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ONE &TWO FAMILY ONLY-BUILDING PERMIT
Town of Yarmouth Building Department or
1146 Route 28,South Yarmouth,MA 02664-4492
508-398-2231 ext. 1261 Fax 508-398-0836 i' �'�. E
Massachusetts State Building Code,780 CMR
Building Permit Application To Construct,Repair,Renovate Or Demolish
a One-or Two-Family Dwelling
This VW)
For Official Use Only
Building Permit Number: , .Z)` c71 TW)81 Date Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors t Parcel Nuers
1.1 a Is this an accepted street?yes '------no Map Number Parcel Number, i
' 1.3 Zoning Information: 1.4 Property Dimensions: C'� i 1 1,i f 3,• F
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) c,._ ._...,_..--—f------—r -)
C�iaG Pr>RTM�N r
1.5 Building Setbacks(ft) i
v
Front Yard Side Yards Rear Yard i
Required I Provided Required I Provided Required Provided II
I
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?
Public Private 0 — Check if yes0 Municipal 0 On site disposal system jiic
SECTION 2: PROPERTY OWNERSHIP'
11 caner'of Record: ) /1i r
Name(Prin City� State,ZIP
/iAj 'cA Al// V Te7-6ff? 71h ( :Per-
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) _
New Construction 0 Existing Building,Building X Owner-Occupied X Repairs(s) i'e.- Alteration(s) Addition ❑
Demolition 0 Accessory Bldg.0 Number of Units Other 0 Specify:
Brief D iption o oposed Work'-: ? t�64.t'tT /41�ll E li C e- 1 F i
SECTION 4:ESTIMATED CONSTRUCTION COSTS. vLIB I
Item Estimated Costs: •Official Use Only 8 i N �'-" sA R Trvl E Iv
(Labor and Materials) dr
1.Building S/$ 000 1. Building Permit Fee:$40e) Indicate how fee is determiner";--
�.Electrical $ l0 Standard City/Town Application Fee
,7oc.o
3 — 0 Total Project Coss eta 6 ult li�� x
3.Plumbing $ j,Do J 2. Other Fees: $ S�i
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ -
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost $ e)047 0 Paid in Full 41 Outstanding Balance Due:' 6 5
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) ` ;,AZd� �'7 -, } �i
j.�y111 z 1. (0it r'r 6'rt License Number Expired Date
Name of CSL Holder 1, •
List CSL Type(see below)
"42.0 /yam /,C l C!
No.and Street _ Type Description
/,/�'c✓ • ,,.. f;' Q /274 ,• ? / U Unrestricted Buildings up to 35,000 cu.ft)
City/1own,State,ZIP R Restricted lJc2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
i . SF Solid Fuel Burma Appliances
...77i1.)-�i . 5 ;ply/.(Q t,'&/1 c jer g AO/-�r y'l I Insulation 8
Telephone Email' address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name
I HIC Registration Number Expiration Date
No.and Street l
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 No ,❑
. SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIESFOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize .1 G h rt IA). or ekr
to act on my behalf,in all matters re ative to work authorized by this building permit appl• ation.
1 irify ( . .� ' / .--c` C >�' , / ' 7 r�'
v �
Print Owner's Name(Electronic gnature) 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 acc•«ate to the best elf my knowledge and understanding
J014•1 1ti. ��vrYto e • ,;2/7 I
Print Owner's or Authorized s am ectronic ignaturc) 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 rpm 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.aov/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
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
*"'\ The Commonwealth of Massachusetts
NW k_ l_S/ Department of IndustrialAccidents
"' l� 1 Congress Street,Suite 100
r
er. Boston,MA 02114-2017
^v`r www.mass.gov/dta
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/l �.- C C,/"/10 t'/.
Address: L/?&7 'ia' !,Yd_� �
Cit /State/Zi : °�'%`)i/'ir1 1-et ' '' /
Y P /�� � ` lt'h`' Phone#: •77�/- '70 C' -/��
Are you an employer?Cheek the appropriate box:
Type of project(required):
I. 1 am a employer with
gemployees(full and/or part-time).• 7. 0 New construction
2. I am a sole proprietor or partnership and have no employees working for me in 8.gRemodeling .
any capacity.lino workers'comp.insurance required.]
3.7 1 am a homeowner doingall work myself 9. Q Demolition
y (No workers'camp.insurance required.]r
4.0 I am a homeowner and will be hiringcontractors to conduct all work onii i 0 Q Building addition
Jmy property. I w 1
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5.0 1 am e 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 13.0 Roof repairs
6.0 We are a corporation and its officershave exercised their right of exemption per MGL c. 1�•Q Other
152,§I(4),and we have no employees.(No workers'comp.insurance required.]
*Any applicant t:tat 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
/� �J k, fri
Insurance Company Name: //,/� /a P/i/ ✓,-
Policy r or Self-ins.Lic.#: f d� < �'
,✓/ / Expiration Date: / t�
Job Site Address: //�/i`"��evi 'e' /[QJ City/State/Zip: :d 4+0'-.
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.
1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: ;. Date: >'/" LAG
Phone : ✓ C/,- Z/62 — 2.1`- '
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 , 'r '�'�' s�'� /4-6,71,4
Work Address
oat the followingLIVf 5 4' S,
Is to be disposed of location:
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. 111, §150A.
Signature of Application Date
Permit No.
Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Co n st r.NCtilSn,'S itpe ry i so r
CS-051258 Spires:09/03/2020
JOHN W COURNOYER
HARDWICK R0 .
NEW BRAINTREE MA 01531 ,_.
Commissioner CL
AWRDa CERTIFICATE OF LIABILITY INSURANCE oATE(MM/DDlYYYY)
02/18/20
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 CONTNAME ACT MATTI
The Westbrook Insurance Agency Inc PHON Niro,path 508-867-6894 I Imo,N,1: 508-867.7856
PO Box 1013 ss:
130 East Main Street
West Brookfield,MA 01585 INSURERS)AFFORDING COVERAGE NAIL a
INSURER A: ARBELLA PROTECTION
INSURED INSURER B:
JOHN W COURNOYER INSURER C
420 HARDWICK ROAD INSURER 0:
NEW BRAINTREE,MA 01531
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 POUCY 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.
TYPE OF INSURANCE ADDLI5UBR
Jf) POLICY EFF POLICY EXP
INSD WVD POLICY NUMBER RAWDDN'YYY) (MWIDD/YYYY) LIMITS
X COMMERCIAL GENERAL UABILITY EACH OCCURRENCE S 500,000
CLAIMS-MADE OCCUR PREMISES 1EEEa RENTED
S 100,000
MED EXP(Any one person) $ 5,000
A 9520038274 04/28/19 04128/20 PERSONAL&AIV INJURY $ 500,000
GENI.AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S 1,000,000
RPOLICY❑JECaT ri LOC PRODUCTS•COMP/OP AGG S 1,000,000
OTHER:
AUTOMOBILE UABIUTY COMBaBH D SINGLE LIMITten S
ANY AUTO BODILY INJURY(Pet person) S
AUTOS ONLY AUTOS
SCHEDULED
AUTOS BODILY INJURY Per occident) $
HIRED NON OWNED PROPERTY DAMAGE S
AUTOS ONLY _ AUTOS ONLY (Per accident)
S
UMBRELLA LIAB — OCCUR EACH OCCURRENCE S
EXCESS LIAR CLAIMS-MADE AGGREGATE S
DED RETENTIONS S
WORKERS COMPENSATION I PER I OTN•
AND EMPLOYERS'UABILI Y Y I N STATUTE I ER
ANY PROPRIETOR/PARTNER/EXECUTIVEr— N/A E.L EACH ACCIDENT S
OFFICER/MEMBER EXCLUDED' ' I
(Mandatary In NH) E.L. DISEASE.EA EMPLOYEE $
It yes,aescaNle under
DESCRIPTION Or OPERATIONS below E L DISEASE•POLICY LIMIT $
DESCRIPTION OF OPERATIONS!LOCATIONS!VEHICLES(ACORD 107,Additional Remarks Schedule.may be attached If more space le required)
CARPENTRY
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
TOM&USA BAKER ACCORDANCE WITH THE POLICY PROVISIONS.
10 MACKENZIE RD.
SOUTH YARMOUTH,MA 02664 AUTHORIZED REPRESENTA
14
47
ID 1988-2015 ACORD.CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
ACCMT.2, CERTIFICATE OF LIABILITY INSURANCE DAa2ne
12020
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. TIES CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER.AND THE CERTIFICATE HOLDER.
IMPORTANT: If the osrtitiate holder is an ADDITIONAL INSURED.the pollcy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
the tens and conditions of the policy,cerMin policies may require an endorsement A statement on this certificate does not confer rights to the
aRlIats holder In lieu of such endoreemsnf(s).
,,I0OIICER NOMIM William Mansfield
THE WESTBROOK INSURANCE AGENCY INC axe lm '`(sus)e -eoo4 "xWC.Mit
r mandeverlzon.net
P O BOX 1013 nou s)AFwnmme COVERAGE AMC a
W.BROOKFELD MA 01585 MUMMA: AIM MUTUAL INS CO 33758
INSUIRA 115151E a:
JOHN W COURNOYER DSIm■Rc:
420 HAROVVICK ROAD MINN E:
NEW BRAINTREE MA 01531 INSURER
COVERAGES CERTIFICATE NUMBER: 508289 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTIMTHSTANO$NG ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WRATH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 18 SUBJECT TO AU.THE TEAMS,
e1�EEXCLUSIONS AND CONDITIONS OF SUCH POLICIES.WAITS SHOWN MAY HAVE BEEN REDUCED BYPAID CLAIMS.
L7R TYPE aFeOIaMNC[ r ADM rub ►OUDYNWeER MA1I00111ri111 ND VIM, LASTS
OOIOIMICMLOENERALUAesrTY EACHOCCURItENCE S
1CIAIHS.HADE ❑OCCUR 1 $
RID EXP(My arm pe amg i
WA PEReONAL s ADV INJURY e
GEENL AGGREGATE Lae/APPLIES PER GENERAL AGGREGATE $
Rit 1 POLICY D ❑LOC PRODUCTS-CO*sl PAOG $
OTHBk
A*TOMOaeaLM MAY aMNN DINGLE UNIT 5
ANY AUTO BODILY INJURY(Par pNaon) $
ALL OWNED —SCHEDULED WA pBOOOLYY INJURY(Par aoddenl) $
HIREDAUTOS Wa I
AME
$
_ U LALam OCCUR EACH OCCURRENCE s
eXCEeSLIAO CLAIMS-MADE WA AGGREGATE
DED I I RETENTIONS ppe p $
AND EMPLOYERS'I,N 1 WORKERS COIMIIIMA11011 X I.TATUTE I ER
Y f N
ANYPROPRETORIPARTNMVEXECUTIVE E.L.EACH ACCIDENT t 100,000
A OFPIcERAIEMBEIREX LUDEDr NM NIA VWC10050205202019A 11/04/2019 11/04/2020
fileeltlaNi�yyw��_�� M N E.L.DISEASE•EA EMPLOYEE $ 100,000
DaSQ�fnON under
OF OPERATIONS beIrm EL DISEASE-POLICY Low a 500,000
WA
DISCRIPTIONOF OPERATION/LOCATIONS/W J5CLes(ACORD101.Madam!RawlsSdndele.maybsaMORodI mere ewe IersgWoq
WYakes'Compensation beneMa Mt be paid t0 Massachusetts Employsse only.Pursuant to Endorsement VC 20 03 0$B.no authorisation is given to pay claims for beneNs to
employees in stabs other than MaaaadMwetle E the insured hires,or hops EMrod those employees outside of Massachusetts.
This osrekaie of insurance slows the policy in force on the dale that this medicate was issued(unless the expiation date on the above podgy precedes the Nee dab of this
audio*of Inane). The stake of this coverage can be monitored day by accessing the Proof of Coverage-Coverage Verification Search tool at
www. .
Sole proprietor has not elected coverage.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OP THE ABOVE DESCRIBED POLICIES se CANCELLED BEFORE
THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELNEREO IN
TOM&LISA BAKER ACCORDANCE WITH THE POLICY PROVISIONS.
10 MACKENZIE RD
AUTNORIND pPRIMMI/Arlie
SOUTH YARMOl1TH MA 02584 Daniel M.CJq y,CPCU.Vice President—Residual Market—VVCRIBMA
019SS 2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name end logo are registered marks of ACORD
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