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HomeMy WebLinkAboutBld-20-001887 • 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 CAS Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use 0 y Building Permit Number: ELIO—azQ Appli : 19 , r SACS 10 to i 5 Building Official(Print Name) ignature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 12 Flintlock Way,Yarmouth 122 11 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: R-40 Residential 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 30 20 20 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public W Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system C Check if yes® SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'ofRecord: Off;j 1 5 2019 Doreen Vreeland Yarmouth,MA 02675 C Name ock(Print)y 774-3 State,ZIP CAW CG�/f C/ 12 Flintlock Way 774353 6078 d.vreeland@gmail.com • No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building E Owner-Occupied ® Repairs(s) 0 Alteration(s) M Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2:Remodel existing 1st floor bathroom. Update fixtures and flooring. SECTION 4:ESTIMATED CONSTRUCTION COSTS - Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 1 1,950 1. Building Permit Fee:$ ISO Indicate how fee is_determined: 2. Electrical $ 700 Standard City/Town Application Fee 0 Total Project Costa Item 6)x multiplier x 3.Plumbing $ 2,350 2. Other Fees: $ 4.Mechanical (HVAC) $ List 5.Mechanical (Fire $ Suppression) Total All Fees.$ Check No. Check Amount: Cash ount: 6.Total Project Cost: $ 15,000 0 paid in Full ®Outstanding Balance e: 1\.5 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-006083 20200114 T. VARNUM PHILBROOK License Number Expiration Date Name of CSL Holder 107 BEACH STREET List CSL Type(see below) Type Description t t N N IS, MA 02638 U Unrestricted(Buildings up to 35,000 cu.ft.) I R _ Restricted I&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding 508-737-0039 ANDREW@PECSG.COM SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 180569 20201130 T. VARNUM PHILBROOK HIC Registration Number Expiration Date Iil6 :eerA liERftgistrantName ANDREW@PECSG.COM i3'EeRt MA, 02638 508-737-0039 Email address City/Town, State,GIP 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 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 See Attached Authorization Form 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 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 y4G/Vc.'tained in this application is true and accurate to the best of my knowledge and understanding. �. T, VARNUM PHILBROOK VA-( 1/tt 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 '=moma'aii� ./, Department of Industrial Accidents �1 1 Congress Street, Suite 100 9�� •_ ' Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/Individual): PHILBROOK ENGINEERING AND CONSTRUCTION Address: 107 BEACH STREET City/State/Zip: DENNIS, MA 02638 phone#:508-737-0039 Are you an employer?Check the appropriate box: Type of project(required): 1.©I am a employer with 3 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. ®Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑ Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 E 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, 12.0 Plumbing repairs or additions 5 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.T Roof repairs These sub-contractors have employees and have workers'comp.insurance.: o.ElWe are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees. [No workers'comp.insurance required.] I *Any applicant that checks box 41 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:AEIC . Policy#or Self-ins.Lic.#:WCC50050140272018A Expiration Date:20191030 Job Site Address: 12 Flintlock Way City/State/Zip:Yarmouth, MA 02675 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 covera e verification. I e�i>�4by ertif u``np�er the pains and penalties of perjury that the information provided above is true and correct. X _ VP ,, Q ate: Phon . 08-737-0039 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#: oF' TOWN OF YARMOUTH BUILDING DEPARTMENT - o . y 1146 Route 28,South Yarmouth,MA 02664 cc)7� ^ -A7,J. 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 12 Flintlock Way, Yarmouth Work Address Is to be disposed of at the following location: Contracted Container Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. y*GN I, 1 OCT 2019 ature of Application Date Permit No. PHILBROOK ENGINEERING &CONSTRUCTION Building • Alterations • Renovations • Homeowner Services 107 Beach Street, Dennis, MA 02638 440 PSI LB ROOK 508-385-8682 P F C S G l\(aAIIRlNC&COKb MLA fit'', WWW.PECSG.COM Owner(s) Authorization Form Date: -30 — 2d/l Project Address: /2 F/Nrcocc (, q wnioips z� To Whom It May Concern: I, �oREan1 W uv (printed name), as OWNER of the subject property, hereby authorize Philbrook Engineering and Construction Services Group, LLC., to act on my behalf to submit for and obtain all required permits to initiate the proposed project at the property. Owners Signature 2�1 Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards COnstroChtin'Supervisor • CS-006083 • Expires:01/14/2020 THOMAS V PH$LBROOK 107 BEACH ST DENNIS MA 02638 A taxa,* al" Commissioner 9 4.64t.olk4 • 4 S. • qiit- DIVISION OF PROFESSIONAL LICE..I4SURE BOARD Of ENGINEERING ISSUES THE FOLLOWING LICENSE REGIPROF MECHANICAL ENGINEER a T VARNUM PHILBROOK 101 BEACH ST L •VI, DENNIS,MA 02538-1828 30890 06/30/2020 494052 \—* Imitaximmiamilsatuselmimiumwau. "r'.. tlil7f.+fd{ligf7f. r.IDQd /3,Pnf -.... Office of Consumer Affair's&.Business Regulation HOME IMF'ROYEMENT CONTRACTOR TYPE;40oolement Card 11/30/2020 T.VAi2Nf1M P D/B/A PHILBR O*ERING&CONSTRUCTION ANDREW Pfilus OO 107 BEACH STREET y DENNIS,MA 02638 Undersecretary • Registration valid for individual use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 1000 Washington Street.Suite 710 Boston,MA 02118 of valid withou gnature ACC,RUa DATE(MM/DD/YYYY) 1.�---- CERTIFICATE OF LIABILITY INSURANCE 9/26/2019 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 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 Karen Bernier NAME: Eastern Insurance Group LLC PHONE Extr (800)333-7234 FAX N) 233 West Central St E-MAIL_ADDRESS:kbernier@easterninsurance.com INSURER(S)AFFORDING COVERAGE NAIC# Natick MA 01760 INSURER AArbella Protection Ins. Co. 41360 INSURED INSURER B Associated Employers Insurance T Varnum & Kelley C Philbrook, DBA: Philbrook INSURERC: 107 Beach Street INSURER D: INSURER E: • Dennis MA 02638 INSURER F: ' COVERAGES CERTIFICATE NUMBER:2019 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. INSR ADDL.SUBR I POUCY EFF POLICY EXP I TYPE OF INSURANCE LIMITS LTR'. INSD�'�WYD' POLICY NUMBER �(MMIDDNYYY) (MM/DOJYYYY) ', COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $! I DAMAGE TO RENTED 1,000,000 A I CLAIMS-MADE l X OCCUR ;PREMISES Ea occurrence _$ 100,000 9520045068 05 8/23/2019 8/23/2020 I MED EXP(Any one person) $ 5,000 — PERSONAL BADVINJURY $ 1,000,000 I GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X ;POLICY!. 1 PRO LOC I PRODUCTS-COMP/OP AGG'$ 2,000,000 i$ OTHER: • • • AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED )SCHEDULED 'BODILY INJURY(Per accident);$ AUTOS 1 AUTOS ._. ._. .. ..._... . .. NON-OWNED I PROPERTY DAMAGE $ ........._ HIRED AUTOS ......i AUTOS Y,LPer accident)_ I UMBRELLA LIAB •OCCUR ;EACH OCCURRENCE !$ EXCESS LIAB _CLAIMS-MADE I AGGREGATE $ DED ;RETENTION$ $ WORKERS COMPENSATION i ;Excluded officers: ... .PER % ;OTH- I AND EMPLOYERS'LIABILITY :STATUTE ER Y/N !ANY PROPRIETOR/PARTNER/EXECUTIVE 'T Varnum 6 Kelley C I EL.EACH ACCIDENT $ 1,000,000 !OFFICER/MEMBEREXCLUDED? I Y N/A• 1 B (Mandatory In NH) Philbrook 1 10/30/2018 10/30/2019 I E.L.DISEASE-EA EMPLOYEE$ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below i NCC50050140272018A I I E.L.DISEASE-POLICY LIMIT $ 1,000,000 i • • • . DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Doreen Vreeland THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 12 Flintlock Way ACCORDANCE WITH THE POUCY PROVISIONS. Yarmouth, MA 02675 AUTHORIZED REPRESENTATIVE � �'- John. Kcegel/MPMURP 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025 0n1401 i ^' d0 o ITI _ 11 i'j 3 _ Z Q r ...I D :yk7 0z7 • f- al -._ ..� _�t-9 '. y 0 i7 _ A Zrrro 0 _'. r ' i-1 r n 8 - , C) ,.� to 4; b (!, m 1 �,� n n T Fz> P m a 3 x C r --\' P i r L r r. � v`' r y l NN P m -- n n O a 'y ,•i ;!t —4 ;'Ii� f l4�IZ d.pG. N(' [ r \ \I--L. LI ". . ( 0 F a 1 _ Z. , v /o S ; -•-•L )F 11 0 Ij } r i ti` Z 2 p1 \ O J Z \` N 1 it/j !! !!! \` Qnf D I 0 s ° NO ._ I. Il m aI \ o W_TI c m • ✓ ril y r 0 3 a /S=o'' !Co" 3 44- 26-0" r_ 9 rn � i IlHI-1-1-2 Z Z O C� a G a m <� 0 k, V 2 o 0 0 ' O .Elcy "- •- pp ur m i i. i I z m g V O D z pm A a---' .1 , "- a• _ -------::://- , a.----7 / a ,...., / e.:". , ' • i..-