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HomeMy WebLinkAboutBld-20-003215 L_-0-7/14-a // //3 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 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: . 0 "re(,3/5 Date Applied- Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION Property ddress ,b 1.2 Assessors Map&Parcel Numbers S �44/7 �r?< 7/ 1.1 a Is this an acc r ed 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 / /T 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: Outside Flood Zone? _ Municipal❑ On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Qw er'of 115ccoill.;/, ifarrle(Print) l j� City,Stat‘", ,f/e/t-to-t-t , IP - ;171/..5}14'kt /eie Sift5952700e$.657 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) Alteration(s) 0 Addition ❑ Demolition 0 Accessory Bldg. 0 Number of Units Other ❑ Specify: Brief Description of Proposed Work2: s. 7- r,7 5= k SECTION 4: E STIMATED CONSTRUCTION COSTS ► r Estimated Costs: .�- Item Official vse (Labor and Materials) 1.Building $ �"�t�s-�) 1. Building Permit Fee:$ SO Indicate how fee is determined: 2.Electrical $ Standard City/Town Application Fee 0 Total Project Cost3(It m multiplier . x 3.Plumbing $ 2. Other Fees: $ c_rgS• 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount:: 6.Total Project Cost: $ /2, ` 0 Paid in Full I$1 Outstanding Balance Due: II SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) iy/g^� 'r B Z' 2/ l/ T o 4/r10`s d4 ‘71•17 175.eies 4}//4,0 1-1r License Number Expiration Date Name of CSL Holder /�, QL/� List CSL Type(see below) e� No. and Street T ype!/ ' Type Description Unrestricted(Buildings up to 35,000 cu.ft.) City/Town,Stat Restricted I&2 Family Dwelling N44-- Oc d7Z 3 RooMasfnry (�" RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 5 5 f g 0 0539 P %j liA d i(-4A4(col1 I Insulation Telephone Email addyfits D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date HIC Co73..an4 Nag VC R g' trant Nam / / No. and Street f'e'r, 1,/ 44e Email add s 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 yid 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 /j0il44 1 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: 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 andte accurate to the best of my knowledge and understanding. Z6444 J�Y S1,(G✓ti! °`ti /Z: /f 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.eov/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 ,f I -10- 1 Department of Industrial Accidents 95�I1= 1 Congress Street, Suite 100 s memo = W; _ ;�_ Boston, MA 02114-2017 i , , •,'� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly i _ Name (Business/Organization/Individual): ve_ I-I/ryt 5' e . Address: / - t ;) ,ice, City/State/Zip: 'Tvvg6/...zfri.S( Phone #: Av 1e"1/ e95Y? Are you an employer?Check the appropriate box: Type of project(required): I am a employer with employees(full and/or part-time).* Ip7. ❑New construction _.❑'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 I am a homeowner doing all work myself. [No workers'comp. insurance required.]1. 9. ❑ Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on myproperty. 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 5.0 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 y� 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.g Other 2 -/ r<e-- 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: Z//"rA /jir , Policy#or Self-ins.Lic.#: ive-*//7" Expiration Date: /, -, v •2 v ,� Job Site Address:5,//S�ii A-0--0--xG�jCity/State/Zip: 3• <� Attach a copy of the workers' co ensation 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 and penalties of perjury that the information provided above is true and correct. mature: '� �� Date: //? '5-/9 Phone#: 3-i 7'"9 ,0 1 fi 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#: TOWN OF YARMOUTH . 1 :yg c BUILDING DEPARTMENT • �. 1 r $ 11�6 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 thatf the debris resulting from the proposed work/demolition to be j/conducted at 54445.'/.i a o , / Work rlddress Is to be disposed of at the following location: //4 1- u /404 /t-f/ Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 1 I I, Section 150A. /7. /7 Signature of Application Date Permit No. A O D` CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 09/07/18 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: JIM HINDMAN Schlegel&Schlegel Ins Brokers,Inc. PHONE (A/C Extl: 508-771-8381 FAX No): 508-771.0663 34 Main Street ADDRESS: schlegelinsurance@gmail.com West Yarmouth,MA 02673 INSURER(S)AFFORDING COVERAGE NAIC N INSURER A: NGM INSURANCE INSURED INSURER B: LM INSURANCE COMPANY KREATIVE BARNS INC INSURER C: • 159 OLD MAIN STREET INSURER D: SOUTH YARMOUTH,MA 02664 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 TAE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 1NSR ADM WEIR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR DAMAGETO REN I EU PREMISES(Ea occurrence) $ 500,000 MED EXP(Any one person) $ 10,000 A MPP5983J 08/28/19 08/28/20 PERSONAL 8 ADV INJURY $ 1,000,000 GEM_AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY n JEC7 LOC PRO- PRODUCTS-COMP/OP AGG $ 2,000,000 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 AUTOS ONLY _ AUTOS ONLY (Per accident) UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION x PER OTH- AND EMPLOYERS'LIABILITY YINANY STATt1TE ER Id OFFICER/MEMBERPROPRIETOR/PARTNER/EXECUTIVE N N/A WC-1185197 08/30/19 08/30/20 E.L.EACH ACCIDENT $ 100,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CORPORATE OFFIERS HAVE ELECTED TO BE COVERED UNDER THEIR CURRENT WORKERS COMPENSATION POLICY CERTIFICATE MAY OR MAY NOT BE IN EFFECT AT TIME OF PRESENTATION OF THIS CERTIFICATE,PLEASE CALL TO CONFIRM CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN CUSTOMER COPY ACCORDANCE WITH TH ICY PROVISIONS. KBARNSINC@GMAIL.COM, i(V/ AUTHORIZED REPRESENTAT E _ l ©1 88-20 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of RD • Kreative Barns inc. Building&Remodeling a; �1�rt -" a yr, t kr a s,7yg apt ?`x $" ,ANOx 4 ;a�wu.('M Elt*"'k 1Y.q. v,, 4,aW. y�, 'K riV# � ` d CS No. 93798 Konstantin Aleksandrov DATE:10.29.19 159 Old Main Street Quotation #102919 S.Yarmouth;MA; 02664 Job Description: 508 904 0539;e-mail:kbarnsinc@gmaikcom Bath rehab Property Address Contact Quotation valid Prepared For: Billing Address: Information: until.11.10.19 31 Fishing Brook Rd same Charlotte Prepared by: KAleksand ov Yarmouth MA DESCRIPTION AMOLJ T Strip and dispose existing bathroom window,patch wall,install natural white cedar shingles-assumed no painting Install insulation in former window opening only(It is assumed the rest of the wall has insulation) Strip and dispose tile in shower area and around the bathroom. Strip and dispose existing door at linen closet opening to fit future washer,provide plumbing hook up and outlet for future washer.Replace existing 1 toilet,1 vanity,1 faucet,1 shower valve and 1 shower head All fixtures and tiles are costumer supplied.Please note:there are no warranties on any owner supplied materials Install shower base(owner supplied Kohler-1 piece-it is assumed new shower base is exact fit and no rework is needed.Install tiles in shower area(corner glass shelves are not recommended) Smooth finish or install new drywall and finish in areas outside shower where tile was removed. Paint walls with costumer supplied paint,vanity wall to be finished by costumer. Install costumer supplied vinyl tiles over existing ceramic floor tile(no warranties on product and appearance) Install customer supplied sliding glass door at shower. Replace 1 bath fan-assumed clean swap and no framing change or duct rework to the outside is needed Please note:Electric power and water are assumed to be available for use. Apply for building permit and schedule all necessary inspections. Plumber will apply for a plumbing permit. Work to start no earlier than January,6,2020 and will have an open start date of 2-3weeks Please note:This proposal assumes sound building structure.If any rot is discovered or any other structural deficiencies it will become extra charge at a rate of$65.00 per man hour plus the cost of materials until problem is resolved. Only work in the scope above is included in the total of this proposal,any extra work will become change work order at a rate of$65.00 per man hour or as a previously agreed lump sum or schedule of payments. PLEASE MAKE ALL CHECKS PAYABLE TO Kreative Barns Inc. TOTAL 12,000. 0 All home improvement contractors and subcontractors engaged in home improvement contracting,unless specifically exempt from registration by Provisions of CFap4er 142A of the general laws,must be registered with the Commonwealth of Massachusetts,Inquiries about registration and status should be made to the Director,Home Impr vement Contract Registration,One Ashburton Place,Room 1301,Boston,MA 02108(617)727-8598. Owners who secure their own construction related permits or deal ith unregistered contractors will be excluded from the Guaranty Fund Provision of MGL c.142A. Please see next page for signature pad and payment schedule. htt, _ i,,,,04% ,.„ ,v ,, p A Kreative n ins. Building&Remodeling CS No. 93798 Konstantin Aleksandrov DATE:10.29.19 Quotation 159 Old Main Street #102919 S.Yarmouth;MA;02664 Job Description: 508 904 0539;kbarnsinc@gmaiLcom Bath rehab Property Address: Contact Quotation valid Prepared For: Billing Address: Information: until:11.10.19 31 Fishing Brook Same Charlotte Yarmouth MA Payment schedule AMOUNT 1. Prior work start to book job on the schedule,apply for permit-non-refundable $2,000.00 2. At work start $5,000.00 3. At completion of work as described $5,000.00 obe0 Cle- Aer Ls kre / /1^ , 74 t4'"-r I/ d rare /...6c,/e. 0 i Ae4"-a/W .-fi... ,,t. j it,614,(,/ e -,r2._ ci-J-7-( PLEASE MAKE ALL CHECKS PAYABLE TO Kreative Barns Inc. TOTAL $12,000.00 All home improvement contractors and subcontractors engaged in home improvement contracting,unless specifically exempt from registration by Provisions of Chapter 142A of the general laws,must be registered with the Commonwealth of Massachusetts,Inquiries about registration and status should be made to the Director,Home Improvement Contract Registration,One Ashburton Place,Room 1301,Boston,MA 02108(617)727-8598. Owners who secure their own construction related permits or deal with unregistered contractors will be excluded from the Guaranty Fund Provision of MGL c. 142A. ACCEPTANCE OF PROPOSAL The Above prices and conditions are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. _ All material is guaranteed to be as specified. All work to be completed Authorized ' , in a professional manner according to standard practices. Any alteration rd� of deviation from above specifications involving extra costs will be Signatur �Yr. executed only upon written orders,and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire,tornado, Customer and other necessary insurance. Our workers are fully covered by Signature FC 1 �G j Worker's Compensation insurance. Date of I Acceptance: /4-/Il CArorev f .r�a v- 1 I Iz II( 14 )14 • © 0 TOWN OF if,F. Ni&.+aI d H REVIEWED FOR BI IIL DINSC ANC ZC CODE COMPLI- ANCE. ERRORS OR C1,,:.1iSSI:)NS DO NOT RELIEVE THE APPLICANT FROM THE RESPONSIBILI i Y OF"AS BUILT" COMPLIANCE, FILE COPY DATE; I�-I ---� BUILDING OFFI% L