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HomeMy WebLinkAboutBLD-19-2862 r &M "/irk 114 /1 71/4 ONE & TWO FAMILY ONLY-BUILDING PERMIT • Town of Yarmouth Building Department or.....r 1146 Route 28,South Yarmouth,MA 02664-4492 i�' 508-398-2231 ext. 1261 Fax 508-398-0836let;��'- Massachusetts State Building Code,780 CMR Building Permit Application To Construct,Repair, Renovate Or Demolish .+ a One-or Two-Family Dwelling R EC E I ED This Section For Official Use Only Building Permit Number: L `% /rA ,r1 ' to ate Appiedj 1111111 f. $�R 1B " ISM 1-nI.3 .. . iI<Ig'-/E BUILDING DEPA•TMENT Building Official(Print Name) SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Ma &Parcel Number " 1.1a Is this an accepted street?yes_ no Map Number Parcel N ber 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 2i PROPERTY OWNERSHIP' 2. Owner'of Record: 4-214 Amp Ti-9R14tJ femat2 t&11 7- 1/annworff - pin - 0267- ame(Print) City,State,ZIP 21./ 11.mnRe & o 52222152/A No.andpareet Telephone Email Address SECTION 3:.DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑,,,,Existing Building❑ Owner-Occupied if Repairs(s) 0 Alteration(s) C17-Addition 0 Demolition H Accessory Bldg.0 Number of Units_ Other ❑ Specify: Brief Description of Pr.•osed Work'`R s c ,pas / 4 '4� _-�r.� s-- ' !c, ii ' . -1 1S. . . S i sill i a - i, AiI`.7, tD OP , . / i . /) - ., - _ ti/ ina .•�.edirGl1111ear 4i I. . .SECTION:4f ESTIMATED CONSTRUCTION COSTS ■ a Estimated Costs: .- 'y,.A �� Item Official Use Only . . EPAR1 (Labor and Materials) N. 1.Building $,/�G n :d Building Permit Fee;$a.O0 Indicate how ee is .etermned: 2:Electrical $ ' IStandard City/Tenn ApplicationTee J/C''• ❑Total Project Cost�s�6) x multiplier x - 3.Plumbing $ 2. _: Other Fees: $ W- 4.Mechanical (HVAC) $ . °o4 List 5.Mechanical (Fire Q Suppression) $ Total All Fees $ Check NV. Check Amount: Cash.Amount:1i, 6.Total Project Cost: $yZI �� � - 00 O Paid in Full. . . le Oti standing Balance Due: 1 u - . SECTION 5:.CONSTRUCTION SERVICES SirnConstruction Supervisor License(CSL) �C n3 /I_/,� /_ /9 • • _ A:mi l e rvn.1,S License Number lExpimtionb/_attee }Same of CSL Holder ',C List CSL Type(see below) CJ in Shnwrnur oo and Street Type Description /'„ . rCINa 02 U Unrestricted(Buildings up to 35,000 cu.ft.) City/Town,State,ZIP M ©� R Restricted I&2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 7:167110040 pfihni bruimannc c� I Insulation Telephone al -// , 0j-rn Email address D Demolition 5.2 Registefed Home Improvement Contractor(HIC) /3 7qY3 • -2/,, / 4' RIC Company Name or HIC Registrant Name HIC Registration umber Ex/piraNtion/D/a—t�E No.and Street Dpi(0/U/74 k3QS77J/(/-CM"i ErnaT address City/I•own,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE A14 iDAVIT(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 Issuanc f 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 L0X gel/1„.0UA-7''(e k/S to act on my behalf;in all matters relative to work authorized by this building permit application. 121'l�4\1 U/9-2 q/20 /240/f P ' t Owner's Name lectronic 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 true and accurate to the best of my knowledge and understanding. ti a- F jr/j-S h g/fin /2,0/12 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. 142A. Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/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 l Department oflndustrialAccidents gall_ 1 Congress Street,Suite 100 g_f Boston,MA 02114-2017 • %z www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH TIlE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): / v/ ,A o j/itrn DAA /A. Address: j2 g7ni(//h{ii 2D City/State/Zip: 0111/MA1 /Y)/1- Phone#: J7 f2i/D06(9 Are you n employer?Check the appropriate box: Type of project(required): I. I am a employer with /7- 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 $. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]r 9. ❑Demolition 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 proprietors with no employees. • 12.❑Plumbing repairs or additions 5.0 t am a general contractor and?have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance.[ 13.❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL e. 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 Homeownen 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. t Insurance Company Name: /i ben �/f rt ✓ "I w .- / Policy#or Self-ins.Lic.#: X U/ 15?'3 ' Q L)Lei Expiration Date: �/ �i y// Job Site Address: i ,V,P ' A • hi ILf a /State/Zip: ,t441- 0267 S. Attach a copy of the wor •ers' compensation policy declara.on page(showing the policy number 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 violeto ' opy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verificatio' I do hereby certifynn. r the pain a . a- 'es of perjury that the information provided above is true and correct Signature: (A2-f Date: Q/.740 /o/e PhoneV 7A-( 1/0 .0 .7-211/ 5,24SoCre9 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#: _._ The Commonwealth of Massachusetts . IG=:z i=t' Department of Industrial Accidents ' • is=;1;_=-e 1 Congress Street,Suite 100 �— a Boston,MA 02114-2017 \Z"r, wrvw,mass.gov/d a Workers'Compensation Insurance Affidavit Builders/Coutrxton/DectriaaayPlumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Ilene Print Le¢tblr Name(Business/Organization/Individual): LUX RENOVATIONS, LLC Address:60 SHAWMUT ROAD City/State/Zip:CANTON, MA.02021 Phone#:781-821-0060 Are you an employer?Cie&the appropriate box: l.a I inn a employer with 17 Type of proles( mired): employees(fulland/or part-t®c}• 7. 0 New construction 20I am a sole proprietor or partnership and have no employees working for mem 8. Remodeliry any capacity.[No workers'comp.insurance ,�Qed] ❑ e 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required]t 9. Demolition 4.0!am a homeowner and will be hiring contractor to conduct all work on my property. I will 10 0 Building n ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical'pans or additions proprietors with no employees. 5.01 am a general contractor and I have hired the subactas listed on the started sheet. 12-DPhrmbing repairs or additions � t These sub-contractors have emes ployeand have workers'comp,insurance.: 130Rpof repairs GO Wet are a corporation and its officers have exercised their right of exemption pa MGL c. 14.[Other 152,§1(4),and we have no employees.[No worker'comp.insurance required] *Any applicant that checks box#1 must also fill out the section below showing their workers'composition policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors mit submit a new affidavit isolating welt =Contractor that check this box must attached an additional sheet showing the name of the sub-cofactors and state idiot or not those entities have employees. If the sub-contractors have employees,they most provide their workers'comp.policy Dumber. I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy an!job site information. Insurance Company Name:LIBERTY MUTUAL Policy#or Self-ins.Lk.#:XWO57350449 Eviration 824/2019 Job Site Address• /4/A19O Q/ city/state,: , e— /i Attach a copy of t�rkers'compensation p declaration page(showing the policy number an, expiration dated l/� ' Failure to secure coverage as br, b, ..- MGL a 152,§25A is a criminal violation punishable by a fine tip to S1.500.00 026and/or one-year impriso...,- .. as well civil penalties in the . .. of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator. opy of .: statement may be f. '..ed to the Office of Investigations of the DIA for imurmoe coverage verification. I do hereby certify in. thfr ; and penalties of); ry that the Worms/fivesprovided above is s and Signature: ^ / C�T/ Date: e /i/�r r Phone#•7i t-0Co ( v Official use only. Do not write in this area,to be completed by city or tones 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.Plnmbinglnspector 6.Other • Contact Person: Phone#, till! V h l olnanornweai c/ r 4 • .4 • Office of consumer Affairs and Business Pnoulacibri 10 Park Plaza- Suite 5170 • Boston, Masachusetts 02116 HomeImprovemstration _ Reg LUX RENOVATIONS, LLC. ` 137943 Cad 60 Shawrnut Rd - -r= 'C; �0 0fL 9 02/134/201 Canton, MA 02021 :tr., iCAI b 2AM-0Snl / Address and return Cad. klatmeson for dome. c?2 Q� Arnantoerda��/ta daC�asa�Q 0 Address t7 hof C Z ..:sK t Mee at Consumer Affairs&Business Regulation y g HOME MPROVEMENT CONTRACTOR Racistia0on valid act y,avidual use Orly . ham. HYPE:StrUplemaa Cad before the ecptral5sn data C ford return to; o ieoistrat(orl Expiration Otliw et laza-S to 517is and Bcsixss RegttanonBos . ==-` 02!042019 10 PakPlaza-Stite 5't70 LUX RENOVATIMIT;iL j- D/B/A w+ Dztls D/S/A Owens slam Fnishhg Systems DANIEL WALSH; 60ShawmutRd_ "r.,;�<�:�� Canton,MA 02021" •'' Underseametary Notvaiid tat evutsignature ii Commonwealth of Massachusetts Uv Division of Professional Licensure Board of Building Regulations and Standards Constrll_cht$ 6 � pgrvisor i. CS-079893 h *Ares: 10/050319 DANIEL F WASH •'^ t = e IS 488 KENDAL‘ b • TEWKSBUR187 �` ON T3L-J Commissioner l/^`- TOWN OF YARMOUTH HEALTH DEPARTMENT PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET To be completed by Applicant: Building Site Location: /jinn!?? ye) 'W• y40mCf/ilt- � In G. Proposed Improvement: r 13Fp000mrl tar-them? I S Mi200ml l t�/amu y Dom? AA'1 2 ()Epics /.0/fn zOeyeA . Applicant: ,L(//l' /71,4,00177 ivec Tel. No.: 7l/ez/0060 Address: jO S/Ir4//77// /2/) Ct/A T0/j// /77n- Date Filed:it/l ,e ••Ifyou would like e-mail notification of sign off please provide e-mail address: Owner Name: 4VIZ/.il Owner Address: 7�,/1/7700 e. • ya/zmou u- Owner Tel. No.: 4-502 2 7-1 j3 16 RESIDENTIAL AND/OR COMMERCIAL BUILDING HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements For Septage Disposal and other Public Health Activities. Please submit three (3) copies of plans, to include: (1.) Site Plan showing existing buildings, water line location, and septic system location; (2.) Floor plan labeling ALL rooms within building (all existing and proposed) — Note:Floor plans not required for decks,sheds, windows, roofing; (3.) If necessary, Title 5 application signed by licensed installer with fee. REVIEWED BY: DATE: It /6//a" PLEASE NOTE COMMENTS/CONDITIONS: ruseu .t u( l3-e 3 T edvcc - a gcxSrw .e .�' C ac-e ct IFclvti,b iACo-vAr" nec..4 vpcloft l ccko/S P C.a,os — 0k Aa® CERTIFICATE OF LIABILITY INSURANCE • DATE(MM/DDN " YY 10/042018 •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 rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT Jane Logan NAME: Gordon Mantle Insurance PHONE (781)659-2262 nail". dFWX.No): (781)659-4725 - 306 Washington Street jane@goronaennsurance.comADDREss: INSURER(S)AFFORDING COVERAGE NAICI Norwell MA 02061 INSURER A: American Fire and Casualty Co. 24066 INSUREDINSURER a: Safety Insurance Co. 39454 Lux Renovations.LLC ' - INSURER C: Ohio Casualty Insurance Company 24074 dba Owens Coming of New England INSURER D: ' 60 Shawrnut Rd. INSURER E: ' Canton MA 02021 , INSURER F: COVERAGES CERTIFICATE NUMBER: Master JL 8/29/18 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. -•s " F POLICY EXP LTR TYPE OF INSURANCE POD MD POLICY NUMBER (taWDDM'YY) IMMOWTTYI LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE IG HEN ILD 100000 CLAIMS-MADE OCCUR PREMISES(Es occurrence) S , MED EXP(Any one person) $ 15,000 A Y Y BKA57350449 09/05/2018 09/05/2019 PERSONAL.8 ADV INJURY _ $ 1,000,000 GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 POLICY C jEa 0 LOC PRODUCTS.COMP/OP AGO $ 2.00 0,000 X OTHER, CG0001 4/13 Prop Dmg Borrowed $ AUTOMOBILE LIABILITY GEMMED SINGLE LIMIT s 1,000,000 — (Ee acdtlent) ANY AUTO BODILY INJURY(Per person) $ BI&PDCSL B OWNED X SCHEDULED Y Y 5902260 04/04/2018 04/04/2019 BODILYINJURY(Per ecddent) s 91&PD CSL AUTOS ONLY AUTOS HIRED AUTOS N LY PROPERTY DAMAGE $ BI 8 PD CSL X AUTOS ONLY x AU OS ONLY Pm accident) _ Underinsured motorist 131 $ UMBRELLA UAB OCCUR EKCHOCCURRENCE S 1.000,000 C X EXCESS LI�LI XI X CLAIMS-MADE Y Y US057350449-FOLLOW FORM 09/05/2018 09/05/2019 AGGREGATE $ 1,000,000 DED I XI RETENTION s 10,000 S WORKERS COMPENSATION vl PER 1 10TIL AND EMPLOYERS LABILITY /�I STATUTE 1 ER ANYPROPRIET laRCTNER/EJ(ECUTNE YIN E.L EACHACOIDENT S 1.000,000 C OFFldERSy In NHR E%CLUDED9 NIA Y XW057350449 05/24/2018 05/24/2019 (Mandatory MNH) E.L.DISEASE-EA EMPLOYEE S 1•�'� II yes,describe under 1.°131:0°° DESCRIPTION OF OPERATIONS below E.L DISEASE.POLICY LIMIT 5 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Addltlonsl Remarks Schedule,may be attached M mon span Is required) Home Improvement Contractor-GL Blanket Additional Insured(Al)Primary&Non-Contributory with Waiver of Subrogation for Ongoing&Completed Operations,Per Project Aggregate(CG8810 4/13,C085834/13,CG2503 5/09).Auto Liability Blanket Al Primary&Non-Contriburory&Waiver of Subrogation(SCA 005 4117),WC Blanket Waiver of Subrogation when required by contact signed prior to the loss. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN INSURED'S COPY ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 1 1 ®1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) _ The ACORD name and logo are registered marks of ACORD TOWN OF YARMOUTH REVIEWED FOR BUILDING AND ZONING CODE COMPLI- p ANCE. ERRORS OR OMMISSIONS DO NOT RELIEVE THE 4 cO , LAMS 4 trenep pe it ccs z,>t7E2 2Cgve s i dee p APPLICANT FROM THE RESPONSIBILITY OF'AS BUILT' \� COMPLIANCE. 7Th/S /4/1-A/ /377707 e J TO ejK tS/l/Lti CIZ/G7N/-?L OrUe- DATE II- IG'18� _. ®UILD✓/INOOF'FfC �.d/ruse fit - - CONTRACT Customer Name�rlilen-R J1/ORM-/f/1/p. /✓9/j/fl4J Customer Signature ��/Zg/2a8 CSKETCH Contract Date ,2t/it-ft/no/2e /fin Sales Representative Signature COCMNING• ATTACHMENT Customer Phone h� .� 2 -I '5 3 /ti Contract Price I t/,q , C - , s a • s a ) e s le n 1e 4 14 v re n le to N w n a w ]S A n 3e re so w R a Y a s A M Si 1 r r •• ! r O ee sr st S w Y Se s a t e rl oI ■.e..■■..tL 1 fi tlfr l� I ■ ■ ,L_0�c e I as ■■-- e -51re*=pp■■®O■■o■■■■■■■■■� ■ J f - ■■U�■■ f• • ZI/I�I,I�INIII■■■■■l■ ■®L!!■■■■®® - - I —■I - rf/fh ie„ �7ZMxi79,M i -147011111, ■■■■■■■ ■■■ Iw■III. AI 111111111•1111111Mt at. I ■ • rter"A."l7___ / , .: t _ ■■�fa�■n■■■■■■■■■■■f . 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I -4---LI! + . —± i it--- 1 l I • I l I I I I ;� l 'I I I I - I I I I i I I 1 NOTES: - •Each box equals one foot unless otherwise noted.This sketch Is a good faith representation of the work to be done,It is understood that all dimensions • derived from this sketch are approximate,and that all locations of outlets,Ught fixtures,plugs,jacks arWor switches are subject to change it necessary.