HomeMy WebLinkAboutBLD-22-000643 COO ONE&TWO FAMILY ONLY-BUILDING PERMIT
Town of Yarmouth Building Department •
f 1146 Route 28,South Yarmouth,MA 02664-4492 / .'
508-398-2231 ext.1261 Fax 508-398-0836
Massachusetts State Building Code,780 CMR R � _ %' E D
Building Permit Application To Construct,Repair,Renovate Or Demolish
a One-or Tho-Family Dwelling
MAY 16 2022
This[[Section For Official Use Only _
Building Permit Number: _ �(�(69'"3 Date Applied: BUILDING DEPARTMENT
rl"► �Rl's �Y fr1
.60
I n cud(Print•.:.. - , sigtlidnre Data 3 y
/.� SECTION I:SITE INFORMATION Ll�/7 .
1 1 Property Address L `/ 1.2 Assessors Map&Parcel Numbers
( S'-C •IN.a1(9 [..v Z
1.11 Is this an accepted street?yes no rip Number Parcci N mar E C E I V E D
1.3 Zoning Information: 14 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage ft) MAY 24 2022
1S Building Setbacks(ft)
—
�u_-' .DlNOOLPAP7MENT
Front Yard Side Yards r rk „._ 1!�1�
Required Provided Requires: Provided Required Pmvick��==-- L"- {(Xj
f
L6 Water Supply:(M.G.L c.40.i 54) 1.7 Flood Zone Information: 1.8 Sewage Deposal System:
Public El..--'-Private CI Zoae: — Outside Flood Zone? Municipal 0 On site disposal system 0
. Check ifZesO
SECTION 2: PROPERTY OWNERSHIP' .
21, Owner'of Record: "
Ly-t 4 cr (IPq r,,.t o.-!1 '/t ue S [,C.C .Pd y/,o. 5, 1 f' t- Q a tQ O t
Name
City,
tate,ZIP
PO 6 of t 3 1-ESQ fo os.c 0.11-A q 4.(am/.3 a ll .) cA�`
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all)hat apply)
New Construction❑ Existing Building UK.--Owner-Occupied El Repairs(s) 0-*".'Alteration(s) Q Addition 0
Demolition Il ,Accessory Bldg.O Number of Units '.. Other O Specify: _
Brief Description of Proposed Work2: • 0_,c w‘..tr..` b u n+vu( T wA c n co.-�
re c - 2 (a A...., t
n" ehciic� Lie/7) I-/lam
SECTION 4:ESTIMATED CONSTRUCTION COSTS.
Item Estimated Costs: Officialese Only
SLabor and Materials)_
I.Building $ Qt con I. Building Permit Fee:S-1S0 Indicate how fee is determined:
Electrical S bi,Standard City/Town ApplicationFee
2
�t �) EI Total Project Cost'(Item 6)x mu plier x
3.Plumbing $ Fi ctm 2. Other Fees: S 3 c cm .
4.Mechanical (HVAC) S 2,,trot) List
5.Mechanical (Fire S .. . • -
Suppression) T oral All Fees:S
e.% Check No. Check Amount Cash Amotmt
6.Total Project Cost $ '7 "sCrO. 0 Paid in Full d1 Outstanding Balance Due: I)I
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction SupervisorLicense(CSL) CS—0 5'5 ( `O fly f i
t l 1 l 4.w PC S W•• License Number [ Expiration Date
Name of CSL Holder
I.` /` X 14"S-�-e� /��e— List CSL Type(see below) i
No.and Streets L 'Iype�-/ Description
mil_► t.ot,./�'e-j -,,� out .0.2.6 Z r U rUnrestricted(Buildings up to 35,000 cu.fL)
City own.State.,ZIP R Restricted Idc2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
1ti 61 4 zl 4%2wA-y U� C sF InSolid t oionne Bunting Appliances
Erw� I Insulat
Telephone Email address "- r D Demolition
5.2 Registered Home Improvement Contractor(MC)
HIC Company Name or C Registrant Name HIC Registration Number Expiration Daze
1 T L�-Li A5 -u L,nl • rigt l.t:. a
No.and Street �. �'/ Oa ti f d Cc�.'t e.45 i_
�titQ,� Q o' 4 . M it �4G_f K t6 Finail
City own,Stater ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(11'LG3..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 f the building permit
Signed Affidavit Attached? Yes No 0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
• OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDT NG PERMIT
I,as Owner of the subject property,hereby authorize PA o"Z. r (1An-,•a.e CC .ez ,
to act on my behalf it all matters relative to work authorized by this building permit application.
a 5'�l� /-2.- -
Printr s j4 m rue Signet ue) Dime
•• 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/I in this application is true and accurate to the best of my knowledge and understanding.
hit al 4�.-. P L'44 r.,,,As L( 'S- /)6 / -a_
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a Whiling permit to do hisnher 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.govloca Information on the Construction Supervisor License can be found at www,mass.cov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) /=• s--U (including garage,finished basanent/attics,decks or porch)
Gross living area(sq.it) Ie, 2-o Habitable room count 6
Number of fireplaces O
Number of bedrooms
Number of bathrooms 1 Number of half/baths el
Type of heating system ( [t-g Number of decks/porches
Type of cooling system a Enclosed Open J
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
•
"� The Commonwealth„ of Massachusetts
. —DOI^a Department oflndurtria1Accldents
`l 1 Congress Street,Suite 100
Boston,MA 02114 2017
•''. .,,,, nr
www. ass,gov/dla
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/I'lumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print I eejbly
Name(Business/Organization/Individual): P4 Se - MJ4.w,0.s 5 C.L' I.t-C
Address: r 3--- 4 X I^--5-4 .,-., 4.-<-,
City/State/Zip: \ AnwloA., tY14 Phone#: StD b' ( l ct4 I tf?6
Are you an yer?Check the appropriate box:
Type of project(required):
I. am a employer with 11 employees(full and/or part-rime).*
7. 0 New construction
10 I am a sole proprietor or partnership and have no employees working forme is
any capacity.]No workers'coop.insurance required.] $• r�--,,�� ding
3.0 I am a homeowner doing all work myself(No workers'comp.insurance required.]t 9 ID
0
4.0 I am a homeowner end will be hiring contractors to conduct all work on try property. I will 1 ❑Building addition
homeowner
ensure that all contractors either have',miters'compensation Insurance a are sole 11, eetrical
proprietors with no employees. repairs or additions
5.0 I a a general contractor trail have hired the sub-contractors listed on the attached sheet 12.[ Plumbing repairs or additions
m
These sub-contractors have employe and have workers'comp.insurance.' 13.❑Roof repairs
es
6.0 We are a corporation and its officers have exercisedtheir right of exemption per MGL c 14.0 Other
152,Q 1(4).and we have no employees.(No workers'comp.insurance required]
iAny applicant that checks box i t must also fiU out the section below showing their workers'compensation policy information
Homeowners who submit this affidavit indicating they are doing all work and than hire outside contractors must submit a new a6davit indicating such
tantractors 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 .
P have employees,they must provide their waters'con policy number.
1 am an employer that is providing workers'compensation insurance for my employees: Below is the policy and job site
btformation _
Insurance Company Name: � Ue( 2 S
Policy Par Self-ins.Lic.#: G 4-(up,f,- I k'.6 160-G ^ ?a- Expiration Date: (1'S'/.2ch-2-
Sob Site Address: /.2 c M City/state/zip: yAkwn0,4-- "nor
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). b.Lc t 0
Failure to secure coverage as required under MOL c.152,§25A is a criminal violation punishable by a fine up to 31,500.00
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 ngninst 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 tot th:i1 d penalties of Ali ry that the information provided above is true and correct
signature: 6 o• • �'
Date: c-l r S 2" 0 a
�
Phone#: $ 07-L-6 - 04.Z-C
Ofitdal 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 OFYARMOUrH
1146 Route 28, South Yarmouth, MA 02664
508-398-220 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 1053.1.#4.
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at / OCS-e_eroto_ti OesT A' ' '"^"c'x-'4
Work Address
Is to be disposed of oat the following location: \ q n.vu cao LA-'L-1 3
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. Ill, §150A.
F 4 A3-6
of Application Date
Permit No.
•
•
TRAVELERS J� WOR
KERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POUCY NUMBER: (GRUBLI.K86160-0-22)
RENEWAL OF (6HUB-1E8616o-0-21)
INSURER: THE TRAVELERS INDEMNITY COMPANY OF AMERICA
A STOCK COMPANY
1, NCCI CO CODE:13439
INSURED: PRODUCER:
PROJECT MANAGERS CC LIC MURRAY & MACDONALD INS
15 LEXINGTON LANE 550 MACARTHUR BLVD
YARMOUTRPORT 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 insureds 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 UABIUTY INSURANCE: Part Two of the policy applies to work in each state listed in
item 3.A. 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
um 4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating
•= Plans. All required information issubject to 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
Office of Consumer Affairs and Business Regulation
1000 Washington Street-Suite 710
•
"-, Boston, Ma usetts 02118
. Home lmprovemel, ,;^. ,rector Registration •
•'* +- Type: LLC
11.n --- Registration: .202413
• • PROJECT MANAGERS CC.LLC. ' """ate d Expiration: 06/27/2923
15 LEXINGTON LANE ^ '�' i'_
YARMOUTHPORT.MA 02675 -- `•i
•
�, 1
$ �Up Update Address and Return Card.
•
SCA 1 OiU 4 .o&i7 • •
gvnino/Auinottijo,4. ►ao�lk✓1s
Orno.of Cwuunw Attain s suswww RNuletlon
HOME IMPROVEMENT CONTRACTOR r Registration valid for Individual use only
LLC I before Ma expiration date. If found return to:
,. t,'!ti,.., Expiration Office of Consumer Affairs and Business Regulation
,:.r am 0612712023 i 1000 Washington Street ,..13u
PROJECT k `�St Boston,MA 02118
i. ram . ,
cgi. !`
WILLIAM T.• r. •-,113 5�i /J (1—//'
15 RMOtdGTO e-; • 7:75 a('` 4ldw2gnatum
• , • .
,
Commonwealth of Massaohusatts • •
Division of Professional Licensure.
Board of Building R ulations and Standards,
iiiii •
Cons isr
•• CS-095981 . Aires:10/25/2022
• 'WILLIAM F *.1a tEXM7 •" 4 o
_.,4,, ,
YAROT •� •,
•
.
0 \
•
Commissioner R. ?&nJi&. ,
I