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HomeMy WebLinkAboutBld-20-002736 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 1 1' 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: BU)'1U 173 6 - .Date Applied: +� • l-14 uil3" ldin ,/-/ - 700.,/ g Offlel'al(Print Name) igi re . Date SECTION 1: TE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 34 Phyllis Drive, So.Yarmouth, MA 02664 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 0 Private ElZone: — Outside Flood Zone? Municipal 0 On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP', 2.1 Owner'of Record: Charlene McKenzie South Yarmouth, MA 02664 Name(Print) City,State,ZIP 34 Phyllis Drive 978-836-7576 charlene143@comcast.net No.and Street Telephone Email Address SECTION3: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 ❑ Accessory Bldg.0 Number of Units Other P4 Specify: Roof Replacement Brief Description of Proposed Work2: Remove existing Rnnf Material, InstalLix-footwjdths of Ice&Water in Valleys and on Eaves: Provide and Install GAF Timberline shingle roof system with 8"aluminum drip edge and cap shingles on Hips and Ridges. Provide Manufacturer's Roof System Warranty. COLOR: Charcoal Black SECTION 4 ESTIMATED CONSTRUCTION COSTS. Estimated Costs: Item Official Ilse Only (Labor and Materials) 1.Building $ 6,275.00 .1. Building Permit Fee:$ Indicate how fee is determined: • 2.Electrical $ 0 Standard City/Town Application kee ❑.Total Project Costa(Item 6)x multiplier. ` x 3.Plumbing $ 2. Other Fees: $ List: 4.Mechanical (HVAC) $ 5.Mechanical (Fire Suppression) $ Total All Fees $ 33 m rt Check No... Check Amount: .Cash Amofwt: "' 6.Total Project Cost: $ 6,275.00 D Paid in Full 0 Outstanding Balance Die: ;t [- t5" 1 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-112064 7/14/21 Michael S. Murray License Number Expiration Date Name of CSL Holder 6 Takoma Circle List CSL Type(see below) Unrestricted No.and Street Type • Description North Reading, MA 01864 U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 978-404-2190 mmurray369@aol.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) Michael S. Murray 137667 12/16/20 HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 6 Takoma Circle mmurray369@aol.com No.and Street North Reading, MA 01864 978-404-2190 Email 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 Xl 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 Michael S. Murray to act on my behalf,in all matters relative to work authorized by this building permit application. Charlene McKenzie h# z. ' z- 11/12/13 Print Owner's Name(Electronic Signature) O 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. Michael S. Murray 7 11/12/19 Print Owner's or Authorized Agent's Name(electronic Sture) 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 ►[�=_* _gt Department oflndustrialAccidents 1 Congress Street,Suite 100 ='11T 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): US Roofing d/b/a Building Maintenance Corp. Address: 95 Lynn Street City/State/Zip: Peabody, MA 01960 Phone#: 978-532-6300 • •Are you an employer?Check the appropriate box: Type of project(required): 1.E 1 am a employer with 20 employees(full and/or part-time).* 7. El New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling 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.❑I am a homeowner and will be hiring contractors to conduct all work on mY 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. 12.0 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.: 13.0 Roof repairs 6,Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.®Other Roof Replacement 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: A.I.A. Insurance Company Policy#or Self-ins.Lic.#: VWC-100-6018031-2018A Expiration Date: 12/23/19 Job Site Address: 34 Phyllis Drive City/State/Zip:So.Yarmouth, MA 02664 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 certt fy, der the pains and penalties of perjury that the information provided above is true and correct Signatur ' � Date: 11/13/19 Phone#: 978-404-2190 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#: 1 , -DT:Y ,� TOWN OF YARMOUTH o' ' o BUILDING DEPARTMENT 1146 Route 28, South Yarmouth, MA 02664 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, 1 hereby certify that the debris resulting from the proposed work/demolition to be conducted at 34 Phyllis Drive, South Yarmouth, MA Work Address Taunton Landfill, 340 East Britannia St., Is to be disposed of at the following location: Taunton, MA 02780 Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. ,,,'"'"7 11/13/19 Signature of Applicatio Date Permit No. 8. Entire Agreement: This contract constitutes the entire agreement between the parties and any prior understanding or representation of any kind preceding the date of this Agreement shall not be binding upon either party except to the extent incorporated in this Agreement.The Owner agrees that Contractor has made no statements, promises, commitments or representations not contained herein. 9. Modification: Other than that required as a result of paragraph 4 above, any modification of this Agreement or additional obligation assumed by either party in connection with this Agreement shall be binding only if evidenced in writing signed by each party or an authorized representative of each party. 10. Unforseen Circumstances: Contractor is not liable for delays due to weather, strikes, accidents, acts of God or other circumstances arising out of causes beyond its reasonable control and without its fault or negligence including but not limited to: interior damages, ice damming due to pre- existing conditions; i.e. lack of roof ventilation, hot spots or unmaintained snow or ice loads. 11. Governing Law: It is agreed that this agreement shall be governed by, construed, and enforced in accordance with the laws of the Commonwealth of Massachusetts. IN WITNESS WHEREOF, the parties have signed their names hereto: Date: 10-6-2019 Date: /o-•8'� U.S. Roofing, by its agent, Owner or 0 er Ag Michael S. Murray Printed Name/s: C arlene McKenzie List desired shingle color: (Please Print) Charcoal Black 2 MA .CHIJSET S DRIVER'S ' LICENSE If{ <' t..,. 11'812016 8375 1'02021 1i96.9 s a< ( Nf 9 x Mlt ClRC tMt8fi4.2B24 "+a.mas 15sx Ml sa r5'1D 7/14/ 9 S DO l Y21126f6 Rey002/261* Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constructirt 1StIpervisor CS-112064 E;pires: 07/14/2021 MICHAEL S MURRAY 6 TAKOMA CIRCLE NORTH READING MA 01864 Commissioner C/4' C'96r {Cr,,,ltr rrt�ecafff(.1(;%/47.::Irrc1 cr.;e/.t Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Type: Supplement Card ~' R, i�tr tine Exoiratiort 137667 12/16/2020 Building Maintertance'Corp. Michael Murray 4-15illard St Peabody, C 3 — MA 01960.... .. Undersecretary ; Co 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: 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 06175-001 NAME:CT Branch 6175-1 TDA Inc DBA The Driscoll Agency rA7avo,Eat); (781)681-6656 in.No.: (781)681-6686 141 Longwater Drive EMMp'L ki Suite 203 ADDRESS: ae p@driacollagency.corn Norwell,MA 02061 INSURERS)AFFORDING COVERAGE NAIC# INSURER A: A.I.M.Mutual Insurance Company 33758 INSURED INSURER B: Building Maintenance Corp US Roofing INSURER C: P 0 Box 3118 INSURER D: Peabody, MA 01961 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. TYPE OF INSURANCE INSR � POLICY NUMBER (MINlDD/YYYY) (I SS'li ver) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 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 $ �OLICY FPRO-UECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ H RTEDSAUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS (Per accident) UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE $ DED RETENTION $ $ X'IM RM Cihil% x TORY LAMITS TP- A IETBiR/PARTNER/E ECUTIVE E.L.EACH ACCIDENT $ 1,000,000.00 A 3��Ic��Pr�EM R EX U � N/A VWC-100-6018031-2018A 12/23/2018 12/23/2019 (Mandatory{{ SGRIPa inin� NH) E.L.DISEASE-EA EMPLOYEE $ 1 pon.ono no DETri�N OF gPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000.00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it more space Is required) CERTIFICATE HOLDER CANCELLATION TOWN OF YARMOUTH BUILDING DEPARTMENT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1146 Route 28 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN South Yarmouth,MA 02664 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD ® DATE(MM/DDIYYYY)AC� A.. CERTIFICATE OF LIABILITY INSURANCE 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: 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 CONTNAME:ACT Stacey Mastrangelo The Driscoll Agency PHONE FAX 141 Longwater Drive, Suite 203 (A/c,No,Ext): 781-681-6656 (A/c,No):781-681-6686 Norwell MA 02061 ADDRESS: smastrangelo©driscollagency.com _ INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Navigators Specialty Insurance Company 36056 INSURED 3327 INSURER B:Acadia Ins Co. 31325 Building Maintenance Corp. dba U.S. Roofing INSURER C:Union Insurance Company 25844 PO Box 3118 INSURER D:AIM Mutual Ins Co Peabody MA 01961 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1498262672 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 W M/ LIMITS LTRINSD VD POLICY NUMBER (MM/DD/YYYY) (MDD/YYYY) B X COMMERCIAL GENERAL LIABILITY Y Y CNA 5232495 12/23/2018 12/23/2019 EACH OCCURRENCE $1,000,000 DAMAGE CLAIMS-MADE X OCCUR PREMISESO(EaENTE occur ence) $300,000 MED EXP(Any one person) $5,000 X Inc Contractual PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY X izef LOC PRODUCTS-COMP/OPAGG $2,000,000 OTHER: $ C AUTOMOBILE LIABILITY Y Y MAA5281611 12/23/2018 12/23/2019 EaOMaccBINEDident)SINGLE LIMIT $1,000,000 ( ANY AUTO BODILY INJURY(Per person) $ OWNED x SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS e P Xl& jwi ff OPEIATI S ONS I VEHICLES IACORD 101,Additional Remarks Schedule,may be attached if more space is( 'art nDAMAGE $ A X UMBRELLA LIAB X OCCUR Y IS17EXC8590761V 12/23/2018 12/23/2019 EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED RETENTION$ $ D WORKERS COMPENSATION Issued by carrier 12/23/2018 12/23/2019 SPR TATUTE ERH AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ B Installation CNA 5232495 12/23/2018 12/23/2019 Job Site Limit $100,000 Floater Leased Rented Equip $180,000 CERTIFICATE HOLDER CANCELLATION TOWN OF YARMOUTH BUILDING DEPARTMENT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1146 Route 28 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN South Yarmouth, MA 02664 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD