HomeMy WebLinkAboutBLD-19-004108 •
L[Ill Illti
• 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
Massachusetts State Building Code,780 CMR
Building Permit Application To Construct, Repair, Renovate Or Demolish R - „ire, v
a One-or Two-Family Dwelling
�yThis Section For Official Use Only JAN 1 1 20191
Building Permit Number: 8LD-(QQbb'fl v? : .Date Applied: t._i—r,
136/44) JAY`(( `! +
er'
wilding Official(Print Nam / tgnaNre, . Date
• SECTION 1:SITE INFORMATION
2)4 Pjop Address: `J 1.2 Assessors Map&Parcel Numbers
if impefoymutacat
1.1 a Is this an accepted street?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,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private❑ Zone:_ Outside Flood Zone? Municipal 0 On site disposal system ❑
Check if yes0
SECTION 2: PROPERTY OWNERSB P' .
1 OvynertlofR c rd: O � (
60
Vita"
- 4aM 7_ ,
Name(7�Pr—iin'.)J Lni tt�r/- i\► City.State 1fLl (•�
o.and Street 5.0 tv4.01O�. Te ephone Email Address
SECTION 3:.I SCRIPTION OF PROPOSED WORK'(check all that apply .
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work'': - `
f , rWL- �k11APer.--' -ri` 5u . i Lit -1
KtTt C- (14€ �f A Fr dry-( 4
• SECTION4:ESTIMATED CONSTRUCTION COSTS
. lircEED
Item Estimated Costs: '
V
(Labor and Materials) Official Ilse Only I
1.Building $ 1 Building Permit Feer$Lla Indicate hdw fee rnj_r yd-i f 19
2.Electrical $
0 Standard City/Town Application Fee
i .
❑TotalProjectCost° tem6)xmuhipher . 'BuIxOiNGDEPARTMENT
3.Plumbing $ 2. Other Fees: $ yr t..---_—__
4
--- --
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire =
$
Suppression) Total All Fees $
Check No. Check Amount: Cash Amount: -
6.Total Project Cost $ VOr a' ^ ❑Paid in Full . . ❑Outstanding Balance Due: Fr'
%,
'4
r ' SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) e, _Dct Z39 � -1-i/_4"�
0141144C-4442--..-1" License Number , v t Expiration Date
Name of CSL Ho!1r
I l l S n n bn ter— List CSL Type(see below) C-5
No.and Street _/� ' Type .. Description
�1 1, .k.'d i S .7� U Unrestricted(Buildings up to 35,000 cu.ft.)
'�C` R Restricted I&2 Family Dwelling
City/Ihwn,State,ZIP M Masonry
•
RC Roofing Covering •
/ - WS Window and Siding
SO(), ./t(,( IPSSF Solid Fuel Burning Appliances
,�(J(J V'( `f I Insulation
Telephone Email address D Demolition .
51.�2 Re.gistere ,HoJmeeI�mmp/ro�vementContractor(HIC) /r/// pt0 • �/,{, nLi
D
Vnl tS RIC JJR''eggiststraJtiioonNumber �xxppYiJtonData
HIC CompanyXame or HICr t Name
( I d2-t— C RAR--c ZZ .SIJ , Ca /14
�di ,r/4! ( A W o I Street
E address
City own,State,ZIP l F�'� .S7 Telephone
SECTION 6:WORKERS' COMPENSATION INSURANCE ANN'WAVIT(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 ❑ 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
to act on my behalf,in all matters relative to work authorized by this building permit application.
•
Print Owner's Name(Electronic Signature) Date
• • • SECTION 713: OWNER'.OR AUTHORIZED AGENT DECLARATION
By e,tering my n.Ise below,I hereby attest under the pains and penalties of perjury that all of the information
c.Ita' ed in thi ap slication is e and accurate to the best of my knowledge and understan • g. �\
A _u (- 'Matt .
Print owner s or Autho ed Agent's e(Electronic Signature) Date
• NOTES:
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
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/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"
•
•
The Commonwealth of Massachusetts
..
Department of In dustrialAccidents
X1111= 1 Congress Street, Suite 100
C"SE-1:1— Boston, MA 02119-2017
%ray • www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information / !' Please Print Legibly
Name (Business/Organization/Individual): L.QcoiiS' 1- kticivn
Address: /// IPI R�
City/State/Zip: ct-/t.p,(/,L Wi� Phone #: v^U� 77 a--&---7S
Are you an employer?Check the ppropriate box:
Type of project(required):
L 1 am a employer with 0 employees(Ml and/or part-time).*A7. 0 New construction
_.0 i am a sole proprietor or partnership and have no employees working for me in 7. ❑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.]
4.01 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 workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees. _
12.0 Plumbing repairs or additions
5.0 I am 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.! 13.0 Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 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
3Contractors 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 jor my employees. Below is the policy and job site
information. ^^ S�� �� ��
Insurance Company Name: Sy`� I
Policy#or Self-ins.L'c.#: _a H_ ,-....)964, 63,,,--4 1Expiration Date: 3 (q ( 9
Job Site Address: q 141 {kf rt S 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 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 is statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verific o I
I do hereby cer fy un er the p 'ns nd penalties of perjury that the information provided abov is tr e and correct
Signature: Date: 1 « 1
Phone#:
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#:
•
o YaR • TOWN OF YARMOUTH
BUILDING DEPARTMENT
O , —y
t'� =nYP �?' 1146 Route 28, South Yarmouth,MA 02664 508-398-2231 ext. 1261
.
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE:
•
JOB LOCATION:
NAME STREET ADDRESS S CTION OF TOWN
"HOMEOWNER"
NAME HOME PHONE WORK PHONE
PRESENT MAILING ADDRESS •
CITY OR TOWN •TATE ZIP CODE
The current exemption for`Homeowner' was extended to include .wner—occupied dwellinvs of one or two units
and to allow such homeowners to engage an individual for hire o does not possess a license,provided that such
homeowner shall act as supervisor. (State Building Code Sec on 110 R5.1.3.1)
Definition of Homeowner.
Person(s)who owns a parcel of land on which he/she res''es or intends to reside,on which there is or is intended to
be, a one or two family attached or detached structure a essory to such use and/or farm structures. A person who
constructs more than one home in a two-year period s not be considered a homeowner;such"homeowner"shall
submit to the building official,on a form acceptable o the building official,that he/she shall be responsible for all
such work performed under the building!permit. :ection 110 R5.1.3.1)
The undersigned `homeowner' assumes resp. sibility for compliance with the State Building Code and other
applicable codes,by-laws,rules and regulati. s.
The undersigned `homeowner' certifies 'at he/ she understands the Town of Yarmouth Building Department
minimum inspection procedures and r•uirements and that he / she will comply with said procedures and
requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING 0 ' CIAL
INSURANCE COVERAGE:
I have a current liability ins.rance policy or its substantial equivalent, which meets the requirements of MGL
Ch.142. Yes N.
If you have checked v, ease indicate the type coverage by checking the appropriate box.
A liability insurance po cy Other type of indemnity Bond
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner Agent
h:homeownrlicexemp
i, oT "may TOWN OF YARMOUTH
• . s' :vg c
BUILDING DEPARTMENT
??`_j -l� 1146 Route 28, South Yarmouth,MA 02664
"� :I� 508-398-2231 ext. 1261 Fax 508-398-0836
cs- BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
Pursuant to M.GL Chapter 40,Section 54 and 780 CMR, Chapter 1, Section 1113,
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at� q �/1-fr f st �--
Work Address
Is to be disposed of at the following location: Mime LL l'OlAei p
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. . .er l I , S ction 15QA.
SIV , 1 i( t ( 1
Si an attire of Application Date
Permit No.
• Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contact of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fi11 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
•
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom •
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 02-23-15 www.mass.gov/dia
s
ONE or TWO FAMILY— BULDING PERMIT
APPLICATION REGULATORY APPROVALS NOTICE -
SO
A-1 ``77
Address of Proposed Work: AN q k A-l� 5�- '7- ,,4d9 apt
Scope of Proposed Work:
Date: ( ( (
Based on the scope of work described above, the applicant is required to obtain approval sign-
offs from the following departments as checked-of below:
Health Dept.—508-398-2231 ext. 1241
Conservation—508-398-2231 ext. 1288
Water Dept. —99 Buck Island Road, 508-771-7921
Old Kings HWY. Hist. Comm. —508-398-22631 ext. 1292
Engineering Dept.—508-398-2231 ext. 1250
Fire Dept.—Kevin Huck/Scott Smith, 96 Old Main Street, SY
Note: Please call Fire Department for an appointment. 508-398-2212
Other
Appropriate plans and/or application shall be provided to each 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 your cooperation.
Receipt Acknowledgement:
Applicant's Signature Date
Rev. Jan. 2019
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53POffice of Consumer Affairs&Business Regulatir r
, t HOME IMPROVEMENT CONTRACTOR .
C. TYPE:Corporation
$^ - ` &a!stration Fxnirat!OR
�.. 764680 03/28/2019
LEWIS&W ELDON CUSTOM CABINETRY,LLC.
CLARENCE HART JR .-
•111 AirportRd ' &--CS
Hyannis,MA 02601 Undersecretary
•
A� CERTIFICATE OF LIABILITY INSURANCE • DATE(MMIDDITYYY)
09/19/2018
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 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 Prienny Silva
NAME:
Leonard Insurance Agency,Inc PHONE
IA/C.No,EMI: (508) I(AIQ No): (508)428-6921 FAX 420-5406
883 Maln Street E-MAIL pdy�enn leonarda en com
ADDRESS: 9 �'
Suite B INSURER(S)AFFORDING COVERAGE NAIC I
Osterville MA 02655 INSURER A: Mass Bay Ins.Co. 22306
INSURED INSURERS: Safety Ins Company 39454
Lewis and Weldon Custom Cabinetry LLC INSURER C:
INSURER 0:
111 Airport Road INSURER E:
Hyannis MA 02601 INSURER F:
COVERAGES CERTIFICATE NUMBER: Master 18-19 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. NOTWITHSTANDINGANY 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 INSD Mp POLICY NUMBER POLICYEFF POLICY EXP LIMITS
(MOLICIYEFT (POLICY
X COMMERCIAL GENERAL LIABIUTY EACH OCCURRENCE S 1.000,000
DAMAGEIORENTLD 1000
CLAIMS-MADE ®OCCUR PREMISES IEe occurrence) S 0,0
MED EXP(Any one person) $ 10,000 —
A ZHN906184507 04/01/2018 04/01/2019 PERSONAL 4ADV INJURY _ S 1.000,000
GENT-AGGREGATE UMITAPPLIES PER: GENERAL AGGREGATE S 2,000,000
X POLICY❑JPERP 0 LOC PRODUCTS•COMP/OP AGO S 2,000,000
OTHER: 5
AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT S
—
(Ea accident)
ANY AUTO BODILY INJURY(Per person) $ 500,000
B — OWNED X SCHEDULED 3851369 04/25/2018 04/25/2019 BODILY INJURY(Per saderd) S 1,000,000
AUTOS ONLY AUTOS
HIRED v NON-OVAIED PROPERTYDAMAGE s 250,000
X AUTOS ONLY !� AUTOS ONLY Pe )
s
UMBRELLA UAB OCCUR - EACH OCCURRENCE S— —
EXCESS LIAB CLAIMS-MADE AGGREGATE S
DED I RETENTION$ S
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY YIN STATUTE ERµ
ANY PROPRIErOR,PARTNER/EXECUTIVE ❑ NIA E.L.EACH ACCIDENT S
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S
B yes,&mate under
DESCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT S
DESCRIPTION OF OPERATIONSI LOCATIONS I VEHICLES(ACORD 101,Additional Remark*Schedule,may be attached If mon space Is required)
John Henderson
Scene Pond Condos 844 Maln St.Unit 78 South Yarmouth,MA,02664
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS.
1148 Route 28
AUTHORIZED REPRESENTATIVE /,�
South Yarmouth MA 02664 r jot _
®1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
LEWIS &WELDON
CUSTOM BUILDERS
DESIGN • BUILD
in Airport Road
Hyannis,Massachusetts 02601
508-778-5757 office
508-778-5111 fax
www.lewisandiveldon.com
PROPERTY OWNER AUTHORIZATION
John Henderson
844 Main street(Rt 28)#7-B South Yarmouth,Massachusetts 02664
As owner/owners of the subject property hereby authorize Lewis and Weldon to act on my/our
behalf,in all matters relative to work authorized by this building permit application and all
subsequent sub permits governed by the Electrical Code,as well as Plumbing code
6i batu(Ler,owners / Date
ck Ai / fP b-
Print Nanie/Names
C 60,\I
(( (rP
Lewis& Weldon Authorized Representative Date
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Print Name eacri),,,A CO)N C �
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IN Mitir4 Sr. 3-a,
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tieNtsgtyri
6 , mthuui , f &WELDON Tref OF PROJECT
CUSTOM KITCHENS
CABINETRY•COUNTERTOPS•nu ROOM kfi tke'L- Y kore"•
SCALE SHEET* OF
111 AIRPORT ROAD,HYANNIS,MA 02601
508-778-5757 • Fax 508-778-5111 DESIGNER( ( DATE
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