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HomeMy WebLinkAboutBld-20-002661 ` t "/ Y4, ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department or ► 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 S tion ForI Official Use I • ••7 Build' Perot Number. . W ./l • mg o ®� ' Date )� i�i i r; �Qf► S 11 -1 • ) x •Building Official(Print Name) a'attire Date.. SECTION 1:SITE INFORMATION:: .' 1.1 P�,ppertynAdGress��� �\/ 1.2 Assess��Map&Parcel Numbers�' 1.la Is this an accepted street?yes ‘/ no Map Number Parcel Number 1.3 fogmg 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 CI Private CI Municipal Outside Flood Zone? Municipal 0 On site disposal system ❑ Check if yes❑ SECTION 2: .PROPERTY OWNERSHIP., -. z;F•if'": & 3 2.1 Dyinerl of Recor Nc, p11, u)G(,l r Name t) I City,State,ZIP ('A t °! !7'_ • J(1, No.and Street Telephone Email Address SECTION•3, DESCRIPTION OF PROPOSED WORK2(check;all`thatapp ) New Construction❑ Existing Building' Owner-Occupied Repairs(s) ❑ Alteration(s)" Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work2: 12.e .l -- ) k c,,c-c 1 Et,kd.�. Jw SECTION 4rTSTIMAkTED CON T IJCTI COST Estimated Costs: Item (Labor and Materials) : 1.Building $ Z v' S--7 v 1 Bu2lding I'er itd~ee o$ ?.. indicate how fee is determined 2.Electrical Standard Gity/Town Application Pee. it9 T'oial Project Gosh(Item 6)x multiphor x 3.Plumbing $ S'iO(�7 2 Other,Fees: $ 4.Mechanical (HVAC) $ List t 5.Mechanical (Fire $ Suppression) Total 11 Fees $ 6.Total Project Cost: $ COO C he.010o Ch •cic Amon Cash Amaunt laid in Full Outstanding Balance Due _ SECTION 5:.CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) n'Co G e o y-g e. 31 V Ur License Number Expi do Date Name of CSL>Holder 36 t I OY1�' l, v r e,� List CSL Type(see below) No.and Street �`�l 1 Type „ ,. Description J'o r>u f J& Ya,r w�.o l�II M p 0I.Cp(p 4 U Unrestrictedesctd1 (Buildings Family up tol 35,000 cu.ft) u- !'l J A R Restricted I&2 Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances lei oQ i�q iF- d rd u2,. ('1 d iu t� ( c f.o rc P,GQ cui l ire.0 coo.) I Insulation Telephone V .,Emtlil address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 1020164. oBIC q I �G HIC Registration Number Exp a U ate amettRegisVant Name „ can, cr5 rce,t r(bp ro .dIn-vtp wc.,Cat, 7N . Street `'�J E address ity/Town,State,ZIP Telephone SECTION.6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.in.§ 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 f 0 rel 6 ctv Cf, 1 ikt, to act on my behalf,in all matters relative to work authorized by this.building permit application. 'Ocf pkw� eLl.y ii I ..11? Print Owner's Name(Electronic Signature) , Date • • SECTION 713;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 contained in this application is true and accurate to the best of my knowledge and understanding. �do .17 2 V(s I I Print 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 =•l Department of Industrial Accidents j= 7 1 Congress Street,Suite 100 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 Please Print Legibly Name (Business/Organization/Individual): G 6o(5 e, ctv U', Address: 33 Noy I"�l�.lJn cf- V n et City/State/Zip: tI. Y Ly pik,Q i,1 , 1 ft l o 61 ? Phone#: ,11101 9 + - D Are you an employer?Check the appropriate box: Type of project(required): 1.JI am a employer with 13 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. ErRemodeling any capacity.[No workers'comp.insurance required.] 3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition 10 El 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 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13•❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We area corporation and its officers have exercised their right of exemption per MGL c. 14.El 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. tContractors 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. y Insurance Company Name: tl`T(6e Lo. `,GA, PI.d:(,l:c('tr l(4T kcP ckrCt,h,CC, Policy#or Self-ins.Lic.#: to •5 00 , '(11 4,3 J O„2 Q J 1, Expiration Date: 3/ e o�Q Job Site Address: 0 @ LI.k(r r ?calk) City/State/Zip: 62-ti ya,r{(,t,(96.,tk) Attach a copy of the workers'compensation policy declaration page(showing the policy number and aration 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 certify under ai and penalties of perjury that the information provided above is true and correct. , Signature: Date: '1/4./f 9 Phone#: ,.5 OP -3 (�{ 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#: r TOWN OF YARMOUTH • $ BUILDING DEPARTMENT o • H 1146 Route 28,South Yarmouth,MA 02664 'LA �,,;T;, H s 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 13 U 4 W't(v "Pak yQ opt ouil i Work Address Is to be disposed of at the following location: d,4 trFXC,o Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. � I/4/19 Signature of Application Date Permit No. 0.Ae. aminowrisece,%o Q•L(c, ac/zute/) Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 160164 07/01/2020 One Ashburton Place-Suite 1301 GEORGE DAVIS,INC. Boston,MA 02108 GEORGE F•DAVIS 33 NORTH MAIN STREET SOUTH YARMOUTH,MA 02664 Not valid without signature Undersecretary • a Commonwealth of Massachusetts Division of Professional Licensure ® • Board of Building Regulations and Standards Const` :etlitr §iS'p rrvisor • CS-056130 ppires 03/01/2021 • GEORGE F DAVIS >s 33 N MAINST� $' SOUTH YARMOU/TH MA 02664t • Commissioner C,L • • • • • • • :�i n ��...40 GEORDAV-01 KSCHULTZ ACORO® CERTIFICATE OF LIABILITY INSURANCE DATE D/YYYY) `-� 3/8/2019 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: Mason&Mason Insurance Agency,Inc. PHONE FAX 458 South Ave. (A/C,No,Ext):(781)447-5531 (A/c,No):(781)447-7230 Whitman,MA 02382 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Western World 13196 INSURED INSURER B:NGM Insurance Company 14788 George Davis,Inc. INSURER C:Associated Industries Insuranc 33 North Main St. INSURER D: South Yarmouth,MA 02664-3437 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 SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTRINSD NIVD (MM/DD/YYYYI (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR NPP1516170 1/12/2019 1/12/2020 DAMAGETORENTED 100,000 PREMISES(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 POLICY IMF LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ ANY AUTO _ M9M28491 10/26/2018 10/26/2019 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOSRE� ONLY X AUTOS BODILY BODILY INJURYp (Per accident) $ X AUTOS ONLY X AUOTO ONLY (Perr acc cent)AMAGE $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ C AND EMPLOYERS'COMPENSATION Y/N X STATUTE EERH WCC50050143902019A 3/5/2019 3/5/2020 500,000 ANY PRRO/PMRIIETgORR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ Mandatory fn NH)EXCLUDED? N N/A 500,000 E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) office copy CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE George Davis Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 33 North Main St. South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE C7Z— I - ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 6. No work shall begin prior to the signing of the contract and transmittal to the owner a copy of such contract. Entire Agreement This Agreement represents and contains the entire agreement between the parties. Prior discussions or verbal representations by the parties that are not contained in this Agreement are not part of the Agreement. Permit Authorization By signing below, the Owner(s) authorize George Davis, Inc.,to act on Owner(s) behalf relative to the work to be performed at this address. Project Address: 8 Dunster Path; West Yarmouth, MA 02673 Our signatures indicate that we have read, we understand, and we accept all provisions of this agreement. Owner Date DU 3/ {2' se h Dwelly Contractor Date /O.-S O./7 George Davis, President George Davis, Inc. Initial Initial Pnirn 7 rd "j • of a TOWN OF YARMOUTH HEALTH DEPARTMENT s PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET To be completed by Applicant: \\ Building Site Location: �Du- �rtnr 'I ath W e r t Yar -ou..tA) Proposed Improvement: ti)va,to LK n±h on , ((,pLeue, Lof f/t ILow Applicant: � eo r L 3a /Lu 'r1 Tel. No.:, C - tt Address: 3 Wort ai d Ya,riko�(�t�. at/0Date Filed: l � � eY **Ifyou would like e-mail notification of sign off please provide e-mail address: Owner Name: TocpL LoeLL( Owner Address: JCL it[ Owner Tel. No.: V/-3 G ii- GIS RESIDENTIAL AND/OR COMMERCIAL BUILDING HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements For Septage Disposal and other Public Health Activities. Please submit three (3) copies of plans, to include: (1.) Site Plan showing existing buildings, water line location, and septic system location; (2.) Floor plan labeling ALL rooms within building NOV 0 5 2019 (all existing and proposed) — HEALTH DEPT. Note: Floor plans not required for decks, sheds, windows, roofing; (3.) If necessary, Title 5 application signed by licensed installer with fee. REVIEWED BY: DATE: I Li Sit PLEASE NOTE COMMENTS/CONDITIONS: Property of George Davis, Inc. Do Not Reproduce 11 /1 /2019 FILE COPY Page 1 of 1 Existing window - replace n - _ 0 Shower-to-tub conversion New: • Ceiling, Nails, Floor • Replace window(tempered) • Cabinety & Counter •Toilet • Shower base & fixtures •Add exhaust fan • Update electrical • Replace heat coverTrim © • Paint 0 • New Med-cab, mirror & accessories V Existing Door - Remain 5' TOWN OF YARMOUTH NOV 0 5 2019 REVIEWED FOR BUILDING AND ZONING CODE COMPLI- ANCE. ERRORS OR CNt,,,IISSIONS DO NOT RELIEVE THE HEALTH DEPT. APPLICANT FROM THE RESPONSIBILITY OF'AS BUILT" COMPLIANCE. DATE:1\- tut t5 Bath Remodel BUILDING 0 C L Plans for: Joseph Dwelly 33 North Main Street 8 Punster Path South Yarmouth, MA 02664 YVest Yarmouth, MA 0203 (508) 394-0832 www.GeorgeDavisInc.com