HomeMy WebLinkAboutBLD-23-004413 • f6/ 2/./Ze9
ifiECEIVE
€ v _._ A_.��._- "... TWO FAMILY ONLY- BUILDING PERMIT
FEB 0 7 2023 Town of Yarmouth Building Department
, 1146 Route 28,South Yarmouth,MA 02664-4492 :' __
508-398-2231 ext. 1261 Fax 508-398-0836 -,
(BUIL NO t EPARTMEI T �'':
L - Massachusetts State Building Code,780 CMR
NBz ing ernzitApplication To Construct, Repair, Renovate Or Demolish
a One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: I&-3-{ j1N r) Date Applied:
hr-v ►cS 13,
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
111 -or�.S-i-- "R�.
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 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 1!� Private❑ Zone: _ Outside Flood Zone? Municipal Ilk On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Os tier'of Recor I
J Dh n a C2�s�ot i S- VCWAIDk it'! v a it 6
Name(Print) City,State,ZIP
11I 5-1--- 'Rd %.3DY1e19-7bler bA,tesp_ll:4Ir4s-p&MIt.,54i7:
No.and Street Telephone Email Address-
SECTION 3:DESCRIPTION OF PROPOSED WORK'-(check all that apply)
New Construction Cl Existing Building 0 Owner-Occupied 0 I Repairs(s) ❑ Alteration(s) ❑ I Addition 0
Demolition ❑ Accessory Bldg. 0 Number of Units Other 1$,Specify:sue
Brief Description of Proposed Work2:
9—
SECTION 4: ESTIMATED CONSTRUCTION COSTS.
Estimated Costs:
Item Official Use Only
(Labor and Materials)
I.Building $ 9 75-f,of) 1. Building Permit Fee:S .155 d j Indicate how fee is determined:
2.Electrical $ gl Standard City/Town Application Fee .1
❑Total Project Costa(Ite 6)x multiplier x0 (091‘
3.Plumbing $ ) S/L 5,o D 2. Other Fees: $ " -3 `� ,L
4.Mechanical (HVAC) $ List: Nano
5.Mechanical (Fire '$
Suppression) Total All Fees:$ I Check No. Check Amount: Cash Am t: , .4/1,
77d3
6.Total Project Cost: �7/4$ )), le4[ ,OD ❑Paid in Full Outstanding Balance Du : 1l�1
i
SECTION 5: CONSTRUCTION SERVICES
1 Constr ction Supervisor License(CSL)
ksnas
I OD U?)11 a3
� D(eA.a License Number Expiration Date
Name of CSL Holder Q
4 f`�pAv \ . $�1 List CSL Type(see below) I
o,and Street { Type /�Description
1.1161/(1
L. U Unrestricted(Buildings up to 35,000 Cu.ft.)
0� `G� �0�73� R Restricted 1&2 Family Dwelling
City/Town,State,ZIP Ivl Masonry
�'0�-y+3a� RC Roofing Covering
WS Window and Siding
I SF Solid Fuel Burning Appliances
Vet,`C 104)focltl`. mitt__ I Insulation
Telephone j E l address D Demolition
2rR red Home Improvement Contractor(HIC)
)1,57901
C Co any Name or HIS gtstrant Name HIC Registration Number Expirati n Date
N�./�'d Street .,, // `�/ mess,��.
Ilil t,r7Do i( it_ p.273 Y SDY—93a 5 ' l7 c/
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 p/"- 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 Vieojorr__ ale
to act on my behalf,in all matters relative to work authorized by this building permit lication.
AAr'blif-w. /h1ej; 7k /1 Z S/23
Print Owner's Name(El etronic Signature) )late
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 an accurate to the best of my knowledge and understanding.h
Print wner's or Authorized Ageftt's Name(Electronic Si azure) 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.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"
§TOWN OF YARMOUTH
1146 Route 28, South Yarmouth, MA 02664
508-398-223!1 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 II1 ';red-rl e) - 1l rtn�-
Work Address
Is to be disposed of oat the following location: •2 5 V n pace 5
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. 111, §150A.
ALS/2_,
ignature of Applica ' n Date
Permit No.
w
lne L.ummvnweutan of lvlassacnuseus
Department of Industrial Accidents
=:L' 1 Office of Investigations
Lafayette City Center
2 Avenue de Lafayette,Boston,MA 02111-1750
44y www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):Theodore Bailey
Address:58 Delano Rd. APT 1
City/State/Zip:Marion Ma 02738 Phone#:508-932-5447
Are you an employer? Check the appropriate box: —�—
I am a general contractor and I Type of project(required):
4.1.❑ I am a employer with ❑
employees(full and/or part-time).* have hired the sub-contractors 6 ❑New construction
listed on the attached sheet. 7. ❑Remodeling
2.111 I am a sole proprietor or partner-
ship and have no employees These sub-contractors have 8. Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance. 9• El Building addition
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152,§1(4),and we have no employees. [No workers' 13.® Other Replace existing with new
comp.insurance required.]
*My 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: y•k I "a/A,L)4.
y
Policy#or Self-ins. Lic.#: 1 ? /04/a,Ami o) j Expiration Date:Y/02r/23
Job Site Address: ` / �°��` ^ .• City/State/Zip:
TO .L
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby ertify under the pains and penalties of perjury that the information provided above is true and correct
Signature: 1, Date: 1//i /e241 �.
Phone#: 508-932-5447
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(check one):
10Board of Health 21:I Building Department 31:City/Town Clerk 4.0 Electrical Inspector 5E1"lumbing
Inspector 6.0Other
Contact Person: Phone#:
•
ACd® CERTIFICATE OF PROPERTY INSURANCE DATE(MM/DD/YYYY)
06/08/2022
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.
PRODUCER CONTACT
NAME
PHONE (844 472-0967
(NC.No.Ext): ) IA/C,No): (203) 654-3613
BIBERK Ems: salessupport@biberk.com
P.O. Box 113247 PRODUCER
Stamford, CT 06911 CUSTOMER la
INSURER(S)AFFORDING COVERAGE NAIC#
INSURED INSURERA:Berkshire Hathaway Direct Insurance Compel 238130
INSURER B:
Theodore Bailey
58 Delano Rd Apt 1 INSURER C:
Marion, MA 02738-2011 INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
LOCATION OF PREMISES I DESCRIPTION OF PROPERTY(Attach ACORD 101,Additional Remarks Schedule,if more space is required)
Location: 58 Delano Rd,apt 1 Marion, MA 02738-2011
Bldg #001: Carpentry-7422101
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 POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION COVERED PROPERTY LIMITS
LTR DATE(MM/DD/YYYY) DATE(MM/DD/YYW)
X PROPERTY BUILDING $ 0
CAUSES OF LOSS DEDUCTIBLES PERSONAL PROPERTY $ 0
BASIC BUILDING — N9BP424491 04/28/2022 04/28/2023 BUSINESS INCOME $ *
250
BROAD CONTENTS EXTRA EXPENSE $ *
X SPECIAL RENTAL VALUE $
EARTHQUAKE BLANKET BUILDING
_ $ n/a
WIND BLANKET PERS PROP
$ n/a
FLOOD BLANKET BLDG&PP $ n/a
$
_ $
I INLAND MARINE TYPE OF POLICY $
CAUSES OF LOSS
$
NAMED PERILS POLICY NUMBER $
CRIME
$
TYPE OF POLICY $
BOILER&MACHINERY/
EQUIPMENT BREAKDOWN $
$
SPECIAL CONDITIONS/OTHER COVERAGES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required)
* ALS up to 12 months.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Theodore Bailey ACCORDANCE WITH THE POLICY PROVISIONS.
58 Delano Rd Apt 1
Marion, MA 02738-2011 AUTHORIZED REPRESENTATIVE
er:4 .)l,_, 6c1 -
®1995-2015 ACORD CORPORATION. All rights reserved.
ACORD 24(2016/03) The ACORD name and logo are registered marks of ACORD
Division of fr Licensul
° Board of Buildi Ill
ng >s" g ►i:Standards
Cotes t i or
P
CS-100386 sir tires:10/01/2023
Tt 68 O�?ORE f 1 - m
DEIAND '
A( 1
MARION MA r r
Commissioner . f' t n,.L►a.
J
1
12?-411"a144'7" l',47,1,3e7r,---4.41e/A.;
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
Expiration
7.:11/18/2023
THEODOttE 113N14Y
THEODORE BAILEY-:,:
58 DELANO RD APT 1 _
MARION,MA 02738 Undersecretary
•
%; %.,,,,,,,,,,y 7i/, /
Office of ConsumerAffairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
TYPE:Individual
Registration Expiration
165792 11/18/2023
THEODORE J BAILEY
THEODORE BAILEY
58 DELANO RD APT 1 ,
MARION,MA 02738
Undersecretary
Bath Fitter Bridgewater Inc.("Bath Fitter®")-Terms and Conditions—Massachusetts
4 ,
1. contract Documents. The contract documents consist of this agreement(the Wall,floor or ceiling damages in or adjacent to the immediate work area may occur
"Agreement"),the attached Order,all written modifications of the Agreement or the during installation.Such damages could include,without limitation,the loosening or
Order pursuant to Section 6 below.any required notices and any separate warranty cracking of adjacent tiles,paints or joints,caused by the removal and replacement of
information provided by Bath Finer*(collectively,"the Contract Documents"). existing materials.Bath Fitter*cannot be held responsible for these damages
2. Scone of Work. Bath Fitter*-agrees to provide all the labor and to do all the things should they appear.Moreover,in the case of bath liner or wall only installations.
necessary for the proper installation and completion of the project set forth in further damage may occur to the existing bathtub or wall tiler Bath Finer* is not
detail on the attached Order(the"Project"). responsible for minor damages,due to imperfections in any bathtub or wall tile that
3. Access.Owner agrees that Bath Fitter*shall have complete use of and access to the may result from the Bath Fitter* installation, and Owner remains responsible
Project location during regular business hours,upon reasonable advance notice to to maintain the grout silicone on existing walls.Should Bath Filter*be required to
Owner.Owner shall remove all obstacles such as furniture and appliances front the send a technician for a service call that is the result of inadequate maintenance,Owner
installation area and Owner shall provide all heat and lighting for Bath Fitter*to will be invoiced at the current service rates.
perform the Project.During the installation,Bath Fitter*shall properly dispose of 17. Colors.Marbled colors or panems may vary.Bath Fitter*,cannot guarantee the
remnants and scrap material relating to the Project.If a detect is alleged in either consistency of the color patters throughout the tub,walls or accessories,
workmanship or product,immediate notification must be made and Bath Fitter*
must be allowed ready access in order to assess and:or make any repair of the alleged 18. gag Fitters Right to Suspend or Terminate:Limitation of Liability Bath
defects. Fitter*is not responsible for legal encumbrances.buildingioning code violations,
4. Existing Plumbing.It is expressly understood bythe plumbing or structural deficiencies,or the discovery of or removal of asbestos,mold,
p y parties that neither Bath lead paint or other hazardous or toxic substances or materials.If Owner breaches the
Fitter*nor any Bath Fitter*employee,agent or subcontractor is a licensed architect Contract Documents.or if Bath Fitter*discovers any of the above,Bath Finer*may
or professional engineer.Bath Fitter*;is not responsible for inspecting,servicing,or immediately terminate the Contract Documents without further obligation to Owner
modifying your existing plumbing fixtures and facilities. Because the existing or,in its entire discretion,discontinue work on the Project pending proper cure of the
plumbing at the Project location may be old,corroded,or in need of repair or breach adior applicable correction by properly qualified firms at Owner's expense.
replacement,Bath Fitter*cannot be responsible for damage to the chrome finish, Owner agrees to pay Bath Fitter*the costs of materials,labor and services provided
blocked drains or plumbing below or behind the tub,including shut-off valves,or for by Bath Fitter*through the date/time of termination,plus any other amounts allowed
any damage caused by faulty plumbing. Bath Fitter recommends replacing old under applicable law.
fixtures when installing a new wall system.
IF BATH FITTER*IS UNABLE TO COMPLETE THE PROJECT FOR ANY
5. Contract Prig.Owner agrees to pay Bath Fitter*the amount set forth on the REASON UNRELATED TO OWNER.BATH FITTERS'S LIABILITY SIIALL
attached Order,unless otherwise mutually agreed upon between the panics hereto by BE LIMITED TO A REFUND OF OWNER'S DEPOSIT. BATH FITTER*
virtue of a written change order. CANNOT BE HELD RESPONSIBLE FOR CLAIMS OF INCONVENIENCE OR
6. Chance Orders. Any alteration or deviation from the above contractual ANY OTHER HARM.
specifications that results in a revision of the contract price will be executed only 19. Censeaunaal Damases.Bath Finer*will not be liable to the Owner or any third
upon the panics entering in to a written change order detailing such changes and the party for special,indirect,consequential,exemplary or punitive damages or costs
resulting change to the contract price.Each change order shall become part of the arising out of or related to the Project or these Contract Documents,even lithe parties
Contract Documents. All work shall be performed under the same terms and have knowledge of such damages or costs and whether or not such damages or costs
conditions as specified herein unless mutually agreed in writing. are foreseeable.
7. Method of Payment The method of payment of the contract price shall be as set 20. Warrant' The only warranty offered on the material you purchased in accordance
forth in the attached Order.Immediately upon completion of the Project,the Owner with the Contract Documents is the manufacturer's warranty.For silicone or any like
agrees to pay to Bath Fitter*the balance of the total agreed upon price.less the initial substance jointsiseals a 12-month warranty thorn installation date is offered.The
deposit.If payment is not nude.all discounts will be reversed and an adjusted invoice above warranties arc not transferable and arc for your personal benefit only.The
will be sent to Owner.Owner shall indemnify and reimburse Bath Fitter*for all warranties offered in relation to this Agreement and the remedies set forth therein
reasonable costs of collection associated with late payment or nonpayment including are exclusive and in lieu of all other warranties,remedies and conditions,whether
but not limited to reasonable attorneys'fees.A late charge of I S`:°'o per month shall oral,written,statutory•,express or implied.Bath Fitter disclaims all statutory and
be added to all overdue balances(nominal annual percentage rate of 111%).There implied warranties,including without limitation,legal warranties of quality and
will be a$25.00 fee for any returned check. fitness for a particular purpose and warranties against hidden or latent defects.Bath
8. Payment Option(.Bath Fitter*-offers third party financing ter qualified buyers.It Fitter limits the duration and remedies of such warranties to the duration of the
you choose to finance your purchase and your application is approved,a third party warranties contained therein.
finance contract will prevail and may provide for a different monthly payment 21. Integration and Severabilits. The Contract Documents contain the entire
amount and term than shown in the Contract Documents.The option of financing agreement between the parties here' and supersede all prior oral or written
may only be selected at the time you place your order. understandings.Should any pan of the Contract Documents for any reason be found
9. &utily Owner shall furnish and pay for,at their own expense,taxes,permits and invalid such a determination shall not affect the validity of any remaining portion of
licenses,including without limitation,local and municipal permits and licenses, the Contract Documents.If the Order and this Agreement are in any way inconsistent
required by law or any applicable regulations to perform the work in accordance with with each other,this Agreement shall govern.
these Contract Documents. You hereby agree to defend.indemnify and hold Bath 22. Applicable Law and Dispute Resolution. The Contract Documents shall be
Fitter harmless,of,from and against any claims,liability,suits,damages.expenses. governed and construed in accordance with the laws of the State of Massachusetts.
costs(including reasonable attorney lees),fines and penalties anributable to your For any claims,dispute or other matter in controversy arising out of or related to
failure to comply with the above obligation.In all instances where Bath Fitter would these Contract Documents,or the breach of any provision thereof,Bath Fitter*may
determine,in its discretion,it would provide any of the abovementioned permits or submit the dispute to a private arbitration time which has been approved by the
licenses, it will notify you and the permitilicense tee including reasonable Director of the Office of Consumer Affairs and Business Regulation("OCABR•")
administrative cons will be added to the contract price. Bath Finer**cannot be held and Owner shall be required to submit to such arbitration as provided in MGL,
responsible for any permit related delays. Chapter 142A.The non-prevailing party in the arbitration shall pay the prevailing
10. Delays.Although Bath Fitter*makes every effort to do so,Bath Fitter*cannot patty's reasonable attorney fees,costs,and expenses.
guarantee that your installation will be completed in one day.In addition,on occasion �J??_ '
I I2-20 ?4l:17GST
Bath Fitter*will be forced to postpone the start date of a project whether due to (EjC
scheduling conflicts,labor or material shortages.It is Bath Fitter*'policy to notify / "' "v'"- 2022 t2.20
the costumer as soon as any change is known.You will be informed of reason for --""-KOwners Signature Date
the delay and the revised installation date.If the installation is delayed or takes more 2022-I2-20T12:41:47EST
than one day.Bath Fitter*-cannot be held responsible for any reimbursement,
discount,or any other type of compensation to you for claims of inconvenience or
----ure ._._._.
anyother harm.Unnecessarydelaysexperienced byour technician caused by(honer Pe Bath Fitter*Signature Date
will result in an additional charge. 23. Use of E-mail for Customer Feedback,From time to time,Bath Fitter*(or any of
I L NOTICE OF CANCELLATION. THE OWNER MAY CANCEL THIS its third party strategic partners and service providers)may wish to contact you at the
TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD(3R°) e-mail address set forth on the attached Order.You hereby authorize Bath Fitter*
BUSINESS DAY AFTER THE DATE OF THIS AGREEMENT.BECAUSE BATH (or any of its third party strategic partners and service providers)to use your email
FITTER*PRODUCTS WILL BE CUSTOM MADE FOR YOU.BATH FITTER* to communicate with you for the purpose of improving Bath Fitter*'s products,
CANNOT REFUND YOUR DEPOSIT AFTER THE CANCELLATION PERIOD services and marketing,including obtaining your feedback and conducting customer
IIAS EXPIRED. and satisfaction surveys.
12. HOME SOLICITATION,YOU MAY CANCEL THIS AGREEMENT IF IT HAS roll I agree with the use of my e-mail for these purposes
BEEN SIGNED BY A PARTY THERETO AT A PLACE OTHER TITAN AN 24. Liens.Massachusetts law grants lien rights to builders.Any construction contractor,
ADDRESS OF THE SELLER, WHICH MAY BE HIS MAIN OFFICE OR subcontractor.tradesman or material supplier who is not paid can record a lien on
BRANCH THEREOF,PROVIDED YOU NOTIFY THE SELLER IN WRITING the property being improved.If not discharged by payment,this mechanics'lien will
AT HIS MAIN OFFICE OR BRANCH BY ORDINARY MAIL POSTED.BY become a security like a mortgage on the property.
TELEGRAM SENT OR BY DELIVERY,NOT LATER THAN MIDNIGHT OF 25. Jj gjion.All contractors and subcontractors must be registered by the OCABR.
THE THIRD BUSINESS DAY FOLLOWING THE SIGNING OF THIS and any inquiries about a contractor or subcontractor relating to a registration should
AGREEMENT.SEE THE ATTACHED NOTICE OF CANCELLATION FORM he directed to(H'ABR.
FOR AN EXPLANATION OF THIS RIGHT.
13 pore Rip Do not sign this Agreement if there are any blank spaces.
F JsOL[•Bath Fitter*shall not be held liable for any loss,damage or delay I understand and agree to the terms and conditions above,including without
in connection with this agreement due to delays in transportation of materials. limitation the terms of the attached Order dated and all other
accidents,then,fire,labor disputes.insurrection,acts of God,or any other cause
beyond Bath Fitter*'s control. Contract Documents of same date.
Dated at SO11o'Ya"wth ,Massachusetts on the 2 ' day of '^.b.
14. Removalf E osisdag Fistares.Bath Fitter is not responsible for the removal andior 2022 '
reinstallation of fixtures,including electrical fixtures.Bath Fitter will not remove —
ander reinstall any of your existing fixtures,including,without limitation,shower T_
doors.In the event that the doors will no longer fit,Bath Finer*cannot be held
responsible for any reimbursement,discount,or any other type of compensation to
you for replacement of these fixtures. Signature of Property Owner or Duly Authorized by Property Owner
15. Moaa.Mold occurs naturally in almost all indoor environments.Mold spores enter John 6 Barbara Mespeei
homes through doorways,windows and a variety of other ways.A Bath Fitter* Name of Property Owner or Duly Authorized by Property Owner(Please Print)
installation may include the removal of wet,loose,defective.discolored or odorous tut Forest Road.
surfaces and the washing of remaining surfaces with a household bleach solution. South Yarmouth.Massachusetts.02664
Bath Fitter*and its representatives make no warranty or representation of any kind,
express or implied,regarding the presence or absence of mold,or regarding the Address of Property Owner or Duly Authorized by Property Owner
effectiveness of any biocide designed for reducing the presence,effect or growth of Bath Finer Bndgewater Inc.
mold.and make no warranty or representation with respect to.and cannot be held responsible for,the presence of mold in your home subsequent to the Bath Fitter* 2022-12-20T12:41:49EST
installation.
16. Jnstalation.If,during the installation phase.Bath Fitter*is required to perform Per:
repairs to existing walls,additional charges will apply at the current service rates. Name of Consultant
Pa K K PP Y NameRochard Serino
NOTICE OF CANCELLATION FORM FOR HOME SOLICITATION SALE
Date of Transaction:2022-1 2-20
Ref#:375-LBWG83HF-RSE
}
Date this contract is signed:
Ref#:
You may cancel this transaction,without any penalty or obligation,within three business days from the above date.
If you cancel,any property traded in,any payments made by you under the agreement,and any negotiable instrument
executed by you will be returned within ten business days following receipt by the seller of your cancellation notice,
and any security interest arising out of the transaction will be cancelled.
If you cancel,you must make available to the seller at your residence,in substantially as good condition as white
received,any goods delivered to you under this agreement;or you may,if you wish,comply with the instructions of
the seller regarding the return shipment of the goods at the seller's expense and risk.
If you do make the goods available to the seller and the seller does not pick them up within twenty days of the date
of your notice of cancellation,you may retain or dispose of the goods without any further obligation.If you fail to
make the goods available to the seller,or if you agree to return the goods to the seller and fail to do so,then you
remain liable for performance of all obligations under the contract.
To cancel this transaction,mail or deliver a signed and dated copy of this cancellation notice or any other written
notice,or send a telegram,to:
Bath Fitter Bridgewater Inc.
25 TURNPIKE ST,
WEST BRIDGEWATER,MA,
Not later than midnight of 2022-12-23
I hereby cancel this transaction.
Date:
Signature of Property Owner or Duly Authorized by Property Owner:
•
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 ii. !'`
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: Date Applied:
Building Official(Print Name) Signature R JitiViD
SECTION 1:SITE INFORMATION N 2
• 1.1 Property
o perty Addres [1.2 Assessors Map&Parcel Num ell' 423
�Dlf�s � sd
1.I a Is this an accepted street?yes ✓ no Map Number Parce r tc•�Nt; DFf,A �r��—t!
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 eg Private 0 Zone: Outside Flood Zone? 141unicipal.B On site disposal system 0
Check if yesCl
SECTION 2: PROPERTY OWNERSHIP'
2.1 01_1 er'of Reel,d: 11,, t!
4-' 111! , . '_ L/ - I ),/ w-)4► a- rya 4[r T
Name(Pri t) City,State,ZIP
Ire f . ff. ?st'er
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK(check.all that apply)
New Construction 0 Existing Building❑ Owner-Occupied Cl I Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition ❑ Accessory Bldg. 0 Number of Units Other JiC Specify re jat.0 exi s.47 n i 44, nett)
Brief Description f Proposed Work': —Re f f S n6 T,._6/Sti p�,JP r t�[�1 a "p,t-
a...GryJt C <S hor.�P.rp�n 4- G2E4 I s Se
SECTION 4:ESTIMATED CONSTRUCTION COSTS.
Item Estimated Costs:
(Labor and Materials) Official Use Only
1.Building S 9 r 751 1. Building Permit Fee:$_ Indicate how fee is determined:
2.Electrical 0 Standard Ciiy/Town Application Fee
Cl Total Project Costa(Item 6)x multiplier . x
3.Plumbing $ I Wq 5 O 2. Other Fees: $
4.Mechanical (HVAC) $ List: _
5.Mechanical (Fire
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ '4 jP Cl Paid in Full ❑Outstanding Balance Due:
•
ONE or TWO FAMILY- BULDING PERMIT
APPLICATION REGULATORY APPROVALS NOTICE
Address of Proposed Work: I 1 I - remit' d . ` cur-vA,pi,
4-1
11 (� ' C\
Scope of Proposed Work: eoolat�._ per,�-t;,,, T /�(.�a�v�r 1a;1-1-1 q, hemp
larrS lie_L S n D4.4)e ` QM '1- t9n 11 a
• Date:
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/Matt Bearse, 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 Acknowtedgem t:
iy
Applicant's Signature - Da e
Rev. March 2022
R
Division of YI'#icensulii
Board of Building and Standards
rY
CS-100386 * ires:10/01/2023
THEOOORE f: x,
ji 68 DELANO 0
APs 1'
IIAARION MA 07 0
Commissioner f;
:s
41
is.
(i(m,;,Cfe,Y' X 1/'..!/17Q:3JCGPJefiil'f/i
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
TYPE Intdividual
- Expiration
1-St 1 -11/18/2023
THEODORE J BAILE'
THEODORE BAILEY ‘_s
58 DELANO RD APT 1 £+w t'
MARION,MA 02738 Undersecretary
•
Office of ConsumerAffairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
TYPE:Individual
Registration' Expiration
165702 11/18/2023
THEODORE J BAILEY
THEODORE BAILEY
58 DELANO RD APT 1
MARION,MA 02738 Undersecretary
o1`°=4R TOWN OF YARMOUTH
":". c' 1
BUILDING DEPARTMENT
,,.. . ' 1146 Route 28, South Yarmouth,MA 02664 S0$-39$-2237 ext. 1261
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE: �
JOB LOCATION: LI's eAl., 1► -�'a V-
1 e� 'Kd�•
j� ' f NAM STREET ADDRESS SECTION OF TOWN
HOMEOWNER IMFpei\i U -- l.el°-ally
NAME HOME PHONE WORK PHONE
PRESENT MAILING ADDRESS S
' CITY OR TOWN STATE ZIP CODE
The current exemption for `Homeowner' was extended to include owner—occupied dwellings of one or two units
and to allow such homeowners to engage an individual for hire who does not possess a license,provided that such
homeowner shall act 4 supervisor. (State Building Code Section 110 R5.1.3.1)
Definition of Homeowner:
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is or is intended to
be, a one or two family attached or detached structure assessory to such use and I or farm structures. A person who
constructs more than one home in a two-year period shall not be considered a homeowner;such"homeowner"shall
submit to the building official,on a form acceptable to the building official,that he/she shall be responsible for all
such work performed under the building permit. (Section 110 RS.1.3.1)
The undersigned `homeowner' assumes responsibility for compliance with the State Building Code and other
applicable codes, by-laws, rules and regulations.
The undersigned `homeowner' certifies that he / she understands the Town of Yarmouth Building Department
minimum inspection procedures and requirements and that he I she will comply with said procedures and
requirements.
HOMEOWNER"S SIGNATUREtafai6,,
LJL_ 7rk.
APPROVAL OF BUILDING O14k1CIAL,
INSURANCE COVERAGE:
I have a curren ' ility insurance policy or its substantial equivalent, which meets the requirements of MGL
Ch.142. es No
If you have c ec ed ves, please indicate the type coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity Bond
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.
h41- s?,,,,,..1_, Check one:
Signature of Owner or 0 ner's Agent Owner Agent✓
h:homeownrlicexemp
0f'Yak TOWN OF YARMOUTH
� 4.
.,vit r % BUILDING DEPARTMENT
o �. .i�,.� H 1146 Route 28,South Yarmouth,MA 02664
"4 ' ^ '60 4 508-398-2231 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 1, Section 111.5,
I hereby certify thatt the debris resulting from the(proposed work/demolition to be
conducted at 11► *nr�s1- �� ��p�y,��Ah
Work Address
reit.AC
Is to be disposed of at the following location: )51 t,,,,„ ,Ke s . W. eirj
P
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
. C+14,1 Vol /02-3
Signature of Appf 'on Date
Permit No.
, a.\ i he Lummunweuezn o/wlussucnusects•
' "_.,—a= Department of Industrial Accidents
Office of Investigations
-�., Lafayette City Center
2Avenue de Lafayette, Boston,MA 02111-1750
"'
i wwwmass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A licant Information
Please Print Le ibl
Name (Business/Organization/Individual):Theodore Bailey
Address:58 Delano Rd. APT 1
City/State/Zip:Marion Ma 02738 508-932-5447
F Y �
to er. Check the appropriate Are you an em a ro rate box: Phone#:
1.❑ I am a employer with 4. El I am a general contractor and I Type of project(required):
have hired the sub-contractors
employees (full and/or part-time).*
6 ❑New construction
2. I am a sole proprietor or partner-
listed on the attached sheet. 7. Remodeling
ship and have no employees These sub-contractors have
working for in any capacity. employees and have workers' 8. ❑Demolition
[No workers' comp. insurance comp. insurance. 9. ❑Building addition
3.0required.] 5. 0 We are a corporation and its 10.❑Electrical repairs or additions
I am a homeowner doing all work officers have exercised their
myself. [No workers' comp. right of exemption per MGL 11.0 Plumbing repairs or additions
insurance required.] t c. 152, §1(4),and we have no 12.0 Roof repairs
employees. [No workers' 13.®Other Replace existing with new
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:-
Policy#or Self-ins. Lic. #. j244al
Expiration Date: 02 Y 023
Job Site Address: /// rp q
• 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby ertify under the pains and penalties of perjury that the information provided above is true and correct
Si attire:
Date:
Phone#: 508-932-5447
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(check one):
1OBoard of Health 20 Building Department 30CitylTown Clerk 4.0 Electrical Inspector 5Elumbin
Inspector 6.0Other g
Contact Person:
Phone#:
M
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Technical Data Sheet FITTER®
Acrylic Freestanding Shower Base
• Product name:Acrylic freestanding shower General Use:Available in various dimensions to fit
base
• Trade name:Acrylic freestanding shower your desired location.Can be easily installed along
with Bath Fitter walls.Acrylic freestanding shower
base base can be ordered in different floor patterns and
• Supplier/Manufacturer:Bain Magique/Bath colors.
Fitter
Application overview:For quality assurance,all
Product description:The acrylic freestanding shower
freestanding shower bases must be installed exclusively
base is manufactured from a co-extruded sheet that by Bath Fitter certified installers. Procedural
is approximately.200"thick and that consists of a instructions are tailored specifically for each type of
pigmented acrylic surface reinforced with a blend of freestanding shower base available.
high-impact plastic material. The support pan is
adhered to the floor.The ledges of the acrylic shower Maintenance:Always refer to the list of approved
base are screwed to the wall studs. The support pan cleaners.This information is available on our website:
is pre-assembled and secured to the acrylic shower www.bathfitter.com
base using a proprietary adhesive and installation
technique. Performance characteristics:
•CSA B-45.5-2011/IAPMO Z124-2011,Clause 5.12.
Features&Benefits:The acrylic freestanding -Plastic Plumbing Fixtures
shower base is available in the following colors:
White,Pearl,White Marble and Ivory Marble. Control Tests by Bath Fitter:
• Visual inspection
• Dimensional tolerances
• Impact tests
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Document No PI-026-E-REV-00 Prepared By Product Integration
Page NO 1 Approved by Technical Services
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Technical Data Sheet BATH
Acrylic Freestanding Shower Base FITTER
• Product name:Acrylic freestanding shower
base General Use:Available in various dimensions to fit
• Trade name:Acrylic freestanding shower your desired location.Can be easily installed along
base with Bath Fitter walls.Acrylic freestanding shower
• base can be ordered in different floor patterns and
Supplier/Manufacturer:Bain Magique/Bath
colors.
Fitter
Product description:The acrylic freestanding shower Application overview:For quality assurance,all
freestandine shower bases must be installed exclusively
base is manufactured from a co-extruded sheet that
is approximately.200"thick and that consists of a by Bath Fitter certified installers. Procedural
pigmented acrylic surface reinforced with a blend ofinstructions shreower
tailoredwbase s available.
for each type of
high-impact plastic material. The support pan i freestanding shower available.
adhered to the floor.The ledges of the acrylic shower Maintenance:Always refer to the list of approved
base are screwed to the wall studs. The support pan cleaners.This information is available on our website:
is pre-assembled and secured to the acrylic shower
base using a proprietary adhesive and installation www.bothfitter.com
technique.
Performance characteristic:
•CSA 8-45.5-2011/IAPMO Z124-2011,Clause 5.12.
Features&Benefits:The acrylic freestanding
shower base is available in the following colors: —Plastic Plumbing Fixtures
White,Pearl,White Marble and Ivory Marble.
Control Tests by Bath Fitter:
• Visual inspection
• Dimensional tolerances
• Impact tests
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Technical Data Sheet Acrylic Freestanding Shower Base
Document No PI-026-E-REV-00 Date of Revision 2019-05-22
Page NO Prepared By Product Integration
Approved by
•
AOREP CERTIFICATE OF PROPERTY INSURANCE DATE(MM/ODMYY)
I 06/08/2022
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.
PRODUCER CONTACT
NAME
PHONE (844)472-0967
BIBERK INC.No.Ertl: (dc,No): (203)654-3613
ooRless: salessupport@biberk,com P.O. Box 113247 PRODUCER
Stamford, CT 06911 CUSTOMER iD
INSURED INSURER(S)AFFORDING COVERAGE NAICS
INSURER A:Berkshire Hathaway Direct Insurance Compal 238130
Theodore Bailey INSURERS:
58 Delano Rd Apt 1 INSURERC:
Marion, MA 02738-2011 INSURER D:
INSURER E:
INSURER F:
COVERAGES
CERTIFICATE NUMBER: REVISION NUMBER:
LOCATION OF PREMISES/DESCRIPTION OF PROPERTY(Attach ACORD 101,Additional Remarks Schedule,if more space is required)
Location: 58 Delano Rd, apt 1 Marion, MA 02738-2011
Bldg #001: Carpentry- 7422101
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED 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 POLICY EFFECTIVE POLICY EXPIRATION
LTR POLICY NUMBER DATE(MM/DD/WYY) DATE(MM/DD/WYY) COVERED PROPERTY LIMITS
X PROPERTY
BUILDING $ 0
CAUSES OF LOSS DEDUCTIBLES
BASIC BUILDING - N9BP424491 04/28/2022 04/28/2023 PERSONALPROPERTY $ 0
BROAD 250 BUSINESS
S INCOME $
CONTENTS EXTRA EXPENSE $
X SPECIAL
RENTAL VALUE
EARTHQUAKE $
BLANKET BUILDING $ n/a
WIND
BLANKET PERS PROP $ n/a
FLOOD
BLANKET BLDG&PP $ n/a
$
INLAND MARINE TYPE OF POLICY
CAUSES OF LOSS
NAMED PERILS POLICY NUMBER $
$
CRIME
TYPE OF POLICY $
BOILER 8 MACHINERY/
EQUIPMENT BREAKDOWN
$
SPECIAL CONDITIONS/OTHER COVERAGES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
*ALS up to 12 months.
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Theodore Bailey THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
58 Delano Rd Apt 1 ACCORDANCE WITH THE POLICY PROVISIONS.
Marion, MA 02738-2011
AUTHORIZED REPRESENTATIVE
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ACORD 24(2016/03) The ACORD name and logo are registered marks8of ACORDOTTRD CORPORATION. All rights reserved.
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