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"4t• 1/i/ott7 • ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department :•"or r' 1146 Route 28, South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508-398-0836 " Massachusetts State Building Code,780 CMR I' Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling - This Section For Official Use O.,c - Building Permit Number;�LDZ, Date Applies Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map Parcel Numbers a7 t Sic-Li9 p7 1.1 a Is this an accepted street?yes k. no Map Number Parcel 1 tuber 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❑ Private❑ Zone: — Outside Flood Zone? Municipal 0 On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: 8 mig&ey t" ?AUL- 3v T CA Sot-4 1-1 `t'+ ►o lf+ 144 ©)-C '( Name(Print) P1'7,NfWte)t 1 City,State,ZIP a71 SCTUC TAR 0I772, cor-414-164`l PgurKA evp rit:Iv 4E No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) VI Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2: (Le-7-0>EL THE .l1f4eJ 1 ADD +g �/l, t+u✓ _'n 24t- Wi4LL, 2 ove- A NOiv— a c21N'e- tovl4t-t-• e` n x '`, Ir) SECTION 4: ESTIMATED CONSTRUCTION COST$. Ul . 3 4� Item Estimated Costs: Officia[Use 1 (Labor and Materials) 9Yj :,;. J = U(.1 1.Building $ y0, 0770 1. Building Permit Fee:$ S-C) is determm'ed7 2.Electrical $ 4 Standard City/Town Application Fee *� ❑Total Project Cost3(Item 6)x multiplier . x 3.Plumbing $ L{ Lr0 2. Fees: $ 3562) 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Suppression) $ Total All Fees:$ Check No. Check Amount: Cash Amount: �. 6.Total Project Cost: $ a 0 paid in Full elOutstanding Balance Due: //S SECTION 5: CONSTRUCTION SERVICES '5.1 Construction Supervisor License(CSL) 0531 Or !0—>O6H 1 ti-g S License Number Expiration Date Name of CSL Holder 1 1 t p List CSL Type(see below) u 1et` D. No.and d Stre Type Description ,,�A Unrestricted(Buildings up to 35,000 Cu. ft.) 50 t'�[3a°� ' VIA`A 0 Restricted 1 c&.2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding �Y aq ST( , Ft Nf i-1 SF Solid Fuel Burning Appliances .����{"��`(�`e"� Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) t.20 1? (" LL1 1S v 1 I.DCNG I✓uc. HICL Registration Number Expiration Date H1�Company Name or HIC _Registrant Name (fin t DD><.g" QD, icimr1 L12.a G i4t L. ex ...- No.and Street Soil abovW+ i' s* C(.271 cr;b' 9 y-�WS- Email address T'I 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 eg- 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 1 t{OvS �T jv U...4 • to act on my behalf,in all matters relative to work authorized by this building permit application. P. W�. ,�-�, if—let—I 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. �tlfiV/Vl.f 1" u. 1 —1 9-1 / 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.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 Department of Industrial Accidents "le 1 Congress Street, Suite 100 a��_ Boston, MA 02114-2017 Imp��•�'•� 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): 1—1 -L I �V I i46 1 NG- Address: '? a M i t»T City/State/Zip: cc 1 C tT Phone #: SD S`?-41 Y ' 5'f Are you an employer?Check the appropriate box: Type of project(required): l. m 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. igf.Remodeling • any capacity.[No workers'comp.insurance required.] 3.E 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 mYP property. I will 10 0 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.Q Plumbing repairs or additions 5.❑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.: 1 •I01 Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14'i I 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. $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--C-ftt) ft Policy#or Self-ins.Lic.#: WC-11 S-S9 r 4 g-13 Expiration Date: S ar" >t7 Job Site Address: 31 S Tvn Qiy City/State/Zip: S. yts/LetILflrt t' A 0a 4d y 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 cer ' and h, . ns zd penalties of perjury that the information provided above is true and correct. Signature: Date: 11� I`11 Phone#: svK-' ( -/3-e.0 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#: TOWN OF YARMOUTH ' - . • - c BUILDING DEPARTMENT ( Y ) 1146 Route 28, South Yarmouth,MA 02664 5-� 508-398-2231 ext. 1261 Fax 508-398-0836 BUILDING DEPARTMF,NT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G.L Chapter 40,Section 54 and 780 CMR, Chapter I, Section 1113, I hereby certify that the debris resulting from the proposed work/demolition to be conducted at 9- ( e-ry - 1)Q. Work Address Is to be disposed of at the following location: 511- Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. Signature of Application Date Permit No. Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constr-uetfah Supervisor CS-053105 Expires: 11/10/2021 THOMAS E FINELLI 172 MIDDLE RD SOUTHBOROU 3H MA 01772 Commissioner Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR s Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 118505 03/27/2021 1000 Washington Street-Suite 710 FINELLI BUILDING INC. Boston,MA 02118 t THOMAS E.FINELLI /1"-- k.-"(77,1 172 MIDDLE RD. SOUTHBOROUGH,MA 01772 Not valid without signature Undersecretary A`ORD® CERTIFICATE OF LIABILITY INSURANCE DATE • 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 Dawn Nogueira NAME: Integrated Insurance Solutions,LLC PHONE.No.Exu: (508)370-0002 FA(NX,No): (508)370-0758 1881 Worcester Road ADDRIESS: dnogueira@iisagency.com Suite 101 INSURERS)AFFORDING COVERAGE NAIC# Framingham MA 01701 INSURER A: Acadia Insurance Co INSURED INSURER B: Finelli Building Inc. INSURER C 172 Middle Road INSURER o INSURER E: Southborough MA 01772 INSURER F: COVERAGES CERTIFICATE NUMBER: CL1961840821 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 AUUL SUM( EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF POLICY (MMlDD/YYYY) (MMIDD/YYTYYY) WATTS X COMMERCIAL GENERAL.LIABILITY EACH OCCURRENCE $ 1•�� �/ • DAMAGE1 O RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) S 250,000 MED EXP(Any one person) S 5"0 A CPA5255601-14 05/28/2019 05/28/2020 PERSONALBADV INJURY $ 1,000,000 GEEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE S 2,000,000 X POLICY ( I EST LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) S A OWNED X SCHEDULED MAA5255602-13 05/28/2019 05/28/2020 BODILY INJURY(Per accident) S AUTOS ONLY AUTOS • X HIRED v NON-OWNED PROPERTY DAMAGE AUTOS ONLY /- AUTOS ONLY: (Per accident) $ PIP-Basic s 8,000 X UMBRELLA LIAB - OCCUR EACH OCCURRENCE s 1,000,000 A EXCESS LIAB CLAIMS-MADE CUA5255603-13 05/28/2019 05/28/2020 AGGREGATE $ 1,000,000 DED RETENTION$ S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER A ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT S 500,000 OFFICER/MEMBER EXCLUDED? N/A WCA5259148-13 05/28/2019 05/28/2020 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 500,000 If yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/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 Proof of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I l k Gti,(1 I(19tatri ©1988-2015ACORD CORPORATION- All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ... . r °.1:Yq \\ TOWN OF YARMOUTH tiY : a 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451 F F i` Telephone(508)398-2231 Ext. 1292-Fax(508)398-0836 OLD KING'S HIGHWAY HISTORIC DISTRICT COMMITTEE APPLICATION FOR `OLD``iJ'-'S`iISH ,),1 CERTIFICATE OF EXEMPTION Application is hereby made for the issuance of a Certificate of Exemption under Sections 6 and 7 of Chapter 470 of Acts of 1973, as amended, for the proposed work as described below and on plans, drawings, or photographs accompanying this application. Type or print legibly: Address of proposed work: 1 l Se-t ,c t..l- ill. . Map/Lot# Owner(s): QA'U L iU i K Phone#: $0r4{Ry-/6/Y All applications must be submitted by owner r accompanied by letter from owner approving submittal of application. Mailing address: aelSeTVCtf t - Year built: Email: P ( UT 4 ✓e`[.1'Z0N 4 N Preferred notification method: Phone Jr. Email Agent/Contractor: , r!fV l.l. V Lb)NG' L/VG • Phone#: SA9 F'Y`)y- ,1--rs-- Mailing Address: VI, 'v , COI)t,e 4, C0.1 €oil o Y - r - 0 0 l Email: -r 1 N ert-t-14, _ 6-714W't L. C o M Preferred notification method: Phone Email Description of Proposed Work(Additional pages may be attached if necessary): A p b w r ►ti -n9 it -2 +c-4ctl, • o(=rig v st- 5 e t c s .11-1-r c ti"^ LT/0G cabrn re rf) , ,OLD KING'S HIGHWAY agent):or Signed(Owner a : Z Date: / l/-( 9 9 ) Owner/contractor/agent is aware that a permit may be required from the Building Department.(Check other departments,also.) . This certificate is good for one year from approval date or upon date of expiration of Building Permit,whichever date shall be later. For Committee use only: Date: Z2-1// 9 t/ Approved Approved with changes Denied Amount €20 Reason for denial: Ca dp . /6,9 II Rcvd by d V Date Signed: /2)/qlzcif Signed: 67 4,,w.v 0 APPLICATION#: 1 7-E VA V52017 • • ..,„,.._. .. . . ...'1, \ , _ 4 . „ -- • ir . . , ... . .. .. 1 . ,..„, ,,. - i I V t; t 1 - i I ! 1 t ..., 4,1,*4.-;4"-_"•- -, ...,_-:-.-_ --.' -- . . -.- ,.,,,-,e...,,,_ 4- \ •. . . . . . . . .. .. . ,.. ,.... - ) . , ,, \ ',‘. - - ... ...._. i ) kV • . i . 1._ . / i 1 ...... , - \\ ( . ,,, • . , ' I 1` k •-' , ,:- __-- gi.- Valb.214‘ n". 7 - f 1 1. / / . .,,,,, . • -.,. _,.,. .. - .,-- -v- -. -,.... •-..-.7-...: . . ...-..,.: . _..., .1 .. . , . „,... ..,. .„.., . r ilo , ,A,', ,. \ v ' '.''‘ ' ---,„ ..„, ,., ,,, 1 II 1111N1j1 11 \ . I HILIiiIII 11 . , , HillIl 11 ! 1 ' . . . , ! •.iffi I ,I iii,', . * ' , I , • :,: , ; • ., I I , ) I , BCWS:30 il 1 iC VVI.>1() ' ,, 1 . ....._ _ I VVIN.g AN'I A ; . 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I I gi1/4 en are subject to 1/4 erilicztti(m on Michele I.iricolii,('1‹.I) !I not he released or copied unless Printed: ()/7/-)(11 8 1 I '.- !lob site and :icljustrneilt It) III job 1 lyannk I.()cati()n 'applicable lee has been paid t)rjob I I ......... I I c()Iiditions. 508-81.5-I().-18 order placed. I i ' I "C-11/4 I I i -....._ I 51") 1 I !Ill I KA. Sue and Paul 2 IA!! 11)ritwing /I: I I No Scale. f/ mid r-3 F- J r f"' , >�/ \ REVIEWED For'II"LCINC AND 4-"> , 1 w��p ��`��� ANCE. ERR r, C DE C0,1PLI ■ Cl,tc uit�_r>;;.,iSS'O'',5 DC NCT FLhvE TH'_ / WINDOW SEAT \\ APPLICANT FROM THE RLSr�ON•SIBILI I Y OF"AS 6UlLT" N N N COMPLIANCE. - DATE: 17 - 0 132s" , UiLDAG I�iAL 1 En j ,i- : l B A 1354' Pu rTIC '�'O D 77' 14'y 36„ �f 1 v , EXISTING SLIDER ♦ Y s� v N ! ■ ■ i i 1E111 LI 120" I� Q I 1I a i °y REMOVE EXISTING WALL i___ 71: .1750SSFS j • p • / �a 46i" BW018 BPRI �`,}� .I- a mimnouh.,_All a m NEW SINK LOCATION Ce Nth Ai ' a ! N *, NEW_BEVERAGE CENTER M ,> SS 8030.03et------i3E44 B027.03 pFH151,` B18R JC-24B-LH/S B18L Eh In�� WB3720.24 W183_____ i 6 `O� S4524 W4536 W4536� R WRX2424 iW18361. N \ `Il .... .., u, .,,,.c..(, a ..,.,.., ,, .,', an, z,r+< . 4-,,.`:'h..l_ ' " `'7, -..,-,- _ ..s, s NEW GAS RA GE LOCATION ' I� / 914' 86:" A 17;"-/X 424" A' 411r t / 196" / All dimensions_size designations CAPE_ISLAND KITCHENS This is an original design and must Designed: 8/15/2018 given are subject to verification on Michele Lincoln,CKD not be released or copied unless Printed: 9/7/2018 job site and adjustment to fit job Hyannis Location applicable fee has been paid or job conditions. 508-815-1648 order placed. r BUTKA, Sue and Paul 2 All Drawing#: 1 No Scale. i Iti i .j • t 4 1 '1 i . - ' ; ''(1./.h p1,eJ l+i11 t'U(r'. , , Dg� u1fl 1� 11�c�R.- 'I ��' �tY j r. i 5 YiI x 3 '� k FAQ # �(LD I NG , : f i . S { I • f