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HomeMy WebLinkAboutBld-20-1353 ONE & TWO FAMILY ONLY-BUILDING PERMIT Town of Yarmouth Building Department or t• 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 F I E 1 This Section For Official Use Only Building PermitNumber:13U)- I' , 3 Date Applied: ' 1 t' 2019 ESQ-0 �r �� �� G- Buil•' :!:.04rint Name) Signature Date r34_ R i SECTION 1:811'11 INFORMATION. . 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 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 0 Zone: _ Outside Flood Zone? Check if yes❑ Municipal CIOn site disposal system CI SECTION 2: PROPERTY OWNERSHIP' 2.1 Rwnpri of Record: Name(Print City,State, IP No.and tr I Telephone Email Address SECTION3:.DESCRIPTION OF PROPOSED WORI(2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg.0 Number of Units Other ❑ Specify: Brief De cri lion of Proposed Work2: S • - r • . ,, id �, g. S Roo • SECTION ESTIMATED CONSTRUCTION cpsTs. : -; Item Estimated Costs: Official Jse Ouly (Labor and Materials) 1.Building $ \ QJ t O O :1.:Building Peimit Fee:$ Indicate how fee is determine±2.Electrical $ ❑Standard Cityrrowa Application Fee: ❑Total Project Costa tem:6)x multiplier x 3.Plumbing $ 2. Other Fees: • List: 4.Mechanical (HVAC) $ ... .., 5.Mechanical (Fire Suppression) $ Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ I riJ Ct d 0 p paid in Full . 0 Outstanding Balance Due: �'• SECTION 5:.CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) O��`l-a I � 2-i f L� 1� License Number Exp' tion ate Name of CSL Holder 30 LaireA S-1 List CSL Type(see below) RC/3S No,and Street Type Description Si w St '„ram l e )12 c U Unrestricted(Buildings up to 35,000 cu.ft) City/Town,n,St ZIP } T / R Restricted 1&2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding // SF Solid Fuel Burning Appliances ?Si '4 b/ Z. j y� lecji— 00rwei„x. I Insulation Telephone !J :y,1 address D Demolition 5.2 Registered Home Improvement Contractor(HIC)) HIC Compane or HIC Re ant Name HIC Registration Number áaat -egsf No.and,Street address City/Town,I Siet I� 1r�,/o g.o� Telephone� C/ 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 [ii/ 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 j�t�jl /eO LA Aaeta_ to act on my behalf,in all matters relative to work authorized by this building permit application. C� cA j , 1 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 application is true and accurate to the best of my knowledge and understanding. 9/i 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.aov/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"maybe substituted for"Total Project Cost" The Commonwealth of Massachusetts trM,,1l,_ t Department oflndustrialAccidents _'sdNl= 6 1 Congress Street,Suite 100 • _';��_ 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): Z4, tl(�y� ( Address:3 0 1,3 a k City/State/Zip: s ,� �� �(p i ./V2n 1 Phone#: I-- 3S 6-/ Are you an employer?Check the appropriate box: Type of project(required): I.❑I am a employer with 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. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall work myself t 9. ❑Demolition ❑ y [No workers'comp.insurance required.] 4.❑I am a homeowner and will be hiring contractors to conduct all work on mY PPertY�ro I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.giLl I am a general contractor and I have hired the sub-contractors listed on the attached sheet I3 [ Roof airs These sub-contractors have employees and have workers'comp.insurance.= rep 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.III 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 tContractors 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: 1—raio__1.49A..5 Policy#or Self-ins.Lic.#: ( (A/3 -- ,S 9 6 3 d Expiration Date: Li/3 p/3 Job Site Address:0 q fs--k City/State/Zip:13 e y Oiy,c,�' /t 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 and penalties of perjury that the information provided above is true and correct. Signature: Date: ei/V(q. Phone#: I .-6 Pi 6 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): I.Board of Health 2. Building Department 3.City/Town Clerk 4,Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: °�� TOWN OF YARMOUTH c BUILDING DEPARTMENT 1146 Route 28,South Yarmouth,MA 02664 t►-.o 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 Work Address `A Is to be disposed of at the following location: A C n<c. Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. a of A q/e I Si l pplication ate Permit No. r • SECTION'St CONSTRUCTION SERVICES _______""" — ^s' .„,*' " ioa � ar T lodue(C5I) ei 1 c ` c a .f. . it License Number as y r «,:t . -t9d ram. Sal; Last c5c Type(see keel w " Wit .. t -- �' Type Description � ' [ l f ; Z U Unrestricted Aui1din6s up to 35,{}tlt}cu ft) 'd awn,n 7t ZIP ? Restricted l&2 Family CtwC ling ," - M. Masonry RC Roofing Covering - .. ,,,, WS QY'tadow and Siding ka.:14SF Solid Fuel Minting Appliances ,,,''' ',, >, " �,,, r D Demolition fig" :: y ',. ,, re tea1tCo*trtutr(SIC} , xV a MC Registr o Numbee R, .Dote r ' •\ -.:s;d< 6 a � �% `i • �. . 83 Ili g y . ° `LY a it i E! y Y •, y . " j es ,--'a ,." ' R b 0 , I k 3c I q4"✓ . NA ,, ' . i".,•:,,0; rnt;: '41%i,' Tom< :K ';'• y *- REDSCO NSAIUON S TRAPiat' A lDAVI +�.•c•x. . b V •z' iR,''" toffidevitimist be tmteretedind submitted with this appikation. ? pin ::aa•<. , >r >. 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Scanned with CamScanner AC R Y DATE(MM/DD/YYYY) -�: CERTIFICATE OF LIABILITY INSURANCE 09/03/19 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 CONTACI- NAME: Rocco Rose Insurance IPAIHc No.Est): 508-584-7100 jac,No): 508-580-4924 360 Oak Street E-MAIL Brockton,MA 02301 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Nautilus Insurance Co INSURED INSURER B Z&R Specialty Work LLC INSURER C: 30 Water St INSURER D South Walpole,MA 02071 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. INSR ADDLSUBR 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 DCLAIMS-MADE X OCCUR PREMISES SES EaAGE TOtoccurrence) $ 100,000 MED EXP(Any one person) $ 5,000 A NN1000957 08/23/19 08/23/20 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY n PE9 n LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOkiOBILE 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 LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE7 E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N I A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN 01111/ ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPR VE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD y® DATEIMM/DD/YYYY) .,,� � CERTIFICATE OF LIABILITY INSURANCE 7/29/2019 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(les)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 Ileu of such endorsement(s). PRODUCER CONTACT NAME: CHARLES OBEID INSURANCE ac — ONE o.E<t): (617)327-0003 FAX ,No):(617)327-1548 1895 Centre St 55 INPO@obeidins.com West Roxbury, MA 02132 INSURER(S) AFFORDING COVERAGEWIC* INSURER A:ATLANTIC CASUALTY INS CO INSURED Z & R SPECIALTY WORK LLC INSURER B:TRAVELERS INS INSURER C: 30 WATER ST INSURER D: - WALPOLE MA 02071 INSURER E: 781-635-6146 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. INY EXP TA TYPE OF INSURANCE INSR WO POLICY NUMBER (MM/DDNYYY) (MMIDF D/YYYY),_ LIMITS GENERAL LIABILITY EACH OCCURRENCE $ EU X COMMERCIAL GENERAL LIABILITY PREMISES{aEoccu occurrence) $ illeirliglet CLAIMS-MADE CI OCCUR MED EXP(Any one person) $ _ A411110101, 1111111111111/11011111.1PERSONAL&ADV INJURY $ Ilerellergiell GENERAL AGGREGATE $' -r ,,v Ob GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG 5 i agetesa —1 POLICY n JE o- ri LOG S COMBINED SINGLE LIMIt AUTOMOBILE LIABILITY (Ea accident) S ANY AUTO BODILY INJURY(Per person) $ ~— ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS — NO OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) S UMBRELLA LIAB [_ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE S DED RETENTIONS S WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER Y/N ANY PROPRIETORrPARTNER/E%ECUTIVE EL EACH ACCIDENT $ 1,000400 i00 A OFFICER/MEMBER EXCLUDED? NIA 04/22/2019 04/22/2020 (Mendsto/In NN) UB-5B96324—A E.L.DISEASE-EA EMPLOYE E5 1,000400 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,0 0 0,0 0 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WIT T E POLICY PROVISIONS. ///AUTHORIZED R IIRES E _ mow` — ©1988-2010 ACORD CORPORATION. All rights reserved, ACORD25(2010/05) The ACORD name and logo are registered marks of ACORD 1111.*WI" MAU AU'.44. • at': •