Loading...
HomeMy WebLinkAboutBld-20-003263 ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department :. o ._._.r: .. 1146 Route 28,South Yarmouth,MA I. 02664-4492AMA 508-398-2231 ext. 1261 Fax 508-398-0836 .� , Massachusetts State Building Code,780 CMR I' 1 ' Building Permit ApplicaApplication To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only • Building Permit Number: - Date Applied: !IL( i i Bu• g ial rint Name) SignatuCe Date SECTION 1:SITE INFORMATION 1 S/V 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 401,Atassachw ave 1.1a Is this an accepted street?yes no Map Number Parcel Numberj(14\; Jt/ 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 I 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' 1 caner`ofRecord Ua MC iOhn n VeL 4 yarrnpl3.4M , (\' A- Q zu(Dui Name(Print) City,State,ElP 40 Mc sac vwSe-tom ave. 11(4-2761--]gbo No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply) New Construction 0 I Existing Building 0 Owner-Occupied 0 I Repairs(s)' Alteration(s) 0 I Addition 0 Demolition 0 I Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2 -Y;p 6na' re-ram SECTION 4: ESTIMATED CONSTRUCTION COSTS. • Item Estimated Costs: Official Use Only (Labor and Materials) I.Building $ 343 0. Oo 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost3(Ite (.3)xsejn Itiplier 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: $ S-4_3 0 •OD 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) I� ^ �` n'n C SL-l0102-1 121q(21 Po .`�`�-/ Sol k(� License Number Expiration Date Name of CSL Holder —7(03 (A/melt/9 t/y wee 1_ List CSL Type(see below) R(�. 'w S No.and Street v'1 'f Type Description -Er-aYy%l n harYi MA-A 01-7 62 U Unrestricted(Buildings up to 35,000 cu.ft.) City/Town,Stat ZIP R Restricted 1c&2 Family Dwelling Ivl Masonry RC Roofing Covering WS Window and Siding f p� '�"I SF Solid Fuel Burning Appliances 50g-6, A 5 kot6nmotss oahr-17At4rq c�yr� I Insulation Telephone dEmail address U D Demolition 5.2 Registered Home Improvement Contractor CHIC) -� 2 EXr 15�26(P $� I Zo HIC Company Name or C Registrant Name HIC Registration Number Expiration Date (03 tAICUW Wee-f No,and Street Email address Pr-coinawcifyi imA- 0176a 5cc-3Likt/3118 City/Town,State,ZIP Telephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(IYI.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 O 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 behalf,in all matters relative to work authorized by this building permit application. SCE C 01'7 r 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. on I 8oa+no 12-14 I►1 Print Owner's or Authorized Agent's Name(Electronic ignature) 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 riot 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.) (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 ►a — 1, Department oflndctstrial.Accidercts g =iiir= 1 Congress Street,Suite 100 tt � ?f= Boston,MA 02114-2017 w•''y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lecribly Name (Business/Organization/Individual): 4.4 l., 2 D 06 n9 Address?(4)3 kaverR J S -. City/State/Zip. rrov han) nvq-0112 Phone#: 5c -3q8-43gg t Are you an employer?Check the Wpropriate box: Type of project(required): LQ I am a employer with employees(full and/or part-time).* 7. Q New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in any capacity.(No workers'comp,insurance required.] 8• ❑Remodeling • 3.0 1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 4.Q y property. I will • I am a homeowner and will be hiring contractors to conduct all work on m 10 ❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 ElectricaI 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. 12.0 Plumbing repairs additions These sub-contractors have employees and have workers'comp. insurance.t 13. Roof repairs 6.{J We are a corporation and its officers have exercised their right of exemption per iNIGL c. 14.0 Other 152,§I(4),and we have no employees.(No workers'comp.insurance required.] *Any applicant that checks box mI 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'cornp.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-,/14 M.U-t ij a I /Ars- c-o Policy k or Self-ins.Lic.#: Expiration Date: 12I Zc I I Job Site Address:tin MgssQ 'u1se-iis ave. City/State/Zip:hi \ictrinotA4 du4 0/4073 Attach a copy of the workers' compensation policy declaration page(showing the policy numl er 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and pen ides of perjury that the information provided above is true and correct. Signature: 0 200 q/ '� _CO�Q 0. �Q `? Date: ah it q Phone#: S��V Lig 431-/8" Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone T. §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-22311 ext.-1261 Fax 508-398-0836 Office of the Building Commissioner BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G.L. Ch. 40, §54 and 780 CMR- Section 105.3.1. #4. I hereby certify that the debris resulting from the proposed work/demolition to be conducted at Li0 MgsSUGVi( e aye Work Address SONS Is to be disposed of oat the following location: (OS h0Q1<-i"D() <S-� -v eSboaT. Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. )20)-79 /.07 /9 I I I Signature of Application Date Permit No. 53(glik Roofing & Siding 763 Waverly Street-Framingham,MA 01701 Office(508)348-4348 Fax(508)270-9158 roofinamass(&,hr-roofin2.com MA H.I.C.#152205 MA Construction Supervisor License#CSSL-101027 RI#28442 Fully Licensed and Insure Patricia&Doug Monahan 40 Massachusetts Avenue,Yarmouth,MA 02673 We hereby submit specifications and estimate We propose hereby to furnish material and labor—complete in accordance with the attached estimate for the sum of$ 8730.00 with payments to be made as follows: $ 2910.00 at the signing of this agreement, $ 2910.00 at the start of work and$ 2910.00 upon completion of the work. All the work is to be completed in a professional manner according to the specifications described in the attached estimate,per standard practices. Any alteration or deviation from the attached estimate, involving extra cost,will be executed upon a verbal or written confirmed order and will become an extra charge over and above the attached estimate. If a deterioration of the structure requires repair or replacement and it is found after the work has started, any additional costs will be paid by the property owner. All agreements are contingent upon strikes, accidents or delays beyond our control. Respectfully submitted by: Ronaldo Solano ,H&R Roofing and Siding representative. Acceptance of Proposal The attached prices, specifications,and conditions are satisfactory and are herby accepted. H&R is authorized to do work as specificed. Payments will be made as outlined above. Si gnpur of Owner: i//}k- Date: .'�C/� r f" `i (,V.N, 10/30/2019 Signature of H&R/ Representative Date: a,1,- ,0�9 /C.,/�,, 0190 10/30/2019 tdPIA05 ssew'au ► µ ao ooze- (ti.9)Iwo soft Uoiu4 40d •esua itf41 to 01.10i esue Si 41900 0U4P41u8 S sgssrugosse imp t4 s I o} M d buiPit Pus eopu1M-Shk1SS3 ButPubl altriSSO .o3 Pl 4J41I Aue40•118 10sin1ednSO _' ,xr ? Aauotsst WOO S NINON9L tZOZVSOIL :seutd LZ &ti4.-1SSO 4teci J Pruisa SP4SPuels!sue suoppe nusj 5u1pltng jo p.eog a�e►sua tsupissa1.0. Oo titaiSIA10 SflaSiliPeSSItirg 40 l S MUOW to' • • H00111 raga Comordan Way the mtpleadondsmo. It found felons tot Otiros of Consumer Allah and BMsinsss Saguislion -Suits 740 • t 1 e.G1 RC3lAit wAv . iR Not v v��s� FRAM&1t ,MA 01102 Undesson Y i""'1 H&RROOF-02 CINDYPAQ '4�c,,,o,Ro° CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 12/4/2019 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 CONTACT Thomas J.Woods Insurance Agency Inc. ' PPHHONE FAX 20 Park Ave (NC,No,Est):(508)755-5944 (A/C,No): Worcester,MA 01605 ' E-MAIL I.nfo@woodsinsurance.com ADDRESS: I INSURER(S)±AFFORDING COVERAGE NAIL# INSURER A:Atlantic Casualty Ins.Co INSURED INSURER B m Commerce Insurance Company p Y i34754 H&R Roofing&Siding Corp i INSURER C: 16 North St INSURER D: Framingham,MA 01701 — - 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 UMITS LTR INSD.WVD I(MM/DDIYYYYI 1,000,000 A INSURANCE TYPE OF INSU�L ADDL SUER. POUCY EFF POLICY EXP ' LIABILITY POLICY NUMBER (MM/DDIYYYYI EACH OCCURRENCE $ RAN COMMERCIAL GENERAL 1 ,L261003084 4/10/2019 4/10/2020 I DAMAGE TO RENTED 100 000 PREMISES(Ea Oc-currence) $- —_- MED EXP(Any one person) $ 5,000 CLAIMS-MADE OCCUR PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- LOC I PRODUCTS-COMP/OP AGG a$ 2,000,000 JECT OTHER: I $ B AUTOMOBILE LIABILITY ' I 1 COMBINED SINGLE LIMIT (Ea accident) ANY AUTO I 'BCNV84 4/28/2019 4/28/2020 j BODILY INJURY(Perperson) $ 100,000 AUTOS ONLY AUTOS BODILY INJURY(Per accident) 300,000 OWNED X SCHEDULED $ XHIRED PROPERTY DAMAGE 100,000 AUTOS ONLY 'AUTOS NON-OWNED ONLY I (Per accidents $ I X L $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LWB CLAIMS-MADE AGGREGATE $ DED li I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY V I N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? 'N/A (Mandatory In NH) 1 I E.L.DISEASE-EA EMPLOYE $ 'If yes,describe under E' I DESCRIPTION OF OPERATIONS below Ali E.L.E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers compensation coverage will be provided under separate cover by the assigned risk carrier. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 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 AC 0® CERTIFICATE OF LIABILITY INSURANCE DATE 12/04/2o srr) 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 CONTACT NAME: Cynthia Paquette THOMAS J WOODS INSURANCE AGENCY INC (fA/CNNo,Est): (508)755-5944 FAX (A/C,No): E-MAIL a ADDRESS: c p quette @woodsinsurance.com 20 PARK AVENUE INSURER(S)AFFORDING COVERAGE NAIC# WORCESTER MA 01613 INSURERA: AIM MUTUAL INS CO 33758 INSURED INSURER B: H&R ROOFING &SIDING CORP INSURERC: INSURER D: 16 NORTH ST INSURER E: FRAMINGHAM MA 01701 INSURER F: COVERAGES CERTIFICATE NUMBER: 480024 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. LTRINSR ADDL TYPE OF INSURANCE N W SD SVD POLICY NUMBER POLICY EFF POLICY EXP (MM/DD/YYYYl (MM/DDIYYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- CT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE OTH- ER AND EMPLOYERS'LIABIUTY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBER EXCLUDED? N/A N/A N/A VWC10060235042018A 12/25/2018 12/25/2019 (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 N/A DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensation/investigations/. 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 AUTHORIZED REPRESENTATIVE (;V South Yarmouth MA 02664 Daniel M.CroW)ey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD