HomeMy WebLinkAboutBld-20-4535 ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department of r'-Att
___
1146 Route 28, South Yarmouth,MA 02664-4492
508-398-2231 ext. 1261 Fax 508-398-0836 47
41i)
Massachusetts State Building Code,780 CMR I'
Building Permit Application To Construct, Repair, Renovate Or Demolish
a One-or Two-Family Dwelling
This SectionFor Official Use 0
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Building Permit Number: 3 C)—AO " j ) 'c 3�te Appli : .l—]V
/i r^ -911 rs
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Proper_ty Address: N � 1.2 Assessors M(7 J&Parcel Numbers
(cf
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)
1.5 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:
Zone: Outside Flood Zone?
_
Public 0 Private 0 Check if yes❑ Municipal 0 On site disposal system 0
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ow er'ofRecord:•
AAP(' kki ,1)et Nrn(MAC0 kGr (Ann , c. 7armau 1 m A
Name( nnP ' t) City,State,ZIP
(ea 3•-355-7754f \ rSCar5J msn.awl
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) W Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work2: 1240 -f 1 Z9 51•42 -- ?ode •
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 5 �,Ga 1.. Building Permit Fee $-604 Indicate how fee is determined:
*Standard City/Town Application Fee
2.Electrical $ 0 Total Project Cost'(Ite 6)x multiplier_. - x
3.Plumbing $ 2. Other Fees: $ t Z/
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:T
6.Total Project Cost: $ 5000. p Paid in Full ill Outstanding Balance Due: r6 5
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) o /4`-731 2—I 6 ,2-0i3 �
/")1\i4 `1A-- b-7a.-739 License Number Expiration Date
Name of CSL Holder
3( ' l—IrI w List CSL Type(see below)
No. and Street Type Description
/AV-� "�,c� 1IN MA-
CS2446-- U Unrestricted(Buildings up to 35,000 cu. ft.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
✓1f_ I c
. �r ,,t y4/�,_ ci, SolidFuel Burning Appliances
f (/`,)p '/� v ��/• ' '" "'^ 4(T� lr Insulation
Telephone Emai address D Demolition
5.2 Re istered Home Improvement Contractor(HIC)
jn ek i (r1-- g 7(0 7 S _ .
H C Registration Number Expiration Date�
HIC Corn any Namp or Re&starit Name
#444, „,21sfakid
No. Street iC Email a dress ^
City/Town, State,GIP 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 . 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
to act on my behalf, in all matters relative to work authorized by this building permit application.
,6(kl�.e r Lowe a! r r low
Prin Owner's Name(Electronic Signature) Date
• SECTION 7b: OWNER1 OR AU'IHORIZED 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 Owners 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.eov/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
• W�
1 Congress Street, Suite 100
Boston, MA 02114-2017
,�_�•``�y 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): pA)
Address: 2� h ����VVVV`"` "''
crierc—ri
City/State/Zip: 4qrk)t4' m Pt- int y Phone #: 77/1--)4 -'11'Z6"--
Are you an employer?Check the appropriate box:
Type of project(required):
l.5Km a employer with / employees(full and/or part-time).*
I 7. New construction
2.E I am a sole proprietor or partnership and have no employees working for me in 8. E Remodeling •
any capacity.[No workers'comp. insurance required.]
3.E I am a homeowner doing all work myself. [No workers'comp. insurance required.]r 9. 0—Demolition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my ProPr 'e Iwill 10 Building addition ensure that all contactors either have workers'compensation insurance or are sole 11._ Electrical repairs or additions
proprietors with no employees. 12.E 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.t 13. Roof repairs
6.�We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other ylldi� '� iy t�
152,§1(4),and we have no employees. [No workers'comp. insurance required.]C
*Any applicant that checks box 41 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: 'B I Q '(P - " PO / 113297 . n„ (V al l'1
Policy#or Self-ins. Lic.#: /// Expiration Date: J— /6 y ?-/
Job Site Address: IT5.. fie iffier4Y1 S . 5 ,larphoixi ►!City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy num eb r 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 to er tl e pains and penalties of perjury that the information provided above is true and correct.
Signature: Date: `10
.20
Phone#:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/Licenser •
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
- . S' Y •gig oC BUILDING DEPARTMENT
, 0 ' j • y 1146 Route 28, South Yarmouth,MA 02664
q 5_� 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
resulting from the proposed work/demolition to be
conducted at I4,j 1 t(\ 54—, c Yievoak-44A,Work Address
Is to be disposed of at the following location:
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
r
2,- 10 .-2-624
Sigma re of Application Date
Permit No.
TOWN OF YARMOUTH
c HEALTH DEPARTMENT
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To he completed by Applicant:
Building Site Location: \S }1 `Y\c-y.r‘_ c S- ` 6c tko,ave k--)C� A,
Proposed Improvement: "etkat-t.. ' f'c/ 0 NovS SL'
Applicant: QCv .r` `\. Tel. No.: 1.-Vl•Q,w - Vq'k5
Address: eaA kviSort crct.X V142-CW4N-. HR CDIA�-s Date Filed: `.V\ Z.-y
**Ifyou would like e-mail notification of sign off please provide e-mail address:
Owner Name: NX eris.
Owner Address: Q).. S .--Azt- Owner Tel. No.: UC -S`
RESIDENTIAL AND/OR COMMERCIAL BUILDING
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
Please submit three (3) copies of plans, to include:
(1.) Site Plan showing existing buildings, water line location,
and septic system location;
(2.) Floor plan labeling ALL rooms within building
(all existing and proposed) —
Note: Floor plans not required for decks, sheds, windows, roofing;
(3.) If necessary, Title 5 application signed by licensed installer
with fee.
REVIEWED BY: Cfr DATE:
PLEASE NOTE
COMMENTS/CONDITIONS:
.
•
Division of Professional Licensura _ .yile ttrmmarc,4a wl6f of✓264 .1ezvya /a
Board of Building Regulations-and Standards Sul!CAs8c Regulation
TWPE:.inditidual
CS-072739 Expires:08/10f2020 R =: glalkildke
_05 2021
.. BRIAN
BRIAN.1 KINSELLA __ -
21 UBERTY TRAIL - -
HARWICtf MA 02¢45
BRIAN IdNS !'
21 LIBERTY TRAIL = 'a-t -
HARW ICH.MA 028t5-" Undersecretary
Commissioner
Construction Supervisor
Unrestricted-Buildings of any use group which contain
less than 35.000 cubic feet psi cubic meters)of enclosed
space. Registration valid for individual use only
before the expiration date. If found return to:
Office of Consumer Affairs and Busies Regulation
1000 Washington Street -Suite 710
Boston,MA 18 _
Failure to possess a current edition of the Massachusetts
State Bulldog Code is came for revocation Weds license. _ Id signature
For hdomedion alert this hcanse
• Call(617)727-3200 or visa wwwmass.gov/dpl
AC ORo DATE(MMtIDDIYYYY)
® CERTIFICATE OF LIABILITY INSURANCE 02/10/2020
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:
biBERK PHONE 844-472-0967 FAX 203-654-3613
P.O. Box 113247 (NC.
E-MAIL � INC No):
No. SalesSupport@biBERK.com
Stamford, CT 06911 ADDRESS:
INSURER(S)AFFORDING COVERAGE NAIC it
Q INSURER A:
nar) K National Liability&Fire Insurance Company 20052
insella INSURER B:
BK Construction INSURER C:
21 Liberty Trail INSURER D:
Harwich, MA 02645 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 ADDL SUBR POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE MSD WVD, POLICY NUMBER (MM(DDIYYYY) (M MDDIVYYY) LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 0
DAMAGE TO RENTED
CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ O
MED EXP(Any one person) $ 0
PERSONAL&ADV INJURY $ 0
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 0
POLICY JJEECTT LOC PRODUCTS-COMP/OP AGG $ 0
OTHER:
AUTOMOBILEUABILTTY 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)
$
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS LIAR CLAIMS-MADE AGGREGATE $
DED RETENTION$ $
WORKERS COMPENSATION X
AND EMPLOYERS LIABILITY STATUTE ER OTH-
N
A AOFFICERAIANYPROPRIEMETBER EXOR/PARTCLNEUDED9R/EXECUTIVE N NIA N9WC141192 01/16/202 )1/16/2021 E.L.EACH ACCIDENT $100,000
(Mandatory in NH) EL.DISEASE-EA EMPLOYEE $100,000
M yes describe under 500 000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ r
Professional Liability (Errors& Per Occurrence/
Omissions): Claims-Made Aggregate
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Additional Named Insured:BK Construction
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
B Builders Inc THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
66 Beach Plum
Brewster, MA 02631 AUTHORIZED REPRESENTATIVE git
®1988 2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
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