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HomeMy WebLinkAboutBLD-20-001012 - OM if cr , ONE & TWO FAMILY ONLY-BUILDING PERMIT Town of Yarmouth Building Department ; 'oF 1146 Route 28, South Yarmouth,MA 02664-4492 • �� 508-398-2231 ext. 1261 Fax 508-398-0836 `R ' �'4� Massachusetts State Building Code,780 CMR Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: ,e40— ,9- ,4")/2----. Date Applied: ht. 9Ars 1 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION. 1.1 Property Addres 1.2 A sess rs Map&Parcel Numbers 1.1a Is this an accepted street?yes no Map Number Parcel Number RECEIVED 1.3 Zoning Information: 1.4 Property Dimensions: ^- Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) SEP 9 201� 1.5 Building Setbacks(ft) IL I P T 19 T1 Front Yard Side Yards Rear Yarr By 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 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: ,�j .34,✓i o/ --Z.- W i v/�c Z,v //a. r>-►Z.sw /`(4 77. e--Zi 6'6 y Name� (Print) City,State,ZIP �+�j / C,fai Oak 9�g�d(�"' �/J 0� ��Z�n/ )GK<.Y ( 9r7all/.cu� No.and Street{ Telephone Email Address / SECTION 3:.DESCRIPTI OF PROPOSED WORK'(check all that apply) New Construction 0 Existing Building Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0' rtytin la ! V E �) Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: r. -fir' 7 Brief Description of Proposed Work2: /3' A r , Y Y"1 'e , ' 0b i SECTION 4:ESTIMATED CONSTRUCTION COSTS. -- � Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ '- d Q d 1.. Building Permit Fee:$I So Indicate how fee is determined: 2.Electrical $ i le Standard City/Town Application Fee d o d 0 Total Project Cost3(Item 6)x multiplier.. x 3.Plumbing $ I/ d d d 2. Other Fees: $' 3 4.Mechanical (HVAC) $ ' List 5.Mechanical (Fire Suppression) $ Total All Fees: Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ /d` ad 0 0 Paid in Full Outstanding Balance Due:II c r SECTION 5:.CONSTRUCTION SERVICES 5.1 Construction Sup sor License(CSL) d q, /S 7/3 di' 6Z ci 1 License Number Expiration Date N o CSL older ` r d z y A 0Listf CSL Type(see below) V 1 No.and Street Description .T I —V U Unrestricted(Buildings up to 35,000 Cu.ft.) e, t a,w 0. Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances So75 36`77oSO OR.4®sa,,-.d(otol)1 1o.tCwg-Li+, I Insulation Telephone Email address D Demolition 5.2 Regis red Home Improv ment Contractor(HIC) / 9 3 6 .7 /d/,t.c2 d S`; C� S L �' HIC Registrn Number Expiration Date HIC Company Name or HIC R,�- istrant e y[ /i_5 j R /,-..tn.-i 4 se 5a //_st f ci., o»15-t o PA No is'Itik o�, 6Z6 0% 505fttgii�6/ ,/ Email address City/Town, State,LIP Telephone �f SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) Workers Compensation Insurance affidavit must be c pleted and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuanc 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. a‘/) 9 A 7 Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION By entering my e below,I hereby attest under the pains and penalties of perjury that all of the information contained in s application i�true and accurate to the best of my knowledge and understanding. //l "--N....• g7 ) q A 7 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.eov/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 cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" The Commonwealth of Massachusetts Department oflndustrialAccidents _:111111= 1 Congress Street, Suite 100 1.4 = Boston, MA 02114-2017 N. "•�`'� www.mass crov/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): S(jl'vim adet/ CUSYCYr s Address: c3,19 fer‘ f A 74, 6- c; City/State/Zip: 5 d l�l�' 1 f Gt Phone #: Saf Are you an employer?Check the appropriate box: Type of project(required): l t am a employer with I employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. f Remodeling ' any capacity.[No workers'comp. insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.] 9. ❑ Demolition 10 El Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11. Electrical repairs or additions proprietors with no employees. 12.[]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.a 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: y2C/'et(*44 F4V44, Policy#or Self-ins.Lic.#: G4JCC. —63 45.-b 9t70. / /e Expiration Date: /W 9 Job Site Address: 7 (4 p I Y I1. City/State/Zip: .SG . yo/MVy1+ d" "-/ 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 ce fly under he ai s penalties of perjury that the information provided above is true and correct. Signature: Date: 67 A" Phone#: c (( 9-5-6( 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#: •°� Y�-� TOWN OF YARMOUTH • o BUILDING DEPARTMENT 1-31146 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 1113, I hereby certify that the debt-is resulting from the proposed work/demolition to be conducted at "2 (c,'I yct Work Address Is to be disposed of at the following location: c vnj ` X1'7/1/444' Said disposal site shall be a licensed solid waste facility as defined by NI.G.L. Chapter 111, Section 150A. Signature (/C//5 re PPlicahon Date Permit No. .T4 W 4- Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, M .„.husetts 02118 Home Improve -. tractor Registration i .=7k' . , Type: Corporation SAND DOLLAR CUSTOMS LLC 2 i', Registration: 193567 M -_y ? Expiration: 10/29/2020 1851 FALMOUTH ROAD 441, CENTERVILLE,MA 02632 _ a c == sf Tr 11 w Update Address and Return Card. SCA 1 0 20M-05/,7 ,7i g mo.w eadl o/. a�wo�iaJa!!� Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TY . oraorafion before the expiration date. If found return to: Exoirotl=n Office of Consumer Affairs and Business Regulation _ 10/29/2020 1000 Washington Street-Suite 710 SAND DOLLAR Boston,MA 02118 Li WALTER R.WA w VV, Cc 1851 FALMOUTH ;, 6 CENTERVILLE,MA 02632 Undersecretary Not v." - I out Ignature it Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constr.1tc4:‘3i1`%itpervisor CS-091653 4 r Wires:09/30/2020 I'd WALTER R ' - C 40 ALEXAN 0* YARMOUTH P MA f _• >` Commissioner L. ""' SANDD-2 OP ID:DS '`��CRCP CERTIFICATE OF LIABILITY INSURANCE DA12/19/20 8 TE ) 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 M 508-775-6060 CONE:TACT Bryden&Sullivan Insurance Bryden&Sullivan Ins Agency PHONE 508-775-6060 I FAX 508-790-1414 88 Falmouth Road (ac,No,Eat): (A/C,No): Hyannis,MA 02601 Wass: Bryden&Sullivan Insurance INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Mapfre Insurance 34754 INSURES INSURER B:Associated Employers Insurance an o11 Cus ms LLC outh Yarmouth, A 02664 INSURER c INSURER D: 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. INTRR TYPE OF INSURANCE ADDL 1NVD POLICY NUMBER JMM/DDY EFF I IMM/DDY�I LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY jEeT LOC PRODUCTS-COMP/OP AGG $ OTHER: COMBINED $ A AUTOMOBILE LIABILITY (Ea accident) SINGLE LIMIT ANY AUTO BHMWLT 02/02/2018 02/02/2019 BODILY INJURY(Per person) $ 100,000 _ _ AUTOSAE ONLY X AUTOSSyUyLNEED BODILY INJURY(Per accident) $ 300,000 X AUTOS ONLY X AUUTOS ONLDY (P20PERTY DAMAGE $ 250,000 er acc dent) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION PPER ATUTE ERH AND EMPLOYERS'LIABIUTY WCC50050197212018 12/04/2018 12/04/2019 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ FICERAIEMBgER EXCLUDED? Y NIA 500,000 (Mandatory m NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Certificate issued for insurance verification. CERTIFICATE HOLDER CANCELLATION COMMUNT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The Community Development ACCORDANCE WITH THE POLICY PROVISIONS. Partnership 3 Main St.Mercantile AUTHORIZED REPRESENTATIVE Eastham,MA 02642 Bryden&Sullivan Insurance ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Sand Dollar Customs LLC Estimate 23 Whites Path Suite G2 Date Estimate# South Yarmouth MA . 6/5/2019 362 02664 Name/Address Dave Zwicker 7 Captain York South Yarmouth Ma. 02664 Project Description Qty Cost Total Hall Bath Remodel: 0.00 0.00 7 Captain York,South Yarmouth Ma. Gut bath. Install curbless shower. . Enlarge entryway door to 36". Install new sub-floor and tile floor in bath and shower floor.Tile allowance$6.00 per square root. Install solid surface walls on shower area walls. Install two grab bars in shower area. Install one fan Tee light in bath area. Install two grab bars around toilet,(one rear,one exterior wall side). Install comfort height toilet,allowance$500 includes toilet,new shut off and labor to install). Install new vanity and vanity top,allowance$2000.00 for cabinet $1000.00 for vanity top. Electrical allowance$750.00 Plumbing allowance$1500.00 *Does not include any finished electrical or plumbing fixtures. Owner agrees to allow disposal container on site during construction. All construction related materials to be removed by contractor. Owner agrees to allow contractor to install street sign for advertisement purposes for duration of project. Owner allows contractor to take pictures of work and to use pictures for possible future advertisement purposes. All materials to be of first quality. • Total Customer Signature �c� � "1jr>._ Page 1 — i .,..n, i V...:-....I eti;e.„ i_.. i 1 ot=Y`kk TOWN OF YARMOUTH .- 1„.,..i ` c 4HEALTH DEPARTMENT .,;. PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET To be completed by Applicant: l/ Building Site Location: 7 CA Ye ( k , , Proposed Improvement: P cl a, a Re 1,--1 e At.. 1 C k 7 )''1 j Applicant: /J i,�, XI'('-e ri Tel. No.:s'0S(-0 y -.S 6/ Address: Z 3 Z/dt.5 is'..,, uJ 6--Z.. Date Filed: '/9 // , **If you would like e-mail notification of sign off please provide e-mail address: Owner Name:�A, ,�, j 1^" 4`t y Owner �7, Ye i Owner Tel. No.:/ 7�'So�" Z S'CS Address: -7 C=70 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: 0)711r-1DATE: `J l " G /I I. l PLEASE NOTE COMMENTS/CONDITIONS: I ,,,, 1, -Ns-J t..) 7 —7— 0 / ' i t4 � � A 7 C -1 ip. Yo r k _______y__ 0% ---- — _ --— /3,4 ko ,„ . ittc,, TOWN 0 i ' E {- REVIEWED FOP II!!.'PING AND CCU:";(;LODE COMPLI- ANCE. ERPCk;; ,IsS:)h!S nC NU1 RELIEVE THE APPLICAa FROM TH st UN BILl i Y OF'AS BUILT" COMPLIANCE. DATE: b -A `N BUILDING OFFIC L Mal COPY