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Home My WebLink AboutBld-20-002137 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 a One-or Two-Family Dwelling This Section For Official Use Only Building PermitNumbeeLD 40-6-bei)/37 Date Applied: 040 f:/diey .79 Building Official(Print Name) Signature Date SECTION 1:S TE INFORMATION 1.1 Property Ad�dyress: 1.2 Assessors &Parcel Numbers 1.1a Is this an accepted street?yes no Map Number Parcel umber , (,' P � ��+ � ,.0 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) C ! 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❑ Private ElZone: — Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Name(Print) City,?ttate,ZIP 6105 a vc vZ, /e Rea &S .)303-9 93 earoliNe rn es a)X, eio,s/ No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other ❑ Specify: Brief Description of Proposed Work2: J�;� w' cc7 'r•G 7-1F4f t,Ga.. 15 Lie - —// r' - i;"r 'fir " ,1' ! /r%m `,dose ;46.76, max/ ems SECTION 4 ESTIMATED CONSTRUCTION COSTS. L '' Item Estimated Costs: (Labor and Materials) Official Use Only /257 1.Building $ 1.:Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ 0 Standard City/Town Application Fee 0 Total Project Costa I 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List 5.Mechanical (Fire Suppression) $ Total All Fees: csc. Check No. Check Amount: Cash Amount: 6.Total Project Cost: $`'(5." a 0 Paid in Full El Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5. Construction Supervisor License(CSL) • C)#hl4y es—o3o&�"7 ///6 / ari in„ License Number Expiration Date N e of CSL Holder F6,dsx `�l List CSL Type(see below) V No.and Street Type Description Unrestricted(Buildings up to 35,000 cu.ft.) ��At&,2� ' Restricted 1 c&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances Sob' ? '- 2), r m l'oPlawl4 , ,►4�/� I� Insulation Telephone Email address �'"U Demolition 5.2 Registered Home Improvement Contractor(HIC) /ti1� 2�, u� HIC Registration Number Expiration Date I5O orry�an'y Nn �C Regi ant Name r t ro edAts"�`ry o 6 `, No.and treet Pry --))19 Email address City/Town,State,LIP 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 ❑ 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 7b: OWNER;OR AUTHORIZED AGENT DECLARATION By ente i s g my name below,I hereby attest under the pains and penalties of perjury that all of the information ••ntaine• in this app ' tion o,i e and a ate to the best of my knowledge and understanding. .0.0•;1.4‘ /e/ , •st.t er's or Authorized Agent'�tronic 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/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 1 = a /, Department oflndustrialAccidents .6.1= 1 Congress Street, Suite 100 q »��_t Boston, MA 02114-2017 �,•"'� www.mass.gov/dia 1 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/organization/Individual). rn0,vel Z.:),jy&J/�,/ Address:/ , ,r 96' l `� City/State/Zip: Z /fk # /,,es 4, Phone #: 3Z5$ 9 - as `t' Are you an employer?Check the appropriate bor Type of project(required): 1.CK I am a employer with / employees(full and/or part-time).* 7. ❑New construction 2.111 I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling • any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp. insurance required.]t 9. ❑ Demolition 4.❑ my I am a homeowner and will be hiring contractors to conduct all work on property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.j Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.01 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.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[1]Other 152,§I(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: o•Z fie."3, A,7Cazi Policy#or Self-ins.Lic.#: 6)d -^--3/S ' C c._'7/—C/c Expiration Date: 4 6' -mod Job Site Address: o? I ilJe-91 City/State/Zip: Yarmau y9 NAL Cki)C.?„5-- 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 hereb ertify u,der the pains , 'en;lties of perjury that the information provided above is true and correct. ii ,/ Si•nat'►r_i.i .ice 1i= _ Z.L, 4 Date: 1 f i Phone#: 5 &' 9 25 ,9 ..a>/9 ' 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#: TOWN OF YARMOUTH o 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 I, Section 1113, I hereby certify that the debris resulting frorn the proposed work/demolition to be conducted at 01Ur)}(1&` D` ��rAtv°4 .)12154 Work Address Is to be disposed of at the following location: ylns �� Said disposal site shall be a licensed solid waste facility as defined by M.C.L. Chapter 111, Section 150A. i afore of Applica n Date Permit No. 17 October 2019 Yarmouth Town Hall 1146 Route 28 South Yarmouth, MA 02664 Attention: Bradford Inkley Subject: Building Permit Transfer and Release—Permit No. BLD-19-005948 Dear Mr.Inkley: This letter hereby requests the transfer of the subject permit to be released from Whalen and put in the name of Ray O'Malley CS-030857; Home Improvement Contractors No. 128444 for work to be performed at 25 Pine Street,Yarmouth Port,MA 02675.The fee of$60 is has already been sent. Should you have any questions please feel free to contact me on my mobile phone at 757.303.9993 or via email at caroline.ternesgalvahoo.com. Sincerely, Caroline Ternes, Homeowner Cape Cod Address: 25 Pine Street Yarmouth Port,MA 02675 Permanent Address: 800 Coverdale Lane Virginia Beach,VA 23452 • + ce Wo mw the /A/o0, adut4ee Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Reaistration Expiration 128444 04/07/2021 RAYMOND O'MALLEY RAYMOND M.O'MALLEY ,,..rlc.�+� ' 30 DEPOT ST DENNIS PORT;MA 02639 Undersecretary c Commonwealth of Massachusetts t� Division of Professional Licensure l Board of Building Regulations and Standard's. - Const\�I$t ti ltdpiprvisor CS-030857 ' yires: 11/16/2019 RAYMOND M!OMALL i PO BOX 976 T �ba `�. , ', Y 30 DEPOT ST ,. DENNIS PORTMA102839i 0.AN Commissioner Cl4 • 4 4; Liberty Mutual Workers Compensation Assigned Risk r INSURANCE P.O.Box 66400 London KY 40742-6400 Telephone: (800)653-7893 Fax: (603)334-8162 Email:IMS@LibertyMutual.com RAYMOND OMALLEY P 0 BOX 976 DENNIPORT MA 02639 / June 18,2019 4 '1,".e?3 Policy Number: WC5-31S-622271-019 441:4 , Policy Period: June 8,2019 - June 8,2020 Dear RAYMOND OMALLEY, Welcome to Liberty Mutual Insurance! We are pleased to have been selected to service your assigned risk workers compensation policy.Our team is committed to providing you the best customer experience and most responsive service possible. You should have received your binder from the Plan Administrator. You can use the binder as proof of coverage until we issue your policy shortly.Once you receive your new policy,we encourage you to reference it for details about your coverage. We are here to help. Our dedicated Assigned Risk Customer Service Center can be reached by phone at (800)653-7893 or via email at IMS@LibertyMutual.com. The center is staffed with professionals who are available Monday through Friday,7 a.m. to 7 p.m. (CST)and can answer your questions related to: • General inquiries regarding your coverage • Loss Runs • Billing inquiries-questions about payments,invoices • Premium audit inquiries Contact your agent if you need: • Certificates of insurance • Coverage in other states Your agent can request certificates of insurance from the WCRIBMA website. Report a claim: Have a safety & health question? Phone: (800) 362-0000 Phone: (866)757-7324 Fax: (800) 969-3062 Email: RCConsultingCenter@LibertyMutual.com Email: ciclaimreports@LibertyMutual.com Please see the reverse side for important reminders. 1M 0026 0211 WC5-31S-622271-019 Page 1 of 2