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HomeMy WebLinkAboutBld-20-004129 f LM ot AAA.? ONE &TWO FAMILY ONLY-BUILDING PERMIT Town of Yarmouth Building Department ort r 1146 Route 28,South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508-398-0836t .L,�., ¢, 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 RECEIVED Building Permit Number -oil) lay App' d- Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION : ' I� ;�'li t- hat I - 1.11 roperty7Absy: I _ 1.2 Assyc Map&Parcel Num r� 1.1 a Is this an accepteAs (tree,t?yes ✓ no Map Numberum Parcel Number 1.3 Zoning Information: 1.4 Yrogertty i 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.O.L c.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Private❑ Zone: Outside Flood Zone? Municipal 0 On site disposal system X Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2. caner'of Reco d: ra-m,-1 a 4_ iv cal (,o. 4a.ir otA 14A 7 Pa I� 0 2-4 7 3 Name(Print) City,Stitt,ZIP if-7 Mc:bi Lame Sots• 474. 10137 p ba-tt 5 Peo++nEA.*, (le:p No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WQRK2(check all that apply) New Construction❑ Existing Building bc Owner-Occupied"I Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg.0 Number of Units Other 0 Specify: Brief Description of Proposed Work2: 1e Imo p ,.1 Q..r i�fi•,•� C fr oft ( .`ry�c�/dt)1 Tit&45 ,t w a i-[ao r, 4 } :t.,k 5 k0 r V au 1QAl,3, ti fn F, •L^(� ri. A, n f "SECTION 4:ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 1 i ttloo.00 1. Building Permit Fee:$I6C) Inndicate how fee is determined: 2.Electrical $ `>b Standard City/Town Application Fee ❑Total Project Costa(Itemj)x multiplier . x 3.Plumbing $ 3 10°0•e43 2. Other Fees: $ 4.Mechanical (HVAC) $ N IA List: 5.Mechanical (Fire $ Total All Fees:$r Suppression) Af IA 1 Check No. Check Amount:_Cash Amo 6.Total Project Cost $ 14 �0b ❑Paid in Full i3 Ou e I s 5 i t I 7. i } i _ B�iiLDi1c., Di PART'.' BY _ SECTION S: CONSTRUCTION SERVICES Construction Supervisor License(CSL) CS—to8 357 �1�s1� Iwt item on Name of CSL Holder > ate P.0. 13 ox 23? List CSL Type(see below) td No.and Street TYPe Description p) v vara red c�na 00 3s,000 c tt, c�� �'1'A 026�Zr R Raoial�d lli FaMI�Dwebat State,ZIP hi Masao RC Rooting Comilla Q WS Window and$(dint 60e �j�o o '55/j00am I Insulation Appliances Telsohone Email address D Demolition 6.2 Rgistered HoTs�.Itapro t Contractor(RIC) 1 7:17,/ .1/ .0 Mat ry V i�i �1 Lit 1/�[ hWon Date D., . .. Name t4A d jt•ls ��P!fear ur1, r / - ! I .aeX1 5ortest cgs< (API 4nat i s tatu ,i , 'C.,orn .,, . . State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.152.$25C(6)) Workers Compensation Inseam affidavit must be completed and submitted with this application. Failure to provide this atlidavlt will moult in the denial of the boom of the bulldog permit Signed Affidavit Attached? Yes.. it No p S>aGt 7a:OWNER UT®DRFZATFION TO BE COMPLETED WHEN OWl IR'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT t,as Owner of the subject property,hereby authorise Ag 44&D 1 V t FII!.. S rt 4 C.CS to act on my behalf In ail matters relative to work authorised by this building permit application.r2 n _ .213 K hbtt OJessica Ball(Jan 21,2020) wawr's Name[Elseeeate 8lp an n) tab SECTION 7bt OWNER*OR AUTHORIZED AGENT DECLARATION By entering my alms below,I hereby attest under the pains and penalties of perjury that all of the i ntbtmation contained In this application Is true and acmes to the best of my knowledge and understanding. ��- AZ1e. 1121243 hint Owner's or Authorized Agent's Nome(Electronic Sigoe are) 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 gigi have access to the arbitration program or guaranty ilmd under M.G.L.c.142A.Other important information on the HIC Program can be found at snauggas.levoloea bib/melba on the Corot ustion Supervisor License can be found at www.mass.eov/due 2. When substandal work is plumed,provide the information below: Total floor area(sq.R) (including garage,mod basement/attics,decks or porch) Gross living area(sq.Q) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of lalSbeths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage'may be wed for"Total Project Cost" __ °"� The Common wealth of Massachusetts Department ofIndustrialAccidents g - 1 Congress Street,Suite 100 = y� Boston,MA 02114-2017 www.mass.gov/dia \Yorkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information A Please Print Legibly Name(Business/Organization/Individual): A'H 044 I(' D VeeS e Sry t cc S Address: P.O. oqc 237 City/State/Zip:Sajam e. etAch rn ItO?hone or : 5 0 g • nt• 54yes- Are you an employer?Check�ie appropriate box: O(/ Type of project(required): am a employer with employees(full and/or part-time).* 7. El New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling • any capacity.(No workers'comp.insurance required.) W� 3.0 I am a homeowner doing all work myself.(No workers'comp.insurance required.)t 9. Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on property. I will l0❑ Building addition ensure that all contractors either have workers'compensation insurance or r sole 11.[]Electrical 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. Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance,t 13.El Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[l 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 jor my employees. Below is the policy and job site information. Insurance Company Name: I-1 OV14VV'C* 1116(Aran icitAu +► Policy#or Self-ins.Lic.#: 0 0 W e•c. C L..j.S *4 y Expiration Date: 10 i i 2 12.0 Job Site Address: 4I tLoso I4 .,Vi.kitintp,41 /1 City/State/Zip: UM Oz9 37 Attach a copy of the workers'compenshtion policy deck tion page(showing the policy numb 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 penalties of perjury that the information provided above is true and correct Signature: / Date: I (z—z.4' _o Phone#: 7r•*5-55. 642 ' 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 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 lk .f �y, _ ./, a . _/ WI rk Address Is to be disposed of oat the followinglocation: i '3'146a,S 92ui v & Crmy Pa• Site. etKrliPs!-e42 Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. ///1 - /11' (1%141-0 Signature of Application Date Permit No. ` �'� ATLADIV-01 MALBIS ACORO" CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDOlYYYY) 11/1/2019 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 COONTACT 434 RteGrBy,Inc. PHONE !FAX ----- 34 (A/C,No,Ext):(800)553-1801 No):077)816-2156 South Dennis,MA 02660 E-MAIL mail r0 erS ra COm ADDRESS: 9 9 y• INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Travelers Casualty Insurance Company of Americ 19046 INSURED INSURER B:Arbella Protection Insurance Companyjnc. 41360 Atlantic Diversified Services,Inc. INSURER C:Hartford Insurance Company of the Midwest 37478 PO Box 237 INSURER D: Sagamore Beach,MA 02562 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD IMM/DDIYYYYL IMM/DD/YYYY! A X COMMERCIAL GENERAL LIABILITY 1,000,000 ��X. EACH OCCURRENCE ($_ ____ CLAIMS-MADE OCCUR 6808E8307111942 7/11/2019 7/11/2020 DAMAGE TO RENTED 300,000 PREMISES occurrence) 5 _ MED EXP(Any one perso 5 5,000 r� 1,000,0 0 PERSONAL&ADV INJURY __.$ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 5 2,000,000 POLICY X JECOT- LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: 5 B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 ANY AUTO 1020056292 7/12/2019 7/12/2020 BODILY INJURY.(PerriersonZ_ OWNED SCHEDULED AUTOS ONLY X AUTOS BODILY INJURY(Per accident) X HIRED I x NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY der accident) $ 5 UMBRELLA LIAB i OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE 5__ DED RETENTION$ C WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN X STATVTE _ER__ _ ANY PROPRIETOR/PARTNER/EXECUTIVE 08 WEC CL2544 10/12/2019 10/12/2020 1,000,000 OFFICER/MEMBER EXCLUDED? PINIA E.L.EACH ACCIDENT 5_. (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE 5 1,000,000 If yes,describe under 1,000 000 DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) The certificate holder is named as an additional insured on a primary non contributory basis as required in a signed written contract. Waiver of subrogation applies if required by contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED —REPRESENTATIVE /s+ SE 7/4e • ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD .... • . ir-z ro,,,....de6>ziA.,,,,,,,,,,,,,,,,,,,/,‘, Office of Consumer Affairs and Business Regulation One Ashburton Place-Suite 1301 Boston, usetts 02108 Home improve ntor Registration Registration: 178710 ATLANTIC DIVERSIFIED SERVICES,INC. __--wilt- t Expiration: 08/12/2020 108 STATE RD - 8At3AMORE BEACH,MA 02682 = =_- �v t _I ; sit, update Address and Return Iterd. $CA 1 O 20M OW17 .9r4 liMosrrw+uvadV*4 4watilemact OM*et°enamor Mats a Bomeo aint��1tladen MOMS IMPROVIMIINT CONTRACTOR Roidelratton valid ter Indlvldual use only , hdwul � W before tia Iratlon dots. If found return to:• k.k MOW me of Consumer Affairs and muMress Rsputstion 08h Ono Aapbtm'lon Russ-Sults 1301 I., ► ATLANTIC■ flit_ ., "' ,INC. Boston,MA ono WILLIAM - 108 STATE RD 1 1/4‘, ,10' valid 11108t signature BAtiAIdDFtir BEACH, '` 0 , Not • Commonwealth of Massachusetts Division of Professional Licensure Board of Building.* s and Standards Const 4 l rvisor ' ft CS-108357 tiS $ ; ; I ires:02t26/2021 i , r YYILLIAM R114 P.O.BOX 237 SAGAMORE - . ! • - a` (-)/W13C Commissioner Construction Supervisor Unrestricted-Buildings of any use group which contain less that 36,000 cubic feet(6o1 cubic meters)of enclosed space. FaNure to possess a current edition(Atha Massachusetts State Building Code is cause for revocation of this license. For information about this license Call(617)727-3200 or visit www.mess govtdpl ... -..--- > E...• ,.. f::.; r•-• l•-• .... .--- P c 7 tc 1 _ .... - r",01 ke-1 C.,) 7-',, k.:,.. E ' et, .4) c inli ilc°1) tyaml [Si . N - 0 C.: ›. ›.. 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