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HomeMy WebLinkAboutBld-23-002807 R E C EA V E & TWO FAMILY ONLY- BUILDING PERMIT �O� 17 20Z Town of Yarmouth Building Department 1146 Route 28, South Yarmouth,MA 02664-4492 / ��� _ _ 508-398-2231 ext. 1261 Fax 508-398-0836 i k' ■ Massachusetts State Building Code, 780 CMR -�°I� BUILDI DEPARTMENT e By: .. — P4gPermitApplication To Construct, Repair, Renovate Or Demolish ..::;_ .•••. a One-or Two-Family Dwelling ��yy This SectionFor Official Use Only Building Permit Number: BLb—2-3'3�C.)28(5/ Date Applied: ) %1 r, P,I t S 11, a a, Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION ✓ 1.1�Prop rty Address: 1.2 Assessors Map&Parcel Numbers 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❑ Private 0 Zone: Outside Flood Zone? _ Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: r iMev, Tr..nV o ryl, M 0204-S Name(Print) Cityjtate,ZIP $ Pvhns.` Laves, (l4•'599•'5424 146s�ex,Ty..34belta clru No.and Street Telephone Email MIT ess SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied ❑ ) Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2: i 9:2°° Of et/qr d I-gili:t I�rseI b x scitrew 1` SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 1. Building Permit Fee:$ I c0 Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ Cle3S4 ac cry • 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire S Suppression) Total All Fees:$ A ,AS n.' Check No. Check Amount: Cash Amount: b \^ 6.Total Project Cost: S j�0 V 0 Paid in Full 0 Outstanding Balance Due:I 1 / boo, L n-€ c 4h i &inilt V SECTION 5: CO NSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL Type(see below) No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) _ City/Town,State,ZIP R Restricted I&2 Family Dwelling M Masonry • RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Company Name or HIC Registrant Name HIC Registration Number Expiration Date No.and Street Email address City/Town, State,LIP 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 9.- ' a(q) to act on my behalf, in all matters relative to work authorized by this building permit application. 1\ 1ya er's Name(Electr is Signature) 1 Date • SECTION 7b: OWNER1 OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Print Owner's or Authorized Agent's Name(Electronic Signature) Date • NOTES: 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.aov/oca Information on the Construction Supervisor License can be found at www.mass.2ov/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" '`.1"/ . SECTION 5. CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) / 0 2 License Number Expiration Date Name of CSL Holder �6 /„e r1 J©`� List CSL Type(see below) No. d tree 7 ?^ �� Type Description ' 'r--Goat A U Unrestricted(Buildings up to 35,000 cu.ft.) City/Town,State,ZIP R Restricted I&2 Family Dwelling � 1 7 ,/ M Masonry ��++ e_�0'L7`�C-/'�/J/ or, OZC¢j_ RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Regist 7.ered ow Improvement Contractor(HIC) i 7 el EA 3 G A t7 HIC C••,'an Nam; C Recistr t N e HIC Registration Number Expiration Date No. d Stre t yfQrzi �.(j �C� l n 7•G Email address City/Town, State,ZIP6Lh vi f e 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 2-- No U SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize to act on my behalf; in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 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.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" _ \ The Commonwealth of Massachusetts 1, 41....... Department of Industrial Accidents __ 1 Congress Street, Suite 100 ='r_f Boston, MA 02114-2017 .• 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). �d f J 4 e F co r 5-/ r-v C '„, e Address:Y 47e ( S (k L ,4 City/State/Zip: Cep, 4-,e fe-4/, We. 1 i Phone #: .--pg 2, -7 Z Are you an employer?Check the appropriate box: a g a.3.2_, Type of project(required): 1.0 I an,...›ceployer with employees(full and/or part-time).* 2. I am a sole proprietor or partnership and have no employees working for me in 8. ❑New C eIin UCtiOn any capacity.[No workers'comp. insurance required.] • emod lig 3.0 I am a homeowner doing all work myself.[No workers'comp. insurance required.]r 9. ❑ Demolition 4.{:I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 El Building addition ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 11.0 Electrical repairs or additions 5.0I 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.t 13• Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per,MIGL 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. tContractors 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.#: Expiration Date: Job Site Address: 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 I ze in i enalties o 1 P f perjury that the information provided above is true and correct. Signature: Date: lL /7 Z2. Phone#: 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#: of TOWN OF YARMOUTH BUILDING DEPARTMENT Tr.!". Sf. ad 1146 Route 28, South Yarmouth,MA 02664 508-398-2231 ext. 1261 �� MICI1f�'r HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DATE: t\\I'-1IZ9D2.2 JOB LOCATION: NAME STREET ADDRESS SECTION OF TOWN "HOMEOWNER" Ii( v1"Tr$0 _ C21-4 •5yq•5LON NAME HOME PHONE WORK PHONE PRESENT MAILI.\i TG ADDRESS 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 as 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/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 R5.1.3.1) 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 / she will comply with said procedures and requirements. HOMEOWNER"S SIGNATU APPROVAL OF BUILDING OFFICIAL INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch.142. Yes No If you have checked 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. 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 A44 �y y J Work Address Is to be disposed of at the following location: Qatf r-5llthetk Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. l _ Signature of Applicant Date Permit No. AcGRD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDlYYYY) klaimak.,," ,, 03/25/22 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,EXTENA 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(es)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 NAMEACI JIM HINDMAN PHONE 508-771-8381 FAX 508-771-0663 Schlegel&Schlegel Ins Broker No,Eel): ( c,No): 34 Main Street ADDRESS: schlegelinsurance) gmail.com West Yarmouth,MA 02673 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: NGM INSURANCE INSURED INSURER B: GUARD FLAVIO FIGUEIREDO INSURER C: ' 77 SILVER LEAF LANE INSURER D: WEST YARMOUTH,MA 02673 INSURER E: 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. ILTR TYPEADULSUBR POLICY EFF POLICY EXP LIMITS OF INSURANCE 1NSD WVD POLICY NUMBER (MMIDD!YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 500,000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 A MPJ6026E 09/08/21 09/08/22 PERSONAL&ADV INJURY $• 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO- 2,000,000 LOC PRODUCTS-COMP/OP AGG $ POLICY JECT OTHER: COMBINED SINGLE LIMIT $ AUTOMOBILE Lip`'.,CITY (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY ROPERTY accident)DAMAGEGE I$ RTY AUTOS ONLY ^AUTOS ONLY $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ $ DED RETENTION$ - -"'- PER OTH- WORKERS COMPENSATION STATUTE ER AND EMPLOYERS'LIABILITY Y I N E.L.EACH ACCIDENT $ 1 OO,000 ANY ETOR/PXCLUDE/EXECUTIVE N/A FLWC282409 11/06/21 11/06/22 B (Mandatory InOFFICER/MEMBERNH) EXCLUDED? Y E.L.DISEASE-EA EMPLOYEE $ 100,000 (Mandatory In NH) If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CORPORATE OFFICERS HAVE ELECTED TO BE COVERED UNDER THEIR CURRENT WORKERS COMPENSATION POLICY INSURANCE COVERAGE IS LIMITED TO THE TERMS,CONDITIONS,EXCLUSIONS,OTHER LIMITATIONS AND ENDORSEMENTS OF THE POLICY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. MIKE BURGESS 108 WATERSIDE DR CENTERVILLE MA 02632 AUTHORIZED R E NTATIVE I , ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD • • Commonwealth of Massachusetts ) Division of Professional Licensure Board of Building Regulations and Standards • Consiliit �ijivisor if CS-103622 w F�cpires:03/19/2023 f ROBERT S JQNES �:�ws , 206 CEDRIC RD i!1 -', Al1 '1 CENTERVILLE�M& r Commissioner oaa i bleknr tik- HOME IMPROVEal5flon MENTCONTRgCTOR TYPE;Individual Re istrati n Ex iration • ROBERT SCOTT 174832 06/20/2023 .ONES { ROBERTJONES 206 CEDRIC Rp 't Z CENTERVILLE,MA 02632 Undersecretary r TOWN OF YARMOUTH HEALTH DEPARTMENT PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET To he completed by Applicant: Building Site Location: O `3 00l, Proposed Improvement: ? Qe.,“\A'k Y15A \S`C IZA Applicant: ck C'`lr: Tel. No.: '-77) ).n Ss J12. Address: `1 ���c.c COSC ��� • b�t�2�2— Date Filed:` J \1 \ 27 **If you would like e-mail notification of sign off please provide e-mail address: (2_3)\\@...COn1C._G -t . cf;A.-- Owner Name: ' V` e n \ ( _ \ \ J Owner Address: `j T \\ . k` Uwner Tel. No.Q f 1 S (7 D2--4 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 (all existing and proposed) - NOV 1 / 2022 Note: Floor plans not required for decks, sheds, windows, roofing; HEALTH DEPT. (3.) If necessary, Title 5 application signed by licensed installer with fee. ,„./d /— REVIEWED BY: DATE: i PLEASE NOTE COMMENTS/CONDITIONS: I pm I 9'11"x 16'5" HALL ■ 4'2"x 14'1" im III- • FAMILY ROOM 15'2"x 37'5" 101 LAUNDRY • 69 x206 GROSS R FLOOR is 681 sq,INTE ft,FLNALOORAREA 2:1158 sq,ft FLOOR 3:665 sq,ft,EXCLUDED AREAS: GARAGE:483 sq.Ft,DECK:307 sq.ft BALCONY:32 sq.ft TOTAL:2703 sq.ft I/ ZZ SIZES AND DIMENSIONS ARE APPROXIMATE,ACTUAL MAY VARY. `Q�'‘' NOV 17 2022 (f J ) - I_! ICI BEDROOM BEDROOM 11'8"x 10'6" ~ 12'5"x 10'6" " ' DECK ' 26'4"x 117" • II Q % .J M 0'0 m Q X _4 l KITCHEN 8'5"x 10'9" ENTRY 1C _ DINING AREA II 10'7"x T1" GARAGE 23'4"x 20'9" LIVING ROOM 26'5"x 131" I FOYER _ ' 9'3"A3'6" ' •• - • i GROSS INTERNAL AREA FLOOR I:881 sq.ft,FLOOR 2:1158 sq.ft FLOOR 3:ES sq.ft,CROWDED AREAS: -GARAGE:483 sq.ft,DECK:307 sq.ft BALCONY:32 sq.ft TOTAL:2703 sq.R SIZES AND MEMOS ARE APPROXIMATE,ACTUAL NAYVARY. NOV 17 ZOZZ BALCONY 8'5"x 3'9" • PRIMARY BEDROOM 247 x 14T sri � d 1111 BATH TT'x 8T ao I.C. x 8'8" r1 HALL 24T x 3'4" • OPEN TO BELOW GROSS INTERNAL AREA FLOOR 1:881 sq.ft,FLOOR 2:1158 sq.ft FLOOR 3:665 sq.ft,EXCLUDED AREAS: GARAGE:483 sq.ft,DECK:307 sq.ft BALCONY:32 sq.ft TOTAL:2703 sq.ft SIIES Nil DIMENSIONS ARE APPROXIMATE,ACTUAL NAY VARY. NOV .1 7 211L't_ EMMOI COMPLI- At • EVE THE A: :BUILT" cla yz CU„Irt'L\inivVi=. 111 9'11"x 16'5"• OFFICIAL HALL ■ 4'2"x 14'1" II FAMILY ROOM 152"x 37'5" J LAUNDRY 6. x2a6 GROSS INTERNAL AREA FLOOR 1:881 sq.ft,FLOOR 2:1158 sq.ft FLOOR 3:665 sq.ft,EXCLUDED AREAS: GARAGE:483 sq.ft,DECK:307 sq.ft/, BALCONY:32 sq.ft f' g TOTAL:2703 sq.ft SIZES AND DIMENSIONS ARE APPROXIMAT[,ACTUAL MAY VARY. .tea