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HomeMy WebLinkAboutB-19-3737 • el>a - /2-4k • • • ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department w r 1146 Route 28, South Yarmouth,MA 02664-4492 �. 508-398-2231 ext. 1261 Fax 508-398-0836 :._t Massachusetts State Building Code,780 CMR Building Permit Application To Construct,Repair, Renovate Or Demolish a One-or Two-Family Dwelling RECEIVE 1 Thus Section For Official Use Only Bualding Permit Number V../) 4617 273.,. :Pate Apphe [7 ` 11BUFLOGEPARTF .T - I 1TM :S-tflrs �Lia‘ /J 24 / . )luilding0fficial(PrmtName) Signature AY r�atF�= SECTION 1:SITE INFORMATION • t ' . 1.1 ro�erty Address: 1.2 Assessors Map&Parcel Numbers 4 !)annr (Ja,.y (JY 4') _ h. ' 1.1a Is this an accepted streets 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:(MO.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site-di system 17:j' , t 3 Check if yes❑ ry Ir y c , '3 'I:- . SECTION 2 :PROPERTY;QWNERSHWt t=c s. - ''.: . 2.1 Owner'ofRecord: �+ Sulk G JAN Q r"1 MLCItQ P.I, � l7(hl,lN(1, l7nYfh,�`�fl1U' Name(Print) City,State,ZIP .— --' " r iaCttY - -- fax Call- GEO- e319 Fusco: :,. -- No.and Street Telephone Email A dress_.:‘,..:.----- SECTION,3;DESCRIPTIONQt.RR41$9$EI?*MC_(che(it*11 that apply) , New Construction❑ Existing BuiidingX Owner-Occupied ❑ Repairs(s) ❑ Alteration(s)PFJ Addition ❑ Demolition ❑ Accessory Bldg.0 Number of Units_ Other 0 Specify. Brief Description of Proposed wore: Re.nq va..k.A. Yle ilsc t'x.th ....`::.:^,;.;!'f?'':,,:-a..5"4 .n,,. .SECTION:4mTCIIKA'CEDCs,ON5'1 U,CTIdrf cOSTg. ' r .':,iy» ht' Estimated Costo ;` ,ry t W4ls8 o r t.s rIem (Labor and Materials) , fi ? , . :�, , svuy1 : ", 1.,, 1.Building $ 2 U bO C) 4.-.5.-.13.1..1.!.1dmg PermitFee$I Sj O .),4#,9.1".4P1.0?,e is detemiih• eth 2.Electrical $ 1/00(0 i$Sta?idazd CitYYl' itApp11cktkin I ee,t, w, :'„ s r A, . :7,..."7„,,-,oalProject Cosh tem 6ys mttltipher a r X , ` 3.Plumbin $ 3,itO I r Plumbing 3 Other Fees $ �� •1':laty lMxifw• t- L .> S tryn... l a ? r—r 4.Mechanical (HVAC) $ 5.Mechanical (Fire :1, ' ` 4 rs r 1',.• sir `!,«-i t4^F v `" Suppression) $ •T0ta1 A 1 F'ee5 $. v>,. . "' Checl(No 7:: _Chick`Amount ,�° _Casio mount 6.Total Project Cost: Set III SOO I Pazdlnfi l ' ` rs 70utstanding.l#hlahbe Dpe-lir, . • • - . • SEC'T'ION 5:.CONSTRUCTION SERVICES • 5.1 Construction Supervisor License(CSL) IC30 G e n tQ eaLV/cf License Number Expir do Date Name of CSF-flolderr !13 N nr+,k, tf�.i.N, t t.irr,r, . List CSL Type(see below) 0 No.and Street /� /1 Type , ., .. , . Description to 35, l fo tl,t t, vaL r wt o t ;t)L I�A o a 6 c, T U Unrestricted(Buildings up R Restricted 1&2 Family Dwetllinghing35,000 cu.ft) City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding • SF Solid Fuel Burning Appliances C%01-1(14--Delo., it IV. (ale ,i I i ,. . 1, I Insulation Telephone Em.; address D Demolition 5.2 Registered Home Improvement Contractor(MC) / ;_ nn • I COo l ra � • !!/ra�J_II Ai GeOYQL ��Q,Vt'r ) 7he. HIC Registration Number Exp ate IBCy am IBC Regi�n tNam ort,h. fi.ut, d'Grr.et _r lfildcf s acnrr fdfl vitfi hr.000A, N . Street v `U E l address {� a,yvu.nc>,.-F(n , IA naI^Dloc �i1i City/Town, State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.g 25C(t7) 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 X No 0 •- •. , • 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 t j r n rq c, cD(j,V W, TM, to act on my behalf;in all matters relative to work authorized by thM.building permit application. M Cd1n t(, 4 6 etil (?nrcylsrt C.le $2/Ui/ i f Print Owner's Name(Electronic Signature) Date • • • • SECTION 7b: OWNERIOR 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. cavr5 taloa? Print Owner's or Authorized Agent's Name(Electronic Signature) D • 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 Horne 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,xnass.aov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finishedbasement/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 og'tikar TOWN OF YARMOUTH • • ��•C BUILDING DEPARTMENT O H 1146 Route 28,South Yarmouth,MA 02664 Yc�"C....,;S',a 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 conducted at q UO,ALIl Or (Jay (A�y Work Address Is to be disposed of at the following location: LJ 4 £XC'n Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. I? 51M Signature of Application Date Permit No. PERMIT AUTHORIZATION By signing below, the Owner(s) authorize George Davis, Inc., to act on Owner(s) behalf relative to the work to be performed at this address. Project Address: 9 Jannor Way,West Yarmouth, MA 02673 Our signatures Indicate that we have read,we understand,and we accept all provisions of this agreement. Do not sign this contract if there are any blank spaces. Owner Date ( I4 I $ `chae G enstein Owner arralS �A Date /2//#//o Galina Gorenstein Contractor Oar Daws Date 72/6/18 George Davis,President George Davis,Inc. Initial G'• initial ). 0 7 • The Commonwealth of Massachusetts IE_ —5/. Department of Industrial Accidents Ismeff. I Congress Street,Suite 100 :_ N= Boston,MA 02II4-2017 " ,` www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information /ntPlease Print Legibly Name (Business/Organization/Individual): l' PppttY. t0 ( )(1,V Le ) Kra Address: 33 IVd��K. ' 1,14:, t]Lreet City/State/Zip:J;VQ,nci AtAA,L,, FLA o g_Gent Phone#: 661)-(19q- O 6(32, Are you an employer?Check thetappropriate box: Type of project(required): I. y,r I am a employer with employees(full and/or part-time).* 7. 0 New construction 2.01 am a sole proprietor or partnership and have no employees working for me in $. Remodeling any capacity.[No workers'comp.insurance required.] r�L 9. Demolition 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4.01 am a homeowner and will he hiring contractors to conduct all work on my property. 1 will 10 0 Building 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 5.0 l am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.0 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: ,A ,es OCt(L cri, I1.O,(AAPtrc(4' tj0.4'(i. rrz. hr.e. Policy#or Self-ins.Lie.#: WCC 3106,k O 43 q OZ O lit Expiration Date: 3/ b 1 Q Job Site Address: q 5#0,Kan,' DI. City/State/Zip: (). V..r?Km u{k) Attach a copy of the workers'compensation olicy 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 verification. I do hereby certify under th ins and penalties of perjury that the information provided above is true and correct Signature: Date: I a.1114 i r Phone#: 5 O P- q - O eat 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#: • �e eF.nmonmeem/(I OLC.{ll4urrr/mJeta Office of Consumer Altai s&Business Regulation HOME IMPROVEM ENT CONTRACTOR Registration valid for Individual use only TYPE:Corporation before the expiration date. If found return to: Reolstration Expiration Office of Consumer Affairs and Business Regulation 160164 ' 07/01/2020 One Ashburton Place-Suite 1301 GEORGE DAVIS,INC. Boston,MA 02108 GEORGE F.DAVIS 33 NORTH MAIN SYREET SOUTH YARMOUTH,MA 02664 Undersecretary Not valid without signature ., Massachusetts Department of Public Safety - V Board of Building Regulations and Standards License: CS-056130 • Construction Supervisor ' , • GEORGE F DAMS , 33 N MAIN ST '1 , , ' S YARMOUTH MA 02664 • A �j� — Expiration: Commissioher 03/01/2019 • • • • • aft • • ' l"t GEORDAV-01 KMELCHER 44.// CERTIFICATE OF LIABILITY INSURANCE DATE 0 /05/3/05!202018 ) 018 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 suchpendorsement(s). PRODUCER NAm 'CT Gwen Vosburgh Mason 8.Mason Insurance Agency,Inc. PHONE )'( j ( 458 South Ave. (A ,Ext 603 356-3392 ac,No):(603 356.9290 ¢ c, L Whitman,MA 02382 DDRESS gwen@mmins.com INSURER(S)AFFORDING COVERAGE NAIC 4 _INSURER A:Western World 13196 INSURED INSURER e:NGM Insurance Company 14788 George Davis,Inc. INSURER c:Associated Industries Insuranc 33 North Main SL INSURER D: South Yarmouth,MA 02664.3437 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. /NSR TYPE OFINSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTRINSO VNO IMM/DO/YYVY1 IMMIDD/YYYYI A X COMMERCIALGENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR NPP1477087 01/12/2018 01/12/2019 DAMAGETORENTED 100,000 PREMISE TOREN unarm) $ MED EXP(Any one person) $ 5,000 — PERSONAL&ADV INJURY_! 1'000'000 GEMAGGREGATE LIMIT APPLIES PER: • GENERAL AGGREGATE $ 2,000,000 POLICY❑ja n LOC PRODUCTS-COMP/OP AGGJ 2,000,000 OTHER: $ B AUTOMOBILE LIABILITY (Ea accidenSINGLELIMIT $ 1,000,000 ANY AUTO _ M9M28491 10/26/2017 10/26/2018 BODILY INJURY(Per person) E – _ AUpT�O�S ONLY WJED X AUTOSWULNEE°p BODILYPqINJURY(Per accident) $ X AUTOS ONLY X ?ARM (Per ecar trMAGE E - _ E UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ _ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION E $ C WORKERS COMPENSATION X SEATUTE EOTH AND EMPLOYERS'LIABILITY Y/N WCC50050143902018A 03/05/2018 03/05/2019 500,000 ANYNPROPREIETgO�RR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $ (Mandatory in NH)EXCLUDED? N N/A 500,000 EL DISEASE-EA EMPLOYEE $ If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If mon space Is required) Office Copy CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION NOTI George Davis,Inc. ACCORDANCE WITH DATETHEPOLICYR ROEOFVIS ONSCE WILL BE DELIVERED IN 33 North Main St. South Yarmouth,MA 02664-3437 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD otAk TOWN OF YARMOUTH HEALTH DEPARTMENT : •`� PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET To be completed by Applicant: Building Site Location: 9 5-0-icKor t Lt°.ft y[I,riM.Ota,tk Proposed Improvement: 'Lead()\/(1 &&c.Ptcr b/l:.tK.Ira ovi,. tree. p1 titP. Applicant: GfOYt9P, hQVld' l to Tel.No.: , OA'- c3g4-O?d,2 Address: (30 klm-1-1. C.K. St, Jo AL, Yarncntifb Date Filed: JrN , I7//8 ••Ifyou would like e-mail notification of sign off please provide e-mail address: Owner Name: f"liCI�.QGL, 4 a (LL LKa, (8rGh,ifttl.iu Owner Address: cf(Lyk G Owner Tel. No.: G - /3)9 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: Le7//a PLEASE NOTE COMMENTS/CONDITIONS: TOWN OF YAR1UCUTFI °2�,, 3 REVIEWED FOR BUILDING AND ZONING CODE COMPLI- \ �,, ,i 3 ANCE. ERRORS OR VE �i�� ����Y COMPLIANCE. APPLICANT EVRESPONSIBILLIITYTRASEBUILT � - � a DATE:id•-Ay 'IS _ Iri s BUILDING OF1IC ; TAL m g ryE.8 0 g'6 2668 ! ,- r– v '+_ — o o e ooa IN\ i—ICi Cl I New larger I shower ° vanity at I l ay. emain 1 i \ / cd Ls3 i — N -S 1 I IL 1 oma } ea z° New Linen m 0 (:,:o Closet r Exist. toilet - remain I `orC jdistS t s= o� EJ tr i v ia I DATE: I .. 9/27/18 Existing Proposed RECEIVED SCALE: Noted DEC 172018 SHEET: 3/811 C 11 0" 1011 HEALTH DEPT Pg-1