HomeMy WebLinkAboutBLD-19-4049 . , of•y.j BUILDING PERMIT APPLICATION
2
•e- APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE,OCCUPANCY OF,
•1• �€ cOR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING.
Town olYarniotith Building Departnirnt
,L2' 1146 Route 28 • larrnouth, MA 02664-1492
-• Tel: 50S-398-2231 ext. 1261 Fax 508-398-0836
%�,r.41 nn / Office Use Onfy Planning Board information Assessors Department Intormatiort
L ofl CI ate Plan Type Mao Lor
Permit Fee $ Endorsement Date /
Recording Date New
Deposit Reed. $ Date_ PLn No. 1.1 Property Dimensions.
Net Due $ Other Lot Area(sf) Frontage(It) - Lot Coverage
This Sectice for Office Use Only
Building Permit Number Date Issued:
Signature: / ..�/'✓4..-- / 07'9 Cert fixate of Occupancy
Builal g Official Date is .h not required
Section 1 - Site Information
1.1 Property Address' - 1.2 Zoning Information:
2,2. rtiv 'ccH ORM
W , Y t�R I10 Ut M Ti 4 4 26 7 3 Zoning District Proposed Use
1.3 Building Setbacks(rt)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.4 Water Supply(111.12.L e.40.S 54) 1.5 Rood Zone Morrtmtiort Comments
Public Private Zone: BFE
Section 2- Property Ownership/Authorized Agent
2.1 Owner of Records
GL�111
15145,V) II-3C. Or" RE-II LToR 2 KID TE•cH Pg. w.YIlRtip ott-I
Name(print) Mailing Address:
see: aidetcCa_ci -4S7- 43o 0
Signature Telephone Telephone Email Address:
2.2 Authorized Agent
fRitvN! 67 51-0- NYA-NIUIS.dlP-
Na (p ) Mailing Address:
�(
5-v9-77e-2100 tgrrtcaht/eeriytncfeesQgntvl•cowl
gne re Telephone 1 0 Email Address: I
Section 3- Construction Services
3.1 Licensed Construction Supervlsort - Not Applicable ❑
ft R N C►u sane-lily/4w
v1
a S — �s eziHp$vnivNiSrDuo / License Number
Addres f lobi 02
q , so7-776- 2100 Expiration Date
gnatur / Telephone Email Address: 10 • 2• Z o
t of 4 - - OVER
3.2 Registered Home Improvement Contractor.
Company Marne Not Mgr-able ❑
C/ORry f COREY H1 SEK) 9. )-iAWtUtSr )yl9- b7-641 Re9isbabnNunoer
Address 13 3 20 Z-
YSOS- 76-2900 Ecirabon Date qt13 , tQ
Signature Telephone
Section 4•Workers'Compensation Insurance Affidavit(M.G.L c.152 S 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 L7 No
Section 5•Professional Design and Construction Services•for Buildings and Structures Subject
to Construction Control Pursuant to 780 CMR 116(containing more than 35,000 c.f.of enclosed space)
Section 5.1 Registered Architect
Not Applicable ❑
Hams(ReVlstrantn Registration Number
Address Eepiratbn Dale
Signature Telephone
Section 5.2 Registered Professional Engineers)
I
Area d ResponsibilitResponsibilityName
Address Registration Number
Signature
Telephone Expiration Date
Area d Reaponssbilny
Hams
Address Registration hunter
Signature Telephone Expiration Date
Area d Responsibility
Name
Registration Number
Address
Signature
Telephone Expiration Date
Area d Pesponmighty
Hams
Registration Number
Address
Signature
Telephone Expiration Date
Section 5.3 General Contractor
Not Appfitable O
CORP/ kP4O CIAPY
Company Herne
fRrt Ift) SI FPRYAIV
Person ResponsiibleetorConstnfn to D
I. S7 A- .
Addreskt . I Soi-776- C n
4OO \.
Telephone _
Signature
1 2ot a
Sectibn 6- Description of Proposed Work(check an applicable)
'New Construction 0 (I or multiple family only) No.of Bedrooms (tor multiple fortify only) No.01 Bathrooms
Existing Bldg. ❑ Pepair(s) par Alterations ❑ Addition ❑
Accessory Bldg. 0 Type Demolition Other Specify:
Brief Description of Proposed Work:p �Y11 � pn
Section 7- Use Group and Construction Type
Building Use Group(Check as applicapable) Construction Type
A ASSEMBLY ❑ A-1 9 A-2 ❑ A-3 9 IA 9
AJ ❑ aS ❑ 19 ❑
B BUSINESS ❑ 2A ❑
E EDUCATIONAL ❑ - 28 9
F FACTORY ❑ F-1 ❑ F-2. ❑ 2C ❑
H HIGH HAZARD 9 3A ❑
•
- 1 INSTT(VTIONAL ❑ 1-1 ❑ F2 ❑ 1.3 ❑ 38 ❑
M MERCHANFILE 9 4 9
R RESIDENTIAL 9 R-I 9 R-2 ❑ R.3 ❑ sA ❑
S STORAGE ❑ s-1 ❑ 5-2 ❑ 58 0
U UTILITY 0 SPECIFY: ._ ..._. .
M MIXED USE ❑ SPECIFY:
S SPECIAL USE (3 SPECIFY
Complete this section B existing building undergoing renovations:additions and/or change In use.
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34 Proposed Hazard Index 780 CMR 34
Section 8 Building Height and Area •
Building Area Existing lit applicable) Proposed
Number of doors or stones
Include basement levels
Floor Area per Floor(sr)
Total Area All Floors(sf)
Total Height(ft)
Section 9-STRUCTURAL PEER REVIEW(780CMR 110 11)
Independent Stnxttural Engineering Structural Peer Review Required Yes No
SECTION 10a OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
,as Owner of the subject property,
hereby authorize to act on
(my behalf, in all matters relative to work authorized by this building permit application.
SSignatura of Owner Dab
3 of 1 OVER
y
1
SECTION 10b OWNER/AUTHORIZED AGENT DECLARATION ,
I, /+RML-rU SM4 RYP rf ,as Owner/Authorized Agent
hereby declare that the statements and information on the forgoing application are true and acurate,to
the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
f}Rn &IV
Print Name
a, 1.
nature of OwnertAg t - Data
Section 11 -ESTIMATED CONSTRUCTION COSTS
ttem - Estimated Cost(Dollars)to be
completed by permit applicant
1.Bulldmq
2.Electrical..
3.Plumbing/Gas
a.Mechanical(HVAC)
S.Fire Protection
6.Total.(1.2.3.4.5)
7.Total Souare FL sem.wow I WbY 441 0017
Check Below
Q Conservation-Commission Filing
(if applicable)
❑ Old Kings Highway&Historical
Commission approval
(if applicable)
4ofa
01'Y t TOWN OF YARMOUTH
-`• - • o BUILDING DEPARTMENT
' o e«;'g y 1146 Route 28,South Yarmouth,MA 02664
ta r -7
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 S,
[hereby certify that the debris resulting from the proposed work/demolition to be
conducted at 12 MID TLL=LH DI2IV - . W. YhleVYOv't>rl
Work Address
Is to be disposed of at the following location: V (m.Ou4-4, W
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Se don 150A.
ignature owl P.hcation Date
Permit No.
• The Commonwealth of Massachusetts
•
u. _,t Department of Industrial Accidents
rid Office of Investigations
--ec 600 Washington Street •
• _1 Boston,MA 02111
'—.-' 'www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): R t yr\GYM S asat rya v-%
Address: 6 7 Ste, 5 ir
City/State/Zi.: aha ` A A— 0 . O Phone r# S'O S - 7 7 6 - 7.4 0 0 vAre y an employer?Check the appropriate box:
Type of project(required):
I. I am a employer with 4. 0 I am a general contractor and I
have hired the subcontractors . 6. ❑New construction
employees(fall and/or part-time).'
2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling
ship and have no employees [hese sub contractors have g, 0 Demolition
working for me in any capacity. employees and have workers' 9. Building addition
No workers'comp.insurance Camp.insurance? ❑ m7g
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
•
3.❑ I am a homeowner doing all work officers have exercised their . 11.0 Phiptbing repairs or additions
myself,[No workers'comp. right of exemption per MGL
insurance required.]t c. 152,§1(4),and we have no 12. f repatrs
3a.❑ I am a homeowner acting as a employees.[No workers' 13.0 Other •
general contractor(refer to#4) comp.insurance required.].
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensadodpofcy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outride contractors must submit a new affidavit indicating such
tCotaemn that check this bat must attached an additional sheet showing the name of the sub-contractors rd state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp,policy number.
a
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site
information.
Insurance Company Name:
Policy#or Self ins.Lie.#: . Expiration Date:
Job Site Address: City/State/Zip:
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 certtfy tn
de ls and penal' of perjury that the information provided above is true and correct
Signature: Y
Date: ( O t 9
phone#: 5'o1 - 776 - 100
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/l'own Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
•
•
•
COREY & COREY
" The Roofers "
APT#A4,SEA STREET APT#A4, HYANNIS MA 02601
PHONE 1., 508 -775-8240
CERTAINTEED LANDMARK
LIFETIME -ALGAE RESISTANT
ARCHITECTURAL STYLE
RE - ROOFING PROPOSAL
October 10,2018
CAPE COD AND THE ISLANDS ASSOCIATION OF REALTORS TO:KIM PINA
22 MID TECH DRIVE EM:kpina@cciaor corn
W.YARMOUTH,MA 02 C 73 Tel:508-957-4300
COREY & COREY hereby proposes to perform the following services in a neat and professional
manner and in accordance with the manufacture t s specifications and local building codes.
Remove and Haul Away All of the Old Asphalt Roofing Shingles(One Layer)from the Whole Building.
Re Nail All Plywood Sheathing as needed. 1
Supply and Install SCERTAINTEED TART PROTECTION CLASS A FIRE RARK AR: TED,WARRANTY,
ORR vTY,10 YEAR SURE
STONES for a FULL 10NYEAR WARRANTY AGAINST ALGAE
CONTAMINENT,240 POUND,EXTRA HEAVY WEIGHT,130 MPH WIND
WARRANTY,CATEGORY IH HURRICANE.STORM/HURICANE NAILED
16 NAILS PER SHINGLE) MULTI-LAYERED,
MUL
-LAYD,LL
CLOM FIBERGLASS ASPHALT SHINGLES.
COLOR: CCL..o/on:e44S/ite
Supply and Install 8"WHITE ALUMINUM DRIP EDGE on All of the Eaves.
Supply and Install CERTAINTEED WINTER-GUARD(Ice&Water Shield)WATERPROOF
UNDERLAYMENT SYSTEM on Roof Eaves&Valleys
Under the Step Flashings,on the Skylights and Chimneys.
Supply and Install CERTAINTEED'S"ROOF RUNNER"SYNTHETIC ROOFING PAPER
Supply and Install AIR VENT SHINGLE VENT
II RIDGE SOIL PIPE VENTLon the Entire
tire Ridge.
Supply and Install ALUMINUM
S
Clean and Remove Debris from work area after job is completed.
TOTAL INVESTMENT ------------- $45,000.00
1
-11
COREY & COREY
" The Roofers "
POSSIBLE EXTRA CARPENTRY:Any Rotted or Otherwise Deteriorated Trim Boards,Plywood
Sheathing,Missing Metal Flashing,Side Walling or Any Other Carpentry Needing Replacement
will be done and charged for as an Extra:Mateirials Plus Labor at the Rate of$60.00 per Hour(For Each
Laborer Involved).
PAYMENT SCHEDULE: A Deposit of One Half is due at the Signing of this Roof Proposal and the
Final Payment for the Balance is Due Immediately Upon Completion.
WORK SCHEDULE:All Roof Work is Scheduled for Completion Within 90 Days of Acceptance and
Deposits Received are Non-Refundable Aftei a Three Day Cooling Off Period from the Date of signing.
Please Make Checks Payable to:
COREY & COREY
COREY & COREY Warranties the Shingles and Labor for 10 years.
CERTAINTEED Warranties the shingles and labor 100% for
theeFrst bst10 Years
defective.
and the Shingles your LIFETIME the
CERTAINTEED Warranties the Shingles uplto a
CATEGORY III HURRICANE-130 MPH WIND WARRANTY.
LeCERTAINTEED Warranties the Shingles to be Algae Resistant for a Full 10 Years.
COREY & COREY
carries Workman's Compensation and Public Liability Insurance on the above work
DATE OF ACCEPTANCE:J .0414 -- SUBAiITTED BY:
ACCEPTED BY:
M is 5
? teat OP ?.cc O SEN SAFARYAN
COREY St COREY
AUTHORIZED PERSON HIC # 183202
CSSL# 106102
•
. 1 ,914 g: , -p ,aa __
Office of Consumer Affairs and Business Regulation
One Astiburton Place - Suite 1301
Boston, Massachusetts 02108
Home ImprSement Contractor Registration
ndiVidUal
1 =
ARMEN SAFARYAN Regtsrraoon 18
67 SEA ST APT A4 Expiration: o9n ,e •
HYANNIS, MA 02601 ,:,....1, rz- If.. : .:.L.:,,:.2.. -
I '• `
10 20µ05/17 .. . Update Address arM slum Bald.
g !
...__1.
emmemeeenetzeSgenUres
Officeof Consumer Atfal&Buin sHavel -
gulatioHOME IMPROVEMEMrCONTRACTTOR n
TYPE:IndMdual
Registrationoretvalitiondattd for dualudretu
before the expiration date. If found return to:
1832 4!] Office of Consumer Affairs and Bust :;t Regulation
09/132019 , 10 Park Plaza-Sufte 51 i '
ARMEN SAFARYAl.J. Boston,MA 02116
D/B/A COREY'AND COREY:;
ARMENSAFA/ ANi I I(
HYANNIS,MA 02601:;-- i -
Undersecretary Not valid thout ...n;Tune
i .
I
ti: Massachusetts DepaRment of Public.Saf
Board otSUllding Regulations and Standards
•License:CSSL-106102
Construction Supe or Specialty d
ARMENRAFARy
AN
6T SEA STREET ApT Ae ttt
HYANNIS MA 02601
•
/'+:' I •
Commissio er Ex pi ration:
10/02/2020
i
TE
A CERTIFICATE OF LIABILITY INSURANCE DAos(MM/ "
DOYYY
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: H 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).
CONTACT Ashley Parva
PRODUCER
tame:
Eastern Insurance Group WPHONEo.Exit (508)997.6061 r Nog (508)990-2731
439 State Rd. ACIiia.NDDRESS: apaiva@easteminsurance.com
P.O.Box 79398 INSURERS)AFFORDING COVERAGE RAICA
North Dartmouth MA 02747 swum A: Arbella Protection Insurance 41360
INSURED INSURERS:
Armen Safaryan INSURER C:
DBA:Corey and Corey INSURER D:
67 Sea Street Unit A4 INSURER E:
Hyannis MA 02601 INSURER F:
COVERAGES CERTIFICATE NUMBER: 2018-2019 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.
INER mix EMIR POLICY EFF POLICY EXP— LIMITS
LTR TYPE OF INSURANCE INSD END POLICY NUMBER (MMIDD/YYYYI (MMIDDNYYY)
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1'000'000
DAMAGE TO REN IED
CLAIMS-MADE OCCUR PREMISES(Es aaLvnence) $ 100'
MED DT(Any one Person) I 5,000
A — 9520046441 04 09/18/2018 09/18/2019 PERSONAL.a ern INJURY $ 1,000'000
i 2,000,000
GEENIAGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
X POLICY❑PRC"JECT LI
LOC PRODUCTS-COMP/OP AGO $ 2,000.000
5
OTHER: COMBINED SINGLE LIMIT
AUTOMOBILE LIABILITY (Ea acciCenll $
parson)ANY
BODILY INJURY(Per perl $
OWNED SCHEDULED BODILY INJURY(Per occident) i
AUTOS
AUTOS ONLY AUTOS PROPERTY DAMAGE _
— HIRED NONUWNED (Pa accident)
_ AUTOS ONLY _ AUTOS ONLY $
UMBRELLA DAB OCCUR EACH OCCURRENCE S
EXCESS UAB CLAIMS-MADE AGGREGATEI ERµ
$
DED I I RETENTION$ I SPUTUM I Xi
WORKERS COMPENSATOR
AND EMPLOYERS'LIABILITY YIN ELFACH ACCIDENT s 1,000,000
ANY PROPRIETOR EXCLUDED?
REXECUTNE ❑ NIA 9520046441 04 09/18/2018 09/18/2019
A OFFICERRAEMBER EL DISEASE•EA EMPLOYEE s 1,000.000
(Mandalay In NH) 1,000,000
It yes.deserts U EL DISEASE-POLICY LIMIT S
DESCRIPTION OF OPERATIONS below
DESCRIPTOR OF OPERATIONS I LOCATIONS I VEHICLES(ACORD/et,AddMa:al Remarks Sc/mda may be aaadw4 It more specs Y nuked)
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.
Display Purposes Only
AUTHORIZED REPRESENTATIVE
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