PERM T
I,as Owner of the subject property,hereby authorize
to act on my behalf h all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signattte) Date
SECTION 7b: OWNER'.OR AU'i'hORIZED AGENT DECLARATION
By entering my name below,I hereby attest tinder 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.
Print Ownet'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)Pro am),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142k Other important information on the HIC Program can be found at
www.masssov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) /69' (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) / S2) - Habitable room count 5
Number of fireplaces d Number of bedrooms Z
Number of bathrooms /r 5 Number of half/baths Id
Type of heating system 5 ets {n rue tt ✓ Number of decks/porches /
Type of cooling system a/V Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
y •• .....•...•vurr C.IUrs uJ traUJauunuaCLLS
f Department o
��—_ c 6tIndustrial Accidents
% ceig.II_-
— P— 3. . 1 Congress Street,Suite 100 • •
:egB_
Boston,MA 02119-2017
�.� • www.mass.gov/dia
• Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information /� p �^w ( Please Print Legibly
Name (Business/Organization/Individual): TJ&K 1. rS ''OCMs. \ `
Address: t-t'- 0 v € A •
•
City/State/Zip:Mort1-ca t'g,, iNN.c.4 Phone #: &bY17b `t 93Zj
Are you an employer?Check the appropriate box: •
Type of project(required):
l. C am a employer with employees(full and/or part-time)."
7. 0 New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in
capacity. 8. remodeling •
any p ty.[No workers'comp.insurance required.]
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. 0 Demolition
4.01 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.
12.0 Plumbing repairs or additions
5.❑I an:a general contractor and I have hired the sub-contactors 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 tll out the section below showing their waken'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 atached an additional sheet showing the name at 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.
lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. t
Insurance Company Name: I47 ) t 4{/to}po_e
Policy#or Self-ins.Lira.#: W cc--3-06 �1c{s'L Expiration Date: /0(i/Zoyg
Job Site Address: 11 1 'WQu vn 114 City/State/Zip:AlIAM-0-441 We--
Attach a copy of the workers' compensation policy declaration page(showing the policy n ber 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 her . car: under the pains and penalties of perjury that the information provided above is true and correct
Sienature - - Date: Scat11 ains
Phone#: 5n. j— —as 9 f 7 y—
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#:
01•YAR TOWN OF YARMOUTH
72r So
BUILDING DEPARTMENT
�_ •,� 1146 Route 28,South Yarmouth,MA 02664 508-398-2231 ext. 1261
•
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
•
DATE:
•
JOB LOCATION:
NAME STREET ADDRESS SECTION 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 dwellings 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 R5.1.3.1)
Definition of Homeowner.
Pers on(s)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 R5.1.3.1)
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 OItICIAL
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 vesplease 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 requiredby
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 or 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 a joint 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."
MGL 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, §250(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contact for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely, by checldng 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 patters,are not required to cavy 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 Accidents. 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 bum 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. # 617-727-4900 ext. 7406 or 1-877-NLASS AFE
Fax g 617-727-7749
Revised 02-23-15 www.mass.gov/dia
TOWN OF YARMOUTH
e C BUILDING DEPARTMENT
-dl���
din 'c y 1146 Route 28,South Yarmouth,?VLA 02664
IscLOP 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 31 -CtPao.. \r ylvotft\„
Work Address
Is to be disposed of at the following location: Cop rocQ gt:Skbs<
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.
r,
1F _ /
Q°111[% V'//V//W/�tG.V'VWVV/!l t{�f/ `:=i�IC%�/U/J"JLW�//WJVVV✓ ,
a_iy Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170 •
Boston, Massachusetts 02116
Home ImprovemdriiCantractor Registration
((}} i Y� — Type: Corporation
t''22r " 4 Registration: 128174
Rolfe Construction Inc r i :. Expiration: 03/04/2019
. 141 Bog Rd. �Y� W
- Marstons Mills, MA 02648
' s
_n. — .
:�.\ __
Update Address and return card. Mark reason for change.
•
SCAT 0 20M-0Srn n A...,.-a.7 n o,...n...n) n a.-.J.......!.... n,.......r•..-r
—
651 Grnmonernw/t%n/Calfn.Uacawe//A
' Office of Consumer Affairs&Business Regulation
_S7=r r HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
e� �i--'C `�� TYPE:Corporation before the expiration date. M found return to: I
=_� --Registration Expiration Office of Consumer Affairs and Business Regulation t
. ,� F' ,�,r.--;-::-c. 728174 q 03/04/2019 10 Park Plaza-Suite 5770
Boston,MA 02116
Rolfe Construction Inca;7 v I, I
MICHAEL ROLFE ,}. ',,>; II
• 141 Bog Rd - ' -,,sMarston Mills',MA 02648.4
_- Undersecretary Not valid without signature
r'
.. ! 1
•
- Commonwealth of Massachusetts
'' Division of Professional Licensure
Board of Building Regulations and Standards
jj
Constructbd'Supervisor
CS-068858 2u ,r E Aires:04/29/2020
M I J
MICHAEL ROLFE, '-• / ¢(7. -
- 141 BOG ROAD (� t
• MARSTONS MILLS MA 02648 ��v s Ji, t -
._t0/1\-i 1111," 0,014,0:,..,
Commissioner Cori"'" 1
.r .
�� ROLFCON-01 ASANZO
ACORO' CERTIFICATE OF LIABILITY INSURANCE DATE(MMA)D YYYY(
Los/ 08/06/2018
'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 teens 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 License it 1780862 CONTACT
HUB International New England PHO"No,EMI;(508)945-0446 I FAX
265 Orleans Road A ,No):(508)945-9136
North Chatham,MA 02650 ADoakSS:
INSURER(S)AFFORDING COVERAGE NAIL a
INSURER A;Selective Insurance Company of South Carolina 19259
INSURED INSURER a:Associated Industries of Menachusette Mutual Insurance Compsn 33758
Rolfe Construction Inc. INSURER C;
141 Bog Road INSURER D;
Marstons Mills,MA 02648
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.
ADOL SUER POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER IMMIDDNYYYI (MM/DDIYYYY1 LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE n OCCUR X S2262830 04/03/2018 04/03/2019 pREMI3E3 fEBEomxrOmlce3 $ 500,000
MED EXP(Any one person) $ 15'000
—
PERSONAL&ADV INJURY $ 1,000,000
—GE .AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE j 3,000,000
��4 POLICY jEqa n LOC PRODUCTS-COMP/OP AGG $ 3,000,000
OTHER: $
AUTOMOBILE UABILITY /Ea eec dent SINGLE LIMIT $
ANY AUTO BODILY INJURY(Per person) $
—
_ SCHEDULED
AUTOSNLY SBODILY INJURY(Per accident) $
_ AMS ONLY _ AUTOSµNY PUsYtrMAGE $
$
UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $
EXCESS UAB CLAIMS-MADE AGGREGATE S
DED RETENTION S (( S
B WORKERS COMPENSATION I-PERTIIfE ET
AND EMPLOYERS'UABIUIV WCC5005017452 08/02/2018 08/02/2019 500,000
ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $
p(MandaRrty EIn gN�Hp)EXCLUDED? NIA 600,000
1Mandataryln NH) E.L.DISEASE-EA EMPLOYEE $
Sdescribe under 600,000
DESCRIPTION OF OPERATIONS below El,DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLESACORD 101,AddltIonel Remarks Schedule,may Ea attached If mon space Is required)
Certificate holder Is listed as Additional Insured for General Liability when required by written contract
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Town of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS.
200 Main Street
Hyannis,MA 02601
AUTHORIZED REPRESENTATIVE
ACORD 25(2016/03) ®1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
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1.+141:: APPLICANT FROM THE RESPONSIBILITY OF*AS BUILT' _
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•All dimensions size designations k, This is an original design and must Designed:8/12/20181
given are subject to verification on ` 2
not be released or copied unless Printed:8/1 018
I job site and adjustment to fit job `�1 - applicable fee has been paid or job
conditions. order placed. '
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•
ESTIMATE
Kurt Casanova
(508) 280-0466
Rolfe Construction Inc
141 Bog Rd Estimate # 000079
Marstonsmills, Ma 02648 Date 09/04/2018
Phone: (508) 776-9932
Email: rolfe.construction@comcast.net
Description Total
Permit $350.00
Kitchen remodel
This is for permitting only
Subtotal $350.00
Total $350.00
Kurt Casanova
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