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HomeMy WebLinkAboutBLD-23-003194 1 Office Use Only _ F.YAR t/ �l 9 I� 'i Permit# � . o P qo i� 'f;�! C Amount n4 T�cn°,CPI 1Permit expires 180 days from e,,,,.,�. I issue date 50 --.3 -003 0 EXPRESS BUILDING PERMIT APPLICAT TOWN OF YARMOUTH ____—_._______.___ s Yarmouth Building Department DEC (� 2012 1146Route28 South Yarmouth, MA 02664 B + I (508) 398-2231 Ext. 1261 eY CONSTRUCTION ADDRESS: .I k< c.%-4i W k6`'.—)A ut ASSESSOR'S INFORMATION: I Map: 1./3 3IParcel: /C4/—v�av� 17' 972- 3303 OWNER: �NAME A PRESENT ADDRESS TEL. # CONTRACTOR: I7 h J 411 i {,1 I IN ADDRESS "' & TEL.# NAME MAILc d 0 Commercial 'Z3 (`t�� Est.Cost of Construction$ O o d 0 0) Residential ''//� Home Improvement Contractor Lic.# Construction Supervisor Lic.# O Z.,", T/6 Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor ?have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove P Siding: #of Squares Replacement windows: # Replacement doors: # Roofing: #of Squares ( ) Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing • � *The debris will be disposed of at: �/r p,,, ,,,, ,,_ocation c_cf. ccv (G I l of Fa ility I declare under penalties of p ' Ty that the -me, herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial r re o . in Il.e and for prosecution under M.G.L.Ch.268,Section 1. Date: Applicant's Signature: '� Date: O wners Signatu�e(or atta ment) / ' 7.�—% Date: `- - Gv_ INI- ApprovedBy: . � EMAIL ADDRESS: Building Official(or designee) Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No ❑ Yes 0 No eAr (2 LeK1,5 -)4 6 Co ' 1 ict 6 C__— The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 *, Boston, MA 02114-2017 ,,. www.mass.go v/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): P _0- kUj) eo S PLC Address: /2. yQ c bin L i9?1e City/State/Zip: ��C /�SS�T 141 OZ 5SY Phone#: ? g"I - 36 o - 5D Are you an employer?Check the appropriate box: Type of project (required): I.E 1 am a employer with employees(full and/or part-timed." 7. KNew construction 2.0 I am a sole proprietor or partnership and have no employees work.ng for me in • any capacity.[No workers'comp.insurance required.] 8. I❑� Remodeling 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9 1aa Demolition 4.El I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 C Building addition ensure that all contractors either have workers'compensation insui ance or are sole proprietors with no employees. 11.0 ElcctricaI repairs or additions 5.goam a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.0Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance.t 1 •❑Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other 152,§I(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 for my employees. Below is the policy and job site information. Insurance Company Name: L. /I'l .'h S C0�P Policy*or Self-ins.Lic.4: u!C 53/.G Z 0 0?70 e // Expiration Date: /d/zz./2 o 2 2— Job Site Address: /8 S p v1 e 4Ve, g, YA-n4tottni City/State/Zip: o 2-to 7 3 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 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury.that the information provided above is true and correct. Signature: l?J1 Date: l Phone T: Sv' ?r j /S6 Z Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone it: ACO DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 02/08/2022 THI,$- RTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS t ERTIFICATE 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 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: Diane Lima-Ferreira PARTNERS INSURANCE GROUP LLC WcNNo.Exo: (508)491-3663 FA,No): E-MAIL ADDRESS: dferreira@partnersinsgrpllacom 73 ALDEN RD INSURER(S)AFFORDING COVERAGE NAIC# FAIRHAVEN MA 02719 INSURERA: LM INS CORP 33600 INSURED INSURER B PROMOD HOMES LLC INSURERC: INSURER D: 12 ROBIN LANE INSURERE: POCASSET MA 02559 INSURER F: COVERAGES CERTIFICATE NUMBER: 742984 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 EFF POLICY EXPINS)) W POLICYLIMITS LTR INS)) NUMBER (MM/DD/YYYY) (MM/DD(YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO RENTED $ CLAIMS-MADE OCCUR PREMISES Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ _ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ _ DED RETENTION$ �/ $ WORKERS COMPENSATION X STATUTE OTH- ER AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUDED? N/A N/A N/A WC531S620270011 10/22/2021 10/22/2022 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If es,describe unde DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 Daniel M.Crowly,CPCU,Vice President—Residual Market—WCRIBMA I ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts Y�� Division of Professional Licensure S Board of Building Regulations and Standards Constr t4A*Arvisor CS-023046 F spires:10/03/2023 JOHN E SMITH 7 CHACE DRIVE ,/ . k. v LAKEVILLE MA 02347 : s e / * 3C Commissioner do. fc. CJ rch .. rte....,.....,, , _. .,,,,-- . . Office of Consumer Affairs&Business Regulation ! HOME IMPROVEMENT CONTRACTOR TYPE:Individual l Registration Expiration 173646 11/04/2022 i JOHN SMITH • D/B/A SMITH DEVELOPMENT GROUP TRUST JOHN E.SMITH 7 CHACE DR. �a ge-6 4. LAKEVILLE,MA 02347 UridErSC6f8fy /\ }o Y R TOWN OF YARMOUTH ° BUILDING DEPARTMENT MATTA M 3[_ L.no•�� $ 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 261 BUILDING DEPARTMENT TOTAL DEMOLITION SIGN-OFF FORM State Building Code (780 CMR) Chapter 33, Section 3303.6-Service Connections "Before a building or structure is demolished or removed, the owner or agent shall notify all utilities having service connections within the structure, such as water, electric, gas sewer and other connections. A permit to demolish or remove a building or structure shall not be issued until a release is obtained from the utilities, stating that their respective service connections and appurtenant equipment, such as meter and regulators, have been removed or sealed and plugged in a safe manner." "All debris shall be disposed of in accordanw480CMR 111.5." Building or Structure Location: /8"SSS*¢ a Lot: Owner's Name: 6t5/L 2 lud2oow p �ddress: Phone: Contractor's Name:J n Sop A. Address: 7 C.4i &e-A.ti Phone: Co 8'7 8'g /S6 Z Eversource: Date: 124Z/Z . !..4 Kew Ite- BY: 6-1 eLT/c Sefti'ct. ScirfJA-LT-CenY`e/l., Title: National Grid: Date: t 2-/s-r ZZ By: i/ / s'retl Title: Jam,cS'P 1, G"S Cr 1 S`ct 'h X21S7/r Si.( var/✓ Water Dep .: Date: By: Title: _Beard of Health: Date: / z_ ZZ By: Pivr,e.xe 5041 its-CAS A en-►*r Title: cuST'Sut✓iG'e" Condition: CATrt-cR-e v Fire Dept.: Date: By: Title: Historic Commission: Date: By: Title: —Esnsery_ation: Date: By: Comcast: Date: 3/15 §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 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 /rS Sctivi ew 14 V e /1ii}ruimou. Work Address Is to be disposed of oat the following location: AkAt) c d WAS e f S' cure ►2D Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. %. /1731 Si: ature of Application Date Permit No. national ri gd December 8,2022 John Smith Pro-Mod Homes, Inc. 12 Robin Ln. Pocasset, MA TO WHOM IT MAY CONCERN: RE 185 Seaview Avenue, South Yarmouth, MA This email is to confirm that there is no live gas at this property. This letter DOES NOT preclude the excavator or homeowner from calling Dig Safe at 811 before commencing any work. State law requires anyone planning underground excavation work to notify local utilities by calling 811 to get your underground utilities identified for you prior to doing any digging. The call to 811 is the LAW and must be made in advance of starting work. This confirmation letter of a gas cut-off DOES NOT relieve the excavator of making the call to 81 I. It is a State Law requirement. I can be reached directly at 508-760-7439 should there be any further questions. Sincerely, Mew Whelan, Residential Gas Connections National grid 127 Whites Path S. Yarmouth, MA 02664 (508) 760-7439 Ellen.Whelan@nationalgrid.com .0�Y.... TOWN OF YARMOUTH WATER DIVISION 99 Buck Island Road �* West Yarmouth.MA 02673 'i„tio Telephone:SO8-771-7921 Fax,308-771-7998 December 2,2022 John Pro-Mod Homes RE: t 85 Seaview Ave,South Yarmouth -Cut and Cap complete and inspected The Yarmouth Water Department performed a cut and cap of the water service at 185 Seaview Ave,South Yarmouth on 1 U15f22.This service has been paid in full_ If you have any questions please don't hesitate to give us a call 508-771-7921 Sincerely, Yarmouth Water Department C:Ltsancpsuturra.Do.umcs%135 senuw-cut and cap.duca From: SmithCabrera, Patience ,SmithCabrera@yarmouth.ma.us Subject: 185 Seaview Cut and Cap letter Date: Dec 2, 2022 at 10:19:38 AM To: John Smith ohn@pro-modhomes.com Hi John. Here you go! Patience Smith-Cabrera Customer Service Supervisor Yarmouth Water Department 99 Buck Island Road West Yarmouth, MA 02667 508-771-7921 EVERS=URGE E'"''s'au ce „"f 247 Wash/modSta cn OT Wash/mod Massachusetts 92090 923G ENERGY December 7.2022 185 SEAVIEW AVE BASS RIVER.MA 02664 RE: ADDRESS REMOVAL To Whom It May Concern: At Eversource.we're committed to delivering great service. This letter serves as confirmation that,as of December 7,21122 the electric service to above address has been removed. Based on this information,there is no electric power at this address.If you have any questions,please contact us at(888)633-3797. Sincerely, Eversource Electric Service Support Center Energy disclaims all liability for any resulting damage, errors, or omissions. EVERSsURCE EvnwurcaEngrq, ENERGY247 Staion IX Westwood,Massachusalt:02030-9230 December 7.2022 185 SEAVIEW AVE BASS RIVER,MA 02664 RE: ADDRESS REMOVAL To Whom It May Concern: At Eversource,we're committed to delivering great service_ This letter serves as confirmation that,as of Deee'ber 7.2022 the ekctric service to above address has been removed. Based on this information,there is no electric power at this address.if you have any questions.please contact us at[888)633-3797. Sincerely. Eversource Electric Service Support Center