Bld-20-002583 43h/
ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department oF "r
1146 Route 28, South Yarmouth,MA 02664-4492e ���!!��
508-398-2231 ext. 1261 Fax 508-398-0836 i.•,.�,v..:4
Massachusetts State Building Code, 780 CMR . *je .,
Building Permit Application To Construct, Repair, Renovate Or Demolish
a One-or Two-Family Dwelling
EIV '
This Section For Official Use Only '1. -RECEIVED '
-i
Building Permit Number: �� '� ,Date A d:
; 11" Seflcs - \1-1 y , 1 - i
2,
Building Official(Print Name) Signature '
- --IT
SECTION 1:SITE INFORMATION - }
1.1 Property Address; / D 1.2 Assessors_] Ix&Parcel Number�o
9 Idteei LGA. Gv Q( /
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❑ Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIPI
2.1 Over! f Recor
Name(Print) City,State,ZIP
29 how Strec 6/7-6.45-8306 £borgeS 2?e is Ogd.(Ow,
No.and Street Telephone Emai 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. ❑ Number of Units Other li Specify:
Brief Description of Pro sed Work2: je.44j yea o/ £c{. /jf;,rr A ejrii, D -
h/' •41 ' Aro?, for ow !v Ios-d • in a too 04-.0 o
.t 'Ps a. .ft-4I i'vrID • ' AG" .' /19 a--/44
0✓i M S x i fifi%t�
SECTION 4:ESTIMATED CONSTRUCTION COSTS.
Item Estimated Costs: Official Use Only
(Labor and Materials) ,b.,z
1.Building $ /8, 5-90 1.. Building Permit Fee:$ S o Indicate how fee is determined:
2.Electrical $ Pi Standard City/Town Application Fee /"' 7 L.2-
0 Total Project Cost3(Item 6)x multiplier " x
3.Plumbing $ 2-5 S 2. Other Fees: $ „57--,
4.Mechanical (HVAC) $ —
List
5.Mechanical (Fire
Suppression) $ ----- Total All Fees:$
D Check No. Check Amount: Cash ount:
6.Total Project Cost: $ /d 8 y ,�
� 0 Paid in Full IN Outstanding Balance ue: 115
` SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) O9790,29 /0,0f. 2020
1O'1;74I £fJ/ 'hiza- License Number Expiration Date
Name of CSL Ho der �) / Q
List CSL Type(see below) vnr.0 1 I 1,
60 ,�� 1'1 414
No.and Street Type Description
ja,4 ith d hJ� Ill 'L6`ff U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted I&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
�^ WS Window and Siding
5'1 291.Ir23 p a ; p'a h SF Sold Fuel Burning Appliances
/'T Ki i '���1 I Insulation
Telephone Email address D Demolition
5.2 Registered
Home Improvement Contractor(HIC) �6 9148 �, ��.2p20
&/,0t/ 4,,, f'M '1 4�G/y10 4%.ff, !�—G HIC Registration Number Expiration Date
HE Company Name r�C ant Name �/ `_ L /
No.and S eet fff`"'''' kiporfklai e G�Y.0. GO/'I
N• N. AAO ,1/1/14L, W iV i123 Em address
City/Town, State,ZiP 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 t( 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.
S i ►*(
P a.t Owner's Name(Electronic Signature) Date
SECTION 7b: 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 acc e b of my knowledge and understanding.
Dm;l/'t �4/`l,�f�, /0. 3o. /9
Print Owner' or Authorized Agent's Name tonic gnature) 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.2ov/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
• Z Department oflndustrialAccidents
•
1 Congress Street, Suite 100
` Boston, MA 02114-2017
IMP 5�• •� www.mass.gov/dia
\'orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): ,8 G/,p♦ fi i44''7 D(t g 'P g7 u�
Address: fZv Ja4-i a`l '1 A i
City/State/Zip: �jjf, if /N, h /Hi Phone #: , , 297 4.1.123
Are you an employer?Check the appropriate box:
Type of project(required):
1.0 I am a employer with employees(full and/or part-time).* 7. 0 New construction
2.1?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 1 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 m y p roPrtY�
e I will 10 n Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions
proprietors with no employees.
12.r]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.: 13. Roof repairs n --
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.1gOther G�f�'l�/r i..er LfG�'O
152,§1(4),and we have no employees.[No workers'comp. insurance required.] WitAl ram f/
*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: Anfatar, .i7p , �p
Policy#or Self-ins.Lic.#: `l/Ci0/6' 9of Expiration Date: OS. 04. 2 0
Job Site Address: / d'7f'/V?' G /( +i City/State/Zip: , / /*ern4e-4-/4_
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 certify under the pains lti of perjuiy that the information provided above is true and correct.
Signature: /O. 5 /`3
Date:
Phone#:
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#:
f '1'� Y o TOWN OF YARMOUTH
` Q) :�lg c BUILDING DEPARTMENT
1 = 11�6 Route 28, South Yarmouth,MA 02664
t*�.-L 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 I, Section 111_5,
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at I give,- Iect.0 Z. G,! Y�,,,07 744-
Work Address
Is to be disposed of at the following location: -CV \T , D-e/l",/,,g— M 1
I,xC 9
Said disposal site shall be a licensed solid waste facility as defined by N/LG.L.
Chapter 111, Section 150A.
Ale/ AC/ /a i-a. i 9
v ration
Date
Permit No.
ACCP E® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY)
10/11/2019
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 Deborah Kelly
LEONARD INSURANCE AGENCY PHONE
t .Ext); (508)428-6921 A Nod
CRESS: DeborahK@Leonardagency.com
683 MAIN STREET SUITE B INSURER(s)AFFORDING COVERAGE NAIC#
OSTERVILLE MA 02655 INSURER A: AMGUARD INSURANCE CO 42390
INSURED
INSURER B
BELPORT BUILDING AND REMODELING LLC INSURERC:
INSURER D:
P 0 BOX 2881 INSURER E:
HYANNIS MA 02601 INSURER F:
COVERAGES CERTIFICATE NUMBER: 459930 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 LTR TYPE OF INSURANCE INSD SUBR POLICY NUMBER POLICY EFF POLICY EXYV UNITS
(MMIDD/YYYY) (MMIDD/YYYIf)
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
CLAIMS-MADE OCCUR DAMAGE TO RENTED
PREMISES(Ea occurrence) $
MED EXP(Any one person) $
N/A PERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
POLICY JET LOC PRODUCTS-COMP/OP AGG $
OTHER:
S
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
(Ea accident)
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $
NON-OWNED PROPERTY DAMAGE
HIRED AUTOS AUTOS (Per accident)
UMBRELLA 1lAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $
DED RETENTION$ $
WORKERS COMPENSATION X S ATUTE OTH-
AND EMPLOYERS'LIABILITY Y I NER
ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000
A OFFICER/MEMBEREXCLUDED? N/A N/A N/A R2WC062905 05/04/2019 05/04/2020
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ 500,000
N/A
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached It more space Is required)
Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay
claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts.
This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the
issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification
Search tool at www.mass.gov/Iwd/workers-compensation/investigations/.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS.
1146 Rte 28
AUTHORIZED REPRESENTATIVE
�
nwk
S Yarmouth MA 02664 Daniel M.C y,CPCU,Vice President—Residual Market—WCRIBMA
I
@ 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
TYPE:LLC
alNINktIgg_ Egabligg
1641M- 04/16/2020
BELPORT BUILDING&REMODELING,LLC.
MAZHEIKA DZMrTRY
60 JOSIAHS PATH
WEST BARNSTABLE,MA 02668
Undersecretary
Commonwealth of Massachusetts
Division of Professional Licensure
' Board of Building Regulations and Standards
ConstructiOn'Supervisor
CS-097029
Expires: 10/08/2020
DMITRY MADEIRA 4
60 JOSIAH'S PATH , s
WEST BARNSTABIX MA 02668 11
Commissioner .CA-
D '
and are
The ��and O° g.Ldsfacto prized to do
Remodel
t#)e waif as tpedtied.
of the contra-and
.:tb-work st ai bogie to the sig f9 you.the buyer may
Olhil()wryer a SPY of s and of the third business
camp;OEauguac on at any rye Prwr
eeY A QO
$18,845
TOTAL
Accepted Date —
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