HomeMy WebLinkAboutBld-20-001880 ti•
ONE & TWO FAMILY ONLY-BUILDING PERMIT
Town of Yarmouth Building Department or
1146 Route 28,South Yarmouth,MA 02664-4492 e'
508-398-2231 ext. 1261 Fax 508-398-0836 fk)'
Massachusetts State Building Code,780 CMR
Building Permit Application To Construct, Repair, Renovate Or Demolish R _.''' ...
a One-or Two-Family Dwelling
This Section For Official Use Only 9
Lk
Building Permit Number: 1tS C CI ,Date Applied: 51.111 DING V Na RT I T
Buil • ' (Print Name) gn re' Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street?yes ,/ no Map Number Parcel Number
1.3 Zoning Information: S r,eitt �d't Z „ /U 1.4 Property Di nsi
to'I d MuthicrlietiV / 7 i 1 if A-Cei4
nmg District&/1 roposed 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 upply:(M.G.L c.40,§54) 1.7 Floo Zone Information: 1.8 Sewage Disposal System:
Public Uf Private 0 Zone: f l 11- Outside Flood Zone? Muaicipall On site disposal system 0
• l Check if yes❑
SECTION Zc PROPERTY OWNERSIITP1 _
iZ.1R �eeRe It � ��
j�
Ce W/ - - 3Sy
Nam(r ) City,State,ZIP
33 ( r Iv GOD — - 7 /-0,30-I V 1 R- 14r 0Coldie4-57 M 'l--
No.and Street Telephone Email Address
SECTION3:.DESCRIPTION OF PROPOSED WORKZ(cheek all that apply)
New Construction❑ Existing Building 0 Owner-Occupied 0 Repairs(s))90 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg.0 Number of Units Other ❑ Specify:
Brief Description of Proposed World: S'1'1 l P "4- 4 V 4.Do I
a1sci
. • SECTTON:4:.ESTIMATED CONSTRUCTION COSTS. : . : . .
Estimated Costs: - . :•- ...
(Labor and Materials) � .' . : ; � °:Ofi"iciahlJse Only:..: �.
Item
1.Building $ a 50,
cV :1...Building Permit Fee:$ .' :. .. Indicate how fee is determine±
r •❑.Staadard City/Town -:
2.Electrical $ 0
❑.TotalProject dose tem0. uttip a... x
3.Plumbing $ 02. OtheiFees: $ "' .
4.Mechanical (HVAC) $ aLtst
5.Mechanical (Fire ;.:..::; ._ - .. _
$ O ..
Suppression) Total All Fees:$.
Check NO. Check Amount .Cash Amount:
6.Total Project Cost: $ ff---0 sot ,/ 6 paid in Full . 0 Outstanding Balance Due:
SECTION 5:.CONSTRUCTION SERVICES
5.1 Construction�, Su/pervisor�License(CSL) �s G� 11 / (.20
l CryL l 21,c rt4Lti I L License Number iratio Date
Name of CSL Holder
/ a l p� L�� ! r��^ 4 List CSL Type(see below) Lk
No.and Street v �[J�Y ' ,j' T e . Description
/7S [ U) Unrestricted(Buildings up to 35,000 cu.f.)
01440719// ,,` ! Restricted 1&2 Family Dwelling
City/Town,State,ZIP ! M Masonry
RC Roofing Covering
�/ G WS Window and Siding
` SF Solid Fuel Burning Appliances
cCtCS4afDr r•(f I Insulation
Telephone Email address D Demolition
5. Registered omme/f Improvement Contractor(HIC) _A�''' go, 4I7 /3//4
fiJ I. '" �M al EOC - "� HIC Registration Number Expiration Date
HIC • AnyName R eo,,1-0 �- /j I S /`
No. d tr
�JbOr f / /,r f4 0O &77-O7 / Em address
City/Town,State,7TP /"< Telephone �P
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 p No ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLE 1'El)WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize 70'�'`n � P00t/1 a" '
to act on my behalf in all matters relative to work authorized by this building permit application.
Rober4' 10, 4e44/C) .26
Print Owner's Name(Electronic Signature) D
SECTION 7b:OWNER'OR 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.
JM /o mE mtaravcP£Aff �l 1 is As a 6 _ _
Print Owner's or Authorized Agent's Name(Electronic Signature) / D
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/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 coolin system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
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~ dr.Yf}� TOWN OF YARMOUTH
. �i y BUILDING DEPARTMENT
1146 Route 28,South Yarmouth,MA 02664
`..._. s 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 I, Section 111.5,
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at / 3-/ 5 L o g ern K 0
Work Address
Is to be disposed of at the following Location: i2 Dvotrice sem/lei-1
, (4«.1L,#. 44 l4 .
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
41.110.
4i/ t3A/ 7
Signature's f Application Date\
Permit No.
•
The Commonwealth of Massachusetts
Department of Industrial Accidents
•
rr __ 1 Congress Street, Suite 100 -
r =�.1_ Boston, MA 02114-2017
'�.,. wwwmass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers,
TO BE FILED WITH THE PERMITTING AUTHORITY.
A licant Information PIease Print Le 'bl
Name (Business/Organization/Individual): ,23-l �`�!�/ ���{� �/� r .•�- //'
_ T ��`•�
Address: / / �(� r>6.9( cif/'1.I�p\ r.457
City/State/Zip: 06/21 C.r�y h M ' OPlhon one#: /7-61 5
Are you an employer?Check the appropriate box:
Type of project(required):
1.0 I am a employer with employees(full and/or part-time).*
7. New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in
any capacity.[No workers'comp.insurance required.] 8. ❑Remodeling
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. Demolition
4.0 I am a homeowner and will be hiring contractors to conduct all work on myproperty. 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.
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 12.❑Plumbing repairs or additions
These sub-contractors have employees and have workers'comp.insurance? 1.5 Of repairs
6,, e are a corporation and its officers have exercised their right of exemption per MGL c. 14.11]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
1 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-contactors 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. /�< 0.-�
Insurance Company Name: 70 111 T 5),4e(-2 i\ -
Policy#or Self-ins.Lic.#: WC 2- 3/ S �P / ' f( (�' . Expiration Date: // 2
Job Site Address: /3—Z OieeRa X1*9 City/State/Zip: _ A/2 0,O 24'7
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 this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
1 do hereby certify under the pai lties of perjury that the information provided above • true d correct
S•enature: l
_ Date:
Phone#: (Q i? ( 7 -
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 Departinent 3.City/Town Clerk 4,Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
AoRO® LIABILITY INSURANCE CERTIFICATE OF DATE(MIWDDIYYYY)
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CO 09/
CERTIFICATE
HOLDER.
THIS
9
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE VERAGE 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 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
ONTPOINT INSURANCE INC NAMES JESSICA BARRETO PHONE I
P
191 CONCORD ST ► No.Ern: 508-875-5B00 I INC.Nog 508-875-5RRS
EMAL
FRAMINGHAM,MA 01702 ArmREss:JBARRETOOPOINTWSURE.COM
INSURERS)AFFORDING COVERAGE NAIC 0
INSURED INSURER A: EVANSTON INSURANCE CO
MJT HOME IMPROVEMENT INC INSURES B: LIBERTY MUTUAL FIRE INS CO
INS
181 BOSTON POST RD E STE 01INSURER c: OHIO SECURITY INSURANCE COMPANY
MARLBOROUGH,MA 01752 INSURER 0:
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 CONDmON 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.
LTTRR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP
INSR WVO POLICY NUMBER
GENERAL t Ieeu,RY JMD/YYYYI /MSVDD/YYYY1 WAITS
DAMAG
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCETORENTED
s 1 000 000
IPREMCLAIMS-MADE X OCCUR
ISE ES ) S 50.000
A MED EXP(Any one person) $ 1,000
3EV8011 07/10/2019 07/10/2020 PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE s 2,000,000
GEM.AGGREGATE LIMIT APPLIES PER:
POLICY n yea n LOG PRODUCTS-COMP/OP AGG $ 1.000.000
AUTOMOBILE LIABILITY (— s
�.1 COMBINED SINGLE LIMIT
ANY AUTO fEa accident) . S 300.000
C AU.OS�D x SCHEDULED BODILY INJURY(Per person) s
NON-OWNED BAS(20)60217071 08/24/2019 08/24/2020 BODILY INJURY(Per accident) S
HIRED AUTOS AUTOS PROPERTY DAMAGE
(Per accident) S
S
UMBRELLA LIAR OCCUR
EXCESS LU18 EACH OCCURRENCE $
CLAIMS-MADE
AGGREGATE $$
DED !RETENTION S
WORKERS CON ENSATION S
AND EMPLOYERS DABS ITY Y/N x I TDSLiMRS l ER
B OFFFFICEIME ABERR EXCLUDEDE m�vE n N/A WC2-31S 616864 o29 07/11/2019 07111/2020
E.L EACH ACCIDENT S 1.000.000
(Mandatory in NH)
I(yes,describe under E.L.DISEASE-EA EMPLOYEE $ 1,000,000
DESCRIPTION OF OPERATIONS belowr r E.L DISEASE-POLICY UMIT _$ 1,000,000
1 1
DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES(Attach ACORD 101,AdditIonal Remarks Schedule,if more space Is required)
FOR OFFICE USE ONLY""
""FOR CURRETN VEFRIFICATION,PLEASE REACH OUT TO THE CONTACT LISTED • :••
CERTIFICATE HOLDER CANCELLATION
MJT HOME IMPROVEMENT INC SHOULD ANY OF THE BOVE DESCRIBED POLICIES BE CANCELLED BEFORE
PIRATION 'ATE THEREOF, NOTICE WILL BE DELIVERED IN
181 BOSTON POST ROAD E STE 01 a?:•ONCE E POLICY PROVISIONS.
MARLBOROUGH,MA 01752 litil
ATiVE
0000.,
I J' -RETO
0 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name an• logo are regis red marks of ACORD
MO'Bane improvement Inc.. Estimate
181 Boston Post Rd E,Suite 1
Marlborough, MA 01752
(508)624-9000
mjthomeimprovementinc@gmaIl.com
www.mjthomeimprovement.com
ADDNESS SHIP TO
Robert Moorhead 13-15 Lorena Rd
33 Greenwood Ave West Yarmouth,MA 02673
Pembroke, MA 02359 Roofing Project
781-630-1812
r-bobm@comcast.net
CIE# DATE
1593 09/24/2019
SHIP DATE
09/24/2019
WY DESCRIPTION RATE AMOIMT
21 Scope of the work to be performed: New Shingles Roofing for the Whole House. 350.00 7,350.00
Protect and safeguard at all times,all surrounding structures,fixtures and all elements
that may be affected by the proposed work.
Remove of existing asphalt shingles and roofing related products,down to the plywood
or boards.
Dispose dumpster provided by MJT Home Improvement Inc.
Renails any loose plywood using 8d ring shank nails.
Determine if there is any rotted plywood or boards that will need to be replaced(for
labor and material additional$5.50 per linear foot for 1 x8 ledger boards or$55.00 per
sheet of plywood).
Install 8"aluminum drip edge and rake edges on all roofing perimeters and reflash all
pipe penetrations.
Install 6'ice and water leak barrier along edges and 3'across valleys eves and edges,
skylights and chimneys.
Install pre-cut starter strip,cover surfaces with synthetic paper deck mate underlayment
protection allowing a minimum of 6"over lap.
Install life time architectural shingles(GAF,Timberline HD, Pewter Gray Color)over
entire roof area using a hurricane nails pattern of six nails per shingles,versus the
industry standard of four nails per shingle.Shingles will be installed in step fashion.
Install cobra or equal ridge vents and ridge cap,plus flashing devices.
Perform daily clean up at the job site as well a thorough cleaning once the job is
completed,including a magnetic sweep to remove all nails.
Inspection of job site at the end of each day to ensure is complete and the customer is
satisfied.
Permits will be obtained by MJT Home Improvement Inc.
10 years workmanship warranty.
Liberty Mutual Insurance Company
Policy#WC2-31 S-616864-029
Expiration Date:7-11-20
HIC License#192017 Exp.:5-31-2020
CSL License#055318 Exp.:01-16-2020
By having both home owner and business owner signatures in this document, it
becomes a contract,and both parts agree to the content of it.
QTY..DESCRIPTION RATE ANT
Terms and Conditions for payment:
$ 1,050.00-upon contract signature cAc-ck ci!'89- 9�02/(`�
$4,200.00-upon job start
$2,800.00-upon job completion
1 Building Permits 150.00 150.00
1 Cleanup& RestorationV er). 550.00 550.00
Homeowner Signatur : te: ( 1074/2019 0.00
Mr. Robert Moorhead
AI di/
Contractor Signature: i , Date: 9 /0a /2 1 g S.rr �/I�.� at 0 9
Mr. Marcos Terrenas r).
411,
Approximate date for starting the job is: i0 /t /2019
TOTAL $8 00
Accepted By Accepted Date