HomeMy WebLinkAboutBLD-19-002694 ONE & TWO FAMILY ONLY- BUILDING PERMIT
•
Town of Yarmouth Building Department oR r
1146 Route 28, South Yarmouth,MA 02664-4492
508-398-2231 ext. 1261 Fax 508-398-0836F�':1_� -:
' Massachusetts State Building Code,780 CMR R is . , g,'
• Building Permit Application To Construct, Repair, Renovate Or Demolish " 1
a One-or Two-Family Dwelling tnOV 09 2018 '
This Section For Official Use Only R„ } ' C. ,
Building Permit Number — C!t�Date Applied: / ey t � t-
li,� SPAS ,./ tr . 11-c- /d
Building Official(Print Name) Signature DSI..,
SECTION 1: SITE INFORMATION C C I ELD
1.1 Property Address: 1.2 Assessors Map &Parcel Nuri s •OCT2 6
4r�115 , 2019
1.1a Is this an accepted street?yes l� no Map Number Parcel pmher
-7t hf7.}�-NT
1.3 Zoning nformati�:' �,a 1.43 Property Dimensions: ZZ�,v C�.__`_g!t/•
�' Co Q gni
oning 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 Wate upply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: h........,.
Public Private 0 Zone: Outside Flood Zone? Municipal 0 On site disposal system
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: e,f0�
' ,Ao (J 6Si-WA S. NA•rzPwJt•( 1044- �l
Name(Print) City,State,ZIP•
,�¢
2"7 MLes LAt� -770 2 A 3_ �A`°Ds fic
No.and Street Telephone Email Address
' SECTION 3:DESCRIPTION OF PROPOSED WORKZ.(check all that apply) .•
New Construction 0 Existing Building 0 Owner-Occupied 0 .Repairs(s) air Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units_ Other 0 Specify:
Brief Description of Proposed Work'-: F!•OO -TWO 1LTC tat oZ (...k.fa`LS t)t- A-
S4CO&it/J •Sar4 to h& pi rriy2t ce,#70V20 J- ,
4igft4eATS i 6 ' -k- I?0 vi 1.0(4—'- ?fCNtYS 1-49 612- ctiltr3 0
C.?q PO eAcro t S .
-- • : SECTION 4::ESTIMATED GONSTRUGTIOO`t COSTS. . :•.' .-.,:....•1.t.:;;;... . ,. .
Item Estimated Costs: .. _ :..,::.'r-':.-.:_..'.':-.,..
(Labor and Materials) .,.. ••Of. . ; ..se Only' . ... -.
1. Building $ 5-09 :1. BntldmgPermitFee $ 17Jb•.- Indicate'liowfee is,deteiThmed:'
2.Electrical Statidar3.City/TownAgipUcatioiiV'ee:`• =s:l;_-;:::`,:+-1. !: :-
$ 560 DDaTtalproject`Cosei.titemtiiiimultipli®i:_,=..... -;. ; =a.i
3. Plumbing $ 57,0--k)OD •2::'Si&Fees: $- S T :2.."
4.Merhauical (HVAC) $ • List:.' .. ..- -_`•... . .. . ...'•r.;.'
5.Mechanical (Fire :::..'i;.i.r..:.; L,s t:c.-:�:as; .ircer` _:..i.; .; ._: i.:....::::
Suppression) $ .Toto Aire-. - $::ter:_:a:..___. - ..T.'1.:
_: ... ..-..• --.-'. ... •
6. Total Project Cost $ 0c.' CliecaNb '•=`.'•= Chi&Amoain[ Cash Amount
/S—� o pal Fp..a tit Outstanding Raia toeDue:16 6 -
TzSOoti
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction^^ Supervisor License(CSL) CS— 1O/_6M '�
li1Nil C] EA- ALFA M O License Number E irati a Date
Name of CSL Holder
List CSL Type(see below)
n Loco Ot.At 'Q S r
No.and Street Type Description
ggp 1 C. MA V 1 C1to-7 Unrestricted(Buildings up to 35,000 cu.ft.)
City/Town,State,ZIP l U Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
WS . Window and Siding
i�47.`J-6376 GnatGeR-r 4001,eon SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor CHIC) I n 7 1712210_
Vl� V. o54gA HIC RegistrationNumber Expiration Date
HIC Company Name or MC RegisSe
e
2-7 SiNf'retti qN ' m 'payee e.� c� Fk eant2 5.cov 1
NAm-ride- MA 01-40 �7)-333? Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.g 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 o sub;-ct pr/8 erty,hereby authorize s�/ (VAUE 0 0 SI70A)
to act on� i' . 104 ers relative to work authorized by this building permit application.
• ice.. +U/opS4gig 1645
Print Owner's Name(Electronic Signature). • : ate
• SECTION 7b: OWNER1 OR AlstEORIZED 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.
DA-)i o O 5 wA id t.9 l(15
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. 142k Other important information on the HIC Program can be found at
www.mass.govloca Information on the Construction Supervisor License can be found at www.mass.eov/dps
2. When substantial work is pllanned,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"
—a—
The Commonwealth of Massachusetts
T-'1
i Department of Industrial Accidents
' .fel_ I Congress Street, Suite 100
�" _'pit= Boston, MA 02114-2017
' ... wwww.mass.;ov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Elediricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
'Wane (Business/Organization/Individual); 0 0 ' '�� (Cjy.t9A- ) ?QcPe Sajc;
Address: 9--`1 Si4 ttAA ,) r
City/State/Zip: LA-nc12._ M A 01-74,o Phone #: 17h1 270 - 3 33 ci
Are you an employer?Check the appropriate box:
Type of project(required):
1.01 am a employer with employees(full and/or part-time).?
7. ❑New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in
any capacity, [No workers'comp. insurance required] 8. Remodeling
3.0 I am a homeowner doing all work myself [No workers'comp, insurance required.]t 9. El Demolition
4. am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13 ❑Plumbing repairs or additions
These sub-contractors have employees and have workers'comp.insurance.? 13.0 Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGI.c. 14.Q Other
152,§I(4),and we have no employees. [No workers'comp. insurance required.)
"Any applicant that checks box 41 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: / ribluj S )/(i5, ea.
Policy#or Self-ins. Lic.#; NP g''4I o? Expiration Date: 'ZO( 7 lam] r l 2j ri
Job Site Address: 17 44 isty 'Atte__ City/stateizip:c ,
enol p] Aoxc(o -
Attach a copy of the workers' compensation policy declaration page(showing the policy num er 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 urn, fns an.',enalties of perjury that the information provided above ' true and correct
Signature: ;//�
Date: / le• f ell
Phone#; 77/' z7D — 333 /
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):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
•
• 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 hind,
express or implied, oral or written." •
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or mote
of the foregoing engaged in ajoint 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 contract 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 checking 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 partners, are not required to carry 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 bellied 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 burn 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-MASSAFE
Fax# 617-727-7749
Revised 02-2345 www.mass.gov/dia
OF•y. ., TOWN OF YARMOUTH
Ok "! J!D LJ 9.9Ji191`I lT D.@��PA. P 1Y1�'r1 V 4' 1146 Route 28, South Yarmouth,MA 02664 508-398-2231 ext. 1261
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE:
JOB LOCATION: Thrtn OS MR- z7 M`c 1q Ma-- (3,V11-47-44-) -n/
NAME STREET ADDRESS SECTION OF TOWN
• "HOMEl�
OWNER" Pi O O Si-ICA -171-270 -3331 SAM-C-
NAME HOME PHONE WORK PHONE
PRESENT MAILING ADDRESS a7 SMKQn,VN 5 r/VA's'/L t. /114 d/760
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:
Person(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 R.5.1.3.1)
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 require nts d'that he / she will comply with said procedures and
requirements.
are- Ate_ ( to
HOMEOWNER"S SIGNATURE MOL-Le, itv • FI -0 AS
0,00..t Q- OU-"p pi cl-D
APPROVAL OF BUILDING 01.111CIAL
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL
Ch.142. " - No
'u have checked yes, please indicate the type coverage by checking the appropriate box.
bility insurance policy Other type of indemnity Bond
OWNER' INS • • C WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 4 of a eeM. ( General Laws and that my signature on this permit application waives this requirement.
— �� t !//_� Check one:
Signature of Owner or Owner's Agent owner Agent
h:hameownrlicexernp
r ' •£ 'r'4R TOWN OF YARMOUTH
• �C BUILDING DEPARTMENT
• o ' "j"g—y 1146 Route 28, South Yarmouth, MA 02664
' MI�TTKII C3
% C.„1: .' <a. 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 87 (rei,-t
Work Address
Is to be disposed of at the following location: -Mot" 7a)L.k0
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 1 , S-ction 150A.
r ,oArA0
ignature of Application Date
Permit No.
•
Office of Consumer Affairs and Business Regulation
One Ashburton Place - Suite 1301
Boston, Massachusetts 02108
Home Improvemeiit_CB�ttractor Registration
=�jk= Type: Individual
Registration: 164336
DAVID P.O'SHEA ,I �" '=i{'_ Expiration: 12/21/2019
27 SHERMAN ST. _ cc —
NATICK MA 01760
Update Address and Return Card.
SCA 1 O 20M-05/17
Office of Consumer Affairs 8 Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
TYPE:Individual before the expiration date. If found return to:
Reaistratiort Fxoiratiort Office of Consumer Affairs and Business Regulation
j 1843367-71 12/21/2019 10 Park Plaza-Suite 5170
DAVIDP OSHEA ' A�" Boston,MA 02116
.tel'—'•�i�'4i�
' c2'
DAVID
DAVID P OSHFJA�. -��'� '
27 SHERMAN ST. Not valid without signature
NATICK,MA 01760 Undersecretary
COMMERCIAL LINES POLICY-COMMON POLICY DECLARATIONS
NAUTILUS INSURANCE COMPANY
r J An Arizona Corporation
Transaction Type: New Policy No. NN874108
Renewal of Policy# Inspection Ordered:
• Rewrite of Policy# ❑ Yes ® No
Cross Ref.Policy# This policy is Insured by a company which is not
NIC Quote# admitted to transact insurance in the commonwealth,
Named Insured and Mailing Address is not supervised by the commissioner of Insurance
(No.,Street,Town or City,County,State,Zip Code) and, in the event of an insolvency of such company,
DAVID O'SHEA a loss shall not be paid by the Massachusetts Insurers
27 SHERMAN STREET Insolvency Fund under chapter 175D.
NATICK MA 01760
Agent and Mailing Address Agency No. 0600 00
(No.,Street Town or City,County,State,Zip Code)
R-T Specialty, LLC
20 Church Street, Suite 1500
Hartford, CT 06103
Policy From 01/02/2018 to 01/02/2019 at 12:01 A.M. Standard Time at your mailing address shown above.
Business Description: CONTRACTOR Tax State MA
Form of Business: ® Individual 0 Partnership 0 Joint Venture 0 Trust 0 Limited Liability Company(LLC)
0 Organization,including a Corporation(but not including a Partnership,Joint Venture or LLC)
IN RETURN FOR THE PAYMENT OF THE PREMIUM,AND SUBJECT TO ALL THE TERMS OF THIS POLICY,
WE WILL PROVIDE YOU THE INSURANCE STATED IN THIS POLICY.
THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED.
THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. PREMIUM
Commercial General Liability Coverage Part $ 884.00
$
$
$
$
$
$
Tax&Fee Schedule TOTAL ADVANCE PREMIUM $ 884.00
STATE TAX $ 35.36 Minimum&Deposit
POLICY FEE 50.00
$ 85.36
TOTAL $ 969.36
Form(s)and Endorsement(s)made a part of this policy at time of issue:
Refer to Schedule of Forms and Endorsements.
POLICY IS SUBJECT TO AUDIT �/
Countersigned: Hartford, CT By �1!�
01/09/2018 EMILYC Countersignature or Autho94 r' ed Representative,whichever is applicable
TW
THESE DECLARATIONS TOGETHER HATH THE COMMON POUCY CONDITIONS,COVERAGE PART DECLARATIONS,COVERAGE PART COVERAGE
C.)
FORM(S)AND FORMS AND ENDORSEMENTS,IF ANY,ISSUED TO FORM A PART THEREOF,COMPLETE THE ABOVE NUMBERED POLICY.
Includes copyrighted material of Insurance Services Office,Inc.,with its permission.
E001(02/14) ORIGINAL
COMMERCIAL LINES POLICY-COMMON POLICY DECLARATIONS
NAUTILUS INSURANCE COMPANY
An Arizona Corporation
Transaction Type: New Policy No. NN874108
Renewal of Policy# Inspection Ordered:
Rewrite of Policy# ❑ Yes (i No
Crossf.Policy# This policy is Insured by a company which is not
NICICQuote# admitted to transact insurance in the commonwealth,
Named insured and Mailing Address is not supervised by the commissioner of insurance
(No.,Street,Town or City,County,State,Zip Code) and, in the event of an Insolvency of such company,
DAVID O'SHEA a loss shall not be paid by the Massachusetts Insurers
27 SHERMAN STREET Insolvency Fund under chapter 175D.
NATICK MA 01760
Agent and Mailing Address Agency No. 0600 00
(No.,Street Town or City,County,State,Zip Code)
R-T Specialty, LLC
20 Church Street, Suite 1500
Hartford, CT 06103
PnF
Peeod: rom 01/02/2018 to 01/02/2019 at 12:01 A.M. Standard Time at your mailing address shown above.
Business Description: CONTRACTOR Tax State MA
Form of Business: ® Individual ❑ Partnership ❑ Joint Venture ❑ Trust ❑ Limited Liability Company(LLC)
0 Organization, including a Corporation(but not including a Partnership,Joint Venture or LLC)
IN RETURN FOR THE PAYMENT OF THE PREMIUM,AND SUBJECT TO ALL THE TERMS OF THIS POLICY,
WE WILL PROVIDE YOU THE INSURANCE STATED IN THIS POLICY.
THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED.
THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. PREMIUM
Commercial General Liability Coverage Part $ 884.00
$
$
$
S
$
Tax&Fee Schedule TOTAL ADVANCE PREMIUM $ 884.00
STATE TAX $ 35.36 Minimum&Deposit
POLICY FEE 50.00
85.36
TOTAL S 969.36
Form(s)and Endorsement(s)made a part of this policy at time of issue:
Refer to Schedule of Forms and Endorsements.
POLICY IS SUBJECT TO AUDIT
tt
Countersigned: Hartford, CT By <`1��� J"7
01
/09/2018 EMILYC Countersignature or ed Representative,whichever is applicable
TN
•
THESE DECLARATIONS TOGETHER WITH THE COMMON POLICY CONDITIONS,COVERAGE PART DECLARATIONS,COVERAGE PART COVERAGE
FORM(S)AND FORMS AND ENDORSEMENTS,IF ANY,ISSUED TO FORM A PART THEREOF,COMPLETE THE ABOVE NUMBERED POLICY.
Includes copyrighted material of insurance Services Office,Inc.,with Its permission.
E001(02114) ORIGINAL
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`�_ il►I1 ' —I_ ! !)p �u- - 1
REVI FOR BUILDING AND ZONING CODE COMPLI- I ' �- I ' I
ERRORS OR OiJ:11SSIDNS DO NOT RELIEVE THEI I I I I j r ( ji / fii-- - t LW�j- i i?
_APPLICANT FROM THE RESPONSIBILITY OF'AS BUILT' - I__ -1___1
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