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HomeMy WebLinkAboutBLD-23-004480 pu SAij 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 i' i i, %.0-0. Massachusetts State Buil ding Code,780 CMR Building Permit Application To Construct, Repair, Renovate Or Demolish /`l_ a One-or Two-Family Dwelling This Section For Official Use 0 y Building Permit Number: J 0-2,3 Iv.•;��i' f Date Appli 1 1� curs �� BuildingOficial(PrintName) ���D� a3 v Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numb )0 2 C.e T F,C J : y444,41-A„7- 1 i 1.1 a Is this an accepted street?yes no Map Number Parcel um E C E V D 1.3 Zoning Information: 1.4 Property Dimensions: ,j Zoning District Proposed Use FEB 0 8 2O23 Lot Area(sq ft) Fronts (ft -1.5 Building Setbacks(ft) BUILDING DEHAI.2 r/jENT By: Front Yard Side Yards Rear Yard Required I Provided Required 4 - 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? Check if yes0 Municipal C1 On site disposal system 0 SECTION 2: PROPERTY O WNERSBIP1 2.1 Owner'of Record: Name(Print) '"1� © -1 ty,State,ZIP i al C e,e ii .1 -, i,5.c�lbw}Z. ..t�, • Z/9 --4ra ha 'J1-..,2 '1,'- e P��"' ` 1 ,�°t. �,!ti- No.and Street � Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'-(check all that apply) New Construction 0 I Existing Building 0 I Owner-Occupied 0 I Repairs(s) 0 I Alteration(s) XI I Addition 0 Demolition ❑ I Accessory Bldg. 0 I Number of Units I Other CI Specify: Brief Description of Proposed Work2: noo; #` eevi i n u _4. r', �.,.7-0_The.> SECTION 4:ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: (Labor and Materials) Official Use Only I.Building S ‘4 ovv 1. Building Permit Fee:SJ_Indicate how fee is determined: 2.Electrical $ - al Standard City/Town Application Fee n" ❑Total Project Costa I e 6)x multiplier x stils3okr 3.Plumbing $ #, 2,0: 0 2. Other Fees: $ (--� _ . 4.Mechanical (HVAC) $ List: NA, �c5 (� 5.Mechanical (Fire Y Suppression) $ Total All Fees:$ J'6.Total Project Cost: $ 6S:i (90c, Check No. Check Amount: Cash �...,. ❑Paid inFull titi Outstanding Balancer LI 101/ 2-I SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) Name of CSL Holder License Number Expi tion Date List CSL Type(see below) Lk No.and Street John S.Clark ________ 25 Oyster Way T Description Mash•ee,MA 02649 gr U ( Unrestricted(Buildings a•to 35,000 Cu.ft) City/Town,State,ZIP - R Restricted 1,k2 Family Dweilin• M Masonry • RC Roofing Coverin: WS Window and Sidin-SSC 0 ,0-7'1,3afi dot SF Solid Fuel Burning Appliances 7 /5' / -9- gin 0,1 Cc yam, I Telephone Insulation Email address D Demolition 5.2(Registered Home Improvement Contractor(HIC) HIC Company Name or HIC Registrant Name HIC Registration Number Expir tion Date No.and Street ' ��? gc 6 3���4(.�'2rtc,& .v, 4 A- 0 6 Li 9 y 77-•73 ; 3 Email address City/To ` ,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(AI.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 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 ap lication is true and accurate to the best of my knowledge and understanding. • wnerrs ut orized Agent's Name(Electronic Signature) <li-V/L 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.aov/oca Information on the Construction Supervisor License can be found at www.mass.nov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including Gross living area(sq.ft.) ( g garage,finished basement/attics,decks or porch) Number of fireplaces Habitable room count Number of bathrooms Number of bedrooms Type ofi g system Number ofhalf/baths Type of cooling system Number of decks/porches Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" a i t. 111 w i �/ jj R $ Z040 asp a ,,.; -`_ 4\"3 ' '�' c° f `� � 1U Qa � jY 0., � Ai n 2O= .0 1 * (0 ..., il) 41. 42 as coi 4-7 n E d = ¢ e 0 O t°v 1Q m a) O or i_ _OD _ O to .0 .4 i W 0 m o E _ T a 2mn (A 1 T .,r ›.rt=..� c0 _o' H E CL6 3 i C- P 3 < c t T 0 rnX 0 >▪ a. 2� •CO m !L W � c r $ 2 maser • = � ° >en O � � � ¢o oocsa Z 2 ='� i O 8U . 0ww� f- •- o '° to 0 � C �� l!80=� Q cm a) ex-oo Q � 5 ¢ m0,-co cp (1) z0 Ms' o ° .s oomE m U U E ( 0 u m I a) = cWn as¢ `� F— v = ° A 2 O v� Nm � z0 I- V)4 = 0-2. O a, 2 coc. cc 0OttFOa O QZ}p = III `O -0>Q -ILL1� QQ W> CO CD CC < A }2 2 c _ ' crM O Qcn 2v g ¢ o¢ N �0c 0 p 0 zs2 cr < _� CQW 5¢ IY0 Ow W 0 g@ �I a Um SOLai I • §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-22311 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 /0 (7.7,2 f.t J✓ Work Add riss Is to be disposed of Oat the following location: (4_9 40 ,.1L'i4I23�� Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. 0/4.22_3 gna e of Application ate Permit No. The Commonwealth of Massachusetts � „_, Department of Industrial Accidents —;;0 1 Congress Street, Suite 100 II MK it Boston,MA 02114-2017 ‘177-*/ 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/Organi7ation/lndividualy JS Clark Builders Inc. Address:25 Oyster Way City/State/Zip:Mashpee, MA 02649 Phone#:508-477-9003 Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. D New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in any aP c aci tY-[l`1 o workers'comp.insurance required.] 8. 0 Remodeling 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 D 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. 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. ✓❑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:Farm Family Policy#or Self-ins.Lic.#:2001 W6337 Expiration Date: it/Z, z j Job Site Address: /®jy re.,J'it -- 1,/,it,t t .L City/State/Zip s yt;,<<,k :,�,;-- 47'4-AS.Attach a copy of the workers'compensation policy'declaration page(showing the policy tuber and Apiration 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 un er epains and penalties ofperjury that the information provided above is true and correct Signature: Date: ah...0 J 7 Phone : 08- 003 /// 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: i ACORD CERTIFICATE OF LIABILITY INSURANCEDATE(MM1DDIYYYY) 02/02/2023 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 - Will Donna Ostrowskl Mark Sylvia Insurance Agency, LLC PHONE IArcji,"atr (508 957-2125 404 Main Street EMAIL — tAAic xoT; (508)957-2781 ADpREss, mark@marksylviainsurance.com INSURER(S)AFFORDING COVERAGE NAIC IS Centerville MA 02632 INSURER Farm Family Casual Insurance Yr 000000 INSURED --�-- I INSURER B: JS Clark Builders,Inc. INSURER C: 25 Oyster Way INSURER D: INSURER E: Mashpee MA 02649 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 {ADDL SUBR I POLIC LTR TYPE OF INSURANCEY EFF 1 POLICY EXP JN$Di,WV POLICY NUMBER MM/bDlYY X COMMERCIAL GENERAL LUIBIUTY YYj ijMMlOD1YYYY1 LIMITS t LEACH OCCURRENCE I S 100,0000 ,CLAIMS-MADE 1 OCCUR �DAItAGE T RENTED I 1 PREMISES(Re occurreme( _r.$ 100,000 A _ MED EXP(Any one person) $ 5,000 r ( 2001X0243 04/29/2022 i 04/29/2023 PERSONAL S ADV INJURY _$ 100,0000 GEN'L AGGREGATE LIMIT APPLIES PER' �'PRO- GENERAL AGGREGATE '$ 2,000,000 POLICY LOC L__1 JECT L-� I PRODUCTS-COMP/OP AGG {$ 2 000,000 OTHER Y I AUTOMOBILE LIABILITY r-- COMBINED SINGLE LIMIT i ANY AUTO jEa accdent, $ I J OWNED 1 I SCHEDULED ' BODILY INJURY(Par person) 1$ i _1 AUTOS ONLY *___,AUTOS BODILY INJURY{Per accident) $ HIRED NON-OWNED AUTOS ONLY r AUTOS ONLY PROPERTY DAMAGE Wet aCcrde t] $ : ' $ UMBRELLA LIMB OCCUR EXCESS LIAR I LAIMS MADE? { EACH OCCURRENCE __ i C AGGREGATE OLD ;RETENTION$ I$ S 'WORK ERS ION { ST F AND EMPLOYERS'LIABILITY Y!N EATUT `ORH ANY PRCPRIETOR/PARTNERIEXECUTIVE — A {FF'iCERIM MBER EXCLUDED? V NIA j 2001 W6337F L FACH ACCIDENT S 500,000 (Mandatory In NH) : 12/2/2022 12/2/2023 �-._— _ .... _ ...z If yes,describe under I ! E L DISEASE-EA EMPLOYLL_$ 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 500.000 I i I I 1 f DESCRIPTION OF OPERATIONS!LOCATIONS,VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached tt mom space is required) Builder. Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived or extended the coverage provided by the policy provisions. 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 i South Yarmouth MA 02664 (/I'ft•.�S_w• Fax: Email: ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD @deigns REMODEL BATHS, KITCHENS & MORE October 17, 2022 Town Of Yarmouth Subject: Letter Providing Authorization to Obtain Building Permit To The Building Department: Ruth S. Holland 108 Center St. Yarmouth Port MA 02675 This letter is to authorize John Clark of JS Clark Builders/@designREMODEL to apply for a building permit for work to be performed at 108 Center St. . I am the owner of the property and have retained Mr. Clarks company to perform the aforementioned renovations. If further clarification of this matter is required, please do not hesitate to contact me via telephone at 215.219.1770. Kind Regards, Ruth S. Holland Address:25 Oyster Way, Mashpee MA 02649 ( Phone:508.477.9003 I Website:AtDesignRemodel.com . 1 . ONE or TWO FAMILY— BULDING PERMIT APPLICATION REGULATORY APPROVALS NOTICE Address of Proposed Work: I' Ce.s rf ,-r': 14,6,10 L (21 Scope of Proposed Work: u! e /, cc � � f4.44 Ls"tic rs 'TvtoJ , ../j7IL t.�n ( 1t C7Oic9-G L/I/ yiAJc Perm►, iJ Zu Date: //2c.12 3 Based on the scope of work described above,the applicant is required to obtain approval sign- offs from the following departments as checked-of below: Health Dept. —508-398-2231 ext. 1241 Conservation—508-398-2231 ext. 1288 Water Dept. —99 Buck Island Road, 508-771-7921 Old Kings HWY. Hist. Comm. —508-398-22631 ext. 1292 Engineering Dept.—508-398-2231 ext. 1250 Fire Dept.—Kevin Huck/Scott Smith, 96 Old Main Street, SY Note: Please call Fire Department for an appointment. 508-398-2212 Other Appropriate plans and/or application shall be provided to each departments checked-off above. Each of these regulatory authorities has their own requirements outside the jurisdiction of the Building Department. All applicable approvals shall be obtained prior to submitting a building permit application to the Building Dept. Thank you for your cooperation. Receipt Ack I dgement: (9/ A n gnature �`� C 3 ate Rev.Jan. 2019 ? CD m m c o tD = O N m cc) x 7 219 3/4" y $ X 65 1/4" f 1 1541/2 y N-0 a'7. g. 0. �— 1 C 7 (D fD (/- '00 0 / 1).-1 �"- "' r to N .Cr to e.i tp O.Q 4-10' _ :4: 14- 15: 1 '161 Co N co 111I v pa/ 'F'l\ .. 28 0 D y ;311i '3' `A`1 . t rn N j. ---', i 0� a)Tito 5 —lc, x Q IDO• . •rn o v • ! coStQ '1I no.a•n: i • w- i za, ( 1 O 0 3 11 a 0C (D (I) .1 It in \ N N F (Z6- ti a II O 0 co co o 0 0 11 1. —I ,8: Cr'CI co CD O N & E6 I. 25 1 I I coo< y L 0 —C O / 45" / 1 1 IIJ c r m m �� N CD t i 1 m qk •• c my.0 i 1 - � � ` # a Q@ < i QC 0 C � v - _ --,} f5 to O rn -• t i 3 Ntz 4 , 0.d C ( 1 5 frl \ 1 IAH� A \ II \ ,1 813/4' `. c H ti 32" I ga0 ,\ N A rt z A Et °r 1146 Route 28 Town of Yarmouth Receipt No.: 87133 tO South Yarmouth, MA 02664 Receipt Date: 02/13/2023 508.398.2231 RECORD&PAYER INFORMATION RECEIPT Record ID: BLD-23-004480 Record Type: 1 &2 Family Dwelling Property Address: 108 CENTER ST,YARMOUTH,MA 02675 Description of Work: Alteration-Remodel kitchen 508-477-9003 Payer: Applicant: JOHN S CLARK,John JOHN S CLARK,JOHN Mashpee,MA 02649 PAYMENT DETAIL Date Payment Method Reference Cashier 02/13/2023 Check Comments 2209 RFALLON Amount $150.00 FEE DETAIL Fee Description Invoice# Application escr Fee Quantity Fee Amount 90892 Current Paid 1.00 $35.00 Miscellaneous 90892 115.00 $35.00 $115.00 - - $115.00 $150.00 $150.00 AA_Receipt Template.rpt Print Date:03/02/2023 Page 1 r