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HomeMy WebLinkAboutBLD-23-002855 i ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department ' r 1146 Route 28, South Yarmouth, MA 02664-4492 _ 508-398-2231 ext. 1261 Fax 508-398-0836 `= ;`' - Massachusetts State Building Code,780 CMR 1 Building Permit Application To Construct, Repair, Renovate Or Demolish .. -, a One-or Two-Family Dwelling This Section For Official Use Only 1 Building Permit Number: -2;��x Date Applied: [RFCE R V E D Building Official(Print Name) ignature NO1JatE 2 2C22 SECTION 1:SITE INFORMATION BUILDING DER'M'TMENT • 149 1 Proper 1.2 Assessors Map&Parcel Numbers By: -- 1.1a Is this In accepte�d``street?yes ''l 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: Public 0 Private 0 Zone: Outside Flood Zone? — Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: EJ �, der-: q P1r. 1; S Oc , q 4_ , WC/G+l/ Name(Print) City,State,ZIP ILI i Lni 9 596 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 1 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) gel Addition 0 Demolition ❑ Accessory Bldg. 0 Number of Units they 0 SpecifVil : Brief Description of Proposed W `2: �,}-5 (1 Q►v 1❑C1Q I ‘.k L 4)di Wc,11AsUkil, al. �rV� U'C ` . ,on • SECTION 4:ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 1. Building Permit Fee:$ ‘5 p Indicate how fee is determined: 2.Electrical $ 'Standard City/Town Application Fee 0 Total Project Costa(Item 6,x multiplier x 3.Plumbing $ 2. Other Fees: $ 3 5�(( 4.Mechanical (HVAC) $ List: GC.,0 Ito K3 5.Mechanical (Fire Suppression) $ Total All Fees:$ - Check No. Check Amount: Cash tint: 6.Total Project Cost: $ ) ( / S,>.D 0 Paid in Full M Outstanding Balanc ue: 7 SECTION 5: CONSTRUCTION SERVICES 5.1 CII -o'nstruction Supervisor License(CSL).� 101096 __� 'D o1 4 Y\ V\Y\ .)m License Number Expi ation ate Name of CSL Holder r I 57' (� U V' List CSL Type(see below) V No.and Street 11 `/" \ Type Description jU. C SIVI (� (' \< 03668 U Unrestricted(Buildings up to 35,000 cu.ft.) City/Town,State,ZIP """��— ) R Restricted 1&2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding / � �L��,, (� , SF Solid Fuel Burning Appliances 1314 a3Z €f'? s 1rVAt.l, ijtilII)� I Insulation Telephone Email address �j&WI._ N D Demolition 5.2 Registered Home Improvement Contractor(FaC) -r'ME 3��)s��� 1 C Coo n l C� any or HIC Reslrant Name HIC RegistrationNumber E pirat on Date N``--ojj dStreet �� .AD` ���\-)Ct1)lll1011Wil &VI U. 0 7711 ZS } / Email address City/Town,State,ZIP I Telephone `"'J�O 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 Issuancean of the building permit. Signed Affidavit Attached? Yes d3 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 buil ' g permit application. � Ii'a aq a Prin Name(Ele nic ature) ate 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 accurate to the best of my knowledge and understanding. 4 �l ,y\b, Print Owner's or Auu horized Agent's Name(electronic Signature) Da 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 _:;=tkg_1� Department of Industrial Accidents ��c= =eel= I Congress Street, Suite 100 c'J'(- Boston, MA 02114-2017 .;,5.•'� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant Information Please Print Lepibly Name (Business/Organization/Individual): 1 \IV.N7 T � � Address: 3 7 6)(U M `" City/State/Zip:U. ( c(q15A-4141 VA< CAW Phone #: d7"-/9 ,a J 6 Are you an employer?Check the appropriate box: Type of project(required): l.gl am a employer with I employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp. insurance required.] 8. [remodeling 3.0 I am a homeowner doing all work myself. [No workers'comp. insurance required.]r 9. ❑ Demolition 4.D I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 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 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(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: `A ET. y C Policy#or Self-ins.Lic.#: ( Jkj5ry //vat, Expiration Date: n/nO /a),g, Job Site Address: 4 rll ' f,S City/State/Zip: -6 4, 4,--iv _ ij , in , t 6O L_) )P Attach a copy of the workers ompensation policy declaration page(showing the policy number and expiration datt . U 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 violat A co y of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verificati I do hereby certify u r th pains and penalties of perjury that the information provided a ove is true and correct. Signature: Date: 0') ( f1 /Q( Phone#: 77 U) g3& O361 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#: JOHN-10 OP ID:JA ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MM DD/YYY Y) 11/21/2022 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 508-775-6060 CONTACT Bryden&Sullivan Insurance Bryden&Sullivan Ins Agency Y 9 Y PHONE 508-775-6060 FAX (NC,No):508-790-1414 88 Falmouth Road _LAX,No,Eue): Hyannis,MA 02601 E-MAIL Bryden&Sullivan Insurance DREss: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:NGM Insurance Company 14788 INSURED INSURER B:Citation 40274 Johnson Home BuildingLlc and Timothy P Johnson Associated Employers Insurance TIMOTHY P JOHNSON ONSTRUCTION INSURER C: P y 378 Plum St West Barnstable, MA 02668 INSURER D: 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 TYPE OF INSURANCE TADDL�SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD IMMIDDIYYYYI IMMIDDIYYYYI A COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE X OCCUR SOO OOO MPT7064K 11/10/2022.11/10/2023 DAMAGE PREMISES(Ea occurrence) $ X Business Owners MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 2,000,000 GEM.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 X POUCY L JECT PRO- I I LOC PRODUCTS-COMP/OP AGG $ 4,000,000 OTHER: $ B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ ANY AUTO BCLRYL 04/28/2022 04/28/2023 BODILY INJURY(Per person) $ OWNED jr SCHEDULED AUTOS ONLY AUTOS� BODILY INJURY(Per accident) $ A R S ONLY AUTO ONLYY MOPERTY DAMAGE (Per $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I RETENTION$ $ C HANPL �REI X STATUTE ER D EMPLOYERS' _ Y/N WCC50050114562022A 11/02/2022 11/02/2023 100,000 ANY ,OFFICER/MEIMBEREXCLUDED PROPRECUTIVE Y N/A EL.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under 500,000' DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION YARMOUT 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. Buck Island Road West Yarmouth, MA 02673 AUTHORIZED REPRESENTATIVE Bryden&Sullivan Insurance ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Regulations and Standards Const( dl a rvisor ,ti. CS-101696 4.7 Ipi res: 08/23/2024 TIMOTHY P#DH a 378 PLUM S f WEST BARNWJABL I 4� '%.011,va A)J Commissioner 0,- 1 L THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Roston, Massachusetts 02118 Home Improvement Contractor Registration Type: Individual Registration: 179608 TIMOTHY P JOHNSON Expiration: 08/20/2024 378 PLUM ST WEST BARNSTABLE, MA 02668 Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE:Individual Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street -Suite 710 179608 08/20/2024 Boston,MA 02118 TIMOTHY P JOHNSON TIMOTHY JOHNSON 378 PLUM ST ! i ' WEST BARNSTABLE,MA 02668 Undersecretary Not valid without signature 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. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section 111/5 I hereby certify that the debris resulting from the proposed work/demolition to be conducted at 1 a,i,1 Dr S- tkC, ; Work Address Is to be disposed of at the following location: V L ..-\ Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chap 111, Section 150A. M DD/aQ Signature of Applicant Date Permit No. ...10 ..,-.0 5-... 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