HomeMy WebLinkAboutBLD-22-006592 •
ONE &TWO FAMILY ONLY-BUILDING PERMIT
Town of Yarmouth Building Department r
1146 Route 28,South Yarmouth,MA 02664-4492 (f( )
508-398-2231 ext 1261 Fax 508-398-0836 �'E�
Massachusetts State Building Code,780 CMR R E D
Building Permit Application To Construct,Repair,Renovate Or Demolish ::1•
a One-or Two-Family Dwelling MAY 1 fi 2022
t�This Sectim For Official Use Only
Building Permit Number. -C �I Date Appli • BUILDING DEPARTM NT
us,-
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{{.r^ �PArf __, . 11"-' )--- 3 5
.65
Building Official(Prim tune • Signature Dale
I SECTION 1:Sf1'L INFORMATION ( tt.l h
1.1 Property Addre • 1.2 Assessors Map&Parcel Numbers
(a S-e evkA-ri. t.,� 1/4/ w
1.l a Is this an accepted street?yes t/ no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(It) D
1.5 Building Setbacks(ft) R E C
Front Yard Side Yards Rear Y d
Required Provided Required Provided Required 44 2022
PARTMENT
1.6 Water Supply:(M.G.L c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal S tBtd1i. ______________
Zone; _ Municipal❑ On site i
Outside Flood Zone? Br `—
❑ f�- ((jV„G+�t,I'l
2_,
Public l /Private 0 Cheek if yes0 dsp em
SECTION 2: PROPERTY OWNERSHIP'
2 Owner'of Record:.e -T \ ,n,a-- 1 trS u�, �.4ry :c_S I 1�--L>r DaloA C
Name(Print) City,State,ZIP APt' �..K
Po s a( 3�t z 5-0 E- In o_aS NP,,Jc y 1.C.�J ,L.�- •�R-
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all ghat apply)
New Construction 0 Existing Building U OOwner Occupied CI Repairs(s) Alterations) 0 Addition CIm Demolition A/ccessory Bldg.❑ Number of Units '�. Other ❑ Specify:_
Brief Description of Proposed Work: ( wk u.0-,_ I"J u it vc-e.( 7-4- ^Ce- ..
Wk.. w !Z fQL-<._ en.A.., 0,04-& Stc,l-os
. /
SECTION 4:ESTIMATED CONSTRUCTION COSTS.
•
Item Estimated Costs:
Official Ilse Only
(Labor and Materials)
1.Building $ O C I Building Permit Fee:$i S d Indicate how fee is determined:
2 Electrical S �7r Li Standard City/Town Application Fee
a t cern 0 Total Project Cost'(Item 6)x multiplier z
3.Plumbing $ yt cum 2. Other Fees: S i__C ,S
4.Mechanical (HVAC) $ a S'Ua List
5.Mechanical (Fire s — •
Suppression) Total •
All Fees:S
e- Check No. Check Amount Cash Amount
6.Total Project Cost S �`$-cs-c 0 Paid in Full ' 13 Outstanding Balance Due: /j(
•
•
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CST.)
tut ,a.� �C.��, cs-a -'5? Si /0 rA-�ja..n-
1 ��' SC_ License Number Expiration Date
Name of CSL Holder
5— 4,e101 {,.v L�4K.�L List CSL Type(see below)
No.and Street Type Description
OL ce „1ttr m D'� r- U y Unrestricted(Buildings up to 35,000 Cu.ft)
City tale,ZIP •
6? R Restricted 182 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
• w // a SF Solid Fuel Burning Appliances
Jbir 2(-1- 14Z4+ F4/(2-lalA Y 5 Coa-Ita4- I Insulation
Telephone Email address f-xtr'r- D Demolition
5.2 Registered Home Improvement Contractor(E;IC) D.2`(t 3 b 1a-1 1.2-bxc
n
y.ao-icc:r (AA^yrit-e&r C C (-LC IitC Registration Number Expiration Date
HIC Company Name orIi4C Registrant Name
Lev .
No.and Street ��" cad
ids Co.,- c u4S i,
U r4ftr,..t�,.,4-L.
/, p el.-, a 5-&tr 6-/1124
�matl aCtr-ss
City own,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 building permit
Signed Affidavit Attached? Yes No C
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_ MQ✓v.a�_p,,ts CC•( C.
to act on my behalf all matters relative to work autt.orized by this building permit application.
Print a eetronic Signature) Date
• SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby atrPst under the pains and penalties of perjury that all of the information
contained in this application is true and accurateto the best of my knowledge and understanding.
/e f(f/14--t PLit�-.a/10 -sL c r
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
t• 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 fiord under M.G.L c.I42A Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License cart be found at www.mass.eov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) /c Fs U (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft) /b R-o Habitable room count 6
Number of fireplaces Number of bedrooms
Number of bathrooms 1 Number of half7baths ry
Type of heating system CL� Number of decks/porches Z
Type of cooling system j Enclosed Open c-
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
Office of Consumer Affairs and Business Regulation
. 1000 Washington Street-Suite 710
Boston, Ma • usetts 02118
Home Improveme . ractor Registration •
-, �? Type: LLC
� Registration: 202413
• .. PROJECT MANAGERS CC.LLC. =`-- Expiration: 06/27/2023
15 LEXINGTON LANE c;_== w
YARMOUTHPORT,MA 02675 -•—� l a
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\/4,8 ,y• Update Address and Return Card.
sCA r O ?jllb-05n7 ••
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.. .�Fi✓rn.e...v.gzdrl o,,."Aa uao�.�elr. •
Office of consumer Afrsks&Business R.gulatlw+ •
•
HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
PIPE:LLC before the expiration date. If found return to:
Duiiratlon Office of Consumer Affairs and Business Regulation
Jteplsfr�t4gn 06/27/2023 I 1000 Washington Street -Su 1
•• ••PROJECT —-4._ Boston,IAA 02115
WILLIAM T.P /
15 L.EXINGTO srf a.�` Not slid w hoot signature
004-
YARMOUfNPO • •75 Undersecretary
•
•
Commonwealth of Massao usetts •
likt .
Division of Professional Licensure
• Board of Building Regulations and Standards
• Conslt ${>�(visor
•- •
CS-095981 ' , spires:10/25/2022
tlIAIAM F LLAM r ,f iiiii .
16 L Q� C l mi d
. YARMOUTH RQ. . • -• •
orstiaa61° •
Commissioner daept K. +rat.;.-
I .
• The Commonwealth of Massachusetts
N !l Department of XndustrialAccideRts
•
=1111= 4 1 Congress Street,Suite 100
_ = Boston,MA 02114-2017
"^�v=�Q•`Q www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Le,tibly
Name(Business/Organization/Individual): Prkt:Ise,_1— (1/1�1+ti L1S S (IL' t!. IX.
Address: r S 1,ex •
t'�-5 �-., �•�
City/State/Zip: \ who • "� (✓1>rQ Phone#: Sn d- /tl(76
Are you an a oyer!Cheek the appropriate box: Type of project(required):
I. am a employer with 't( employees(full and/or part-time).* 7. ❑New construction
❑I am a sole proprietor or partnership and have no employees working for me in 8. EiScetipdelin •
any capacity.[No workers'comp.insurance required.] ��/ J
3.0 1 am a homeowner doing all work myself.[No workers'comp.insurance required]t
9. L�tvemolition
10 0 Building addition
4.❑1 am a honxowntr and will be hiring contractors to conduct a:1 work on my property_ I will
ensure that all contractors either have workers'compensation insurance or resole I I. ectricaI repairs or additions
proprietors with no employees.
12.
5.0[am a general contractor and I have hired the sub-contractors listed on the attached sheet Plumbing repairs or additions
These sub-contractors have employees and have workers'comp.insmancat l3.Q Roof repairs
6. we are a corporation and its officers have exercised their 14.0 Other
❑ right of exemption per MGL c
152,§1(4).and we have no employees.[No workers'comp.insurance required.]
*Any applicant that circlet box OI mutt also 611 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.
tContractors that check this box must attached art 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 member.
X am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: 24a—V C( G/S
Policy k or Self-ins.Lic.k: 644 U(,~ 1 k p b 1(6 t -o -a Expiration Date:
.2 'r �—sI
Job Site Address: / (�-e- m44.c.. t- City/State/Zip: �!/-1•/Lwr0,.. 4X.1 .4'I.
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Off.(0
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to S1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a
day apirst 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 tot e tlr�� a,d penalties of,r erj ry that the information provided above is true and correct.
Sirnature: /11 11 • _ , Date: Jr `S 1/4-6 a
Phone: 5t)
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#:
or
•
§TOWN OF YARMOUTH
1146 Route 28, South Yarmouth, MA 02664
508-398-223). ext.-1261 Fax 508-398-0836
•
Office of the Building Commissioner
•
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
Pursuant to M.G.L. Cl .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 a (2 da-/-` 44-A-v"-C-A-34•
Work Address
Is to be disposed of oat the following location: VA�►u
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. 111, §150A.
5- ), ` /
" -
Signs of Application Date
Permit No.
•
Amok
TRAVELERS J WORKERS s•
COMPEN ATION
AND
EMPLOYERS LIABILITY POUCY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (6HUB-1K86160-0-22)
RENEWAL OF (6HUB-1E86160-0-21)
INSURER: THE TRAVELERS INDEMNITY COMPANY OF AMERICA
A STOCK COMPANY
NCO CO CODE:13439
1.
INSURED: PRODUCER:
PROJECT MANAGERS CC LI.0 MURRAY & MACDONALD INS
15 LEXINGTON LANE 550 MACARTHUR BLVD
• YARMOUTHPORT MA'02675 BUZZARDS BAY MA 02532
Insured is A LIMITED LIABILITY COMPANY
Other work places and identification numbers are shown in the schedule(s)attached.
2. The policy period is from 02-25-22 to 02-25-23 12:01 A.M.at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s)listed here:
MA
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
item IA. The limits of our liability under Part Two are:
Bodily Injury by Accident $ 500000 Each Accident
Bodily Injury by Disease: $ 500000 Policy Limit
Bodily Injury by Disease: $ 500000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states. if any,listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B
- D. This policy includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
▪ 4. The premium for this policy will be determined Ey our Manuals of Rules.Classifications.Rates and Rating
Plans. All required information is•subjectto verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: 02-09-22 we ST ASSIGN: MA
OFFICE: RMD POOL 161
PRODUCER: MURRAY & MACDONALD INS 75NBN
012335
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•BRUCE WAYNE DEVLIN •• •
DESIGN
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