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HomeMy WebLinkAboutBLD-23-000335 ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department •yF"" . 1146 Route 28, South Yarmouth, MA 02664-4492 jL.508-398-2231 ext. 1261 Fax 508-398-0836 �' \ ': Massachusetts State Building Code, 780 CMR Building Permit Application To Construct, Repair, Renovate Or Demolish _ - a One-or Two-Family Dwelling ''\\ This Section For Official Use Only Building Permit Number: BLV-22)-- 33S Date Applied: RECEIVED /' .za5 �— ck_ JUL182022 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION BUILDING DE;ARTMENT 1.1 Property Address: By -— — 1.2 Assessors Map&Parcel Numbers - - A 3 hr 4-- Si-rr el-f a6 IV) .00 1.1 a Is this an accepted street?yes 1./.-no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property-Dimensions: CK=it R- Yu Pat 371sr 70r Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) lb 5 3 1.5 Building Setbacks(ft) Front Yard Side Yards i Rear Yard Required ! Provided Required Provided I Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Private❑ Zone:A-y() Outside Flood Zone? `� Check if yes❑ Municipal❑ On site disposal system Cg SECTION 2: PROPERTY OWNERSHIP' 2.1AOwner'of Record: (Y —C i'f'i. r es�33 t�rrs. r S.'. yad/I�ev"� 47 /�J Name(Print] — �5 City,State,LIP e.2.33 elril ,, — s j-r rv-4-- 777 xx7 33Ta n.'1+AyCAtrith"FhLet.L, c cr.% No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction ❑ i Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition ❑ i Accessory Bldg. ❑ Number of Units Other It Specify: pail_ fc � Brief Description of Proposed Work'-:_ /u of `1 vac,[ cc_ RECEIVED Au& 2 9 '022 SECTION 4: ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: Official Use Only BUILDING DEP•RTMFNT (Labor and Materials) Y By 1. Building $ 1. Building Permit Fee: $ i c,c), Indicate how fee is determined: 2.Electrical $ U �U� �+— Standard City/Town Application Fee ! 0 Total Project Costa(Item 6)x multiplier x 3. Plumbing $ j Ai(/O(/, t` 2. Other Fees: $ I U 1(fib 4. Mechanical (HVAC) $ List: 5.Mechanical (Fire Suppression) $ Total All Fees: $ „..._.___)-- IA Check No. Check Amount: Cash ount: ‘,\ 6.Total Project Cost: $ 4420 ea. V`" 0 Paid in Full Outstanding Balance Du : ^�\ , SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) ÷V•ei-% 1) Cc-Er License Number Expiration Date Name of CSL Holder - /'/ List CSL Type(see below) cv �v� rer+ Drt u No. .aand Street Type Description •//1fSS "As /f?�i, Unrestricted(Buildings up to 35,000 Cu.ft.) City/Town,State,ZIP Restricted 1&2 Family Dwelling M Masonry 0.2 G q • RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 77Y-fa O/Gf situc..6 Cc k C(!5+e , C G/'I, I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) , S-�-t Cats ciwtrrr. Horn=s d-ar►wilt. 4C OQgi Y`r /p y-on D MC Com any Name or HIC Registrant Name HIC Registration Number/+ Expiration Date , (O V't 'e ri a(1r`— 5+el.(1 G(} C6 No.and Street J �a -- CVsZ'�Yn►. �G✓1� "arsc f, AVIIS �cf J/T f�G� Email address /Yf� . Oat City/Town, 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 of the building permit. Signed Affidavit Attached? Yes 0 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 '.‘--{ , 0 celr to act on my behalf, in all matters relative work aut ized by this building permit application- °"^ —7/ r v2 L Print Owne 's Name(E ectronic S gn re) 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 accurate to e best of my knowledge and understanding. Print Own s or Auth ized Agent's Name(Electronic Signature) Date 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.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) AV—. (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 == = Department of Industrial Accidents =Mill= 1 Congress Street, Suite 100 C�=' 'f=_ Boston, MA 02114-2017 t1t,.....,.• • www.mass.gov/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): 4.-,eve.,.. Co le_ [mow. tkeres d,Ref...6thu�.l,,c. Address: Col -,„,j,..r- City/State/Zip:,/off,-3'6t4-s 4-z,/<s AA P'Z f T Phone #: 77Y-7/7 a/G.P Are you an employer?Check the appropriate box: Type of project(required): I. I am a employer with employees(full and/or part-time).* 7. 2.0 I am a sole proprietor or partnership and have no employees working for me in ❑New construction any capacity.[No workers'comp. insurance required.] 8. ❑ Remodeling • 3.0 I am a homeowner doing all work myself [No workers'comp. insurance required.]t 9 ❑ Demolition 4.❑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.❑ 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•❑Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14•❑Other P(/GL 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: �S C' �1n3 krriw•cc_ $'t'Ckefeft, ,7,41C- Policy 4 or Self-ins.Lic.#: _5/1.4-G©a7`36 5 Expiration Date: /,/i y/Z.Z Job Site Address: epljf PIr i,j..'— .4,1„r — YA,0'44I. City/State/Zip: 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$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 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 o rjury the the information provided above is true and correct. Signature: /� / Date: 7 1 �� / Phone#: 7 y-3/ 7 6/ y Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License As- 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 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 a9,33 P/ ,,00,,, yAr.r4J Work Address Is to be disposed of at the following location: yGttyrtuAL -1-ev,,,k Ii,yp Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. Signature of Applicant Date Permit No. TOWN OF YARMOUTH s ° HEALTH DEPARTMENT PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET To he completed by Applicant. Building Site Location: F- Proposed Improvement: PLe, Applicant: Ste�,•� U/. (. �t Tel. No.: 77V-.Y13-Q/ J Address: si-3 / ,, //s Date Filed: ZG-• **/fyou would like e-mail notification of sign off please provide e-mail address: Owner Name: /UA c y Owner Address: p?_ rg., J _ r-i- {— Owner Tel. No.: - RESIDENTIAL AND/OR COMMERCIAL BUILDING HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements For Septage Disposal and other Public Health Activities. Please submit three (3) copies of plans, to include: (1.) Site Plan showing existing buildings, water line location, and septic system location; RECEIVED (2.) Floor plan labeling ALL rooms within building JUL 2b 2022 (all existing and proposed) — Note: Floor plans not required for decks, sheds, windows, roofing; HEALTH DEPT. (3.) If necessary, Title 5 application signed by licensed installer with fee. ' REVIEWED BY: DATE: E- / PLEASE NOTE COMMENTS/CONDITIONS: Commonwealth of Massachusetts Division of Occupational Licensure Board of Building R ulations and Standards Cons oaff5 {v isor CS-057712 ` ' i pires:03/30/2024 STEVEN D CQLE :W A 61 EVERGREEN ' t, a' , O MARSTONS*ILL ; 2 Commissioner cia8 K. `dl&aL:a.- ` ,Ji�e [�nrrrsno2urP,o,�G2 a�/o[9�ak�ariuGtc�/1 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Corporation Registration EXDiration 01/14/2023 STEVEN COLF;CLLTOM HOMES&REMODELING INC. STEVEN D.COLL 61 EVERGREEN CAW- MARSTONS MILLS,MA'`02648 Undersecretary • kv€ — & SUM • ( o�.ygR rO\\',N OF YAR\tnt 1TFI 1k' o WATER DEPARTMENT ci- -`,-I .i., 99 Buck Island Road q°7-.! West Yarmouth, MA 02673 �' :''4 Telephone: (508) 771-7921 • Fax: (508i 771-'998 D in 19 2022 BUILDING PERMIT APPLICATION FOR B�.)ll D NG DEPARTMENT WATER DEPARTMENT SIGN OFF TRANSMITTAL FORM BUILDING SITE LOCATION: p �..7 ift-Ar - 1- (s rz-1-- j PROPOSED WORK: 'Ric'L 8-- pQoL t c'v._ APPLICANT: S---\--e t.-e—' 0_ C ei r ADDRESS: C/ t'ec,9..rce, Dn /I�e-,.... 4 .1 „44,//s TELPHONE: 77 5" jer GIGS RESIDENTIAL AND /OR COMMERCIAL BUILDING Water Department: Determines Compliance of Water Availability and or existing location Engineering Department: Determines Compliance for Parking and Drainage Conservation Commission: Determines Compliance to Wetlands Act; i.e. If lot(s)border any type of wetlands.streams, ponds,rivers, ocean. hogs, boys, marshland, ETC... Ilealth Department: Determines Compliance to State and Town Regulations, i.e. requirements for Septage Disposal and other Public Health Activites II Fire Department: Determines Compliance to State and Town Requirements for Personal Safety. Property Protections, i.e. Smoke Detectors, Sprinkler Systems,etc Z----------- APPLICANT SIG: : C' E )ATE OFFICE USE: COMMENTS ON PERMIT .APPROVAL. OR DENIM. REVIl,W BY 141---L''ATER DIVISION SIGNATURE /DATE 2. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 07/05/2022 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 Gregory Bates NAME: RSC Insurance Brokerage,Inc. PHONE Extl: (781)986-4400 FAX No): (781)963-4420 (A/C.No,15 Pacella Park Drive E-MAIL gbates@risk-strategies.com risk-strafe ies.com ADDRESS: @ Suite 240 INSURER(S)AFFORDING COVERAGE NAIC# Randolph MA 02368 INSORERA: Safety Insurance Company 33618 INSURED INSURER B: Steve Cole Custom Homes&Rem INSURER C: 61 Evergreen Drive INSURER D: INSURER E: Marston Mills MA 02648 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2111341696 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 LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE RENTED CLAIMS-MADE X OCCUR PREM SESO(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 10,000 A BMA0028365 11/14/2021 11/14/2022 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 - O X POLICY P J R LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED BMA0028365 11/14/2021 11/14/2022 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED v NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY /� AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N X STATUTE ER A ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N/A BMA0028365 11/14/2021 11/14/2022 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 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 I u,�►--- IJYr! ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD