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Home My WebLink AboutBLD-19-002276 4. • CU ap IW!A pmr .aS }M 30 Icj rI sa{ « i A rt J4su rr 4441 , (ny p 1 I cr ,x U D — i a n - f ii i 1 i i . It WJUj C ye �� a.�- W �' lJ •.�, �g � 0 I Is p. R7GiGe _l If ta- 0 6-I GG 6 , • uWrZ SSI iii y��{ �,.;yy ,a a C tr! 1 it ` 8 per t . O x I N x' zhU @y „ E. b 4 1 SI p d 0 9 O F. � • U o :z M vi iris- . 0 V t• et '40` ;0 N N N N N N Sr � VY _ WJ . . OrrtiF o iii tRI i e' ca @ illilil ; i A i O vi aG.- y; 4 p !ix Z I2I1 i .: r. - _. .. SECTION 5:.CONSTRUCTION SERVICES _ - 5.1 CoastreetionSupervisor Licrose(CSL) GS cm, CDP/3//PO/ I's 20 D2h* W. en✓1 t S 3 License Number Expiration Date Name of CSL Holda � (( List CSL Type(see below) No.andStreeta-1 I ��'r�,2-ST • Ina B 1^r S e t, S.. )V) A L. Umenrisad(Beadingsupto35,000 at.R) R Restricted I&2 Family Dwelling City/Town,State,ZIP M Masonry • 'SDS'32(0 1071/ - RC Roofmg Cavaing 'NS Window and Siding / 1 SF Solid Fuel Ba®mgApplianas eto e✓/r,�•si r&C4 rncQ.sl.P e I Insulation Telephone'- Email address D Demolition 5.2 Registered Home Improvement Contractor MC) . /k 1?- /oro 20/S HIC RegistraticeN®ha Date MC Company Name or BIC RegistraotName ad _L A t No.and Street 1`w curl$�F@ address eaf'C. to Ta..1 City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(Mi .L e.152.;25C(6)) Workers Compensation Insurance affidavit must be completed and submittedwiththis application. Fatluretoprovide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes No...... ❑ - SECTION 7n.:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTORtAPPUTS FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize coSQeb* W V e n n i s JY to act on my behalf,in all matters relative to work authorized by this Mulcting permit application. CC(Mit tcr1-t 'Doe A 131a1-1 1200 Print Owner's Name(Electronic Signature) Date • • • •SECTION 7b;OWNERI OR AUTHORIZED AGENT DECLARATION . By entering my name below,I hereby attest niAer the pains and penalties of perjury that an of the ikon contained in this application is tine and acme to the best of my knowledge and understanding. e4?e1-* w . 0e.(I rs Il-e lola((I�o►tr 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=registered eanhaaor (not registered in the Home Improvement Contractor(IBC)Program),will not have access to the arbitration program or guaranty fond under MGC c. 142A.Other important information on the BIC Program can be found at www.mass.nov/oca Information on the Construction Supervisor License can be found at www.rnass.eov/dps 2. When substantial work is planned,provide the informationbelow: Total floor area(sq.It) (including garage,finished basement/attics,decks or porch) Gross living area(sq.IL) 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 Cast ReCe• lt, OCT 30 7018 ONE or TWO FAMILY —BUILDING PERMIT 81'uko oep APPLICATION REGULATORY APPROVALS NOTICE \`r Address of Proposed Work: t 103 '0;%SC CQO)C to .1/4-17g1-wi0OTN,-1 Scope of Worlc C) Qew,o @ _6,0 -R. 1'7CCO $11.1. A.: t L: ce. w rn-t P. T. Luw,4.3Z.t2 Cr) -REFR.Ptim+_ 'F l r FLoot Date: 1 u\a4 I Er Based on the scope of work described above,the applicant is required to obtain approval sign-offs from the following departments as checked-off below: INITIALS Health Dept.—508-398-2231 ext.1241 Conservation Comm.—508-398-2231 eat. 1288 Water Dept— 99 Buck Island Rd.phone no.508-771-7921 Old Kings Hwy.Hist. Comm.—508-398-2231 ext.1292 Engineering Dept-508-398-2231 at 1250 Fire Dept.Kevin Huck/James Armstrong,96 Old Main St SY Note: Please call Fire Department for an appointment 508-398-2212 Other Appropriate plans and/or application shall be provided to each of the departments checked-off above. Each of these regulatory authorities has their own requirements outside the jurisdiction of the Building Department AR applicable approvals shall be obtained prior to submitting a building permit application to the Building Dept. Thank you for cooperation. Receipt Acknowledgement: \ l `.c-) a24-,n4Lq . 10 ( 14Il � Applicant's Signature Date Rev.Dec.2015 • Sears, Tim From: Sears,Tim Sent Thursday,October 18, 2018 3:35 PM To: 'nwdennisjr@comcast.net' Cc: Inkley, Brad;Grylls, Mark Subject: 163 Pine Grove Attachments: work in flood zone packet.pdf Robert, I have reviewed your application for 163 Pine Grove, and I have attached a packet for working in a flood zone.You will need to review and fill out and return the affidavits. Please make sure that the affidavits are notarized. Thank you Timothy Sears CBO Building Inspector Town of Yarmouth 508-398-2231 Ext. 1259 mailto:tsears@varmouth.ma.us 1 77teComnwnwealth ofMassachusetts Department ofIndustrial Accidents _;;el= i 1Congress Strtw,Suite 100 _ _ �y Boston,MA 02114-2017 VS-�- www nracsgov/din Workers'Compensation Insurance Affidavit General Businesses TO BE FILED WITH THE PERIIHTITNG AIDTHORHTY. Applicant Information Please Print Legibly Business/Organization Name: ROBERT W DENNSI JR dba HOME STRUCTURAL SPECIALISTS Address: PO BOX 534 City/State/Zip: EAST BRIDGEWATER,MA 02333 Phone il- 506326-2464 Are you an employer?Check the appropriate box: Business Type(required): 1.0 I am a anpkoyer with employees(full and/ 5- 0 Retail or part-time).* 6. QRestmvmd/Bar/FathngEstablishment 2❑ Ian a sole proprietor orpartnership and haven 7. QOffice andforSales(bd.nal estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] 8. 0 Non-profit 3.0 We are a corporation and its officers have exercised 9. 0 Entertainment their right of exanption per c.152,§1(4),and We have 10.0 Manufacturing no employees.[No workers'comp-Mann=required)** 1 LQ Health Care 4.0 We are a non-profit crgaointion,staffed by volunteers, STRUCUTURAL REPAIR with no employees.[No workers'comp.insurance req.] 12.0 Other *Any awl:tth*checks bur al msl also fill at the intim below Women Weir eaten'composer=policy infamalion. arftleanyone offices have csempred dinmei es,ba dr corporation las oder employees,florins'compensation policy i quired ad web so atpm®um shard dock ba al. law est eaiil nt*at 'sprorlangworkers'cimparsalmviesinecrforayemployers Mewls the policy nrfwwssim.. Insurance Company Name: ACADIA INSURANCE CO Insurer's Address: P O BOX 591143 Crty,/Slate/ip: MINNIAPOUS MS 55459-0143 Policy#or Self-ins.Lie.# MAARP-301573 Expiration Date: 05-31-2019 Attacks copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to scant coverage as required under Section 25A ofMGL 0.152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 andfor oneyear imprisonment,as well as civil penalties in the term of a STOP WORK ORDER and a fine of up to 5250110 a day against the violator. Be advised that a copy of thisst temanmaybeforwardedtotheOfficeof Investigations of the DIA for insurance coverage verification. /do haebyaa ,amdertbepe'ra of tlutMeiafwmsewnpr videdabove hhweaaercarm2 Sinn are: Date: ./.0/240 Phone#: 17�-molt/ore owty. Do sit write be ads nes be cump►zld by city wieners offidal city or Turn: Permit/Limiest f Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/fown Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone 4: wwwnaa-nor-din ,J 4 o• '� CERTIFICATE OF LIABILITY INSURANCE 09/2512718 THIS CERTIFICATE TS ISSUED ASA NATTER OF INFORMATION ONLY AND CONFERS NO REFITS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFRRINATIYELY OR NEGATIVELY AMEND.EXTEND OR ALTER THE COVERAGIE AFFORDED BY TIE POUCQES BEIO7f. THIS CERTIFICATE OF INSURANCE IBES NOT CONSTTIUTE A CONTRACT BETWEEN THE ISSUING INSURETQSI„AUTH D REPRESENTATIVE OR PRODUCER.AND THE CERTIFICATE HOLDER ?RTAIn .. it it.aritAcalte Wider it am ADINTIOItU.thISUIRED,the DMlic7TIMsI most be eBdarsed. N SUBROGATION(S WAIVED,subject to the terms and roxlNoaa arae pay,cabals policies may moult as sndoesement.Astb6H®eeta,TIES wat914adadbas oat cosh:dykes trethe eerti6uis holder in lies of such/ndorsalrRE(S). CONTWIOmAs wave Justin Justin DeLoach MCSVVEENEY AND RICO INS AGENCY INC sPHONE ec ,sat (IanIsla-amD ( t FAX •auks; _ PO BCC 850494 4131,10105LIEFONaCCAFINSCE i , WC* BRAINTREE MA 121105 sauces A: ACADIA ANS CO t 31325 eaStreO INSURER e: ROBERT W DENNIS JR 8 DON ATKINSON saletC: DBA HOME STRUCTURAL SPECIALISTS msABae: p, PO BOX 574 Mown= EAST BROGEIA THi NIA 02333 rl NP: , COVERAGES CERTIFICATE NUMBEIh 3105411 REVISION NUT/BER: TNS IS TO CERTIFY TINT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED RAYED ABOVE FOR THE POLICY PERIOD INDICATED_ NOTYADLSTATDIAi ANY REQUIREMENT.TEFL OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT RATN RESPECT TO WIEN THIS LER ItaATE LAY BE ISSUED OR WAY PERTAIN.THE IIESURMI s AFFORCED BT THE Fd1CTE5 DESCRSED IUB IS SUI ECT TO ALL THE TERNS. EXCLUSIONTSAND CONDHIIONS OF SUCH AMIDES Lffiir SHOWN KAY REDUCED BY PAID CLARIS. MR ateSOSSE z relt7Ls r Parr , LER TVPIE FmeelmLE ppm... TRRIIRettlIO9 '.rO'a6Y01N!lN4 NeR�'J °nH. Inn f I co 4�utLMOMTW I II . ;, EACH OCCURRENCE I s III Cr♦iugLAnc n OCCW PREMISE Fiam�aml ! s ) j Isee Pagoesons is § 1 HIL i iveract Rens ARY is TEET LA DAEGFTLmrOPPLESH9k f F k — a 1 CENDIALAODPEGUIE i's ',---4 ACTT i s LJ RCC 1 E.G I s I OTHERIs L_,4eOBMEIMUDT pI SINGLE LOUT s iAWAND = iEOM/VI mBtrrs+! 4s COMO rn EO t ii, NRA Emaxwueratramur.erl:s ' imisontros SUMS I i t Yea:.-: s I: Per 112:2911a_. il 1 s UMBRELLA LIAR occuR EACHOCCURREN E 1 e f�t E�� ,---1Ct� a.s " D7 WA r T d s 3 yes i i unrenON! F # i. rr t s spsemsccoresaRGN i 1. ,)Cr.,.., l f a ASO EfR@QU OTSLOY Rte; k r 55 EL ENDS FNT yyy$ TGO,LCO A jaFaa R>fR `•. ... Hos Nwf TJAAHP3I115T3 , IOSF3,�iBiB5t3111WB imanostasdem b RBE, GI I kl EL DISEASE-EA L 100.000 eyes e®b OFare O ` IJES(RPi'gw6OPERATON6heb r jEl d6FASE-PQFYIDIf ! J�.000 I } WA 1 ' EI I i OESCRIPIIOR CEOP9XIXINS ODCATIONsr1/911QE7 MORD lMt aefarlYob bars sae sesdaL amow smote Ymoi p0-. Workers'Compensatlon benefits SF be Paid b Massachusetts employees only.Pursuant b Endorsement WC 20 03 00 B.no auBlaaabon 6 Oven b pay claims M benefits to employees in stales Oiler Dan Yaszsdasls lit blond hires,or has hied fuse empoyes oasidedYasgdasels. ibis certfcaYdSnot shame*prig it Samos fedace_riPaser mas leased(mien feesokalias daleao Me gave pcFri preaslesteissaedareattts cenFoe of insurance). The__ __ __.daty byas®+gCaPeoctiCa ge-EfleagalsecaftwoseatftEna winsaussowesratarlesscianpensatendesesSgateest .. No miners have elected coverage CERTIFICATE HOLDER CANCELLATION SNXI DANTOFUEABOYEISCEEMPOLCIESTEEENCEUIDPEONE TIE @aATmN DATE TL9®F, FENCE Fora. NE MI Kate Doran ACCOROAfCEs0171EICUCYPIEN ENS. IGS Fine Orme RO AIINOleimWEIEeGTD! Wj L.CkK( � S Yarmouth102GG4 Card at Oesby CFCU.We PiesidsY—Residual NWkeE—VSCRFGIL4 0Me2314*CORD CORPOFULTIOTIL Ai sights reserved. ACORD 25(7314141) The ACOfe ire and logo are registered mals et ACORD _....._..._..,. ..::...,,,w..c viu,-ws+Mf"!?'p,!`,Hk�y ,44irFa rkt4W v+1i AK V,101'0;3 V=:t ;t,.,,t `:. " <a a- Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construction Supervisor 1.„ CS-018348 ' Expires:08/31/2019 4., "1""""-", 524 ORME SY PCBX 534 EAST BRIDGEWATER MA 62333- 4 . - . • . Commissioner CIL - -5-2.• ,„..„......”0.-.7/4( s trice di Cs Wass a Banwar Nicosia ^ "e"' HOWE 111PROYEITENT CORTRACTOR 'TYPE:Intidual 1/4v:14,17; • Pihtai5 _,ETkkEt 02'202019 ROBEFIT W.teeth a DOA Home Strut:Era'Speciakb FIOSERT DENIMS - • ' 524 Brtlge cif-cCresst"-- EastBridgewater,MA 02333 Undenaretay Is 1 • . ' COMMONWEALTH Of TAASSACIRMETTS 4"DIVISION OF PROFESSIONAL LCENSURERtif Pe'to ENCSIEESSIG ISSUES nig FOLLOTIMIG t..trfiSE REmpRoF snweninAL ERGerest . IC ROBERT MrDENNIS EURIDGEISTR, =341534 a • ; � TOWN OF YARMOUTH • bc BUILDINGc BUILDING rcr r� 1146 Route 23,South Yarmouth,MA 02664 503-393-2231 ext 1261 HOMEOWNER LICENSE EXEMPTION PLEASE PRT: DATE JOB LOCATION: l(•3 Ens Cnti%)e So. Yatv,oat\A NAME STREET ADDRESS SECTION OF TOWN 'HOMEOWNER' . lee_i_r)r__rc:2t ado - 9iti- SIR I NAME ]TOME I7 ONF} WORK PHONE PRESENT MALTING ADDRESS 33 lmovt'ts:+sk»rt Cott.. C }tiinc}_ _ c c_ °Gr.) 8'S CT Y OR TOWN STATE - ?1P CODE The curnt exemption for'Homeowner'was extauled to include oner-ac _led dweflines of or cc two frits and to allow such homeowners to engage an individual for hire who does not possess a lieent provided that such homeowner shall act as ser .ricor. (State Building Code Section 110 R5.13.1) Definition of Homeowner: Person(s)who owns a pace]of land on which he/she resides or intends to reside,cm which there is oris intended to be,a one or two family attached or detached structure assessory to scab use and f or farm structures. A pion who caravans more than one home in a two-year mind shall not be considered a homeowner:such-homeowner shall submit to the building official,on a form acceptable to the 'building official.that be she c1111 be resronsible for all such wort reformed tinder the tarldine permit.(Section 110 85.13.1) The uncle sirgned Nanterre assumes responsibility for compliance with the State Building Code and other applicable codes,by-laws,rules and regulations. The undersigned 'homeowner' =titles that he/she trndastznds the Town of Yarmouth Building Dty..u. ad minimum inspection procedures and Trip iremaras and that he / the win aa:iply with said p:oorderes and requirements. V HOMEOWNER"SSIGNATURE h4)4UV"l S• JAI/'\ A/( mnn APPROVAL OF BUILDLNG OFF ICIAi. • INSURANCE COVERAGE.: I have a current liability insurance policy or its strbsta al equivalent. which mous the requiremcees of MGI, Cb.142. Yes 1-1 - oT eCG2.tsetc (d ti' LA.—) If you have checked rs,please indicate the type mvera.ee by checking the appropriate box_ A liability insurance policy Other type of indemnity Band OWNER'S INSURANCE WAIVER: Iamawsrethat the licensee does oct have the iiturance wveragerrquiied by thtapte-. 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 '+t___ tceoneentir e:amQ • o 1.14 TOWN OF YARMOUTH ge��- s..r, O BUILDING DEPARTMENT t£ t 1146 Route South Yarmouth,tidy MA 02664 •e63 ,*fa 508-398-2231 ext 1261 Fax 508-393-0336 BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Po/stunt to M.G.L.Chapter 40,Section 54 and 780 CMR,Chapter 1,Section 111.5, T hereby certify that the debris resulting from the proposed work/demolition to be conducted at 1 co 3 Pi 04r 6114v Work Address Is to be disposed of at the following location: uw1Ps ilt& 01-1. S rr£. (a .e arses 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. Robert W. Dennis Jr. Registered Structural Engineer Don Atkinson dbal Home Structural Specialists P.O. Box 534 East Bridgewater, MA 02333 508-326-2464 rwde n n i s j rna.co m ca st.n et www.homestructuralspecialists.com Proposal 7Structural Work 11j3 5 Pine Grove, So Yarmouth, MA August 20, 2018 We propose to provide engineering design, obtain building permit, and provide labor and material to perform structural work at a property located at 165 Pine St. So. Yarmouth, MA Work generally will consist of the following: 1: Provide cribbing, lumber, and hydraulic jacks to temporarily support structure 2. Remove approximately 1000 sq. ft. subfloor and floor framing 3. Remove approximately 120 ft. sill around perimeter of house 4. Fill hollow sections of block wall with concrete 5. Install new sill using pressure treated lumber 6. Install new 6 mil vapor barrier 7. Install two new air ventilation openings in each side of foundation 8. Install complete new floor framing system 9. Install 3/4" T&G plywood subfloor 10.Remove temporary supports ' 11.Cleanup Estimated time 10-15 days Cost $42380 9 Saw Deposit when sign contract $1300 Deposit when work begins $5000 Two progress payment as mutually agreed $12500 Payment when work complete $10000 Payment after final inspection $1000 All work will be done in a professional manner to the complete satisfaction of the owner. Owner is responsible for removal of debris. We will remove debris for an additional charge of$250. When work is complete, owner agrees to contact the local building inspector for a final inspection at (508-398-2231). This is necessary because the inspector requires that someone be home when they come for the inspection. Please call if you have any questions. Bob Dennis 508-326-2464 Don Atkinson 781-724-4257 Please sign the contract, and return it with the deposit payable to Home Structural Specialists, P.O. Box 534, East Bridgewater, MA 02333. Upon receipt, we will proceed with obtaining a permit and schedule the work. CONTRACT Contractor Home Structural Specialists Owner ' a}khr )'or Yak tierr)D(G..- Signature Print Owner Signature Print Date 9 lap/ c‘I • Robert W. Dennis Jr. Registered Structural Engineer Don Atkinson dba! Home Structural Specialists P.O. Box 534 East Bridgewater, MA 02333 508-326-2464 —.vdcrtnisir_ rc' worwho -t structurzisceci? is LS.corn Revised Proposal Structural Work 165 Pine Grove, So Yarmouth, MA October 23, 2018 We propose to provide engineering design, obtain building permit,and provide labor and material to perform structural work at a property located at 165 Pine St. So. Yarmouth, MA Work generally will consist of the following: 1. Provide cribbing, lumber,and hydraulic jacks to temporarily support structure 2. Remove approximately 1000 sq.ft subfloor and floor framing 3. Remove approximately 60 ft. sill around perimeter of house 4. Fill hollow sections of block wall with concrete 5. Install new sill using pressure treated lumber • 6. Install new 6 mil vapor barrier • 7. Install two new air ventilation openings in each side of foundation 8. Install complete new floor framing system 9. Install 314"T&G plywood subfloor 10.Remove temporary supports 11.Cleanup Estimated time 10-15 days Cost$35300 Deposit when sign contract$1300 Deposit when work begins $5000 First progress payment as mutually agreed $12500 Second progress payment 58000 Payment when work complete $7500 Payment after final inspection $1000 All work will be done in a professional manner to the complete satisfaction of the owner. Owner is responsible for removal of debris.We will remove debris for an additional charge of$250. When work is complete, owner agrees to contact the local building inspector for a final inspection at(508-398-2231). This is nn.essary because the inspector requires that someone be home when they come for the inspection. Please call if you have any questions. Bob Dennis 508-326-2464 Don Atkinson 781-7244257 Please sign the contract,and return it with the deposit payable to Home Structural Specialists, P.O. Box 534, East Bridgewater, MA 02333. Upon receipt,we will proceed with obtaining a permit and schedule the work. CONTRACT Contractor Home Structural Specialists ' e j Owner ^` . 7 i -- .. .. Signature Print Owner Signature Print Date ` • o4•Y4 TOWN OF YARMOUTH FAtil " BUILDING DEPARTMENT 1146 Route 28,South Yarmouth,MA 02664 508-398-2231 ext.1261 HOMEOWNER LICENSE EXEMPTION PIBASBPRRT : DATE: • JOB LOCATION: l (e 3 ?u its. G2auC. Ste_ 'Qr�rt nk NAME STREET ADDRESS SECTION OF TOWN "HOMEOWNER" ECS 1q 1 NAME HOW PHONE WORK PHONE PRESENT MAILING ADDRESS 33 1 r1TrLq iC &J CA Q. Sour4tN4713.a CT. of grf- ' CITY OR TOWN STATE ZIP CODE The cor ant 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 be/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"hontown&'shall submit to the building official,on a form acceptable to the bnil ding official,that he/she shall be responsible for all such wont performed under the building permit(Section 110 R5.13.1) The undersigned 'homeowner' assumes responsibility for compliance with the State Building Code and other applicable codes,by-laws,mles and regulations. The undersigned 'homeowner' certifies that be/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 ("Q-6-1,-3tuOddri.unce A kg/44°n 1- 31..``' SCia CCU/30.0 APPROVAL OF BUILDING OFFICIAL INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent, which mets the requirements of MGL Ch.142. Yes No If you have checked ves,please 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 required by 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 hhomeownr icexemp The Commonwealth of Massachusetts t -"_t Department oflndustrlalAccidents =iee= 1 Congress Street,Sage l00 i str jBoston,MA 02114-2017 www.neass.gov/dia Workers'Compensation Insurance Affidavit General Businesses. TO BE FILED WITH THE PERMI111NC AUTHORITY. Applicant Information Please Print Levr'ble Business/Organization Name: ROBERT W DENNSI JR dba HOME STRUCTURAL SPECIALISTS Address PO BOX 534 City/State/Zip: EAST BRIDGEWATER,MA 02333 phone it: 508326-2464 Are you an employer?Check the appropriate bon Business Type(required): 1.1:1 I am a employer with employees(fill and/ 5. 0 Real orpart-time}• 6. 0Restmeantt/Ba /EatingEstablishment 20 ma sole jnpii or a tunsltip and have in 7. ❑Offaxstaffer Sales(md.real estate,auto,et) employees working for me in any capacity. [No workers'comp.insurance required] 8. 0 Non-profit 3.❑ We are a corporation and its officers have exorcised 9. 0 Ei tntaimre t their right of exemption pat.152,§1(4),and we have 10.❑manufacturing no employees.[No workers'amp.insurance required]•' 11.❑Heahh Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees.[No workers'comp.insurance req.] 12.0 Other STRUCUTURAL REPAIR 'Any applicant dirt checks bin NI mut also fill at the mhos blow diaristibeirntas'conspe1516011 policy information_ "lido copra cams lose wend dsemdsr;bot the aspiration has oPoaatylotees,awatas cm4msaOm pity is camel and such= orrp�le should check boat. 1. I CM an a aploferthM is random humus:•coopassfiar nnnrcefor my employees. Below Es dee polity iafi naafare Insurance Company Name: ACADIA INSURANCE CO Insurer's Address: P O BOX 591143 cityistatecip: MINNIAPOIIS MS 55459-0143 Policy#or Self-ins.Lie.# MAARP-301573 Expiration Date: 05-31-2019 Attack a copy of the workers'compensates policy declaration page(showing the policy number and expiration date). Failure to care coverage as required tinder Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to$1,50050 addamo-yea mgpriso®elt,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Be advised that a copy ofthis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Idohereby < , )i ander the pdnal that the isfwrethowprovided above itore wad correct Signalwe: K— Z} Date: /0/10/2o/cf. Phone if: SzA- ' 32-t. ' o`ll lect Oj/idd use owl, Do not nee In Ms greyly be completed by city or town offiriaL (Sty or Town: PensWLic nse ft Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person Prase S: wwweess govIen • • '4 •• CERTIFICATE OF LIABILITY INSURANCE 0928/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOWER.THS CERTIFICATE DOES NOT AFFER IATNT3Y OR NEGJIMVELY AMBO, EXTEND OR ALTER THE COVERAGE AFFORDED BY TIE POUCFS BELOW. THS CERTIFICATE OF INSURANCE DOES NOT COMMUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER =PORTANT B the,a irrys holder is an ADDITIONAL INSURIED,the pofcyliss)west W endorsed. N SUBROGATION IS WAIVED,sebjecI the terms and conditions el the policy,certain policies nay Legate an=domes= A=lenient en 01$cattle=does not confer ilghts to the certificate holder In IMu of such endorssment(s). PRODUCER CWONe .Matin Delnach MCSWEENEY AND RICCI INS AGENCY INC "1p1E - e+a86e0 FAX eons zkileloachemoweelleificd- cam PO BOX 850984 -- INSURBINSAFRIIIIINGC011ENAGE MACS BRAINTREE MA 02185 INSURER A: ACADIA INS CO 31325 INSURED INSURERS: ROBERT W DENNIS JR&DON ATKINSON feast: DBA HOME STRUCTURAL SPECIALISTS 116111131 B: PO BOX 534 aelfmE: EAST BRIDGEWATER MA 02333 PIS F: COVERAGES CERTIFICATE NUMBER: 316548 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. NOIVMfHSrANDBIC ANY RECKIIRE1ENy,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT'NIH RESPECT TO WHICH TRIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIED HEREIN IS SUBJECT TO ALL THE TERMS. IXCLUSiNS AND CONDITIONS OF SUCH POLICIES LITS SHOWN MAY HAVE BEEN REDUCED BY PAD CLAIMS. RT � LIR TYE6BeArw La y–aw /ffflyflnj POLI TY lana ODMBIaALGENERAL LIABILITY EACH OCCURRENCE S CLAMS-MADE El OCCUR DAMAGES I RENTED CLAMS-MADE DAMAGE TlfR NTElelal $ NEDFLD'(Any w wan* S WA PERSONALSAwefAaa f OBILNGIIEGlE LMR NRS PER GBIERAILAGGRBGATE f PCI-CY�.E�cT ❑LCC PRODUCTS-CONREPAOc f I OTHER- AUTOSIESILELININITY IFI S.aELOST f ANTRUM BODILY RUM(Par f — Oaf® MHOS WA BODILY MIRY p� mdene as _ NLI _ AUTOS Auras HIREDAUTIOS AUTOS 11Par=SINN $ UMBRELLA DAB OCCUR EACH OCCURRENCE f _ - MESS URN aAns-wzr WA AGGREGATE _ f ® I IRETENTION$VOOFSUERSCONFERSf NM ar LAi TY YIN XI$Iw UTE I I Dl A OFFICE RMEMBEREXCLIAR:DP WA NSA MAARP301573 05/31/2018 05/31/2019 EL EACH 100,000 WA (Mandator/In NH) EL DISEASE-EA EMPLOYEE $ 100,000 aye.denote under DESCRIPTION OF COPERNICUS bar EL DSFASE-FOISY IMT S 500.1100 WA DFSCRIPSON OF OPERATIONS/LOCATIONS/VEHICLES(=ORD 101,Addeenel Reade SchMN,may be nailed I mom alma la MAINS) Workers'Compensate benefits All be paid b Massachusetts employees only.Pursuant b Endoomment WC 20 03 06 B,no authorization Is given b pay claims to benefits to employees it tees SINeSat Yaeachseb lee imaed hies.or is TNM Saxe employesatsikt IlassadvaseNs. Th"scertificate or Mayan sloes We poky in free on Reda Mad this cedinade was wed(laden the a:pith=dos at Meahem pore peadsMe®e dale this aa.a5 of iesa cek The saps alas ma®gear be maimed daft by sassaalg Mn Roofed Carnage Canape Year Seadl bd a wwwmassratedleorlossocemensaliondovestgaint No partners have elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANT OFTEABOVE.N a®POW EOUL:E Leal BERME TE EI12NeR10N WOE TFM3®F, NONE WlL E CHIVEED IN Kate Doran ACDDIDMICEINDI MUM PROVISIONS. 165 Fee Gnat Rd AIrnIONZEDRl3e®GTNE S Yarmouth MA 02864 (3-15 Daniel M. ,CPCU,Vice President—Residual Market—IACRIBLIA 019882014 ACORD CORPORATION-Al dgtds reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD og''r`tR TOWN OF YARMOUTH 3�,-s i., o BUILDING DEPARTMENT o !1'c 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, T hereby certify that the debris resulting from the proposed work/demolition to be conducted at l to 3 P wt r ,i/z0,i/z0C Work Address Is to be disposed of at the following location: J`71/43.Mps-(Cr crvi s;- . c •ret t,aw. L.Jca142-) Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. i tS "A) 14-. 1 toI 14( te Signature of Application Date Permit No. Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constructidn`Supervisor It CS-018348 1 Expires:08/31/2019 :A U v" r.h vewrn* 3 :fir ROBERTWDE aSit + .f ` ` . 524 BRIDGE ST PORE 534 .. EAST BRIDGEWATER MA 0233A . . Commissioner a • ,Ku n„u.w.l/,t l/rrsk niatem Office of LlawrrAffairs a Bur iRzgolleas • HOVE NPROVEWIENT CONTRACTOR TYPE:Indvidcsal s" J e 117 -- 02202019 ROBERT W.DEtitaS D/B/A}bme Structural Sperm ROBERT DENNIS JR 524&"dge St L.] a East Bridgewater,MA 02333 Undersecretary'I e s COESMONWEALTH OF PsIASSACMUCtfTS DIVISION OFPROFESSIONAL'LUCENSURE; rS _ Ira?I-Ti ,-r 6SUESTHE FOLLOWING UCBISE REWPROFSTRUCTURAL o ROBERT W'DEMMSJR * s—, " PO BOR 534 . $ E BIf DGEWTR,MA 023.33-5'34 : t;,` : 33 . ,3034 . ^. 4T6795 RECEIVED 004 TOWN OF YARMOUTH NOV 08 2018 BUILDING DEPARTMEN F• .. .ate p••%$c 1146 Route 28, South Yarmouth,MA 026 4auILDING DEPARTMENT Telephone 508-398-2231 ext. 1261 Fax 508-39 83t� C Owner's Affidavit: Substantial Improvement or Repair of Substantial Damage Property Address: \ G3 et Givav-C- Su. L(ail0to ) Y1I4 Parcel ID Number: 82-o(a Owner's Name: "C etAinlea/orc.11 Owner's Address/Phone: 33 1-k-Lik.14i 44 C v. ScAt., A e c4 . Contractor: 'o\aa.A. . Contractor's license Number: C S— ot2531-1K }-4% C - t\ Ff.1'72_ Date of contractor's Estimate: CO4 221 X201 tr- I hereby attest that the description included in the permit application for work on the existing building all improvements, rehabilitation, remodeling, repairs, additions, and other forms of improvement. I further attest that I requested the above-identified contractor to prepare a cost estimate for all of the work, including the contractor's overhead and profit. I acknowledge that if,during the course of construction, I decided to add more work or to modify the work described,that the Town of Yarmouth will re-evaluate its comparison of the cost of work to the.market value of the building to determine if the work is substantial improvement. Such re- evaluation may.require revision of the permit and may subject the property to additional requirements. I also understand that I am subject to enforcement action and/or fines if inspection of the property reveals that I have or authorized repairs or improvements that were not included in the description of work, and the cost estimate for that work that were basis for issuance of a permit. • Owner's Signature: 6 d^^'Y` /00 I " mutt Date: 1/ /3/ /d' " Notarized: JASON TAYLOR NOTARY PUBLIC • AOF COTICUT ` .:,/ MYSTCOMTEM. EXP.01/3NNEC1I2019 �, . • �° Ro TOWN OF YARMOUTH RECEIVED VED a� j _�y BUILDING DEPARTMEN NOV os 2010 Ce � .�•:? 1146 Route 28, South Yarmouth, MA 02664 - �^t...%n-' U LDING DEPARTMENT , ;,, Telephone 508-398-2231 ext. 1261 Fax 508-398- 84—_---_–___-- Contractor's _ ___Contractor's Affidavit: Substantial Improvement or Repair of Substantial Damage Property Address: I C3 Pane Grru.e- So (-?,:;y1...'ou*kr \%q4 Parcel ID Number:_ R'oCeal` v-041 Owner's Name: \C ee r, to o41 ` , Contractor: 3 13 -LAt iC-cd'"► C QC . csu't ►�1,hth.M C- Contractor's License Number: CS - Ol $314 r— \4\c l 1g 272 Date of Contractor's Estimate: CD Cr 9-P 09.0 1 8 _ I hereby attest that I have personally inspected the building located at the above-referenced address by the nature and extent of the work requested by the owner, including all improvements, rehabilitation, remodeling, repairs, additions, and any other form of improvement. _ At the request of the owner, I have prepared a cost estimate for all of the improvement work requested by the owner and the cost estimate includes, at a minimum,the cost elements identified by the Town of Yarmouth that are appropriate for the nature of the work. If the work is repair of damage, I have prepared a cost estimate to repair the building to its pre-damage condition. I acknowledge that if, during the course of construction,the owner requests more work or modification of the work described in the application, that a revised cost estimate must be provided to the Town of Yarmouth, which will re-evaluate its comparison of the cost of work to the market value of the building to determine if the work is substantial improvement. Such re- evaluation may require revision of the permit and may require revision of the permit and may subject the property to additional requirements. I also understand that I am subject to enforcement action and/or fines if inspection of the property reveals that I have made or authorized repairs or improvements that if inspection of the property reveals that I have made or authorized repairs or improvements that were not included in the description of work and the cost estimate for that work that were basis for issuance of a permit. Contractor's Signature a. d'a' —.O Date: 11 ' j/ / & Notarized: Susan C. Gillpattick /`, My Commission Expires July 4,2019 ta_. ir.v-,.. A — c 33 >: I 0 Sacs 97- cnc ( 'TYP) m u. CA. - • -� 3PLY2y� PT cart?e) 1= ^ t7-1 r k v last r- • t L X btri S5 =- $ y3wck ?iEt:S • 4 FiQ -T TOWN OF YARMOUTH REVIEWED FOR BUILDING AND ZONING CODE COMPLI- ANCE. ERRORS OR CM:ASSIGNS DO NOT RELIEVE THE APPLICANT FROM THE RESPONSIBILITY OF'AS BUILT' FILE COPY COMPLIANCE. . DATE: I 13- 1$ BUILDING •-I to tic 9 t bso ° Robert W. Dennis Jr Co 3 Pt 4Q GIZou a /I ROB 9 W.-•j. Registered Structural Engineer SA�wto�rC1� wiA ,� "NISJR. P.O. Box 534 o, Y STRUCTURAL y No.13834 . East Bridgewater, MA A�o,9Fo/s �`�� ' 508-326-2464 ' ONAtet#'