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HomeMy WebLinkAboutBld-20-002918 —a- - /// 011. ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department o* 1146 Route 28, South Yarmouth,MA 02664-4492 1,1 508-398-2231 ext. 1261 Fax 508-398-0836ir !I'� 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 Use Only Building Permit Number:23Z.D.- ao-03 A 9 ,Date Applied: i . ii.,, e--,5a/l Building Official(Print Name) Signature Date . SECTION 1:SITE INFORMATION • 1.1 Pro ertyAddress: 614 1.2 AssessorsZ2 Map&Parcel Numbers "1-1 1.1a Is this an accepted street?yes k no Map Number Parcel Number 1.3 "toning Informatio S 1.4 PijQperlytim�pteas: 723 Zoning District Proposed Lot Areae (sq((tt)) Frontage(ft) (,'t("Y.1:-* 1 I I 1.5 Building Setbacks(ft) Ni,tt I f 5 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. I R of Re d:KkL U ,6e 6 73 Name(Print)s` City,State ZIP S(3 keIC b A , No.and Street Telephone Email Address SECTION3:.DESCRIPTION OF PROPOSED WORK2(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.0 Number of Units Other ❑ Specify: Brief De cri.tion Proposed W.rk2: Q'• / 4 'i' ' o. - y frs�'P.�2. 'i — ,A1" 0 %Ara& C'� '.-fitry p! + k p'h - or„• &De 0 2ud ' Pic.sf . SECTION;4i ESTIMATED CONSTRUCTION COS . - Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ O•, :1.:Building Permit Fee:-$19 Indicate how fee is determined: 2.Electrical $ 0 ❑Standard CitylTown Application Fee ': ❑.Total Project Costa(Ite multiplier x 3.Plumbing $ 2: Other Fees: $ • List 4.Mechanical (HVAC) $ ._ ... . 5.Mechanical (Fire Suppression) $ Total All Fees:$ I Check 1No. Check Amount: Cash Amount: //, "' 6.Total Project Cost $ 0 Paid m Full ElOutstanding Balance Due: `•. SECTION 5:.CONSTRUCTION SERVICES 5.1 Corti ct S ervisor License(CSL) CS-- S_ /►Y()I tC1 u IV 2 j '��Jr ir]�1 /V���l�/�� Licenseic Number 1� IJ Expiration ate Name of CSL Holder Elf3X !)S k List CSL Type(see below) 41 !Di_. ±.* 0 ` No and Stre t Type Description k tinitlatat U Unrestricted(Buildings up to 35,000 cu.ft.) City/Town,State,ZIP R Restricted I8c2 Family Dwelling M Masonry VIA © ,64- RC Roofing Covering WS Window and Siding 6 1 0631 S 110 ,tiqc..10 SF Solid Fuel Burning Appliances ��,,}} T Insulation Telephone mail address D Demolition 5.2 'e!' ter d Home Improvement Contractor(HIC) C' '` 1 ii214, 2D ,,� (l� HIC Registration umber Xpirrataon Date �f 111" �•''!�p��a''n��� e r 'strant ame thdie S �e toles mt. ►'L `. en tatiet V Zb�(,, 6bica 1 d es7 Email address City/Town,State,ZIP `�C( ��vVTeelepphone SECTION 6:WORKERS'COMPENSATION INSURANCE ANT.WAVIT(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? Y�s yi 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 to act on my beha in 1 matters relative to work authorized by this building permit applicati . P � t. Print er's ame lectronic 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. I) itvut� , s Name(Electronic Signature) Date9 _ t ii 20 (C' Print e umoned Age z � 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.) wy, . (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 ►R. / Department oflndustrialAccidents — _ 1 Congress Street, Suite 100 • �1 _ 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 Rely Please Print Legibly Name (Business/Organization/Individual): Relwos Address: 23 City/State/Zip: 'S kfpropitatAPhone#: O'iC CM 0 657 Are yo an employer?Check the appropriate box: 1 Type of project(required): I 1 am a employer with u 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. 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. Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on mY PPeTtY•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. 12.0 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. 14.0 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 provi ' workers'compensation insurance for my employees. Below is the policy and job site information. 1 Insurance Company Name: 111{VARAve, Co / r Policy#or Self-ins.Lic.#: �/ © f Expiration Date;__AkI ______ L.!✓ Job Site Address: S© ; (i-E- b Cf City/State/Zip: 141120AfRAFAoaeit Attach a copy of the workers' compensation policy declaration page(showing the policy number and expirati n 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 imprisonmen 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. • .py sf this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify • 1 he p;; and penalties of perjury that the information provided above is true and correct Signature: �•� Date: Phone#: f,� og s%ct 01)37 19 2J 1 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#: �ti. : °-T' L o TOWN OF YARMOUTH :yg Fe BUILDING DEPARTMENT ' • �• "'t = 1146 Route 28,South Yarmouth,MA 02664 � �- p 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 S, I hereby certify that the debris resulting from the proposed work/demolition to be conducted at �03 (if hi)' Work Address Is to be disposed of at the following location: 0mA P70341ilvA, Said dispos- - s - a- a licensed solid waste facility as defined by M.G.L. Chapter li : : 150A. oil.pil itill ' sigma ir pplication Date Permit No. The same right is not automatically afforded to a contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Offic- of 'onsumer Affairs and Business Regulation and the consumer shall be required to submit to such a •i ati n .s provided In Massachusetts General ws, chapter 142A. I Homeowner's Signature • • '� 'ors Signature NOTICE:The signatures of the parties above apply only to the agreement of the parties to alternative , . dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e. MGL chapter 93A) may not be waived in any way,even by agreement. However, homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described, in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor, all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties.Contracted work may not begin until both parties have received a fully executed copy of the contract,and the three-day rescission period has expired. 01 g'1/I 741 Pairs c OF ' War(' jMaIs.g1. . roue : 4 4. COMMMaoe.r • 44444.Y. +4.1 ff ionsumer Affairs Bu • sine -b,. Regu1a rE■ • . (ocABR) HIC Rog i • nits ' Ew Registration* 17117 Registrant HOP $ ENERGY CORP. Name NIAU. OPKINS Address 118 IELD DR City, State Zip SOUTi YA►RMOUTH, MA ono Expiration Date 04/2 20 ComPilints Details No=Veinta found for is registrant You caul also _ M., CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/13/2019 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: ±f 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 00906-001 C2NTACT N ME: McShea Insurance Agency raNtr.Ext): (508)420-9011 FAX No.: 1645 Falmouth Road,Rt 28-Suite 2 F�MtAIL Centerville,MA 02632 DRESS: INSURER(S)AFFORDING COVERAGE NAIC# ---_ -- - _ INSURER A: Atlantic Charter Insurance Company VDAC 44326 INSURED HOPKINS CORP INSURERS: INSURER C: 311 Paddocks Path INSURER D: Dennis,MA 02638 INSURER E INS]IfIER 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. ILTR TYPE OF INSURANCE INSPR NNB� POLICY NUMBER (MJW ( LaS LIMITS GENERAL LIABILITY i EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY I LOC UEC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS MADE AGGREGATE $ DED I I RETENTION $ $ WORKERS COMPENSATION yyC g U AND EMPLOYERS LIABILITY yy/NN X TORY LIMITS OER A IANY PROQP�R�IIETOoPJPARTNER/E ECUTIVEr� WCV01450000 4/23/2019 04/23/2020 E.L.EACH ACCIDENT $ 500,000.00 OFFICER/MEMBER EXCLUDED I N/A (Mandatory in NH) E.L DISEASE-EA EMPLOYEE $ 500,000.00 If fls ddeNyender Policy Coverage State:MA D SCRIP IO OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000.00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION Town of Dennis SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 685 Route 134 BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY South Dennis,MA 02660 WILL ENDEAVOR TO MAIL NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Aw,a,g..4-1217T/L. ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD CERTIFICATE HOLDER COPY l ' 1 • Ci , :',1 ; -i . u, ; , i s . 4) it,. r \cc: :\ + i •t /� cf7 3 00 $ . / /11IP 10 4)// C;4C-,w , .°." ., / .6.......,,,v5--.)j , - ....... * w A X aJ w =�w co w - ito : o fg J 0 C.9 C: Q S Z z�m ec U f� LL zZ LLO [_, . a CDZ �,.� t7zd V\ Q U.. z w . J Lid Oco O Li. ZC6� ‘ \� OuwQa F_ wza0 QQU 0 ce