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HomeMy WebLinkAboutBld-20-001018 *i g/.29/ 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 V'It Massachusetts State Building Code, 780 CMR Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Sec' n For Official Use •my Building Permit Number:7LD-Ap- voi Date App • d• r N Szfi CS Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION Ert,32.gd7ressAiii `L 1.2 Assessors 1. 1,01&Parcel Numbers iDY 1.1 a Is this an accepted street?yes bo 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: .__ Zone: _ Outside Flood Zone? Public 0 Private❑ Check if yes❑ Municipal 0 On site digiosEs}I n CI F SECTION 2: PROPERTY OWNERSHIP' :I _��_. a 2 Own ' f Reco e - terfre601-4, .2V1 - ; ` :1 2 �4 ame(Print) ity,State,Z / r, r G !)L Li/ 6(3e-d, No.and Street \ Telephone Email Address SECTION 3:.DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s), Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other Cl Specify: Brief Description of Proposed W rk2: seC) SECTION 4:ESTIMATED CONSTRUCTION COSTS. f p,t(b c. Estimated Costs: Item Official Use q,, (Labor and Materials) Q� �`•��i!�.J i^� D F P RT -� ' 1.Building $ 1. Building Permit'Fee:$:15-O Indite- - :-T 2.Electrical $ la_Standard City/Town Application Fee • 0 Total Project Costa Item.6)x multiplier... x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Suppression) $ Total All Fees:$ - 6.Total Project Cost: $ Check No: Check Amount Cash Amount/ 0 Paid in Full ®Outstanding Balance Due: t15 f SECTION 5: CONSTRUCTION SERVICES 5.1 Construction upervisor License CSL)) d � //K `��� License wither Exp' Lion ate�� Dame of CSL Holder t� c / 7 List CSL Type(see below) tr , p S�eet G.r Tj pe Description �,0e( /i 'A_ o2� ✓J� U Unrestricted(Buildings up to 35,000 cu.ft.)' �il,(j 7G R Restricted 1&2 FamilyDwelling City/To n,S ate,ZIP M Masonry RC Roofing Covering WS Window and Siding 64-669 _ �/ SF Solid Fuel Burning Appliances G/V&-'5: I Insulation —1 Telephone Email address . 411 D Demolition 5.2 egistere Home Im�prrooveme C`oInttractgr(HIC) " f� 0 1 / ( ✓— "�21� HIC Registration Number �iEx ration ate . P HIC Company Name or C ReOr ame / r,.� Email address C City/Town,State,LIP Telephone SECTION 6:WORKERS' COMPENSATION SURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) Workers Compensation Insurance affidavit must be mpleted and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuan of the building permit. Signed Affidavit Attached? Yes No 0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTORAPPLIES FOR BUILDING PERMIT ,as I Owner of the subject property,hereby authorize `j/ �/ ,V f .2`e pt ', :. m :-.alf,in all matters ative to work authorized by this building permit application. wig Print Owner's Name(Electronic Signature) D to SECTION 7b: OWNER1 OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information co n thi appl ation is true and accurate to the best of my knowledge and understanding. K., i� ,,----,-/: _.......,,..., _ 9 - --/2 Print Owner's or Authorized Agent's Name(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.gov/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 cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" _ The Commonwealth of Massachusetts hA_TIP":" i Department oflndustrialAccidents _12 1e1- 1 Congress Street, Suite 100 Boston, MA 02114-2017 • =SV• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A lieant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/ ip: r "Jig< 7me# 64 trS77i Are you employer?Che the appropriate box: Type of project(required): 1. am a employer with V"l employees(full and/or part-time).* 7. Nyw construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Vemodeling any capacity.[No workers'comp.insurance required.] 3.❑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 mYP roPertY• 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.t 13. Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q 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: ! jf" eL/L S 6 Ai Policy#or Self-ins.Lic.#: ©G 3���(' X Expiration Date: 9/ p/ Job Site Addres !' City/State/Zip:S � o /� Attach a copy of the workers' pensation policy declaration page(showing the policy nunfber 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 ce ' nder the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 1i S Phone#: dQ` 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#: dam_ TOWN OF YARMO UTH $y BUILDING DEPARTMENT 1146 Route 28, South Yarmouth,MA 02664 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 Work Addr ess Is to be disposed of at the following location: �, f, Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. 2rli Sign-stare of Application Date Permit No. )46 L 0 Town of Yarmouth, -,f Conservation Commission Mnrt�en5�. ` Building Permit Sign-off Application �cx,xs TO BE FILLED OUT BY APPLICANT: � Building Site Location: c���}} 6I7 /p ye/ Or: vie Map # Lot(s) # Properly Owner: V L4 4Jv 6AtG Applicant: �% / - ' i G/(e/1/ 1--e-1 Applicant Address: - ' T L • 7 G�6 Telephone: , Date Filed 254 l Proposed Project Description: 4 53 dam' 4:4.5)-A0 ot 14f Plans: TO BE FILLED OUT BY CONSERVATION ADMINISTRATOR: Does the Proposed Project Require a Permit? NA Comments from Conservatio mission: Approved Conditid`nally Approve Rejected All work related debris shall be taken offsite or disposed in a legal upland location At the end of each day,the area shall be clean and no debris shall be in the Resource Area Refer to: SE83- or DOA permit Conservation Commission Sign-off Signature: Date: 'f2-0// No (,vn/1/4E crouf/ta� wl &idle-`' ova '`�R CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 09/27/18 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 CONTAt.r NAME: United Insurance Agency,Inc. PHONE EMI, 508-759-6595 FAX No): 508-759-3822 199 Main Street � Ari' P.O.Box 1013 ADDRESS: Buzzards Bay,MA 02532 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Atlantic Casualty INSURED INSURER B: Travelers Indemnity Ins Co John Mackenzie INSURER C: 248 Camp Street INSURER D: L1 West Yarmouth,MA 02673 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. 1 TR TYPE OF INSURANCE AUULBUbK POLICY EFF POLICY EXP INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE n OCCUR DAMAGE I O RENTED PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 A L307000257 09/23/18 09/23/19 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY n PRO- JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ — (Ea accident) ANY AUTO BODILY INJURY(Per person) $ — — OWNED SCHEDULED AUTOS ONLY _ AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY Y/N x STATUTE OERH B OFFICER/MEMBEREXCLUDED? 6HUBOG3228918 09/26/18 09/26/19 - PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ 100,000 (Mandato ry in NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 100,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Carpentry John Mackenzie is not included on the workers'compensation policy CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN John Mackenzie ACCORDANCE WITH THE POLICY PROVISIONS. 248 Camp St Apt L1 West Yarmouth,Ma 02673 AUTHORIZED REPRESENTATIVE Kris Dexter I ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ACORD CORPORATION. All rights reserved. 4 1 i flsft '$R I Ve lam" n� . , !«! Q u al,- bil--;0 / 7 -- -- . fr , Ledf it ie- Cfre- /eli A70 r� L✓ fJ 1 ( i) Of /.---. 0/-/- AV7 V4/ trwo to N o oorZ-►.- /Pic'a v t� wo� I?C CI - f. IT) V 1,)-, I__ Cr - /0/Zar°14A-0 '' //41/j7;', 1 _ r , tII ' *I& vi 4, ......,t �r © , c.:), to' 4 CO' .67 it CI f /i t6' Fki-74 ' °"• Lf TOWN OF YA°�,M� .NTH r 2.__ ? 1(74r k 4'/r . • ✓` �� REVIEWED F07,!?I!;"CINC AND zCNI,3 CODE CO"IIPLI- ANCE. ERRORS:oR C,,,;ISSIltNiS DO NOT RELIEVE THE - - - ..., APPLICL,NT FROM THE RESr'ONSIBILII Y OF"AS BUILT" OF MA _ � 14. COmPLIANCE, �P��N SS9cti _� MICHELE Gs � � r DATE, ��—� .1 MOILO a t aI gTRUCTURq- cn BUILDINO OF IQIAL No FQ cc Ca1S1E � e— / (5' KiA41/Z- � �. ��`/�� ...../ _, t -SSIONN- G L1,�7� he - cG Olt r x-f f A/t /Ar7t,i-eak 1 ii v,y, t2 Strt, atea. - } . ---- -----\ 7\1 ri. i- I / — - \17 _ -4 V '^` -•mew _ 1� ` k . K .k .„ r? ‘) - . at ' i Y'k K ---\,N ' c - _ _ ...., -'.\..,k v, _ N., --,,,, ,.. .. ) \b & 4 \ . , k''N . 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