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Bld-20-002269 0. 4?-9 —: ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department o `" 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--�r� For Official Use •i y l7�.�[Z Building Permit Number: ` D) c� 6yi Date App ' d- 1 r-N SRAcs ,�.�, 10-a3-I5 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 1.1 a Is this an accepted street?yes i.J no Map Number Parcel Nur§ 1.3 Zoning Information: 1.4 Property Dimensions: s- i Zoning District Proposed Use Lot Area(sq ft) Frontage(t) 1 ? F! c" 1.5 Building Setbacks(ft) Front Yard Side Yards Re I f42t Required Provided Required Provided Required Provided YI�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 OWNERSHIP1 2.1 Ow e 'of Record: _ 1� � w_` ` ro,t_I plc( 0073 Name(Print) City,State,ZIP 1 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) Addition 0 Demolition 0 Accessory Bldg. Cl Number of Units Other 0 Specify: Brief Description of Proposed Work2: $ L .:%t A. Min'1 II + _:=.fit 1 SECTION 4:ESTIMATED CONSTRUCTION COSTS 07.) li , Item Estimated Costs: Official Use Only ' D f7.c 1. Building $ 1. Building Permit Fee:$ISO Indicate how fee is determined: 2.Electrical $ 0 Standard City/Town Application Fee 0 Total Project Costa(Itenct l x multiplier.. x 3.Plumbing $ 2. Other Fees: $ 6S° 4. Mechanical (HVAC) $ List: 5.Mechanical (Fire Suppression) $ Total All Fees:$ �O Check No. Check Amount: Cash Amount• 6.Total Project Cost: $ �� ® i 0 Paid in Full 0 Outstanding Balance Due: III / SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) ` I/ZIb �, Parr License Number Expir don ate Name of C Holder 'YUatpele b^` (2 List CSL Type(see below) No. and Street rV�C Type Description kar} V`_�.�n /��r ��1 Jnrestricted(Buildings up to 35,000 Cu.ft.) �.U1 i W 1(�1 j I V N�( R Restricted l&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding + o I SIF Solid Fuel Burning Appliances a`tQ Fe�o s ^ Insulation Telephone E address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 4ao HIC Registration Number E piratj Date HICi pW5i r IiIC egistrant ame CIA0INo.and treet ` ""'U l TatI � ��(„ �n �j („l ' nll'4��/'1�}�`47 Email address City/Town, State,LW lJ�L '(' �CTW Telephone/V SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(111.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 o 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 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. /0//6 /4 gent's Name(Electronic Signature) D 1 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.zov/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 of Industrial Accidents ?—=11110:am 1 Congress Street, Suite 100 11_ Boston, MA 02114-2017 ,-,� '� www.mass oov/dia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): YiLf Oar( Address: 1°I cie ir City/State/Zip: d' thfloidi Capri( Phone #: 7r14'5'10 0 0S Are you an employer?Check the appropriate box: Type of project(required): l.�I am a employer with employees(full and/or part-time).* 7. New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. [1rRemodeling • any capacity.[No workers'comp.insurance required.] 3.E 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 11.0 Electrical repairs or additions proprietors with no employees. 12.111 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 13.0 Roof repairs 6.❑We 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.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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: AcTitk Policy#or Self-ins.Lic.#: '.CC. OO-s tei /\ Expiration Date: Job Site Address: +A C Onti— City/State/Zip: \(UiYQn utli tMCk c 61 3 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 0 loS Phone#: '7L g'DO`Lf& Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# • Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: 01' Y -� TOWN OF YARMOUTH ' - � If- c B UII,D ING DEPARTMENT 1 = ,x 11�6 Route 28, South Yarmouth,MA 02664 �--y 5=� 508-398-2231 ext. 1261 Fax 508-398-0836 • BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G.L. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section 1115, I hereby certify that the debt-is resulting from the proposed work/demolition to be conducted at_1111 l.a tmrt /' kA /ckrn1 ( 3 Work Address 7 (�q•�,{� Is to be disposed of at the following location: 3-e5 'pcq Said disposal site shall be a licensed solid waste facility as defined by Ivi.G.L. Chapter 111, Section 150A. re of Application / Date Permit No. - Division of Professional Licensure ^' Board of Building Regulations and Standards Const` riprvisor• {' CS-112010 5Pires: 10/Q4/2021 K FANNING PAR =. ,, 00 BOX 457 % • EAST HARWICII MA 0 -• * +Conimitsioner • • • • -� « «— _ . \ .± 2 © : 6 ® : . r .44 } I/ � � \ � 9$\\ � � § i,, \lf^ ) \411 ,1! }2 : . a < §t {� y . . . . � , w y%\ ° A,GO® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) `ini.".."--. 10/16/2019 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 Benson Young&Downs Ins NAME: Kathy Jones 15 Briar Lane PHONN�r�), 508-432-1256 FAXVUC No),508-430-1532 P 0 Box 717 E-MAIL S: kathyjones@byandd.com AppRE Wellfleet MA 02667-0717 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Associated Employers Ins Co 40959 INSURED INSURER B:Penn America Insurance Company 32859 Parr Building&Remodeling LLC INSURER C: 19 Wayside Drive INSURER D: West Harwich MA 02671- 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR sign awn POLICY NUMBER VAVDDIYYYY). (MM/DDIYYYYI LIMITS B X COMMERCIAL GENERAL LIABIUTY PAV0216685 07/11/2019 07/11/2020 EACH OCCURRENCE 1$ 1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED 100,000 PRFMISES(Ea occurrence) $ 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 JET LOC PRODUCTS-COMP/OP AGG $ 2,000,000 I OTHER' $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident $ AUTOS ONLY — AUTOS ) HIRED NON-OWNED PROPERTY DAMAGE I AUTOS ONLY AUTOS ONLY (Per accident) $ _ $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION WCC50050203682019A 04/25/2019 04/25/2020 X STATUTE PRH AND EMPLOYERS'LIABIUTY ANY PROPRIETOR/PARTNER/EXECUTIVE N N N/A E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attsohed If more space Is required) Residential Carpentry CERTIFICATE HOLDER CANCELLATION Al 008861 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF YARMOUTH THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN BUILDING DEPT ACCORDANCE WITH THE POLICY PROVISIONS. 1146 ROUTE 28 SOUTH YARMOUTH MA 02664- AUTHORIZED REPRESENTATIVE I lsaG'L" `'""x @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Cipro, Linda From: Josh Lyerla <totalimpactt@comcast.net> Sent: Thursday, October 17, 2019 12:05 PM To: Cipro, Linda Subject: Approval Attention!This email originates outside of the organization. Do not open attachments or click links unless you are sure this email is from a known sender and you know the content is safe. Call the sender to verify if unsure. Otherwise delete this email. I Donna Maurice approve of parr building(Kyle parr)complete remodeling of kitchen Sent from my iPhone 1 10 Co 8k-, oft* tact t4tgt- Yckrifivuk-h A'\ek 631d15 soaorn pichw LzAyckA--- !, 1 5(1 1 Tr",14- .,1) T REVI:W:D EC' "I,E;IN:AND EC,\ C‘?DE COMPLI- ANCE ERPrkL u,\ ,SSIr",^S nO NOT RELIEVE TH:: ALC!NT=ROM THE PESCONYBILI OF"AS BUILT" COMPLIANCE DATE:I 3-I BUILDING O. !CAL [5.11ye, 1 ;Tr I 4 \ 1 1 • 416n10