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HomeMy WebLinkAboutBld-20-002636 ///W/ 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 ' .. xi Massachusetts State Building Code,780 CMRvt-gew , Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Us- Only Building Permit Number:8L_ Z ,3.F, Date Ap. -•: I J r SQ,Ais 1\=13-1c1 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Pro erty Address: 1.2 Assessors 1�p Parcel Num s ic/l /p e., c5c , LM, f h, of 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 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: Nt c4h. i J / e /7 uel;n c,sf- c51cc.fhh /hA v0?D v2 Name(Pri t) City,State,ZIP c/o J / L hes r,e s n Pixy AA w;i( I( )-6qI-a/o2 Shnd Ah tJ+1 J.cowl No.and Street 1 Telephone Email Address _ SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) C3 k i ,i New Construction 0 Existing Building ll. Owner-Occupied 0 Repairs(s) ❑ Alteration(s) 0 Addition 1 , z Demolition 0 Accessory Bldg. CI Number of Units Other 0 Specify: ' ' 1 ccs r i- 4: Brief Description of Proposed Wor1c2: �09 th �tir /�nt� .3 e.( � � 'VGA' ,, i& t ,.....,-• t 1 ...._ir SE T t ES TED CONSTRUCTION COSTS i '°" s ate Costs: ----- Item Official Use Only (Labor-aniclXattgi ) ' 1.Building But __ 1. Building Permit Fee:$ 0 Indicate how fee is determined: 2.Electrical $ _ ❑ Standard City/Town.Application Fee ❑Total Project Cost3( 'em 6)x multiplier x 3.Plumbing $ 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: $ 072.v� 0 Paid in Full /3i Outstanding Balance Due: I\ SECTION 5: CONSTRUCTION SERVICES 5.1 ConstructionSupervisor License(CSL) C� _ I '' Lc ccort_ License Number Exfiratioh Date Name of CSL Holder List CSL Type(see below) la tux ri or ka. No.and Street Type Description r'` Unrestricted(Buildings up to 35,000 cu.ft.) ect'S- rRh�cx.L�i' rni 09,04 R Restricted I&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding _ SF Solid Fuel Burning Appliances (f-°R a(LS -ay ®'Cpltpinierii(5j' d, I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) sit m� �3 /as-/ate HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name i /e96— & ri Cr Et & merit i �' ("PIA;1 L3ni o.and..S#eet Email address &ask- r-A- , MA adc3 fa &r )o7Ca5'041 / . 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 Issua e of the building permit. Signed Affidavit Attached? Yes l 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 SC-Ott T't rr ec} lej to act on my behalf,in all matters relative to work authorized by this building permit application. HIA_OlilLS Cf /le_I�, I t1511 `lPrint Owner's Name(E ectronic11),d ignature) to 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. \Qr u1 Te l S 11 Pnnt O1-6,, VNec rs or Authorized Agent' Name(Electronic Signature) D2e 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 3 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 ram 1 Congress Street, Suite 100 5. g Boston, MA 02114-2017 (7v5.17 ,m,�• www.mass.gov/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): A.A, h.)r 1 i ezr.pCir F.i ors Address: /4s -4S'l4nd / City/State/Zip:6'o hfor) / M14 1:496Te2 Phone #: (48l) c31/( iSCO Are you an employer?Check the appropriate box: 1.14/ Type of project(required): a employer with JOt) 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 8. "emodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. CI Demolition 4. 1 I am a homeowner and will be hiring contractors to conduct all work on m YP roPrtY� e I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.n 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.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[1]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: -Alh,et.,f -ln a r4„Ce 6BrviCeS Policy#or Self-ins.Lic.#: 5 /30?Sd 9 Expiration Date: 9/3C1/c2(.3,30 Job Site Address: lljetifi Ln 800-1, l/RR.-frtoct-fil City/State/Zip:c_Sp4cf h Vi otou , /ylp wiettL/ 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 cer'ify under the pains and penalties of perjury that the information provided above is true and correct. Signature: $f-tP Q l7 9 Date: 11/ /i Phone#: n_3111_4800 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#: `S TOWN OF YARMOUTH o� =z•r:�lg y BUILDING DEPARTMENT Y _l ,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 from the proposed work/demolition to be conducted at // f C./p Lei Work Address q n-r rko..A'Ft, DLLn‘1'. Is to be disposed of at the following location: /604 i- /2,d /rct y —`M Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. ., ,,,,,, -_,.„,:,„z( , —, „ Signature of Application y,s Date Permit No. IFDivision of Professional Licensure • Voriunzan,wea1Th of(-21t,acua&lade(f6 Board of Building Regulations and Standards Office of Consumer Affairs&Business Regulation Cons W�tf��l� rvisor HOME IMPROVEMENT CONTRACTOR p TYPE:Individual i Registration Expiration CS-091911 I 1 pires:05/09/2021 169643 02/25/2020 SCOTT G PIMENTAL ati„ SCOTT PIMENTAL, 125 CURRIERJID t E FALMOUTH4IIA 0260 ."/ , t. SCOTT PIMENTAL�.` � �e� �.'-e'--.--. ‘I'(),,,,,',,,o--- - 125 CURRIER RD. y .�— I EAST FALMOUTH,MA 02536 Undersecretary . Commissioner ... /f9 , (1---- • • AC o® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) tir■... -- 10/3/2019 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 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 CONTACT NAME: Stephen Turner Boston-Alliant Insurance Services, Inc. PHONE FAX 131 Oliver Street,4th Floor _Lac,No.Ext):617-535-7200 (A/c,No):617-535-7205 IL Boston MA 02110 ADDRESS: sturner@alliant.com INSURER(S)AFFORDING COVERAGE NAIC a INSURER A:Executive Risk Indemnit inc 35181 INSURED AAWILLC-01 INSURER B:Allied World National Assurance Company 10690 A.A.Will Corporation INSURER C:Water QualityInsurance 145 Island Street Stoughton, MA 02072 INSURER D:Allied World Assurance Company(U.S.)Inc 19489 _ INSURER E: Federal Insurance Company(Can L 20281 INSURER F: COVERAGES CERTIFICATE NUMBER:1171268146 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 POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER SMM/DDMYYYL(MM/DD/YYYYJ LIMITS A X COMMERCIAL GENERAL LIABILITY 54309528 9/30/2019 9/30/2020 EACH OCCURRENCE $1,000,000 I CLAIMS-MADE 1 X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $100,000 I MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY X PE LOC , PRODUCTS-COMP/OP AGG`$2,000,000 OTHER: $ E AUTOMOBILE LIABILITY 54309527 9/30/2019 9/30/2020 COMBINED(Eaaccident)SINGLE LIMIT $1,000,000 _ X ANY AUTO BODILY INJURY(Per person) $ OWNED I i SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY ._____1 AUTOS HIRED I NON-OWNED PROPERTY DAMAGE I AUTOS ONLY AUTOS ONLY jeer accident) $ $ B X UMBRELLA LIAB X OCCUR 0310-9519 9/30/2019 9/30/2020 EACH OCCURRENCE $20,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $20,000,000 DED I RETENTION$ $ E WORKERS COMPENSATION 54309529 9/30/2019 9/30/2020 X PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE I E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 D Contractors Pollution Liability 0310-9515 9/30/2019 9/30/2020 Each Claim/Aggregate $5,000,000 C Vessel Pollution Liability 53-82099 9/30/2019 9/30/2020 Each Occ./Aggregate $5,000,000 Retention 25,000 1 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Evidence of Insurance CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. A.A.Will Corporation 145 Island Street AUTHORIZED REPRESENTATIVE Stoughton, MA 02072 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD JOB AN OPTIMUM EQUIPMENT COMPANY U-RENT-IT SHEET NO. OF THE TOOL CALCULATED BY DATE 68 Beale Street Quincy, MA 02170 CHECKED BY DATE 617-773-0660 SCALE ', / ; r Li14: iiiIi:y . iI .I { I — I e H ALE C pY TOWN OF YARMOUTH REVIEWED FOR BUILDING AND ZONING CODE COMPLI— ANCE. ERRORS OR C A;:.'ISSIONS DO NOT RELIEVE THE APPLICANT FROM THE RESPONSIBIL1 Y OF"AS BUILT" COMPLIANCE, DATE:0,—)' —)5 UB ILDIt‘ OFFICIAL ' JOB • AN OPTIMUM EQUIPMENT COMPANY SHEETNO. OF U-RENT-IT Twe Too�r�oP« CALCULATED BY DATE 68 Beale Street Quincy, MA 02170 CHECKED BY DATE 617-773-0660 SCALE 1 S' (.-* ... ! ,i•) ... \ i (-3 Th(----- i \ ^ I0 1111 ' ... / y E - —.._ _ L.. .�.�..-_ ' JOB AN OPTIMUM EQUIPMENT COMPANY U-RENT-IT SHEET NO. 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