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Home My WebLink AboutBLD-19-004033 V ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department 1146 Route 28,South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508-398-0836 tr„�ry' Massachusetts State Building Code,780 CMR Building Permit Application To Construct, Repair, Renovate Or Demolish .. a One-or Two-Family Dwelling $$,, This Section For Official Use Only Building Permit Number:,&.D -//C-(Z) V03 Date Applied: l A .i`lQ n+ _" _e Building Official(Print Name) . / Sigulture- Dat / SECTI•N 1:SITE INFORMATION / 1J1 P(r•gpert Address: / 1.2 Assessors Map&Parcel Numbers V1111.1a Is this an acc�eepted sstrebt?yes_ no Map Number Parcel Number 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.40,454) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Ill Private❑ Zone: — Outside Flood Zone? Municipal 0 On site disposal system Ilk Check if yesyk SECTION 2: PROPERTY OWNERSI�P' Owner'rld .d. t CAl Name 'Tint Wit.ZIP l t M4 _"" y� ( ) City,State,ZIP wt 6o& tioo=1601/tto I(�cln1N�Aatei\ , Zdv�. No.and Street Telephone ' anal]Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 4 Alteration(s) 0 Addition ❑ Demolition ❑ Accessory Bldg. 0 Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': SECTION:4f ESTIMATED CONSTRUCTION \.TS Ite Estimated Costs: ''Official Use Only ,/{Building $ 3 5 60. oo :1 Building Permit Feet$P.. Indicate how fee is determined: 2.Electrical $ 0 Standard City/Town Application Fee 0 Total Project Case(Item 6)x multiplier. x_ 3.Plumbing $ 2: Other Fees. $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Suppression) $ Total All Fees $ • ',j v ' Check/4d..• Check Amount: Cash.Amount: • 6.Total Project Cost: $ 0 paid in Full • 0 Outstanding Balance Due: a I 1, - SECTION 5:.CONSTRUCTION SERVICES , 5.� nstruction SupepsorLicense(CSL) C[ — ia'aps ii[c f �l ' /C S �� / LicenseicNumber ll Expiration Name of CSL Holder 1 IT (,1 ,14+I List CSL Type(see below) No.and Street T e .. Description 1)4ei vi IIp M A O 1/_cc Unrestricted(Buildings up to 35,000 cu.R) MM tt , 1{� 0.U/ ✓✓✓�� Restricted l&2 Family Dwelling City/Town, tate,ZIY M Masonry RC Roofing Covering WS Window and Siding tI- 10 q is ' 6 e cillo ` ,icL1 SF Solid Fuel Burning Appliances a (wl P ((JU/J l} I Insulation Telephone E ail ddress (k%4& D Demolition .2 Registered Home ascovement Contractor(HIC) 16 1 u� ck i I /c l �I(' !1 A it Ai HIC ARdegiss ation Number Expiration Date / tt Co. any, r ' QlRegistrantName I r , - ' 3c , �4 Jb lel I Lad I . . (,(/1/h ivjteI AOa6ss m• laddress City/Town, tato,ZIP Telephone SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(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 Issuance of the building permit. Signed Affidavit Attached? Yes ilk No ❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN • • OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ( t\IDCl100 / I,as Owner of s ject property,hereby authorize ��` �`r / act on my If all matters relative to work authorized by s building permit application. t�J f� v P Own 's N e etronic Signa e) 1 `�I 'Date • • SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION y entering my name below,I hereby attest under the pains and penalties of perjury that all of the information ntained' this ap\\p\lication is true and accurate to the best of my knowledge and understanding. 1}rV, er's or thorize Agent's Name(Electronic Signature) I Date ' NOTES: 1. Owner o bt ' a building permit to do his/her own work,or an owner who hires an unregistered contractor not registere ' e 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.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dps 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 r 1_ t��t Department of Industrial Accidents i:lef= 1 Congress Street,Suite 100 _'_� Boston, MA 02114-2017 (l// www.mass.gov/dia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY, Applicant Information Please Print Legibly Name (Business/Organization/Individual): r-gl tel / t�kfliA A II C Address: �, M A II vV! . City/State/Zip: D/�c/i'lo/A 51/9 cc Phone#: y)'- tiVe"a3/11 Are you an employer?Check the appropriate box: Type of project(required): 1.$I am a employer with 1 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 8. ❑Remodeling ' any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall work t 9. 0 Demolition ❑ myself.[No workers'comp.insurance required.] 4.❑1 am a homeowner and will be hiring contractors to conduct all work on m YP property. I will 10 ❑ Budding addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions J❑lam a general contractor and I 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 c. 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 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: QCCIJ Policy#or Self-ins.Lic.#: 4144 3316 Expiration Date: SI 114 ei!) I Job Site Address: //'{{,,��.� �'Cr'lIA kite" City/State/Zip: 1LI(41A44, /19 6eln`13 Attach a copy of the workers' compensation py declaration 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 violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage erification. I do h re y c tify uncle G( ains and penalties of perjury that the information provided above is true and correct Signature. N` i\( Date: j I ti / a17 Phone#: ill- i 33 Pc Official us 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#: o-.oTOWN OF YARMOUTH bs'$ _:vg c BUILDING DEPARTMENT E. � �y 1146 Route 28,South Yarmouth,NIA 02664 508-398-2231 ext. 1261 Fax 508-398-0836 BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.GL Chapter 40,Section 54 and 780 CMR, Chapter 1, Section 111.5, I hereby certify that the debris resultin from the proposed work/demolition to be conducted at deg 1i' / wetsf Work Address Is to be Ay O disposed of at the following location: S Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. 4 A I A it)/ d4/ S gnature of A.pli we 'on Date Permit No. 3 Vine timirtnen44 rietla:Xrt/nlcm Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:LLC , a r Realstratloq Expiration 182412 06/18/2019 RYLEY CONSTRUCTION LLC. : I JOHN RILEY \2„G � 35 QUAIL RD. �.] OSTERVILLE,MA 02655 Undersecretary ®} Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constrt ett6r f%ipervisor CS•108005 z5' t Ejlpires: 11/05/2019 'M i JOHN S RYL ' 35 QUAIL ROAQ ',,, OSTERVILLE MA 02655 - '•` • Commissioner V^"' it • e Client#:78040 RYLEYCON ACORa. CERTIFICATE OF LIABILITY INSURANCE DATE(M=DD"YYY) 6/27/2018 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 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 polley(les)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the polity,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 James F Geary Martha's Vineyard Ins Agcy-VH rilotaxNa Ext 508 693-2800 FAX Ne): 7744873145 PO Box 998 E-MAIL Jgeary©mvinsurance.com Vineyard Haven,MA 02568 INSURER(S)AFFORDING COVERAGE NAIC• 508 693-2800 INSURER A:adaaeaaear,aa 11867 INSURED INSURER 5:Aci" Ryley Construction,LLC ' PO Box 1444 INSURER c INSURER D: Duxbury,MA 02332 - 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 POLICIES 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 INSRL WVD POLICY NUMBER (MMNDYWYYY) tAIDDIIYYY» LIMITS A X COMMERCIAL GENERAL LIABILITY S2161576 06/19/2018 06/19/2019 EACH OCCURRENCE $1,000,000 CLAIMS-MADE n PRE OCCUR MISES(ECExourrcnue) $100,000 MED EXP(My one person) x10,000 — PERSONAL B ADV INJURY 51,000,000 GEN.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 POLICY JERCTT 0 Loc PRODUCTS-COMP/OP AGO s3,000,000 OTHER: x AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ _ ANY AUTO BODILY INJURY(Pr person) S — ALL OWNED SCHEDULED BODILY INJURY(Pr accident) $ AUTOS AUTOS JED PROPERTY DAMAGE x HIRED AUTOS _ AUTOS - (Pr accident) S UMBRELLA LIAB OCCUR • EACH OCCURRENCE $ - EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION SS WORKERS COMPENSATION MAARP300349 05/20/2018 05/20/2019 X $TATUrE OT AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE Y I a E.L EACH ACCIDENT $100,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE 6100,000 H yes,describe under DESCRIPTION OF OPERATIONS baba E.L DISEASE-POLICY LIMIT $500,000 t d DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space 4 required) Carpentry CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE -/ I O U1� I(� '1 ( '1 FA.)'%W1V( THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1\9401 J\e -.:�. • S. IK` % A / /A ` 1661 AUTHORIZED7 VE 0 ®1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) 1 of 1 The ACORD name and logo are registered marks of ACORD #51155941/M963068 OJG •• Estimate • Date Estimate# 1/9/2019 15 Name/Address 50 Great Western Rd. Harwich,MA 02645 Project Description Qty Rate Total Repar damged roofing strucxture as needed 1 3,500.00 3,500.00 Schedule of Payments 0.00 0.00 50%Deposit 50%Completion Projects will not be scheduled without deposit Scheduling is done first come first serve The Contractor,Ryley Construction,agrees to perform the work as 0.00 0.00 described above and the customer agrees to pay the contractor in accordance with the schedule of payments set forth below. My,and all additional unforeseen work,which falls outside of the above mentioned scope of work shall be billed at a rate of$65/hr. All remaining balances shall be deemed overdue if not paid 15 days after the completion of the above-mentioned work and in accordance with the sch <• le of payments and will be subject to a 1.5%monthly service • . ge. his estimate is valid for not more th..1 Oda ofitls • •t. Lai i , 7 Sign;d `F D. e Total $3,500.00 • • . • ONE or TWO FAMILY —BUILDING PERMIT APPLICATION REGULATORY APPROVALS NOTICE Address of Proposed Work: g C1641 W Alm' L-1-3A Yafrifra44 41 Scope of Proposed Work: *al • pp l \k\( LAM tt( 4X7efio .) y4 Date: ) I ?NO I 1}V Based on the scope of work described above,`the applicant is required to obt•'• approval sign-offs from the following departments as checked-off below: I • -LS Health Dept.–508-398-2231 ext. 1241 Conservation Comm.--508-398-2231 ext. 12' • Water Dept.– 99 Buck Island Rd.phone no. 508 71- • 1 Old Kings Hwy.His?. Comm.– 508-398-2231 ext. /•• Engineering Dept.– 508-398-2231 ext. 1250 Fire Dept—Kevin Huck/James Armstrong, e 6 Old Main t.SY Note: Please call Fire Department for an appoin 'tent 508-398- 12 Other Appropriate plans and/or application shall be p ovided to each of the dep. an eats checked-off above. Each of these regulatory . orities has their own req ements outside the jurisdiction of the Building Dep. "tent All applicable approv s shall be obtained prior to submitting a building .-rmit application to the Building :-pt. Thank you for cooperation. 67- Receipt Acknowledgement: Applicant's Signature Date Rev. Dec. 2015