HomeMy WebLinkAboutBld-20-001957 _ /Q
V.
ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department o*... yAl
1146 Route 28, South Yarmouth,MA 02664-4492
508-398-2231 ext. 1261 Fax 508-398-0836 41' ■
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 U Only
Building Permit Number: 5/ `AD 4TO/9S jam/.- ,Date A,. ; t O t T '' 7U111
�eA�s 10 )5'-t� - , C
VA.naMa.3 Building Official(Print Name) Signature Date . ..
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Number,
1.1 a Is this an accepted street?yes no 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 Disposa. SRteE: C E 1 \I E
Public 0 Private 0 Zone: — Outside Flood Zone? Municipal 0 On site dlspo�al system —
Check if yes0
SECTION 2: PROPERTY OWNERS OCT 3 1 01
2.1 r Record: b�+ 24 I'x�l -
/ Name rant RlJ1LU!NG D�6r t, i4
(Print)) City,State ZIP �
LI S F► 14n) �� tY, Y 0( 5 3.
No.and Street Telephone Email Address
SECTION3:.DESCRiPTION OF PROPOSED WORIK2(check.all that apply)
New Construction❑ Existing Building❑ Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition ❑
Demolition 0 Accessory Bldg.❑ Number of Units Other 0 Specify:
Brief Description of Proposed Work2:U i1Z'lie.i 4,4101>61. 1! / &7S $ APPIT AAJ(�S
YAM, - W C 41-ivr✓, _XN 51111, L A-1 rj Se/3-'2 ton- N' 4— T it—
i v5uLom 1 .J
• SECTION:4:"".ESTIMATED CONSTRUCTION COSTS. '
Item Estimated Costs: -
(Labor and Materials) • Official'Use Only
1.Building $ :1. Building Permit Fee;.$:1'Sc.'.. Indicate how fee is determined
2.Electrical $ Cl Standard CitytTown Application l ee: ,:
b Total Project Costa(Item 6).x.inultipher . x
3.Plumbing $ 2. Other�Fees: $ �..:� . _.
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) $ Total All Fees:$
•
„j,1 U� Check No. Check Amount: Cash Amo
t
6.Total Project Cost: $ ` )``11
lJ 0 Paid'in Full ❑Outstanding Baiatice Due: I ) :
SECTION 5:.CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
plc 4 l5' /��3/Ze)
UCt I+qS /•!VLte/L) License Number Expiration Date
Name of CSL Holder
G—j /476. tf!L c 2 List CSL Type(see below)4aPr lJ
No.and Street T .e Description
D5 rbavi LGe -v 44- o b5S r Unrestricted(Buildings up to 35,000 cu ft.)
Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Sbi'r-737-37.)-(9 p `4tvize--Ad'4Llc.vet14.A., I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
MvGi i.' F,ur/.p9"h ie ,�i 7 5 /"7 ��z�Z
HIC Registration Number Expiration Date
MC Company Name or HIC Registrant Name
)3 Or ry y tizea LLc '4?u/4.pti4
No.and Street
/tl 1GL 5 A44 o2-€ l 5-0Y-7-57 3ZJ/' Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(l'LG.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 UV—
No 0
. SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT T
I,as Owner of the subject property,hereby authorize t/o'4 10-3 Alt/tc...64/
to act on my behalf,in all matters relative to work authorized by this building permit application.
eai-cly„ 2i,9,D �b a-/C
Print Owner's Name(Ele onic Signature) Date
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.
'DN , m It)/? (1
Print Owner's r Authorized Agent's Name(Electronic Signature) Date
1'p
•
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/batbs
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
4 1„ Department oflndustrialAccidents
'se1111= " 1 Congress Street, Suite 100
.,R= Boston, MA 02114-2017
+� ar www.mass.gov/dia
.. g
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/IndividuaI): /140/(4/J (..1/ ) ei oD N� ` c_
Address: PO )_>c I V7 -
City/State/Zip:MAct`tftau 5 Mt 1.? 04 024,te Phone#: 550 737 =14 e%
Are you a employer?Check the appropriate box:
Type of project(required):
i, am a employer with employees(full and/or part-time).* 7. 0 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. [�-}modeling
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 mY PPam'•ro 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.Q Plumbing repairs or additions
5.❑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: L
Policy#or Self-ins.Lic.#: 1,AG SUO$.v 1,70 12-°l q fl Expiration Date: 9/341/
Job Site Address: 4j e`,7 444t%✓ //�) City/State/Zip: / l�✓l7 /1i -
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.
I do hereby certtiifyqqunder the pains and penalties of perjury that the information provided above is true and correct
V _/-- i Of74 /
Signature: �'uJ
// Date:
Phone#: get'737- 3 7YI
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
b.Other
Contact Person: Phone#:
3. "�.Y -� TOWN OF YARMOUTH
. o� va y BUILDING DEPARThIENT
• �. 1 ,x 1146 Route 28,South Yarmouth,MA 02664
5-�' 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' " frot the proposed work/demolition to be
conducted at tic �` Ir�Y-�/1"
Work Address
Is to be disposed of at the following location: 'y44' 47I .711 Wri. 517917eAj
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
St of A /O 74,
i
ppficalion Date
Permit No.
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
lE:LLC
Rf aistritioi Expiration
r -� .. 05/02/2021
MULLEN BUILT 1- ,till:LING LLC
DOUGLAS MULL `
87 HICKORY HILL r°-' g ...'a•iti
OSTERVILLE,MA 02655 Undersecretary
y
L Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Const` Ctr4Frvisor '
CS-081995 . ires: 0.1/23/2020
I.
DOUGLAS W IAULLE — „
87 HICKORY H5.L CI
OSTERVILLE MA/0 �` ao
Commissioner
DATE(MWDD/YYY1)
ACCORD CERTIFICATE OF LIABILITY INSURANCE 5/3/2019
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 Ashley Paine
Eastern Insurance Group LLC PHONE (800)333-7234 FAX
No):):
233 West Central St A��Ex°::ap •aiva@easterninsurance.com
INSURER(S)AFFORDING COVERAGE NAIC t_
Natick MA 01760 INSURER A Arbella Protection Ins. Co. 41360
INSURED INSURER B Associated Employers Insurance
Mullen Building & Remodeling LLC INSURER C:
PO BOX 1274 INSURER D:
INSURER E:
Marstons Mills MA 02648 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 TYPE OF INSURANCE • ADDL SUBR POLICY EFF POLICY EXP UMITS
LTR INSD WVD, POLICY NUMBER (MIVDD/YYYYL(MIWDDMYYY)
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
A CLAIMS-MADE X OCCUR PR PREEMIMI E S RENTED SES({Ea occurrence) $ 100,000
9520043214 9/8/2018 9/8/2019 MED EXP(Any one person) $ 5,000
PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
X POLICY PRO- LOC PRODUCTS-COMP/OP AGG $ 2,000,000
JECT
OTHER:
AUTOMOBILE LIABILITY COMBINED SINGLE UMIT $ 1,000,000
(Ea accident)
ANY AUTO BODILY INJURY(Per person) $
A ALL OWNED SCHEDULED
AUTOS g AUTOS 1020024224 11/12/2018 11/12/2019 BODILY INJURY(Per accident) $
NON-OWNED PROPERTY DAMAGE
X HIRED AUTOS % AUTOS (Per accident)
PIP-Basic $ 8,000
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAR CLAIMS-MADE AGGREGATE $
DED RETENTION$ $
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY Y/N STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ 1,000,000
OFFICER/MEMBER EXCLUDED? N
B (Mandatory In NH) WCC50050133082019A 4/30/2019 4/30/2020 E.L.DISEASE-EA EMPLOYEE $ 1,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required)
CERTIFICATE HOLDER CANCELLATION
admin@mullenbuilding.cos
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Paul Rybak THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
112 Susan Lane ACCORDANCE WITH THE POLICY PROVISIONS.
Brewster, MA 02631
AUTHORIZED REPRESENTATIVE
John Koegel/MAMURP
®1988-2014 ACORD CORPORATION. Alll rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
INS025/�mami
Kitchen Creations Hogan Residence
560 Higgins Crowell Rd 45 Freemans Way
West Yarmouuth, Ma Yarmouth Port, Ma
Phone 508-775-5311 C 401-575-3305
Fax 508-775-5399 9/19/2019 can125@hotmail.com
Room 1 Not To Scale
#1
213
27 wn44 ..Door88 • �
3/4 3/4
33
23 24I
25 r n 2 3/4 028 4 rah 3r4 11 22 i � ` N O F t 6: t 3 T?'�
19 15, .„.T DW24 „ 2120 18 REF33 17 r i ,
14 ,.. REV IEV�ED f ""'DECOMM.!-
. r r
a: I ANCE. F'^f . ,. r.• I ';;a; RELILVL HILT:
1 IL r u "AS E3UILT"
COM?LiA CE.
DATE;I b
26 - l/
BUILDIN O ICIAL
NOD A E:
_p pp
0 II 1� d am
Door35
�A .ST30
1
18 _18 28 29 30 31
J33 33 30- - 15
�..Win44
#3
213