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HomeMy WebLinkAboutBld-20-004058 elx,e.e/e //A1 # ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department of y 1146 Route 28, South Yarmouth,MA 02664-4492 ��''��� 508-398-2231 ext. 1261 Fax 508-398-0836 ' tE. '�t 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 1 ' +`. Building PermitNumber:XP— 40 ""dO yd.5o Date Applied: , �)M SA(S ✓—� /- 7-do 44-_,L,____\ \ .�' Building Official(Print Name) i ature SECTION I:SITE INFORMATION ; 1.11 Pro erty 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 w k 7 r p i V E D 1.5 Building Setbacks(ft) J Front Yard Side Yards Rear Y d 1tt) 020 Required Provided Required i Provided Required I Provided J i i:�::I v" ' J AIUMLMT 1.6 Water Supply: (M.G.L c.40,i 54) 1.7 Flood Zone Information: 1.8 Sewage Disposal ..- —+ Public Cl Private G ( Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ I(�( SECTION 2: PROPERTY OWNERSHIP' 2 W N e sq T1 Ve‘T f A ours+ 1 MA 40260-13 Name(Print) City,State,ZIP 11 A v. ti, 1-T 74CV Nu - 4D I-ZGt-i 5(,7 K-__ AV61.1-1 t .69 M No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK' (check all that apply) New Construction 0 M Existing Building❑ Owner-Occupied 0 I Repairs(s) 0 ! Alteration(s) 0 Addition 0-1 Demolition 0 i Accessory Bldg. 0 Number of Units 1 Other ❑ Specify: Brief Description of Proposed Work2: % - f _ .2y ISECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building S 2,0-e5.-t I. Building Permit Fee:$1561 Indicate how fee is determined: 0 Standard City/Town Application Fee 2.Electrical S / 5 -O 1 / 0 Total Project Cost/(Item 6)x multiplier x 1 S �} Plumbing � I 3. ' d-D D 2. Other Fees: S - 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire . Suppression) $ Total All Fees:$ Check No. Check Amount: Amount: ~�\ 6.Total Project Cost: I $ ���'W 1 0 Paid in Full 0 Outstanding B ance Due: l/,5 1 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 1 ,.&f g-h. 2tleeleSazt el License Number Expiration Date Name of CSL Holder I / ' �-- t_, 5/ List CSL Type(see below) S No.and Street T Description Q—r die r Unrestricted(Buildings up to 35,000 cu.R) Cityrlown,State ZT? f Restricted l&2 Family Dwelling M nry v(4- gZ_'‘'9', RC ( Roofing Covering WS Window and Siding �j©� Q©Z/O�2 a p SF Solid Fuel Burning Appliances j J" _Tp G,r, � 5 /4,t 4 ,Gfa-/f. I Insulation Telephone Email addresses D Demolition 5.2 a istered Home Improvement Contractor(H C) _c‘�' ZD. 4z/-eo �� P ociLt 5 i- C. WICCam y NarrcpSis /Name C Registration Number Expiration Date i ( No.and Stree( �; ��f�� �� S- Yoyyt t- l� ,34_5 9D�a5JF 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 .. ... O No L] 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 K 1"1 V B , IN to act on my behalf, in all matters relative to work authorized by this building permit application. AU&i ' t 12 t� 2-D 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. /f,/e,,741 1.-4ti! di&5—a.,/--c e 4-� 1 /g ZazD rint Owner's or Authorized Agent's Name(Electronic Signarare) Date NOTES: I. 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.rnass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/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 ""'1., 17, Department of Industrial Accidents 1 Congress Street, Suite 100 lc' , I Boston, MA 02114-2017 ,,,,54•''.z 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): �.eeitd�!1/'� gQ�/lit S �f�C' . Address: t. -------" � /...,,,,,,,7,.. City/State/Zip: �'Z Or ..,),/ Phone #: 5—al PO t O-.' Are you an employer?Check the appropriate box: Type of project(required): I.I am a employer with y 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.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 my ProPnY e 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 5.0 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.t 13.❑Roof repairs / 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.`�i Other ��� - /: 152,§1(4),and we have no employees. [No workers'comp. insurance required.] G *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. ,J� At5.Insurance Company Name: Z/�'..- ,/ 6 I.- Policy#or Self-ins.Lic.#: AK-/7,3-7 � Expiration Date:�. �a, zezQ Job Site Address: /' Z2lit-t `,.e___ City/State/Zip: ell 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 hereb certify under the pains and penalties of perjury that the information provided abovell is true and correct. Sinature: Date: / /t r ZD 2 . Phone#: Z D 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#: nr•YR�o TOWN OF YARMOUTH . .1' • .y c BUILDING DEPARTMENT ' 0 ' .#0 y 1146 Route 28, South Yarmouth,MA 02664 • `"'T a'x 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 � — ork Address Is to be disposed of at the following location: _ix-ce-fri7I/ Avt--30cD7 jfic/t e,/- Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter l 11, Section 150A. 11141M11111 7", 2211 Si a. .tare of Application Date Permit No. -r . ° c . � I < ^ d. R . . .f . m ! § _ | _ % � a ® � . . . . . . � . � . � 2 . . A o L' CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 09/07/18 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 NAME: JIM HINDMAN Schlegel&Schlegel Ins Brokers,Inc. PH( ONENo.Eat): 508-771-8381 FAX No): 508-771-0663 34 Main Street ADDDRESS: schlegelinsurance@gmail.com West Yarmouth,MA 02673 INSURER(S)AFFORDING COVERAGE NAIC N INSURER A: NGM INSURANCE INSURED INSURER B: LM INSURANCE COMPANY KREATIVE BARNS INC INSURER C: 159 OLD MAIN STREET INSURER D SOUTH YARMOUTH,MA 02664 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. IV EXP LTR TYPE OF INSURANCE JNSO INVD POLICY NUMBER 1MMM//DCY EFF D/YYYY) (MMl D/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS MADE X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ 500,000 MED EXP(Any one person) $ 10,000 A MPP5983J 08/28/19 08/28/20 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY JECOT- LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: _E AUTOMOBILE 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) _ _ E UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION S $ • WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'UABILITY Y/N STATUTE ER ANY B OFFICER/MEMBER ELUDED?ECUTIVE N N/A WC-1185197 08/30/19 08/30/20 E.L.EACH ACCIDENT E 100,000 (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 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CORPORATE OFFIERS HAVE ELECTED TO BE COVERED UNDER THEIR CURRENT WORKERS COMPENSATION POLICY CERTIFICATE MAY OR MAY NOT BE IN EFFECT AT TIME OF PRESENTATION OF THIS CERTIFICATE,PLEASE CALL TO CONFIRM CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN CUSTOMER COPY ACCORDANCE WITH TH ICY PROVISIONS. KBARNSINC@GMAIL.COM, AUTHORIZED REPRESENTAT I ` ©1 88-20 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of RD ®� Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Cons�i tlhiit bp4Arvisor CS-093798 spires:07/07/2021 ALEKSANDR9V B K• ' IN f PO BOX 842 ', WEST YARMOUTH X.< 3 Commissioner �- Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TY�- Corporation ,•-1,r,M1 Expiration 05/20/2021 KREATIVE BA140IxI y3y, tt KONSTANTIN B # % V 159 OLD MAIN SOUTH YARMOUTH,MA 02664 Undersecretary • • A - - — — — -I a_ DOWN TO BASEMENT NEW WOOD STEP 1'-0" 1O x •I( / N CURRENT EXTENT OF MAIN HOUSE FLOOR LEVEL • a 28 x 66 N Q v� 2 Z Q EXIST GARAGE t) x J GC ; fV O � 3 Q -�— NEW POWDER M zo . O ei j u 4 41-4" INSULATE ALL WALLS SURROUNDING POWDER ROOM AND UNDER NEW FLOOR Proposed Powder Room 1/2" - 1'-0" 19 Bennett Ave West Yarmouth, MA 12-30-2019 KHA jfrM r rH A i'NO ANC O'APLI- ANCE NOT RELIEVE THE A.:-rr''_ICANT FROM THE RESPO' r"OF"AS BUILT""COMPLiAigOE DATE .a\) t1NC) BUILI:',ING Ca- ICIAL 7 DOWN TO BASEMENT NEW WOOD STEP 1:-0" LE co COPY N CURRENT EXTENT OF MAIN HOUSE FLOOR LEVEL w 28 x 66 < (f) v) 0 < Z Z EXIST GARAGE 0 (4. .gt• w Iziox 9 u_ L_L) NEW POWDER .0 z 2 te 73.) „.1 414" INSULATE ALL WALLS SURROUNDING POWDER ROOM AND UNDER NEW FLOOR Proposed Powder Room 1/2" - 11-0" 19 Bennett Ave West Yarmouth, MA 12-30-2019 KHA