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HomeMy WebLinkAboutBLD-23-002040 t• ► 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 14 508-398-0836 � •.•': Massachusetts State Building Code,780 CMR gal Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: J L b-' - 2c-jq O Date Applied: r-. BRA C ,-'— 1-V- J- Building Official(Printgame) Signature SECTION 1:SITE INFORMATION 1.1 Property ddress: 1.2 Ass s,s s a Parcel Numbe ✓IS a 11(110 Sr � 1 V � OCT 17 2012 1.1a Is this an accepted street?yes V no Map lumber Parcel Number UILUINCa DEPARTMENT 1.3 Zoning Information: 1.4 o erty Dimensions: i► _ `\% 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 Floll Zone Information: 1.8 Sewage Disposal System: Public V Private❑ Zone: Outside Flood Zone? Municipal 0 On site disposal system Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' p i n Miti of a r l ��Varti 1 vort h\ t a3 tt-i5 Name(Print) City,State,ZIP ,/i� Mw, ctti � . i. dcwi n4 axc( m No.and Street Telephone Email Addresdil um SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) GY Addition 1 Demolition 0 Accessory Bldg. 0 Number of Units Other ❑ Specify: Brief Description off Proposed Work2: L` Q /(�( I (t l ,�L'-_,I, i 'i,;�- 5G.it"rr AtAA-/ i'_5..4// , !�.17 difr4'ia ck: e- .Od/4.� SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $t , 12. 1. Building Permit Fee: $ SOO Indicate how fee is determined: 0 Standard City/Town Application Fee 2.Electrical $ (j D/Ul 0 Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 0 2. Other Fees: $ tp 0.00 0 4.Mechanical (HVAC) $ Li,MD List: e- 0(o Rb 5.Mechanical (Fire Suppression) $ 0Total All Fees:$ /� Check No. Check Amount: Cas punt. \ ✓ 6.Total Project Cost: tD i 1 0 Paid in Full 0 Outstanding Balan Due: 94.0 t SECTION 5: CONSTRUCTION SERVICES '5.1 Construction`(�� /w Supervisor License(CSL) 5— 14 A I 1 r t%%1W�` t ► L ,`) (LicenseNumber Expiration Date Name of CSL Holder C,OU -VU 1 If',. t UI,i,Li List CSL Type(see below) No.and Street Type Description VGA`-.jy ',j Mil f\a�' (� U Unrestricted(Buildings up to 35,000 Cu.ft.) City/Town,State,ZIP 11 �`1J w�+' R Restricted l&2 Family Dwelling M Masonry / RC Roofing Covering /'+ WS Window and Siding 6(�( (� ' rh y� CUB tCICL U. SF Solid Fuel Burning Appliances 'S\`t^CJ��L DOI oifc ( WWI c to t l I Insulation Telephone Email address D Demolition 5.2[ Registered Home Improvement Co tr+a\ctor(HIC CNAl\r C��i VIT HIC istratio Re n Number xpiration Date Co or a istr t to. tre �7 Wh`cleasu- i 1 �U W T� MR C 3t� F('4,S' j ��.,)(3 Email address9 fln/��,`.W') City/Town, State,ZIP �J�-� y� W 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 Issu ce of the building permit. Signed Affidavit Attached? Yes No ❑ 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 01 i Ills el . op Paw to act on my behalf, in all matters relative to work authorized by this building permit application. I/ Z9.=..---7 .----- ViVd4 Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest pains and penalties of perjury that all of the information contained ' is application ' e d accurate he best of my knowledge and understanding. Print Owner's or Authori gent's Name(Electr onic me 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.) (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 I•'�= 1 Congress Street, Suite 100 ....L?_ Boston, MA 02114-2017 We vy. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information i Please Print Legibly Name (Business/Organization/Individual):(MIA •�;'� �Q �`�` bj\\'CA t VS Address: 0 our Vli r ..� �/'-t+ 1 City/State/Zip:. U1tT 1 m CI& Phone #:_DOB \t -ubsk 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. ❑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. El Remodeling • 3.0 I am a homeowner doing all work myself. [No workers'comp. insurance required.]? 9. ❑yemolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 rlV-J, Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions proprietors with no employees. 12.n 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.: 13.❑Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14•❑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. Q n j 1n501 ,fl(k ( c i( c Policy f or Self-ins.Lic.#:4 A61k 10C)063 ^'{Expiration Date:1 I'SIkka3 Job Site Address:15 Mai ti'+ 1fl City/State/Zip:VMAIM) j C 1 Attach a copy of the workers' compensation policy declaration page(showing the policy nfmber 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 pen lties ofperj y that the information provided above is true and correct. Signature: /%`�'/G'let., r „ (� h �/�� GG� Date: U ``�'I I�i'x.CJ'3 Phone# I Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# 1 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 � �� , O . BUILDING DEPARTMENT -tio � ;^ =�= °a 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261 HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DATE: JOB LOCATION: NAME STREET ADDRESS SECTION OF TOWN "HOMFOWNER" NAME HOME PHONE WORK PHONE PRESENT A (LING ADDRESS OR TOWN STA'l'E ZIP CODE The current exemp en for `Homeowner' was extended to include owner—occupied dwellings of one or two units and to allow such ho -owners to engage an individual for hire who does not possess a license,provided that such homeowner shall act as pervisor. (State Building Code Section 110 R5.1.3.1) Definition of Homeowner: Person(s)who owns a parcel o .nd on which he/she resides or intends to reside,on which there is or is intended to be, a one or two family attached o detached structure assessory to such use and/or farm structures. A person who constructs more than one home in a o-year period shall not be considered a homeowner;such"homeowner"shall submit to the building official, on a fo , acceptable to the building official,that he/she shall be responsible for all such work performed under the buildin_ .emit. (Section 110 R5.1.3.1) The undersigned `homeowner' assumes res.ensibility for compliance with the State Building Code and other applicable codes, by-laws, rules and regulation The undersigned 'homeowner' certifies that he / s - understands the Town of Yarmouth Building Department minimum inspection procedures and requirements a•d that he / she will comply with said procedures and requirements. HOMEOWNER"S SIGNATURE APPROVAL OF BUILDING OFFICIAL INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent, ,hich meets the requirements of MGL Ch.142. Yes No If you have checked yes, please indicate the type coverage by checking the ap•ropriate box. A liability insurance policy Other type of indemnity B. • OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent h:homeownrlicexemp 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 �.J \ I\ CO\ 6 Sk ¶ i1\ i QCR mil arb Work Address Is to be disposed of at the following location:1)034AL j)t 'f atia Sal gfjC, n U 1`. Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. ?lel- IL IN 1,3C:0 Signature of Applicant Date Permit No. Sears, Tim From: Sears, Tim Sent: Tuesday, November 1, 2022 3:19 PM To: cuttingedgecustombuilders@gmail.com Subject: 15 Mallard St Willians, I have reviewed your application and there are some items needed. 1. A 110mph checklist or stamped plans need to be submitted 2. The use of sonotubes for footings requires plans be reviewed and stamped by a Registered Design Professional Please submit these items for review. There are also open permits showing for this address.One is for windows and another for a deck replacement.These permits will need to be closed before any additional permits will be issued. This email is considered a written denial of your permit application per Section 105.3.1 of the Massachusetts State Building Code. Section 105.3.2 states in part that "an application fora permit for any proposed work shall be deemed to have been abandoned 180 days after the date of filing, unless such application has been pursued in good faith" You may appeal this denial to the Building Code Appeals Board in accordance with M.G.L. c. 143 §100, within 45 days of this notice. Timothy Sears CBO Deputy Building Commissioner Town of Yarmouth 508-398-2231 Ext. 1259 mailto:tsears@yarmouth.ma.us 1 Commonwealth of Massachusetts Division of Professional Licensure Beard of Building Regulations and Standards Cons OPervisor CS-114224 Expires 08106/2023 WILLIANS G DE PAULA 55 CLUB VALLEY DR EAST FALMOUTH MA 02536 " p fcci,l Commissioner -`J THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation HOME IMPROVE O'T���cONTRACTOR XYadual WILLIANS GENTIL D 3 DIB/A CUTTING EDep t"` y -f9 WILLIANS G.DE PAULt' 55 CLUB VALLEY DR EAST FALMOUTH,MA ``"` "�" ' T_ Undersecretary RECEIVE-EY! s°`YY TOWN OF YARMOUTH i i m 1146 ROUTE 28, SOUTH YARMOUTH,MA 02664-4451 AUG€I G 4 �' Telephone(508)398-2231 Ext. 1292-Fax(508)398-0836 l p AHrviOwi i OLD KING'S HIGHWAY HISTORIC DISTRICT COMMITTEE OLD KING';HIGHWAY APPLICATION FOR CERTIFICATE OF APPROPRIATENESS Application is hereby made for issuance of a Certificate of Appropriateness under Section 6 of Chapter 470, Acts of 1973 as amended,for proposed work as described below&on plans,drawings,photographs, &other supplemental info accompanying this application. PLEASE SUBMIT 4 copies OF SPEC SHEET(S),ELEVATIONS PHOTOS,&SUPPLEMENTAL INFORMATION. Check All Categories That Apply: Indicate type of Building: Commercial Residen 1)Exterior Buildin l Construction: , New Building Addition Iterations Reroof l rReE C E I V E D ,Shed I J Solar Panels 1 Other: 2)Exterior Painting: X Siding [Shutters Doors Orrim I )Other: SEP 13 2022 3)Signs/Billboards: n New Sipn Change to pitting fisting Sign — BUILDING DEPARTMENT 4) Miscellaneous Structures: Fence Wall LiFlagpole [Pool Other By ---- Please type or print legibly: (� j Address of proposed work:/ t 1�',4[j 1 ArA 3fte G�t, y&rot NJ( eap/Lot# I )/141 Owner(s). D/ ill fA EA6, Phone#: 7J/"'* 874 — 4— / All applications must be submitted by owner or accompanied by letter from owner approving submittal of application. Mailing ad((d��ress://]] I i C ritl fog Ilk [i4etisfori t�A Ol rd 'f Year built: IJ Email. f A/ I h j ti)14141 • cowl Preferred notification method: !1) Phone El Email Agent/contractor. Phone#.711- O s4- 5K t) Mailing Address: (� (� Email _ Preferred notification method: El ,Phone (__ ) Email Descriptionr of Proposed Work: t 1 Ada,. i, t,1�IJ , ioM" o Sail of hohc + f✓k/K,' Cfo)ci- 4. el A S ter iced fowl . 411 e xfc<<r,� o ,�a�� 3f� fi o�c. Signed(Owner or agent). e9-+0."..-"". ____C.......____ Date' , f . Owner/contractor/agent is aware that a permit is required from the Building Department.(Check other departments,also.) It application is approved,approval is subject to a 10-day appeal period required by the Act. This certificate is good for one year from approval date or upon date of expiration of Building Permit,whichever date shall be later_ All new construction will be subject to inspection by OKH.OKH-approved plans MUST be available on-site for framing&final inspections. For Committee use only: - k/Approved Approved with Modifications Denied Rcvd Date: r81Yf2a Reason for Denial: _ -_.. Amount `'"r Q' ' CashiCK#: C es h G ` Signed: . 6. 'Y't 45 Days: del � , > MI ih 3 t fr LOW KING'S HIGHtNAY Date Signed. )1111/0--0 2.2 1 '�i �l� APPLICATION#: 40N- Y% TOWN OF YARMOUTH : HEALTH DEPARTMENT ''�• PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET To he completed by Applicant:Building Site Location: I ) /9 An of + J ACC� /t' /`v/f 0" 6- -Proposed Improvement: Y i.J,Y S i C )C/ `r!�i//a 1.\"\u IZO i/23 (( CcT ti. `�� c Applicant: �q.`�� i ( 1)7Ud! Tel. No.: ip' ff5-6- CW3 Address: f E I' ur Avc M 04,?`/ Date Filed: ///1/); **If you would like e-mail notification of sign off please provide e-mail address: 0 1-11 JJh ii t/ h 4 a'I' cax, Owner Name: j J' Owner Address: �i i io AiC C I^P'h.J0/ ,4 U I Owner Tel. No.: `7S/- 4 5 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; SEP 2 2027 (2.) Floor plan labeling ALL rooms within building (all existing and proposed) — HEALTH DEPT. Note: Floor plans not required for decks, sheds, windows, roofing; f g; (3.) If necessary, Title 5 application signed by licensed installer with fee. REVIEWED BY: ,/\/K DATE: LEASE NOTE COMMENTS/CONDITIONS: R E C E I V E D SEP 22 2022 BUILDING DEPARTMENT By ----- ACORD Client#: DATE TM CERTIFICATE OF LIABILITY INSURANCE 8/25/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHT 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 pollcy(les)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 Raphael Oliveira NAME• PHONE (508)771-4600 DISCOVERY INSURANCE AGENCY LLC (AI(:,No,Ext): 668 Main ST,#A HYANNIS,MA 02601 Phone:(508)771-4600 EMAIL aphaeldiscovery©Email com ADDRESS: Raphaeldiscovery@gmail.com INSURER(S)AFFORDING COVERAGE NAIC INSURED INSURER A: INSURER B: CUTTING EDGE CUSTOM BUILDERS INC INSURER C: 55 CLUB VALLEY DRIVE INSURER D:PENNSYLVANIA MANUFAC.ASSOC INS CO EAST FALMOUTH, MA 02536 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:000015 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED 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 TALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRL ` TYPE OF INSURANCE ADDLI SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS TR NSR WVD (MM1ODNYYY) (MMIDDIYYYY) A GENERAL LIABILITY EACH OCCURRENCE DAMAGE 70 RENTED COMMERCIAL GENERAL LIABILITY PREMISES(Ea ocurrence) CLAIMS-MADE I I OCCUR MED EXP(Any one person) PERSONAL&ADV INJURY GENERAL AGGREGATE PRODUCTS-COMP/OP AGG GEN'L-AGGREGATE LIMIT APPLIES PER'. 7 POLICY ' PROJECT LOC B ` COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident) ANY AUTO BODILY INJURY(Per person) ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY(Pen accident) NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) C UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE AGGREGATE DEC RETENTIONS D WORKERS COMPENSATION WC STATUTORY OTH AND EMPLOYERS'LABILITY YIN X LIMITS ER ANY PROPRIETOR/PARTNERIEXECUTIVE N OFFICER/MEMBER EXCLUDED? E.L.EACH ACCIDENT WCMA000105902 7/18/2022 7/18/2023 $ i,DOD,000.Do (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000.00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000.00 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE "HE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. RAPHAEL OLIVEIRA 1/1 ©1988-2010 ACORD CORPORATION.All rights reserved. � l ®ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDD/YYYY) 04/04/22 9:40PM 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 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 NAMEACT Customer Service Department Target Financial& Insurance Services, Inc. PHONE FAX (A/C.No.Extl: (800)450-8013 (AIC-Ne)• (800)434-8053 Phillip Salvagio ADDRESS:certificatea@tgfis.com 3256 Grey Hawk Court Carlsbad, CA 92010 INSURERS)AFFORDING COVERAGE NAIC INSURER A: Preferred Contractors Insurance Company, RRG 12497 INSURED INSURER B: Cutting Edge Custom Builders Inc. INSURER C: INSURER D: 55 Club Valley Drive, INSURER E: East Falmouth, MA 02536 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 ADOL SUBR I POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER (MM/DD/YYYY1 (MM/DD/YYYY7 X COMMERCIAL GENERAL LIABILITY PCA5026-PCCM430027 04/07/2022 04/07/2023 EACH OCCURRENCE $1,000,000 A X CLAIMS-MADE OCCUR PR S( RENTED PREMISES(Ea occurrence) $50+000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY, JECT LOC PRODUCTS-COMP/OP AGO $1,000,000 OTHER: $ AUTOMOBILECOMBINED SINGLE LIMIT LIABILITY $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS — AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS _ AUTOS (Per accident) UMBRELLA LIAB _ OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE AGGREGATE _ DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY STATUTE ER Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached IT more space Is required) Verification of Coverage *Subject to all policy terms, exclusions and conditions* CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Verification of Coverage THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I 1;1114:e 511112r. m 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) RECEIVED AUG 0 8 20221 .,----, TOWN OF N'ARMOt•I• _I 01. •, . Y-A:4-- * , \ BUILDING DEPARTMENT WATER DEPARTMENT By. _ 99 Buck Island R(lad %I.II Narmouth MA 0267.i 71-17t2 I • I<iv rsOII: 7.71-79InIi BUILDING PERMIT APPLICATION FOR WATER DEPARTMENT SIGN OFF TRANSNIITTAL FORM BUILDING SITE LocA-rioN 1 ) ill 4 ii 4ra 5tiee4 Ya til 0,/{ 4/L PROPOSED WORK: 141(4.,./wv + CION'Y C;%dotit APPLICANT: On 0 pi ADDRESS: ( i-- /41 aliattil Stiett Y4tiowt. AIX 0,24 75— _,. ...._ — FELPIIONE: 1 il— 6 6 — )0473 DECtil If(,) v,desd i RESIDENTIAL AND OR COMMERCIAL BUILDING Water Department: Determines Compliance of Water Availabilit and or existing location Engineering Department: Determines Compliance fir Parking and Drainage- Conservation Commission: Determines Compliance to Wetlands Act: i e. If lot(s)border any type of \vetlands. streams. ponds,rivers,ocean, hogs. boys, marshland. ETC. I lealth Department: !km-mines Compliance to State and'town Regulations. i.e. requirements for Septage Disposal and other Public I lealth Activites Fire I kpiiriment: I ktermines Compliance to State and Town Requirements for Personal Safety. Property Protections, i.e. Smoke Detectors, Sprinkler Systems.ete 1/Y/f)(2 AM,ICANT SIGNATURE wyrt. OFFICE USE: CONINIENTS ON PERNIIT APPRON.Al OR DUNI Al. .,,,. . A 'E rD BY WATER DIVISION(SIGNATURE) DATE tii4 41.1 SERVICE NO. NAME ? si2e9t8h4 Stoffregen 7/23/99 STREET is (-1)A kIfie. c:, S-c--t VILLAGE a, IiI(MO CC61 514" rit(: _.0, 2J-ey METER NO, 3.z3...e.-Er--."÷-7...?" Oz_z.!y. 50'' I" ,erl‘te i1/4243.1`/ —I le' copper — 2 / tfiniei 14-'r°' l fi qv A13.• \ fr'd ,Is• S. \ ( 31 ) '`‘ I t " fil(ITN -- In U, tz+c“ .-1-- .