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HomeMy WebLinkAboutBld-20-003939 ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department • \ 1146 Route 28, South Yarmouth,MA 02664-4492 11P11 508-398-2231 ext. 1261 Fax 508-398-0836 .-��i� ; Massachusetts State Building Code,780 CAS. Building Permit Application To Construct, Repair, Renovate Or Demolish r ! ' 1 i a One-or Two-Family Dwelling This Section For Official Use Only i r IAN 1 it 202,0 ; i �cb--, ()._,5C7 q Date Applied: i Building Permit Number: � Pp f---- -- _ -, ":17 ,' r;t;i0. l''', F-4-,s, '\d, ii,i ,A B ' m cia (Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers P I 140141, co e ldf!fy""'f06 1.la 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: Zone: Outside Flood Zone? Municipal 0 On site disposal system 0 Public Private 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIPI 2.1 O nerr of Record: , �v (d f�N /�F1i,.,, S' Name(Print) �S City,State,ZIP i rn IC 101414 6 L.1 e el q— Ltd 9 '211 b e- 1Z06C —s( Cur too k No.and Street Telephone Email Address i COI" SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied ❑ Repairs(s) 0 Alteration(s) 0 Addition ❑ Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: ' Brief Description of Proposed Work2: /L i LL D `^ -1, p SECTION 4:ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined: 0 Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cost' I em 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Suppression) $ Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ l A C/in6 .— 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) C „ir9On °� 2"(APM* I'��OLLi IJ cdC �icense Number Expiration Date Name of CSL Holder r cam' CA a- ,� List CSL Type(see below) TIVrtNo.and Street Description t t(jl!"'r O ' 63 1 di Unrestricted(Buildings up to 35,000 cu.ft.) Restricted 1 Qu.2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding f--y 3 8 3 3 cy be �.(s!.:®y SF Solid Fuel Burning Appliances ` ./ L u / I Insulation Telephone Email address C D Demolition 5,Z Registered Home Improvement Contractor(HIC) 3A 44 , t &Pt -12..17 i- f � V��.ILI d� HIC Registration Number Expiration Da e fa HIC Company Name or HIC Registrant Name No.and Street 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 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 41(,0 v_ to act on my behalf,in all matters relative to work authorized by this building periuit application. kLCN &Th W . 6 e-fts - I 10( Print Owner's Name(Electronic 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 pplic tion is true and acc ate to the best of my knowledge and understanding. a � /0/ 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.cov/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 4 Department oflndustrialAccidents ti [l� 1 Congress Street, Suite 100 rBoston, MA 02114-2017 ,.,5�° 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): Deter MULL Address: G- f 57*Frot> ckt-uA City/State/Zip: 16,3 8S \ r /lA4 Phone #: S-6-6 35 9 3 5 3 Are you an employer?Check the appropriate box: Type of project(required): Um a employer with 3 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 any capacity.[No workers'comp. insurance required.] g Remodeling 3.❑I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9 C Demolition 4.E I am a homeowner and will be hiring contractors to conduct all work on my roe 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. 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.: I •❑Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152,§I(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: 0-4. 'vim Policy#or Self ins.Lic.#: Expiration Date: K5 7 l O Job Site Address: (I LIICYLI-a(1 CQU,J bitAnr City/State/Zip: 50 'fothra"vv°-t7' 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 certif under the pains and penalties of perjury that the information provided abo e is true and correct. Signature: Date: f 9 Phone#: 56S 57 (.d 3 3 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#: 4 TOWN OF YARMOUTH BUILDING DEPARTMENT A;acr, �sE�;x'• , 11.46 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261 HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DA'1'h: JOB LOCATION: NAME STREET ADDRESS SECTION OF TOWN "HOMEOWNER" \ NAME HOME PHONE WORK PHONE PRESENT MAILING ADDRESS CITY OR TO, STA 1'E ZIP CODE The current exemption for 'Ho eowner' was extended to include owner—occupied dwellings of one or two units and to allow such homeowners to ngage an individual for hire who does not possess a license,provided that such homeowner shall act as supervisor. (State Building Code Section 110 R5.1.3.1) Definition of Homeowner: Person(s)who owns a parcel of land on wh' h he/she resides or intends to reside,on which there is or is intended to be, a one or two family attached or detached ructure assessory to such use and/or farm structures. A person who constructs more than one home in a two-year pod shall not be considered a homeowner; such"homeowner"shall submit to the building official, on a form acceptable to the building official,that he/she shall be responsible for all such work perfoiuied under the building permit. ( -ction 110 R5.1.3.1) The undersigned `homeowner' assumes responsibility or compliance with the State Building Code and other applicable codes, by-laws, rules and regulations. The undersigned 'homeowner' certifies that he / she understands the Town of Yarmouth Building Department minimum inspection procedures and requirements and that h= / she will comply with said procedures and requirements. HOMEOWNER"S SIGNATURE APPROVAL OF BUILDING OFFICIAL INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent, which m-,ts the requirements of MGL Ch.142. Yes No If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy Other type of indemnity Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent h:homeownrlicexemp 'CDT YA�o TOWN OF YARMOUTH 'fig c BUILDING D EPARTTMENT • ., — ,-3 1146 Route 28, South Yarmouth,MA 02664 s- 508-398-2231 ext. 1261 Fax 508-398-0836 BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAV IT 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 U 1 C C2ki(- j dLl Work Address Is to be disposed of at the following location: c �C____ Said disposal site shall be a licensed solid waste facility as defined by M.G.L.Chapter 1 I I, Section 150A. tWZ------' F- l Signature of Application Date Permit No. . i 5= Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards / Cons r { p rvisor / CS-075863 ,, ' * pires: 05/09/2021 DEREK W MVLL11 ` ." I v 21 STAFFORI CI n , r O DENNISPOR J�IA ' • y 4. (------/ Commissioner �� _ rye Uo7?rn(r,i' o ✓A a9JGrC/e e e%y Office of Consumer Affairs&Business Regulation i' HOME IMPRO EMENT CONTRACTOR T •Individual „t � Expiration . 08/20/2020 DEREK MULLIK I., ` DEREK W.MULs A ',,' 21 STAFFORD CI t ,, 61 DENNISPORT,MA 02639 Undersecretary, Fallon, Rosa From: Ken Rodgers <KWRodgers@outlook.com> Sent: Wednesday,January 15, 2020 9:13 AM To: Fallon, Rosa Cc: derekmullikin@gmail.com;dannino@anninoinc.com;jodiwrodgers@gmail.com Subject: Authorized to work at 11 North Cove Landing, South Yarmouth Atte'nt on! This email©nginates,.outside of the organization Do'>not open attachments or;click links unless you aye lure fhis email is from'a known sender and you'know the content is safe.Call the sender to verify if unsure. Otherwise delete this email Rosa, this Email is to confirm that Derek Mullikin, with Millikin Building and Renovation, is authorized by Josephine and me to work at 11 North Cove Landing, South Yarmouth, MA. If you have any further questions, please let me know and I will be glad to clarify them. Cordially, Ken Rodgers 1 L. MULLIKDE01 MBARRY Al f * DATE(MMIDDIYYYY) v CERTIFICATE OF LIABILITY INSURANCE 1/15/2020 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). CONTACT PRODUCER NAME: Walter J May Ins Agy Inc PHONE (AI Ext):(781)749-4310 I(aC,No):(781)749-1714 188 Whiting St 9St Hingham,MA 02043 aoDRlESS:info@waltermayinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Main Street America Assurance Company 29939 INSURED INSURER B:Associated Employers Insurance 11104 Derek Mullikin INSURER C: 21 Stafford St INSURER D: Dennisport,MA 02639 INSURER E INSURER F:.COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: PERIOD ITHIS IS TO CERTIFY THAT THE POLICIES NDICATED. NOTWITHSTANDING ANY R QO REMENT, TERMF INSURANCE I OR DCONDIIT ON BELOWAVE OF ANY CONTRACTBEEN ISSUED TO OR OTHER DOCUMENT WITH RESPECT TOTHE INSURED NAMED ABOVE FOR THELICY 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. ADDL SUER POLICY EFF POLICY EXP LIMITS INSR POLICY NUMBER IMM/DD/YYYY) IMMIDDIYYYY) TYPE OF INSURANCE INSD WVD 1,000,000 A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED 500,000 CLAIMS-MADE X OCCUR MPT2668K 10/7/2019 10/7/2020 PRFMIFF, (Fa occurrence) $ 10,000 MED EXP(Any one person) $ PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: 2,000,000 X POLICY I I JEtOT- LOC PRODUCTS-COMP/OP AGG $ $ OTHER: COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY (Ea accident) ANY AUTO BODILY INJURY(Per person) $ _ OWNED _SCHEDULED BODILY INJURY(Per accident) $ _AUTEODS ONLY _ AUTOS BODILY PROPERTY DAMAGE _ AUTOS ONLY _ AUTOS ONLYY (Per accident) $ — UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ B WORKERS COMPENSATION I PERfI1TE I I FORH AND EMPLOYERS'LIABILITY WCC50050103672019A 10/7/2019 10/7/2020 100,000 ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N N I A 100,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 500,000 E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Job:Rogers 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 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD