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HomeMy WebLinkAboutBLD-19-3731 FtECEIVEu ' eiita-P/ a/24f_DEC 12 2016 I ik6HUILDINCi DEPARTMENT ONE & TWO FAMILY ONLY- BUILDING PERMIT __— ... Town of Yarmouth Building Department w 1146 Route 28,South Yarmouth,MA 02664-4492 �4� 508-398-2231 ext. 1261 Fax 508-398-0836 k mss' % Massachusetts State Building Code,780 CMR t r.V .F a i_ 1 Building Permit Application To Construct,Repair,Renovate Or Demolish tI' o-Family a One-This Section For Offs iaDwelling Use Duly I . ' .,n 3 WTI" �' Building Permit Number: 5f ./ `6b /3f. Data Applied:': Bli DI S:3UEPARi 1i.N; �M 3enrs' Id-� -l� _..— Building Official(Print Name) : : Signature,',„,:, • .. Date SECTION 1:SITE INFORMATION-: :`. 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers ,2SSt,,,74,.. Aar . S'. 7 ..41-mik. g n'` 1.la Is this an accepted street?yes �` no_ Map Numbet Parcel NumC' 1.3 yyning Information: 1.4 Property Dimensions: , it-rextiby AS; a)Ot� Ste Zoning District Proposed Use C' 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.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood e? Publ Private 0 Municipal 0 On site disposal system Check if ye SECTION 2?:PROPERTY OWNERSHIP' 2.1 wa r'of Record: /Steles.5a1.3 SC/.dire e 1)24. "1,209 Name(Print) City,StSte,ZIP • 1 € 5`fr4ioiv As.L- � No.and Street Telephone Em"ail �s '-. SECTION 3:DESCRIPTION OF PROPOSED WO' ; k all that apply), New Construction 0 Existing Building Owner-Occupied,aAlteration(s) 0 Addition ❑.. Demolition 0 Accessory Bldg.❑ Number of Units_ Other 0 Specify: Brief Description of Proposed Work': L - -,: n / A ._ R - Jr, Ate/aka) W.eA.t.G�-r'L. /44,4L0a.a. /2/o✓Rce., . .0.N'c,e_:1. 4't°uf ...:‘,.. teA4// ,.. SECTION 4t'ESUMATED CONS11311P'I9 COSTS >.1,..- •.:1-;;;l2.1';:::,':!: Item Estimated Costs: k ":Official"UseOniy° " ''' (Labor and Materials) , ;' . „, - _ �l , . -, 1.Building $ 7x03 +1 Building Petnut Fee $ 13'fi Indicate how fee is determined:' 2.Electrical $ nn — ❑Standard City/I'Oil Application Fee x s' " i, Oa" i'if total Project Cost:Item )x multiplier x 3.Plumbing $ 702) ^ 2 Other:Fees $ . 3 * 4.Mechanical (HVAC) $ List", ...S,r *a d ' w "" '' - 5.Mechanical (Fire `i I c '^: a N;1 f'r t Suppression) $ Total All Fees $ 6.Total Project Cost: $ ..--- CheckNo; Check Amount: Cash Amon li Paid in�Full di Otistandiag Dm .to Due: .. SECTION 5: CONSTRUCTION SERVICES .. 5.1 Construction Supervisor License(CSL) 7/)Awaf v, (g-Ar te4,fh.,„f • Licen�seeNNutber E ita onDate Name of CSL Holder ' ) `?q if nom; List CSL Type(see below) V No.and Street •!� Type . . Description • Alec) U Unrestricted(Buildings up to 35,000 cu.ft.) +�\ C5ityo SetaxZI14 oma R Restrictedl&2 Family Dwelling (� M Masonry \\ RC Roofing Covering G‘WS Window and Siding • SF Solid Fuel Burning Appliances S2*51,2-24/9 eiceraccierzsek,€::?e ' .t.in�,4 0 I Insulation Telephone Email address -00.1...."...... D Demolition 5.2 Registered Home Improvement Contractor(HIC) On HIC Coctpang Name or C Registrant Name CC�egistration Number pirafi n Date CI / .t1 £t2-€e G• •C.a.4.4.S.(0e4-3 .Cc-wv No.i . ' Street /, �g„3S�»"( Email address .60 City/To State,ZIP Telephone t y� SECTION 6:WORKERS'COMPENSATION INSURANCE AA'b'1llAVIT(M.G.L.c.152.§25C(t7) p\\\/Vn� 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 WREN r OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT .. `� I,as Owner ofthe subject property,hereby audio ' -4 ✓ to act on my behalf,in all matters relative to work a •orized by this building permit application. yi / /44-En-t1,0 + Ceot-w 7�/J//, P Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNERS OR AUTHORIZED AGENT DECLARATION Ca 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 of.y knowledge and understanding. Fr . I). A.,-, _ i_, / . /p/� ,5a,g' Print Owner's or Authorized Agent's Name(Electronic Signature) / ate NOTES 1. An Ownet 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.aov/dos 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" • =a= The Commonwealth of Massachusetts lr_ tet Department of Industrial Accidents ._=_It'i1= @ 1 Congress Street, Suite 100 t ?TI•r Boston, M4 02119-2017 c :.;;, www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. [Applicant Information � + � Please Print liegibly 7 , Name (Business/Organization/individual): '{�.'A4',#cf char_( Address: 4F �S,Q,, , e City/State/Zip:S ,e ,tt�, � Phone ti: Syr— 221— )), 57 Are you an employer?Check the appropriate box: Type of project(required): I.. I am a employer with 4' employees(full and/or part-time).* 'J, 0 New construction 2. I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required,] 8. ❑Remodeling 3.0I am a homeowner doingall work myself. 9. ❑Demolition y [No workers'comp.insurance required.]t 4.❑1 am a homeowner and will be hiring contractors to conduct all work on m property. I will 10 0 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 5.01 ant 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.[ ]3vv-��y1I Roof re�pa'i"rs� 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14`�Other o/Alt a 1 f 152.¢I(4),and we have no employees.[No workers'comp.insurance required.] ( /29)^77) -- *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: /42/2/2a e.3 /42411,-1,9-1 Policy#or Self-ins.Lic.#: /is)7244- Expiration Date: //Ay? Job Site Address: 176f}7 ro.e. 4.61 City/State/Zip:'+. �gpt�e)# �tt,g e $$� Attach a copy of the workers'compensation policy declaration page(showing the policy number 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. Ido hereby y er the ns and penalties of perjury that the information provided above is true and correct. Signature: Kd th _...( 7....c...--C-,t---t----‘.--- Date: /ielea D/ Phone#: 52) S_42•aU9 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#: • og'YAR TOWN OF YARMOUTH o �' pro BUILDING DEPARTMENT �!s,i 1146 Route 28,South Yarmouth,MA 02664 ?&;tc.,M `ra 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 / l conducted at 2� , z c -t AC, S i>4e kl-iJ /„d{ 2 DW/ Work Address Is to be disposed of at the following location: s '`t/� 9�a, /fie//bnys Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. ago Wpiay Signature of Application Date Permit No. ONE or TWO FAMILY —BUILDING PERMIT APPLICATION REGULATORY APPROVALS NOTICE Address of Proposed Work: /)c 9754r00-4, J�C S Ceppwasia Scope of Proposed Work: Es — ..� _ ►,_ fr • 1... . — • _..A I_ •_• — _ - — Date: //46 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 ext. 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 ext. 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. All applicable approvals shall be obtained prior to submitting a building permit application to the Building Dept. Thank you for cooperation. Receipt Acknowledgement: Applicant's Signature Date Rev.Dec. 2015 • ACORD® CERTIFICATE OF LIABILITY INSURANCE 1n�TnotaD Y) • 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 NAME' Rogers&Gray Ins.-Kingston BranchpHONN FSI,508-746-3311 FAx 63 Smith Lane ,AID Nae 877-816-2156 Kingston MA 02364 no aEss•mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC U INSURER A:Massachusetts Bay Insurance Company 22306 INSURED EFWINSL-01 INSURERB:AllmeriCa Financial Benefit Insurance Company 41840 E F Winslow Plumbing&Heating, Inc. INSURER c:Hanover Insurance Company(The) 22292 8 Reardon Circle INSURER D:Arrow Mutual Liability Insurance Company 13374 South Yarmouth MA 02664 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1807629183 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. INSR ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER IMMIDDIYYYYI IMMIDDNYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY ZDNA78702002 12/1/2017 12/1/2018 EACH OCCURRENCE 51,000,000 CLAIMS-MADE n OCCUR DAMAGE TO RENTED PREMISES(ES occurrence) $100,000 MED EXP(Any one person) S10,000 _ PERSONAL 8ADV INJURY _ $1,000,000 GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 HPOLICY E% !la n LOC PRODUCTS•COMP/OPAGO $2,000,000 OTHER I B AUTOMOBILE LIABILITY AWN-A787098-02 12/1/2017 12/12018 GaaccIdDJINGLE UMIf 5 OMUI LD 1,000,000 _ ANY AUTO 5 BODILY INJURY(Per penin) S _ AO TUTU OSONLY X AUTOSULED BODILY INJURY(Per emidenl) $ HIRED ----X NON-OWED PROPERTY DAMAGE X AUTOS ONLY X AUTOS ONLY (Per acdden0 S S C X UMBRELLALIAB X OCCUR UHN A78702202 12/1/2017 12/1/2018 EACHCCCURRENCE _ $2,000,000 • EXCESS UAB CLAIMS-MADE ' AGGREGATE $2,000,000 DED X I RETENTION$0 $ p WORKERS COMPENSATION 1879A 1/12018 1/1/2019PER OTH- AND EMPLOYERS'UABIUTY Yr N X STATUTE ER ANY PROPRIETORPARTNER/EXECUTIVEE.L EACH ACCOENT $500,000 OFFICER/MEMBER EXCLUDED? n N/A (MandatoryIn NH) E.L DISEASE-EA EMPLOYEE $500,000 If YYes desulbe andel - ' "" DESCRIPTION OF OPERATIONS below - E.L.DISEASE•POLICY LIMIT $500,000 • DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Plumbing&Heating Contractor. Central Vacuum is a division of E F Winslow Plumbing&Heating Inc. Certificate holder is automatically an additional insured with respect to general liability and auto liability when required by a written agreement or contract • CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF YARMOUTH THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1146 ROUTE 28 ACCORDANCE WITH THE POLICY PROVISIONS. SOUTH YARMOUTH MA 02664 AU ED REPRESENTATIVE I . ©1988-2015 ACORD CORPORATION. All rights reserved. . ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD i . Vision Government Solutions Page 1 of 3 �1 175 STATION AVE Location 175 STATION AVE Mblu 79/ 124/// Acct# 10131 Owner BROWN RICHARD A (LIFE EST) Assessment $272,400 PID 10131 Building Count 1 Current Value Assessment Valuation Year Improvements Land Total 2019 $154,300 $118,100 $272,400 Owner of Record Owner BROWN RICHARD A(LIFE EST) Sale Price $100 GARNICK GERALD TRS Certificate Care Of Book&Page 29518/312 Address 175 STATION AVE Sale Date 03/18/2016 SOUTH YARMOUTH, MA 02664 Instrument 1F Qualified U Ownership History Ownership History Owner Sale Price Certificate Book&Page Instrument Sale Date BROWN RICHARD A(LIFE EST) $100 29518/312 1F 03/18/2016 BROWN RICHARD A(LIFE EST) $0 1666/164 06/12/1972 BROWN RICHARD A $0 Building Information - Building 1 :Section 1 Year Built: 1972 Building Photo Living Area: 1,288 Replacement Cost: $179,278 Building Percent 85 Good: Replacement Cost Less Depreciation: $152,400 Building Attributes Field Description Style Ranch http://gis.vgsi.com/yarmouthma/Parcel.aspx?Pid=10131 11/28/2018 Vision Government Solutions Page 2 of 3 Model Residential r r: Grade: Average ^ ^.p 4 { Y �ryy-+ice t-- ,.. �4'� ,f� jre..t, , Stories: 1 Story ,, " + �j `" Occupancy , ,i: i Exterior Wall 1 Wood Shingle Exterior Wall 2 Clapboard 5.01•• +� 'tr4 •gz. i ' '• t Roof Structure: - Gable/Hip Roof Cover Asph/F GIs/Cmp Interior Wall 1 Drywall/Sheet _ ""�•.:.. Interior Wall 2 (http://images.vgsi.com/photos2/YarmouthMAPhotos/A00\01 Interior Fir 1 Carpet \38/894pg) Interior Fir 2 Building Layout Heat Fuel Gas Heat Type: Hot Water w AC Type: None Total Bedrooms: 3 Bedrooms 4 J 13, Total Bthrms: 1 • Total Half Baths: 1 Total Xtra Fixtrs: Total Rooms: Bath Style: Kitchen Style: (http://Images.vgsi.com/photos2NarmouthMAPhotos//Sketches/ Building Sub-Areas(sq ft) Legend Code Description Gross Living Area Area BAS First Floor 1,288 1,288 UBM Basement,Unfinished 1,288 0 WDK Deck,Wood 182 0 2,758 1,288 ....- ...�- �._...- �,.- -.-, r......,_.._� -....._,_.,_ Extra Features Extra Features Legend Code Description Size Value Bldg# FPL1 FIREPLACE 1 ST 1 UNITS $1,900 1 Land Land Use Land Line Valuation Use Code 1010 Size(Acres) 0.23 Description SINGLE MM MDL-01 Frontage 0 Zone Depth 0 Neighborhood 0040 Assessed Value $118,100 Alt Land Appr No http://gis.vgsi.com/yarmouthma/Parcel.aspx?Pid=10131 11/28/2018 Vision Government Solutions Page 3 of 3 J Category Outbuildings Outbuildings Leaend No Data for Outbuildings Valuation History Assessment Valuation Year Improvements Land Total 2019 $154,300 $118,100 $272,400 2018 $154,300 $96,300 $250,600 2017 $154,300 $96,300 $250,600 (c)2016 Vision Government Solutions,Inc.All rights reserved. http://gis.vgsi.com/yarmouthma/Parcel.aspx?Pid=10131 11/28/2018 :Fa, � ',`�''� s -.> v1" ' ''T`'�`. 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DATE: �� ' 4-1 rtoset •Hallway in m 15'Zs �114'6" - B ILI " FI IAL -- LI M - • I� P FILE ��"�j H d / i , ' / / i as Damaged bedroom wall • and window - ,: Richard Brown Residence • 175 Station Avenue South Yarmouth. Ma: 02664 13' "AS BUILT" FLOOR PLAN • • Gl `1- Main Level 2018-10-24-0614 11/28/2018 Pagel -7,e1217,75--7/ &cU/ F s y -3/ ' - - / //tr771k -C�i \-7-0-r-i-a/4,9 b-o-f& -<-2w7 --vg0,---a /2 Rof---h---Gr?--9/,----777-r,--wes H .yc?.. _-J,6/ - 7 .(2-,, -,/ i7-,C - -.7--17)-- -7T.,342// 7 , ,--vG r S- AYt/ p ms S.t 1!m. . iiseX-001:1%%:: .p!Is„rvia..:: ,..-.. ..4,11L it , , , tail ,, , il i i ii ' vC q1 P.19 J illuedblipritizi . -. - I I' i Bi- • , ; ;', , ', . i - Illi 1,1111 . _. _ , ; , il. • s .� OO - aaleaaIcill' G= 11 lead: v1 elco . . r