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HomeMy WebLinkAboutBLD-19-3973 ONE or TWO FAMILY -BUILDING PERMIT APPLICATION REGULATORY APPROVALS NOTICE Address of Proposed Work: ZOO P/C–ii•AH! 1 9free, 1 Scope of Propos Work: 12-€m6oC.l cix:V/c -Acr-AcSUOcA-u'c — (/AW hyS i ew'o flcot lluS9-79-l/ ll -ft* CA/oWP/e S ' lc 1=7(0 r- • 11.414*yr f p s Fi, -nc S • In/uf - Date: 2/3///r 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 prit r to submittinga building permit application to the Building Dept.• a Thank you for cooperation. • eipt Acknowledge . , , . , 1/r pp •a.t's '�.:ture •- Date . Dec.2015 _. SECTION 5:.CONSTRUCTION SERVICES f ►Constracti n-Superviso License(CSL) LisN �/►onDv►) -um� ►rv�w Number Dateration Name of CSL Holder \• t jo �►Vers&I]L - 121� List CSL Type(see below) No.and Street '. .,Type .. Description m iy4 vcoa G tiQ U Unrestricted(Buildings up to 35,000 cu.R) . , 1 - t .- R,.,,, .Restricted lea Family Dwelling City/Town,State,ZIP .� ,• __ ... - - .- _ M . Masonry • • - RC Roofing Covering . . C it WS Window and Siding r _ '• - SF.-_ .-Solid Fuel-Burning Appliances i -a•3y41?% EitSla1 -t .01.)1 I p�- : : ) •.. I Insulation'' l t t Telephone • Email address Ej$i}t 1 •C•4`'t -D - Demolition 1 - - 5.2 Registered Home Improvement Contractor(111C)) _ h 9Tl '_CA*n Date �sl!s Neil QUICetS.I^ _ MC Registration Numb`iEapiraHIC Company Name or RWegistrantName (S) rtlOCittoct 1103-Q aSk6Qe5)141 !'Co ✓ Niiiratert pm cabyq 653a3q-)3 Email address City/Town, State,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)C7 0 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 J A lilt l ►)111l3 \uSw to7- to act on my beehal£in all matters relative to work ,(authorized by this building permit application. 9'&borz►1 Ike/ULU; & s' (r7?in-r-aa.i, I Z 2-9 C Print Owner's Name(Electronic Signature) — I Date • • SECTION lb:OWNER"OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains mid'penalties of perjury that all of the information ..tained in this a.. • 1on is true d accurate to the best of my knowledge and uinderstandtng:' • � ia73///rte` Flag') , .r Authorized Agent's Name ni:Signatuie) ''• )•- Data. e,q: i c :NOTES: r_ . 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 yvww.mass.eov/oc4Information 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.) Ips (ineiuding 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 Cosy' • The Commonwealth of Massachusetts Ik"-,= 111,=.5.1 !/ Department oflndustrtalAccidents •inl_ ;2' 1 t -...• -, I.Congress Street,Suite 100 • =J.1'=- Boston,MA 02114-2017 ,,r __ - .,L '' , w wwmass.gov/dia Worked'Compensation Insurance Affidavit: Builders/Contra toisl'Electricians/Pluriibers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information 1 '�-,a-� . , P1 se Print`Legiblo Name (Business/Organization/Individual)! di kc N�l -1�u i 'er.. j.. Address: .�Q \Il VL('Sb �'taoU 6 • City/State/Zip: I/'IT mR•Graot `•p{l'one tk. . G037.7, L.3 y-'g% ``"' Are you an employer?•Checkthe appropriate box:'.':' rai ' . . : .. . : _ Type Project ;;. roject(required): /❑i• 1. am a employer with I employees(hull and/or part-time).* •r, •7.:❑New construction 2.0 I am a sole proprietor or partnership and have no employees working forme in g• ' Remodeling:'Li , ,.',;:- any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall work myself " " 9 0 Demolition=:: :.::.-_ ❑ Y [No worker'comp.insurance required.]t 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 worker'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0i am a general contractor and I have hired the sub-contractors listed on the attached sheet 13. Roof sits These sub-contractors have employees and have workers'comp.insurance.: ❑ rep 6.0 We are a corporation and its officers have exercised their right of exemption per MGL a 14.0 Other 152,11(4),and we have no employees.[No workers'comp.insurance required] 'Arty 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. :Contractor that check this box must attached an additional sheet showing the nettle of the sub-contractors and state whether or not those entities have employees. if the sub-contractors have employees,they must provide their worker'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: h/M7/oAI/9C,- • Policy#or Self-ins.Lic.#: Expiration Date: ' Job Site Address: 2&o P lei CIMT �I . City/State/Zip:S" rayl Q L2t.i1 Th A ( Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MOL c..152, §25A is a criminal violation punishable by a fine up to$1,500,00 and/or one-year imprisonment,as.weil 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 here ertify u • .e pain.. a i i , 'nahles of perjury that the information provided above is true and correct Signaturearl �► - Date: la)'/3✓//e Phone#: (•P 603-0- 47- `>39C -- 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#: ;is4,tTOWN OF YARMOUTH t :. i CBUILDING DEPARTMENTN ; 1146 Route 28,South Yarmouth,MA 02664 508-398-2231 ext.1261 Fax 508-398-0836. .BUILDING DEPARTMENT . .. DEMOLITIONDEBRIS 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 c;0-0 leRSft S t Work A dress Is to be disposed of at the following location: ){/Vivi 0(7E11 • s 0v\-, Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, See tion 150A. 11110APP44 Er re of Application Date, - - Permit No. yGe1atOastapO(7 69920 VW'33dHSVW OH 3OISH3AiH OS , 7J � N3NIViWIIIIOIAVO t_ Ii -'O11 SH3olina1SBN S31Dy3 i 610d/9Z/L0 996£[1 .r;,,� ' 1 uoileJl°x3 uo9et1s16a1f �� OTI I3dA1 HOi?Vtl1N001N3 W3AOtld W13WOH 9i~11_ uo0elnbstl ssemsng q snellV iswnsuo0 to solllo- x-` C`p I I t iv, • Commonwealth of sure ''W�! Division of Professional Massachusetts 1 Board of Building r°/essional Licen Conc ru R�ula6ons and Standards CS- n opervisor 106543 19 Expires:05/13/2020 i. DAVID LIIMAi "�� 50 RIVERSIDE AINEN,SRS ' HPEE M E ROAD II;_, ,: ar�.x MAS A02549 Commissioner CIL / .-.••• • • • • 1 • • AC R® CERTIFICATE OF LIABILITY INSURANCE °"'E'M""D°""""Y' `.---- 01/03/2019 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(ies)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: Elaine Donoghue McShea Insurance Agency,Inc ,jAlco.NNo.EMII: (508)420-9011 WC.No(508)420-9010 1645 Falmouth Road, Rt 28 BLDG D ADDRESS: elaine@mcshealnsurance.com Centerville, MA 02632 INSURER(S)AFFORDING COVERAGE NAIC/ INSURERA: National Grange Mutual Ins Co. 29939 INSURED INSURERS: NATIONAL GRANGE MUTUAL 14788 Eagles Nest Builders,LLC INSURER C: 50 Riverside Rd INSURER D: Mashpee, MA 02649-4527 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 00000000-0 REVISION NUMBER: 2 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 TYPE OF INSURANCE AWL SUBR POIJCY EFF POLICY EXP LTR INS) VMI POLICY NUMBER IMWDD/YYTYI IMMIDD/YYYY) OMITS A X COMMERCIAL GENERAL LIABIUTY MPP4016A 04/01/2018 04/01/2019 EACH OCCURRENCE $ 1,000,000 AMAGE 10 RENTED X CLAIMS-MADE n OCCUR PREMSES(Ea occurrence) f 500,000 _. MED EXP(Any one person) $ 10,000 PERSONAL di ADV INJURY f 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE E 2,000,000 POLICY I I JEC LOC PRODUCTS-COMP/OP AGG S 2,000,000 I OTHER: f B AUTOMOBILE LIABIUTY M1P4016A 04/01/2018 04/01/2019 fEaeweeDSINGLELIMIt s 1,000.000 _ ANY AUTO (Per BODILY INJURYcereal) f O`AMED SCHEDULED BODILY INJURY ) AUTOS ONLY X AUTOS (Per accident) f HIRED NON-OVMED PROPERTY DAMAGE AUTOS ONLY X AUTOS ONLY (Per ecddent) f $ UMBRELLA LIAR -_ OCCUR EACH OCCURRENCE f _ EXCESS UAB CLAIMS-MADE AGGREGATE E DED RETENTIONS S WORKERS COMPENSATIONPER OTH- AND EMPLOYERS'UABIUTY YIN I STATUTE ER . ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT f OFFICER/MEMBER EXCLUDED? ❑ NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE E DyeadesION under E.L.DISEASE-POLICY LIMIT S DESCRIPTION un OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,AddIUonel Remarks Schedule,may be attached If more apace I.required) PLEASE NOTE THAT THE WORKERS COMPENSATION CERTIFICATE WILL COME DIRECT FROM THE CARRIER. 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 ACCORDANCE WITH THE POLICY PROVISIONS. 1146 RTE 28 South Yarmouth, MA 02664 AUTHORIZED PRESENTATIVE I (ESD) ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Printed by ESD on January 03,2019 at 03:07PM - \ gr- . — ivy 22 ►v0 v -haw 7't coo t ,9Cc cx.,11 r 2 r- Pkm5, T ST• S. )(AT tiv, c?1-1\ At -._. /2/27// - 509-k.ivp. --t. i tc r trvctl � C-1)O __,2 D�� Hill — C' 1 iN I ®\ Z ..ti1 Vv \ \ w ( l �� on `� Qo C " Q\ + ( ) (n \(6(t - i1 ) ./ li Si— \ I I I1N ' y`�'``�cc�,,,� 39 TOWN OF YARMOUTH J f REVIEWED FOR BUILDING AND ZONING CODE COMPLI- ANCE. ERRORS OR OW,.IISSIONS DO NOT RELIEVE THE f L - APPLICANT FROM THE RESPONSIBILITY OF'AS BUILT' �) 111/ ,���` �e W S1�n�u �;5�t S _ COMPLIANCE. 0,J,u, f 4 (9 DATE: I-I4'1 y R \oc_t kkAN�k ?-'Skis i robemek p)L✓tn63 04- 4 I nILDIN OFFICIAL - fa S14U--c* Aik ►a�3:- bac wit S�•E w Z�i�T1ld.,c 1 tilt ?- . V�,;+y 6 Ju- 1 4 01/181 1q FILE COPY ACOF<D' CERTIFICATE OF LIABILITY INSURANCE °A"'"""'T"° 01/07/2019 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 pollcy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require art endorsement A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER 01688.001 NpQpp�g,cT Branch 1688-1 McShea Insurance Agency Inc La.Nis.exq: (508)920-9011 raw. (508)920-9010 1645 Falmouth Rd Suite ID Centerville,MA 02632 B1SL'RVU51 AFTOROtNG COVELAGE ) NAICs fr'R=RA• ALL Mutual Insurance Company i3375R . INSURED • SNSLRc_R a: Eagles Nest Builders ILO ss:rr'RC 50 Riverside Road ### Nashpee, 1 02649-LOCO tAs,ze�D• :1 iNScnint e: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THS IS TO CERTIFY THAT THE POLICIES OP INSURANCE USTED BELOW HAW BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INCIC:.TCD. 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 TUE. POLICIES DESCRIBED HEREIN-IS SUBJECT TO-ALU-THE"TERMS, EX,WSIONSAND CONDITIONG-OFSUCH POLIpCLIEgSp:gtItatTSSFTOWNMATHAVE BEEN REDUCEDL' BYA� PAIDpCLAIMS.,� y LTTR1 TYPEOFINSURANCE �IHSR ?Mt POLICY NUMBER. . (MM/DOttYYp ryWUDt1'YYYI I. LWTS . . iGENERAL LuauTY sack. cca/s.EXCE Is t 1 COYJERCLLL GENERAL LIA3RnY TLL--'.%'S7.c�. )S FP=Y.SES'Eav-Rene- ( 1 CWMS-WDE El OCCUR LED EJP(An ore pence) /5 KS-SCOWL AtV PCXSAY (3 —�_--___. GENERA.A E I3 GENLASSGREGATEUMIrAPPUES PER: • PRODUCTS•COMPAPAGG — S rWCY 1 IIES,T 1-00 _ ^ AUTOMOBILE LIABILITY COMSINcD31N(at6 UM 1 5 (Pa tuelantl ANY AUTO BODILY INJURY(Perperson) S ALL OWNED —SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) S _ .. • 15RLE9I rts-AmAGE-- 3 _AUTOS - IPerecadant1 5 UMBRELLA UAB OCCUR EACH OCCURRENCE S EXCESS LIAO CLAIMS MADE AGGREGATE 3 DED I RETENTIONS VN.�C 55 uu T I A'TP�EU`L�10H.I° a� x TORYIMITS OER A CUTIVE 1� EL.EACHACGDENT $ 100,000.00 ' I(((Mandeeat y I�iNNnH�Ha�FJCGWDEo't` 'y NIA AWC-400-7029200.2018' 6126I2B18 6126/2019 EL.DISEASE•EA EMPLOYEE 5 Un%RI flON VFOPERATIONS Wow600,0.0000 E.L.DISEASE•POLICY LIMIT 5 600,000.00 • L -- I I I I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional RemarNs Schedule,V more space M required) Dave Ll)amatainen Is not covered by the workers compensation policy. CERTIFICATE HOLDER CANCELLATION Town of Yarmouth ' 1146 Rt 28 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE S Yarmouth,MA 02664 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 63 1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010(05) The ACORD name and logo are registered marks of ACORD