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HomeMy WebLinkAboutBld-20-003809 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: G?U -0,2ie Applied: J r 1 .1/9/S J-ti -Rio Building Official(Print Name) Signature Date SECTION 1:SIT+ INFORMATION 1.1 Property 1Addr�e s:6 LD'tk<� Pond) IAssessors Map&Parcel Numbers ,t LLSy�. � _c C 1J !1J( S• ,.,4.,/A, 1.1 a Is this an accepted street?yes r 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? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: 13� �^c.i , C-?_1. t\ Cp Name(Print) City,State,ZIP \ ctk No.and Street / Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building Er" Owner-Occupied 0 I Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition In--Accessory Bldg.0 Number of Units Other 0 Specify: Brief Description of Proposed Work2: ,rce „ ED Ozs,::tt i h c'S 6:tl C .�..k ti SECTION 4:ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: Official Use Only (Labor and Materials) �S 1.Building $ 1. Building Permit Fee:$ ij 0 Indicate how fee is determined: 2.Electrical $ 0 Standard City/Town Application Fee 0 Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire • - Suppression) $ Total All Fees:$ s Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ ad Dd, 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) C_5— 053`7j/ ///7114.<c, iL c 1-, „c - r, ,-N_ c, X License Number Expiration Date Name of CSL Holder List CSL Type(see below) u Fit, - - ,,, No.and Street Type Description C" U Unrestricted(Buildings up to 35,000 cu.ft.) ,Ci_,^ do,,n A 1)4r7 0, 2 _ 3 R Restricted l&2 Family Dwelling City/Town,State,ZIP M boy RC Roofing Covering WS Window and Siding cl_,,7/ SF Solid Fuel Burning Appliances 54 FV /i/3 .�,.c iris eJ 6x,r,{6V-5--Cc,..,, I Insulation Telephone Email addresf D Demolition 5.2 Registered Home Improvement Contractor(HIC) rtGaj' �'C c4/. tSFS " .S,r['; 1i57S iICRegistr n Number Expiration)aieL HIC Company Name or HIC Registrant Name fz-,ctir„ iA. j-j.,,.,.e k �t vc �L, 't ti.r-i: if:,.c, r S l<1-t: i C V5 �"n,,.,, No.and Street �/ cl l Email address _, c.,. A k. ct' c tJ i hot S lr- 5'2 '" elb' ///_7 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 iS17 No ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT d( I,as Owner of the subject pro e4y,hereby authorize to et on my behalf,in all ma rs relative to work authorized by this building permit application. 4 d 0 Print Owner's ame(Electronic Signature) e • 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 and accurate to the best of my knowledge and understanding. 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.sov/oca Information on the Construction Supervisor License can be found at www.mass.aov/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 i Type of cooling system — Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-22* 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 \ A k_¢.�, r t r / - lc, <.�e Work Address Is to be disposed of oat the following location: ,,,,`t,;��{,� - (0 &(c) ¶a .�� - L i c G Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. gnature o plication Date Permit No. The Commonwealth of Massachusetts el, Department of Industrial Accidents • _; 1_ 1 Congress Street,Suite 100 � -_ Boston,MA 02114-2017 9 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE PILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly /r Name (Business/Organization/Individual):/ 44 j'SC ,/ S "/ c- Address: PO ,r/VC Y City/State/Zip: 4,.10/4A CA Is? Phone#: 9. "///3 Are you an employer?Check the appropriate box: Type of project(required): 1.4 r am a employer with o7 b employees(full and/or part-time),* 7. ❑New construction 2.0 l 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.] 9. El Demolition 4.01 am a homeowner and will be hitting contractors to conduct all work on my property. t will 10[]Building addition ensure that all contractors either have workers'compensation insurance or are sole MD Electrical repairs or additions proprietors with no employees. I2.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.irstuance.t 6.0 We are a corporation and its officers have exercised their right of exemption per MCIL e. 14.❑Other__ ^ _ 152,h(4),and we have no employees.[No workers'camp.insurance required.] *Any applicant that checks box 01 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 art:an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site • information. Insurance Company Name: Cd„„//leit/,/ Policy#or Self-ins.Lic.#: `3 9 a R �a2a,& 01 d a Expiration Date: 6 'iv. p76 C • Job Site Address: City/State/Zip: 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 to pains and penalties of perjury that the information provided above is true and correct Signature: C�vjt_r`? 1 .-4. Date: (.0 ' //' ad./ 9 Phone#: 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#: Commonwealth of Massachusetts ® Division of Professional Licensure Board of Building Regulations and Standards • Constr itt ri- p rvisor CS-055731 f ••; • ppires 11/07/2020 RICHARD J LENNQ ( �it PO BOX 480 % #+ v. ; SANDWICH MA;p583 •, x "tom . 17))Sis 1.101\• Commissioner c""""' • �J�YLP ceCL��?/jf' Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvemdntl:Contractor Registration Type: Corporation Registration: 108642 BENABBY INC Expiration: 08/19/2020 D/B/A DISASTER SPECIALISTS PO BOX 480 • SANDWICH,MA 02563 • Update Address and Return Card. SCA 1 0 20M-05117 �/ae%911,MOItteleatia of0(K uric/uatet. t Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:-Corporation before the expiration date. If found return to: Registrat€on, Expiration Office of Consumer Affairs and Business Regulation 08/19/2020 1000 Washington Street-Suite 710 BENABBY INC Boston,MA 02118 D/B/A DISASTER SPECIALISTS 9 AN-5 BASTIAN WAY„. � � SANDWICH,MA 02563 No val d without signatuFe Undersecretary6/ kift.....r'" ...••..•.• •• •�• •. — v .--. ...I ' .II••I I 1 I v avI AI 'Je I 07/10/2019 • 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 poltcy(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 Lynn Blanchard,C1C,CISR FIAI/Cross Insurance PHMONE Eat): (603)669-3218 No): (603)645-4331 1100 Elm Street E-MAIL ess: iblanchard@crossagency,com INSURER(S)AFFORDING COVERAGE NAIC# Manchester NH 03101 INSURER A: Crum&Forster Ins Co A2471 INSURED INSURER B: Crum&Forster Indemnity Company 31348 Benabby,Inc.,DBA:Disaster Specialists INSURER C: Continental Indemnity Company PO Box 480 INSURER D: 9 Jan Sebastian Drive INSURER E: Sandwich MA 02563 INSURER F: COVERAGES CERTIFICATE NUMBER: 19-20 All Lines 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 ADDL SUM POLICY EFF POLICY EXP LTR TYPE OF INSURANCE JySD j fVD POLICY NUMBER JMMIDDIYYYYJ(MMIDDIYYYYL LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE a OCCUR DAMAGE TO REFIT EU 100 000 PREMISES(Ea occurrence) $ MED EXP(My one person) $ 10,000 A EPK127148 06/01/2019 06/01/2020 PERSONAL&ADVINJURY $ 1,000,000 GEM_AGGREGATE LIMIT APPLIES PER; GENERAL AGGREGATE $ 2,000,000 POLICY IA JECT 7LOC PRODUCTS.COUP/OP AGO $ 2,000,000 OTHER: Contractor Pollution- $ 1,000,000 • AUTOMOBILE LIABILITY _ EOMBINEOStNFdLE1UMiT $ 1,000,000 (Ea accident) ANY AUTO • BODILY INJURY(Per person) $ B OWNED X SCHEDULED 1337449662 01/01/2019 01/01/2020 BODILY INJURY(Per accident) $ AUTOS ONLY _ AUTOS HIRED NON-OWNED PROPERTY DAMAGE X AUTOS ONLY X AUTOS ONLY (Per accident) $PIP $ 8,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 A X EXCESS LAB CLAIMS-MADE EFX112896 06/01/2019 06/01/2020 AGGREGATE $ 1,000,000 DED I XI RETENTION$ 0 $ WORKERS COMPENSATION XI PEA UTE 0T — AND EMPLOYERS'LIABILITYER C ANY PROPRIETOR/PARTNER/EXECUTIVE Ya NIA 373982660102(State:3a MA) 06/01/2019 06/01/2020 EL EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? — (Mandatory In NH) E.L DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Confirmation of coverage • CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN For Informational Purposes Only ACCORDANCE WITH THE POLICY PROVISIONS. Informational Purposes Only AUTHORIZED REPRESENTATIVE I Orda ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD t