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HomeMy WebLinkAboutBLD-23-003714 ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department 1146 Route 28, South Yarmouth, MA 02664-4492 ; 508-398-2231 ext. 1261 Fax 508-398-0836 _ Massachusetts State Building Code,780 CMR. o� e' r' Building Permit Application To Construct, Repair, Renovate Or Demolish -• ;i: a One-or Two-Family.Dwelling • This Section For Official Use Only & - —I-V E D Building Permit Number: [3L D -a3 - 6 a137l y .Date Ap .' d: — • — • �tl y f--r�4 . JAN .05 2023 Building Official(Pr e) Signature 1)at4_. SECl'1 N 1: SITE INFORMATION By: TMENT 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers iqj Ad A hank d. i 096 //sers' 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 1 Provided Required Provided Required Provided 1.6 Water Supply: (Iv1.G.1,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: Outside Zone? Municipal 0 On site disposal system 0 Check iff yes yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1Ownerr'of jecord: 1_ ' 4 _ JQ(, c V>n 2-14 at a--- --S a.._Vict mpuIl_ VI 4 D 0160 t Name(Print) City,State,ZIP No.and Stree Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 Existing Building'Owner-Occupied$3 2epairs(s) 0 Alteration(s) ElLAddition ❑ Demolition 0 Accessory Bldg. 0 Number of Units__ Other Specify: fv;nrlµJd fa Brief Description of Proposed Work2: SECTION 4:ESTIMATED CONSTRUCTION COSTS • .. Estimated Costs: - Item (Labor and Materials) , - • _ • Of cial` se��nty 1. Building $ 4N3f�a,Du 1.'Building Permit Fee;$ dicate how fee is determined: 2.Electrical $ E]Standard City/Town Application Fee - — ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ - 4.Mechanical (HVAC) $ 'List: .__ -1r qu5-1.1 5. Mechanical (Fire -�_-- ...— ..__ . Su cession $ Total All Fees:$ Check NO._____,. Check Amount: Cash Amount: — • 6.Total Project Cost: $ pi sa,00 0 Paid in Full 0 Outstanding Balance Due: ` r 5; CTTION S_CONSTRUCTION SERVrCLS� 5.1 Construction Supervisor t,icer se(CSL) 1 .`t = z v —�• r " ' License • Number Expiration Date Na ne of CSL Holder List CSL Tyl e(sec below) No and Street Type I Description ' ' U Unreatrteted{Buildings up to 35,000 cu.fY. q r R Restricted 1&2 Family Dwelling own,State,;ZIP _ M Masonry P.0 Rooting Covering WS Window and Siding' SF Sold/Fuel Burnin &Appliances Insulation Fele)honc_ mail address ll Demolition 5.2 Registered Home improvement Contractor(HIC) i)��G l_'` 1r: L ft..;gistrationNumbee Tic y N or HIC Re ist t Thine 6xpuatron Date No.and Street — r 1_ b.mart add ess City/Town,State,LIP 'telephone f" I �G / SECTION 6:WORKERS'-COMPENSATION INSURANCE AI+'1r113AV T G I (iVI. .I„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 D No... .. D SECTION 7a: OWNER AUTUORIZATION TO BE COftU/LETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner oldie subject property,hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. _ I Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNER`OR AUTHORIZED AGENT DECLARATION By entering my name below, I hereby z.ttest tinder the pains and penalties of perjury that all of the information i contained in t s application is true and accurate o the best of my lmowlecdge and understanding. A Z3 Print Owner's or Authorized Agent's Name(111ectronic Sipature) Date NOTES: 1- I. 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(I lC)'Program),will na7 have access to the arbitration program or guaranty fund under NI_G.L, c. 142A. Other important information on the IIIC Program can be found at www.mass.00t'Idea Information on the Construction Supervisor License can be found at www.Inass.eovidps 2. When substantial work is planned, provide the information belo‘i'' Total floor area(sq. fl.) (including garage,finished basement/atttcs,decks or porch) Gross living area(sq. ft.) Habitable room count Number of fireplaces Number of bedrooms _^ Number of bathrooms Number of halflbaths Type of heating system Nttmber of decks/porches T _ Type of cooling system Enclosed^ _OPcn __ , — 3. "Total Project Square Footage"may be substituted for"Total Project Cost" ____ SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) C S—Dr5/ Yrnia l C �j LS u.4 s'tciAv.6 _ License Number Expiration Date Name of CSL Holder k Q,�& List CSL Type(see below) No.and Street Type Description '"- HA- J2-tod I (U� Unrestricted(Buildings up to 35,000 Cu,ft.) 1��n 1 / It Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered QHome Improvement Contractor(HIC) I�y3 i�o15� `U1;11 1 f - mM �t�� � HIC Registration Number Expiration Date HIC CompanyName or HIC egistrant Name ic Q c y, -tC bby)I bit 114_ _ t.And St eeti�.c� ��.5'7 s Email address City/Town,State,ZIP Telephone efier/ Leh/) 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. Print Owner's Name(Electronic Signature) Date— 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. Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: I. 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.gov%oca Information on the Construction Supervisor License can be found at www.znass.eov/tips 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 Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston. Massachusetts 02118 Home improvement Contractor Registration Type: LLC Registration: 194325 WHITCOMB BUILDING & REMODELING, LLC P.O. BOX 254 Expiration: 01/24/2025 EAST SANDWICH, MA 02537 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:LLC Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street -Suite 710 194325 01/24/2025 Boston, MA 02118 /HITCOMB BUILDING&REMODELING, LLC HARLES A WHITCOMB 3 AUNT SOPHIES ROAD c.- T,,0,,;% «t<< REWSTER, MA 02631 „,,,,,,,,,:,,,,:,,4,,,,.;,,i:;,,t.1,,1,4a,,f,?.! ,,!iii:ii,v_.iI17:,.:,::,,,t,'ilt:;4•z,',`:':i.'t'';'.;.'li' `it,,'.,,,t'''4'',',4.!''','';..,.,',,‘,':.,:i,;.w'',.''',i'''w.'4,;;'li!':';'t:'t:,10::a''',,4'`''',z;,':,, ,,''';::,:!.,1';,g,,,.,_Ii.7..:i4ls::,,4i:iilril;',,i;,*.'0.::1;i‘..14:2,:_z_e,,._, ._il':'cic;;:l;t:!,5i.,1?:tiiiiii.4:11:TL.lkif7.rvl:P:''tiltltt:.t":!'<:.i.;1.ff:,:'i:.;11:.,.::ij:;,i:iii,:4:,1!,::!.;::E',.:,:!.:,::,;a.;;:t1,,f'E;,:,.7':.;:';.,,:;"'...;:.ii,:g,;::i'w':::;::,!,',,,.'il:7:.;;I:..,::':.:.-.:'.'i;;.:;..'i'i:ij..f'::.!.f:!...':!:.'r..:::,:',:S,,i.:.;:.;',::::''.7H'::,,:..i:,:.t;';:..,,::::?.ri:7.,.j.:!:i:::..::'.,:,.,::.::.;j:t.';'::;::..:::;:..t4''I'7i:''.:!r:tiHf:::;!;:;4.,''::;:;L:!'.::;:,411..;!,i';i;iq:'5,:'''!.e,i;":;ti:.;:.:,'il.';'''.i2''Is'',::7::'t.,.,:e.:s''''t':';4.::;::';:;.::;"::;;:i:i::.:;:i14:E,i,t?4H':::::.if:'o;:.,E:..'E;',„::V,g':"::::lsi!l5:'t',,,i:::...':'t4;74*.4;fii:.,..w.H::i:l:::,,t.,':' ''::.,::,':',4.::,,H.,','Ek.,':t':,. :..:,'P:_**:,.:t'';:_l',:,:,:f.z,;c2,,,,„::1-:'':wr'riiir,.,,:ti...i,::::i.::g,.',':,.:',.;:!.. -,',;',:2.,,,It.g.V0,, ,,41,,,-,,,,,::::f.-.4, :cNi,j,:,,,,-„'if:ti„, :Enz.:_.4-7iiA,-;.: 13i;. ...-f-Rif3c.:XtaftigeitMl.-W.4:414:**'''':,'-*:1!,•:4,-;4$,-,..,7*4:0,1:45W1:Mlit*:2*.4.01t..-n,•,,: roti.L;;*attitivi. .,...::4Ji:::rc;?:,,.:Ftv;:ARN.:514,:,,il4....:: if,,,W171.4.,:;,-,”t,-4-4-to,trtmigy,o,,Ate-dpmly.li,;1..it4:tlytelgagi;:ik''•:Aghi44,'Z&'''''rA','..tliV.,.t4'i.AF.:*,;.:::4::.':4.::!..:.:...-i'l•-1,14. eicillitli :::8'..ik.V50.,471":": -:34141*3.i2'.1::::: :•!..a4;11".,•tn.V.4,:i igttiri:;'Vttt!iaib:V:'=-5:.i.OPNFLS'.;'.1!:AV,*ff:"(:'E-;: #,V;.t'::-fii..:, '.' -.:',n:'efria,,VZP:t44.:.•-.::„,,:'.: -4:A;:L:.i .J:;.iji-i't:E..v:?;:--4:i',::;i..41F.'73:;!:akit.0;-',P.::'t:.,1ir;tW,WAt.'it.iar.. 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Applicant Information ' � ,.,l ,,/ Please Print Legibly Name (Business/Organization/Individual); �, t4U,_�l'!rt q' e CIF/►/ Address: PPAik___;151/ City/State/Zip: ('Seeljed);c h _ N4 d537 Phone -#: -7 7 Li:Ida 73�fa� Are you an employer?Check the appropriate box: Type of project (required): .0 am a employer with_ employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp. insurance required.] �• emodellrig 3.0 i am a homeowner doing all work myself. (No workers'comp. insurance required.]t 9. CI Demolition 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 ale sole 11.0 Electrical repairs or additions proprietors with no employees. 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12. Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance.* 13.0 Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGI.c. 14•El 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 ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy #or Self-ins. Lic. #: $O_ X ) )- v 1.- d , // W h Z.- �U- �0 � Expiration Date: /VJd���-� Job Site Address;__ r City/State/Zip: �J Attach a copy of the workers'ALL/ mpensation policy declaration page(showingy ra n�the policy number and expiration date). Failure to secure coverage as required tinder MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 ancUor 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. S.=nature: Date: /,�j1 Phone#: 771 —7 -731-"„) --- Off cial use only. Do not write in this area, to he 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#: r ® DATE(MM/DD/YYYY) ACCo RD CERTIFICATE OF LIABILITY INSURANCE 12/08/2022 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 CONTACT Christian Barber,CIC NAME: The Oceanside Insurance Group PHONE (508)775-0500 FAX (508)790-7955 (A/C,No,Ext): ( No): E-MAIL ADDRESS: 52 West Main Street INSURER(S)AFFORDING COVERAGE NAIC# Hyannis MA 02601 INSURER A: Arbella Protection Insurance Company INSURED INSURER B: Associated Employers Ins CO Whitcomb Building&Remodeling LLC INSURER C: PO Box 254 INSURER D: INSURER E: East Sandwich MA 02537 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2211309345 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 LIMITS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100,000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 A 8500073334 10/28/2022 10/28/2023 PERSONAL&ADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO 0000X POLICY JECT LOC - 20 OTHER: XLEAD $ AUTOMOBILE LIABILITY 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 LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION X STATUTE EOTH AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT W $ 100,000 B OFFICER/MEMBER EXCLUDED? N N/A MZ-800-8008121-2022A 10/28/2022 10/28/2023 (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/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations,and endorsement of the policy.Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions.This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This is to certify that the policies of insurance listed have been issued to the insured named above. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Sandwich ACCORDANCE WITH THE POLICY PROVISIONS. 100 Route 6A AUTHORIZED REPRESENTATIVE (/ 4C�' Sandwich MA 02563 _ I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD �1 TOWN OF YARIMIOUTH o BUILDING DEPARTMENT _ 3 1146 Route 28, South Yarmouth, NIA 02664 s=v 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 from the proposed work/demolition to be conducted at icy l bij k EV At [X Work Address Is to be disposed of at the following location: liall,c)ic Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. G/. ///2_7 Signature of Application Date Permit No.