HomeMy WebLinkAboutBLD-19-1991 Og t1R
r,Office Use Only
Y
I t� O Permit#
C
0 . - 4. Amount 50
•'.....•8't-d :Permit expires 180 days from
issue date
OW—lq -DbIlgI RECEIVE -r
EXPRESS BUILDING PERMIT APPLICATIO
TOWN OF YARMOUTH OCT 03 2018
Yarmouth Building Department
1146 Route 28 o LJ M r
South Yarmouth, MA 02664
/✓1 Mirth
398-2231 Ext. 1261 /' ç,t?/r1NoC74CCONSTRUCTION ADDRESS: { 9 / YVY(h ROt/tC/L ohtASSESSOR'S INFORMATION:
/
//�� /��7/�p�/ �Myayp: 3 0 Parcel: /36
OWNER:ehe tete l te #ec I l CCC.p., Aid M had 00711/4101/4 S?t 352 2915
NAME ,p� PRESENT ADDRESS TEL. #
CONTRACTOR: bait //d��WI�Gd' , ftoa4a3 &dte✓obte 026501- Sob*36.2-2YY&
N SFX `rx Gar MAILING ADDRESS TEL.#
/Residential fVA�VI I 0 Commercial a Est.Cost of Construction$ 1 7 3
Home Improvement Contractor Lir.N /G�60(/ Construction Supervisor Lie.N Se ii
Workman's Compensation Insurance: (check one)
0 I am the homeowner 0 I am the sole proprietor il have Worker's Compensation Insurance
A'' IYS9sw ai9
Insurance Company Name: Dt,r �/vy�"� Worker's Comp.Polic}M'IUCCSDoSoD
WORK TO BE PERFORMED
Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares V Replacement windows:# Replacement doors: #
Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation .
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
�n'^per /� /� ,t
*The debris will be disposed of at: 7W//20 e itl y �l�l /
Loca ' n of Facility
I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s)
will be just cause for denial ocation f/m}license and fororrosecution under M.G.L.Ch.268,Section I.
_ Applicant's Signature: fc// R L/ LG.�(a4ti / Date: 9/SI/ Op,
Owners Signature(or attachment) �' Vv �/ �' Date: '
Approved By: air . Date: /O_ 5-/r
I ding• 1 (or do rgncc) EMAIL ..TRESS:
Zoning District:
Historical District: LI Yes 11 No Flood Plain Zone: Li Yes L No
Water Resource Protection District: Within 100 ft.of Wetlands:
II Yes Il No L Yes 0 No
.
,,,�W9'��''��tt
/� �*'j�+�p t"s `�je,*gittd'J r��i i�� i Y 4i : li �9u�ji iF�'1j h��� „it
BAK R BAKER ylli n II ,� 11 ' rzi� Fi 3S*' �'y 1 t -s.t�4lyi�u3l��i!alKi'�rni
' '' ' BAKER & ASSC'�CIA4. , P i
m AYet MIS.INC. h ASXY'IATH,INC. 5 , t� (`om I t„4. 6
I uvTo'.lt.n'n i AWNINGS ts .fit � '
{IfE��i����ad� Irli �3�
CO. 1km 923 etntvnilk, MA 02632 Plume 506 362 2445 PaK 508 362 6115
Authorization Form:
I ., C\nstnAcA� Uel , as owner of the
subject property, hereby authorize Baker& Associates to act on my behalf, in all
matters relative to work authorized by this building permit application for:
Address of property: 12 North Road
W. Yarmouth, MA
Signature of owner:
Print Name: eicti\,--k-Ss.\�
Date: t) I4t') I g
. .
. ,, .
t. . ;
. ,
. ,
, •
.....
1
... .
Commonwealth of Massachusetts , I
.
Division of Professional Licensure
kleFir
Board ol f Building Regulations and Standards
•
- t , E.
. :EA i ,
Constroctiorf Stipervisor .
•
..., k,„.
,. , . . .
. , .., ' .
• .
CS -009714 „ .
„... t
›,.,
,...A.'-.(:,::::,....i.--)LHiii.--..}:.:,..•:>: ires : ,04/04/2020
.,.,..„: ii:::::„,,y,i,,,,,:u: 1±2t•.-7,..;,..:4,..;:„.:••• 7,.t.,-,.,_, . s i • , „ . .. . . ..
4. ..
' ' •_.' •,--)•'/•'"4.:.'4.,•„1-T,Cro '.. -4.-.kle.d••;;;'7'44'.;;A''':::,..:74.13 - • • f..• : •,. • .. •••••:•-•,-
• 4-Awtfal
-7..42-4:4'4'.4:'$•;':.'4..,-F.'i;it:4.1: '•,0 f-.14: ,:.-,... - %Asia. . • - : -L.,: : "'.:'',: .
. .
-
..4-14,:a r -;-.L5-, . taw - '5-5r--::...: :::•--55.1r 2-0 ..,:..-L .t.
;-:•::,,b.:',',.::,,:.; -.-: :. ,
;,,, „:,ic e- -:: -- •,;-.5-:4 - %,[,,:-. ...-1 . :, .).:-.,',-• ..2,' ' eN, - .,...::.-.Tit,. ,-;„r-- 7,,,-; ..:4..;,....• ' -.: -.-':..•?'..'ii. '.:'-:-.2
RICHARD PGARNEAM4:r-Is, •1:-. 1 ;,:'..]
.s.,,, „)..-. -: . • „i.e.
•
25 I WOODS' ;LI ti.,i 1.-N-4.,',. ‘.,:.,.: '.„ ., ..,-,4 -,z, ,:...:-.5;,F---.A3f,',1,„1-,c';', 'r ,--, .,- - • ' '.-ac„n'‘'?!.:'455:',....52
' ROADOit4j -:::::;71: ::'': --4,6t;-;;:: :::;-:::::::‘ii-Vii;::::::r:1:-1-:. i il .f . .1_ • 11:74',H;; ;;;;t:ti.T:''-:1,')-1
. .
i * s
•;',----s- tiESTL:BARNS . . LE'6,
N-
' - --'--'--;- -i-r..‘r.-i-t' 4 ' 'Ai•TiNs.'-'..5•41"61)2; '......'4•
'--;.44 ,-e,4-;•-4,,r4?,'"` S.-
, .1.-,-. 1 ' ‘''','.• 7t5'.,?::0.4;i,-k.
' -',,,,-[t:;,-,F;•?,.:2,S.:-54:cr'-':',r,,-.1L. . ,k.; `.L , '1 1 '..-±,..,.'.,k. ,Th-,''.. •' ,.;.4.4fr .,“ .." .''.', ,..c 'Oak'''.'.- ' At.
it'.:-:-c,',„". g ..? ' r...'', ...' '''1.r;;;.;1.' .'".:',;i'',`..../., i:'.. .... ;, ,': .1: .ty-L' 1:..1 / k i„ • il ' . -It.±.- ;' : 'I- :". L.. rCt::::::',i-:-
- . . • . ' ()tic ' '....f;,.!
11*.:,.1 .., :'..'-,:t. _: ;::: [..-:..t7,-.,;„;„.,;-:_„7,Y,-, (-'7,-:-. i,-,, ,::,,y L'4,7 : 1 ..„ , -,-, ,,. .::,:;.,.',,,, :::,,,,A,-]1-1."2 3/4. , 7.- .,"-L 1 1,,,.,"1.7.1.7,E;,, Ir., ; !::'....f:;:;,1-1'1 . ,. . . ,, ; - , ..'. ,-. ,... ; ` '.'„ ' "•,,,:/-.411'4
7,:„,,A.:16'' .; : -:f?r' ''.t '., Z."1:-;.i:-::'..4'...<1;-'- ''--1:1,...:;.:71;i": r ; ' ' .- '%-'; ' '-: . 'f't:: :1;,'.; ;II'/lir: C l'' '‘;';‘..;.:-? C:L...,..'-'.:',' ';;;;1 Cl'..''. .:.';;:i'-.1 :1'11 .'2-.5:te--:••„',1-_-• :1;4--rfAti,.11.2=k;.;7;i .::;;•.-:',1-';"i-1,251.c.; :f;;Q:-$";7. ::::
-,-., •, •4 - ••-.., qr.,:-..-.., 2,,-,...•42j''::a, ,;., ti. ::4; '',1;1 :;: .:.'''1'44,: -St'tT-4'4:7-4,'''''€re.- 41 :::4,,':^4',''e',-,--;': -' ',..:f--',' :4 '''''';:''';"144-7,'i,k4fi)--1,4.1.,.{-..47,:.!--;.!"-..`,4'''t-'."4-1 :-.)--,::':,''',:y-- 1:::-C-4.;Y: .„1:•:',.'"'„7"'}':.4:4'.4"----.`.".:
[,...p,-,;;;,.T;,,:.,,..;;.t...---,,,,,,,:;,,,‘„. ..,.:, ,,,:i .:-,,„.„.,..,,,,-„,,:;,..:,f,...- -1:„.. — - _'-':‘:--- .tHr-r-,!;ii,,,,-.;•y:-.!,2-i,t.', :!-, ,. ...,::-,.,• ..--y--- ::-_,.:,,, ...,,,:i,',.,...r: !„--.-..:, .......LV;;.:1 iy,- .".r. :,',...f,„,:.:: , Z.,:•'..=[ c:4.:4.•.„.., f.a.,''..,:.,,,,,t,e).:::,,-.„
',":. 4...,:.:..1-A -,:.'J%,,S,11.,./k-:^;23.1::,:.,'1, ..j.:.::1,1 •'c.11.!L,',:::-;L'7;f:,'...:i. 7.7f.r''', rl''';',a' °,77-t-± ..' .-;' t±"1,3',4);_z.,4 --', — ‘,-.‘•:.',4:4'.iCji,-,::‘,Pri'''t4. ''',.1CZ41?<•`'' ''',,14(:-r:ff:r-e,'v.';':,'4'2.-.5;.:7..Lkr',.,'..%44,1. ..k
i'k 1:- -
.;.-
'5,-1.-;..;:,/c.:-...StY.1.-3.z..; '1,..-_,':••:::1':-.1:.2-:..;..'1'4',s't..... ..,:-..--:.-1 L.' .-......-:.-L...l'r ---- : 14':: : 4 :•-;.-::— -'.1-,, --z,..:;-:„--_-',-- C., Llt,r,4,,: :,-:.--i!"-'1,;;•---.„'" -;•,_0.-;-,r.': -/: .---1--;:"-'i‘b..tz••••. .--,,,-- --i.;,.---T,::::-.=47;..°.-.:-!iii-t-.:7-?.: :1-,
Commissioner- l'}:-'±";-; - 't • - :-: -, ',.. '-,---:-'--:- -,i---, - -- .„ -,„. ,...., ;., „,,,,,,,,,,,,,,,, ,.., , ,,,,,,,f ,,,,,,_ , •Lli ,„ .. lit ,,, .,,,_,
;Thu::::-..- .- -. :-.:-.i.--T: ,-,-; r::..:-.- -':?,.':..y • _- -:1 -- -{-:: :-.T V„',A'''. •'7 -- 1--• •T:-la ":2.-2-: .,'`• S'!,,,-;-- , "5.;:1.... ::::::---•-• —`7:-"..!'CI';.... ' .'7k".1,-.''',47,'..Y`fit, ''-'i, 4:4; .2--r•,•:.•.-!4-,?1•,:- ,...1-.,.),- i' —4 -.-4*:4-'
: .
f u 'Aassacbusetts Department of o.,ol:c Safety
Board of Building Regulations and Stangaras
License' CS-009714
Construction Supervisor
RICHARD P GARNEAU,JR 1,(41:
PO B A6 •
WEST
WEST BAR2868 's'NS7ABLE MA 0
•
Erpirahon
Commissioner 04/012016
r'// (!(Iin//PO ,,<rer<t/f! r %'
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Type: Supplement Card •
BAKER & ASSOCIATES INC. Registration: 162600
P.O. Box 923 Expiration: 03/25/2019
Centerville, MA 02632
Update Address and return card. Mark reason for change.
I-1 e wa....e n n-.......r n e.nN.,.....• f1 i .e.r.ra
Office of Consumer Affairs I Business Regulation
HOME IMPROVEMENT CONTRACTOR
Registration valid for Individual use only
I. ' TYPE:Supplement Card before the expiration date. It found return to:
• Redietrallvrl/ gm/IretonOffice of Consumer Affairs and Business Regulation
162600 03.252019 10 Park Plaza.Suite 5170
BAKER&ASSOCIATES INC. BostonMA 02116
RICHARD GARNEAU ry�
521 Shootflying Hill Rd `%=�;:
Centerville,MA 02632
Undersecretary � of valid without signature
The Commonwealth of Massachusetts
Wit= Department of Industrial Accidents
Ci !
Ofce of Investigations
600 Washington Street
Boston,MA 02111
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): Baker&Associates, Inc.
Address: PO Box 923
City/State/Zip: Centerville, MA 02632 Phone#: 508-362-2445
Are you an employer?Check the appropriate box: `Type of project(required):
1. 1 I am a employer with 1 4. I am a general contractor and I 6. New construction
employees(full and/or part-time).' have hired the sub-contractors
2. I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no employees These sub-contractors have 8. Demolition
working for me in any capacity, employees and have workers' 9. Building addition
No workers'comp.insurance comp.insurance.:
g
required.] 5. We are a corporation and its 10. Electrical repairs or additions
3. I am a homeowner doing all work officers have exercised their 11. Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL
insurance required.]t c. 152, §1(4),and we have no 12. Roof repairs
employees.[No workers' 13. Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowner 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: Associated Employers Insurance Company
Policy#or Self-ins.Lic.#: WCC-500-5002454-2018A Expiration Date: X044/233/19
Job Site Address:42 /v ASAD City/state/Zip: Wos/ prmov/rl�(J C22673
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cerci un er the airs a f penal es of petjuly that the information provided above is true and correct
Signature: Date: •
Phone#: 508-36 - 445
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#:
Cllentft:9742 2BAKERAS
ACORDU CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
04!24/2018
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 POUCIES
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 policyQes)must be endorsed.H 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
Dowling&O'Neil Insurance Agy PAHpMNFAX
(u"g"iFfe,Eat!:508 775-1620 (A/C,No): 5087781218
9731yannough Road EMAIL
P.O.Box 1990 ADDRESS:
INSURER(S)AFFORDING COVERAGE NAM
Hyannis,MA 02601 INSURER Al NDMM..N.Cm.e. 14788
INSURED INSURERS:Aee.cadaM.r..a.. neCompany 11104
Baker&Associates,lnc. INSURER D
P 0 Box 923
INSURER D
Centerville,MA 02632-0071
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 POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR TYPE OF INSURANCE ADDL.SUBR POII,,1Cr EFF c/WpLICyEXP
1NSR VND POLICY NUMBER (MMIOWYYYn OAMID I'D YYYY) LIMITS
A GENERAL LIABILITY MPJ7223M 04/19/2018 04/19/2019 EEpAAqCCMHHp�OEECTC•ppURpRENCE $1,000,000
X COMMERCIAL.GENERAL LIABILITY PREMISES(IaENarr ence) $500,000
CLAIMS-MADE n OCCUR MED EXP(My ere person) $10,000
—
PERSONAL SADV INJURY $1,000,000
GENERAL AGGREGATE $2,000,000
GENT AGGREGATE LIMIT APPLIES� PER: PRODUCTS•COMP/OP AGO $2,000,000
1 POLICY IGI E T I A Il LOC _ $
AUTOMOBILE LJABa,ITY COMBINED SINGLE LIMIT
(Ea accident) $
— ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED — —
AUTOS — AUTOS BODILY INJURY(Per accent) $
NON-OHIRED AUTOS ED PROPERTY DAMAGE
— AUTOS (Por accident $
AUTOS _
$
UMBRELLA UAB — OCCUR EACH OCCURRENCE $—
_
EXCESS LIAR CLAIMS•LIADE AGGREGATE _$ _
DED RETENTION$ $
B WORKERS COMPENSATOR WCC50050024542018A 04/23/2018 04/23/2019 X wcWILuri DTH-
AND EMPLOYERS'LIABILITY YIN TORY LIMBS ER
ANY PROPRIETOR/PARTNER/EXECUTIVE E L.EACH ACCIDENT $500,000
OFFICER/MEMBER EXCLUDED? N/A
(Mandatory In NH) E.L.DISEASE•EA EMPLOYEE $500,000
New describe OFOPERATIONS below El.DISEASE•POLICY LIMIT $500,000
DESCRIPTION e
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Atter*ACORD 101,Additional Romani Schedule,',mon macs Is!squired)
(See Attached Descriptions)
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.
„ . AUTHORED REPRESENTATIVE
I -71r,'' " --wj L ct-
01988-2010 ACORD CORPORATION.All rights reserved.
ACORD 25(2010/05) 1 of 2 The ACORD name and logo are registered marks of ACORD
#S210924/M210923 RPJZ1