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HomeMy WebLinkAboutBLD-23-002009 PO i /2-e-i/zZ._ REbE_ IV BUILDING PERMIT APPLICATION -"OCT{-- . . F APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE, OCCUPANCY OF VCT 1 +0 4; ,;t ��6 OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING. L� ��;' Town of larniouth BuildingDepartment P BUILDING Dt � 1146 Route 2 66 --(-1. BY -- Tel: 508.398-2231 eat. 1261 Fax 508-398-0836 - I<���� Office Use Only Planning Board Information Assessors Department Information: Permit ND. �3r Da9,(7ODate Plan Type_ Map Lot Permit Fee $�o� Endorsemen°Date 0 p Recording Date New Deposit Rec'd. $ Property Dimensions: a_ —Date t Plan No. p Net Due 41P � -7G9 Other `Ola1I a�' Lot Area(SO Frontage(It) Lot Coverage This Section for Office Use Only Buildin Permit Number. I Date Issued: / Certificate of Occupancy Signature: i`, _- � i -�0- ',. P ct Building Official - Date is Is not required Section 1 - Site Information 1 1.1 Property Address: 1.2 Zoning Information: i. „248 C e- p .—r ii . ~ r'' Zoning District Proposed Use 1.3 Building Setbacks(ft) Front Yard ] Side Yards Rear Yard Required Provided Required 1 Provided Re quired I( Provided 1.4 Water1 Supply(M-Q.L c.40.S 54) 1.5 Rood Zone information: Comments Public Private Zone: _ BFE Section 2 - Property Ownership/Authorized Age 21 Owner of Record:QT 17`n.<41 vT TF`CC' Name(print) — 4a C,qvv1P <;1 L3E 61_u �G�JIN Mailing Address: Telephone Telephone Email Address: / 2.2 Authorized Agent: Name(print) Mailing Address: Signature Telephone Fax Entail Address 1 Section 3 - Construction Services I 3.1 Licensed Construction Supervisor. Not Applicable I] -�116 G 4 6 `I e t License Number ` `-i P '7'v 4) (A)L�1 ate U►!-{ 1\ ) O 3(ar-7- Address A Ica U nc, (j-Lk, F'`Q� ,\/...Q j <<.'' � �- Expiration Date` Signature Telephone Email Address: LJ G.i_L.a vAat.r!ta.CI Kit- 1,3-1 -co SECTION 10b OWNER/AUTHORIZED AGENT DECLARATION I. �' ��'� �"^ 1�C1 , as Owner/Authorized Agent hereby declare that the statements and information on the forgoing application are true and acurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name (46>?-00a Signature of Owner/Agent Date Section 11 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be completed by permit applicant 1.Building a Electrical �O vo.r,G 3.Plumbing/Gas I���� G C 4.Mechanical(HVAC) 5.Fire Protection 6.Total=(1+2+3+a+5) 240tc�cx: 7.Total Square Ft.(l new s nctr es&add;bx,n) Check Below ❑ Conservation-Commission Filing (if applicable) ❑ Old Kings Highway&Historical Commission approval (if applicable) Section 6 - Description of Proposed Work(check all applicable) •• New Construction ❑ ! (for multiple family only) No.of Bedrooms (for multiple family only) No.of Bathrooms Existing Bldg. ❑ Repair(s) ❑ Alterations ❑ Addition ❑ Accessory Bldg. 0 Type Demolition Other Specify: Brief Description of Proposed Work: 111A D dc4X —(-k c, o -o &As . • AJ O- ckedAttecis Section 7- Use Group and Construction Type I Building Use Group(Check as applicapable) Construction Type A ASSEMBLY ❑ A-t ❑ A-2 ❑ A-3 ❑ to ❑ A-4 ❑ A-5 ❑ 1B ❑ B BUSINESS ❑ 2A ❑ E EDUCATIONAL ❑ 28 ❑ F FACTORY ❑ F-1 ❑ F-2 ❑ 2C ❑ H HIGH HAZARD 1 ❑ 3A ❑ I INSTMUTIONAL ❑ 1-1 ❑ 1-2 ❑ 1-3 0 39 ❑ M MERCHANTILE ❑ 4 ❑ R RESIDENTIAL ❑ R-1 ❑ R-2 ❑ R-3 ❑ SA ❑ S STORAGE u UTILITY ❑ S-1 ❑ s-z ❑ se ❑ SPECIFY: . M MIXED USE ❑ SPECIFY: S SPECIAL USE I❑ SPECIFY_ _ Complete this section if existing building undergoing renovations,additions and/or change in use. Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34 Proposed Hazard Index 780 CMR 34 Section 8 Building Height and Areal • Building Area Existing(if applicable) Proposed Number of floors or stories include basement levels Floor Area per Floor(sf) Total Area All Floors (sf) Total Height (ft) Section 9 - STRUCTURAL PEER REVIEW (780CMR 110 11) Independent Structural Engineering Structural Peer Review Required Yes No SECTION 10a OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I. =Tke—r-T(,{, 3C.0 v �e S , as Owner of the subject property, hereby authorize 1,J1,t aC,t ,t-{,A,NC to act on my behalf, in all matters relative to work authorized by this building permit application. k c--, /05 act Signature of O7n r Date 3.2 Registered Home Improvement Contractor) Company Names Not Applicable ❑ _ W cS L c' "w\z.c R\I Registration Number Address L}0e \ r� �GSJ c - -tn.....,.....„.. ,,,,lea- _sc)R ,3 Cc, 51_ C7 Expiation Date Signature Telephone Section 4-Workers'Compensation Insurance Affidavit(M,G.L c. 152 S 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 X..... No Section 5- Professional Design and Construction Services-for Buildings and Structures Subject to Construction Control Pursuant to 780 CMR 116(containing more than 35,000 c.f. of enclosed space) Section 5.1 Registered Architect:J Not Applicable la Name (Registrant): Registration Number Address Expiration Date Signature Telephone Section 5.2 Registered Professional Engineer(s) i Name Area of Responsibility { Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Kama Area of Responsibility Address Registration Number Signature Telephone Expiration Date Section 5.3 General Contractor (r c y I>C Not Applicable Liompany Ka (AJr I Hsi Person Responsible for Construction Address v Signature Telephone Commonwealth of Massachusetts �r Division of Occupational Licensure • - Board of Building Reel lations and Standards Const+ ion S ervisor CS-116646 ". stpires: 12/29/2025 WALACI P MM,CHADO 193 CAMP ST- c' APT J5 WEST YARMOUTH MA 02673 ff, �ti��Lft'� Commissioner f. G611r e� .74 'Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration ' 201015 02/22/2023 WALACI PEREIRA MACHADO WALACI MACHADO- 193 CAMP ST APT J-5 erlw,,,,d ( `� WEST YARMOUTH,MA 02671' Undersecretary Registration valid for individual use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 1000 Washington Street -Suite 710 Boston,MA 02118 LAJ3(F^- - gJ , ) Not valid without signature The Commonwealth of Massachusetts Department of Industrial Accidents -' = Office of Investigations . -; _ 600 Washington Street _= r Boston,MA 02111 �•�,,� www.mass.gov/dia • Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PInmbers An nlicant Information Please Print Lee-ibiv Name(Business/Organizatiouilndividna1): ( J ( �C l a�' t geLc' Address: c( j 6c�v� s—r • City/StateJZip:�. .C c�;�V,ns�U 1-i Phone#: .; c 5.11 o Are you an employer?C ck the appropriate bon Type of project(required): 1.® I am a employer with _ 4. I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9 0 Building addition com insurance.: r ed.] comp insurance �� 5. 0 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 repass insurance -j t c. 152, §1(4),and we have no -- - employees.[No work- 13.121 Other Kr-Fr Not i comp.insurance required.] *Airy 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 ten 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 stale whether or not those entities have employeea. 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: ` rr kPolicy#or Self-ins.Lic.#: C cri cl Expiration Date: o !o c /moo 3 Job Site Address: C2 Ll . C vv, . ;-r- (3.5 _Ci /Sta±eJZip: 6.1 c)3 6 I S Attach a copy of the workers'compensation policy declaration page(showing the policy numbell 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 certify under the pains and penrhipc of perjiuy that the information provided above is/true and correct Si_uature: L`J�Qrx;_ �tL.� Date: 1_c.)/e c /boa a Phone# S�Q c Sal e�Official use only. Do not write in this area,to be completed by city or town official City or Town: Perinit/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#:____-_- _—__-- ACORO® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 10/05/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: BIBERK PHONE 844-472-0967 FAX 203-654-3613 P.O. Box 113247 E-MAIL EXt): (A/c,No) --MA` Stamford, CT 06911 ADDRESS: customerservice@biBERK.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:National Liability&Fire Insurance Company 20052 INSURED INSURER B: Walaci Machado INSURER C: 193 camp st apt j5 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. INSR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO CLAIMS-MADE OCCUR PREMISES(EaENTED occurrrence) $ 0 MED EXP(Any one person) $ PERSONAL&ADV INJURY $ 0 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ _ 0 POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 0 OTHER- $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ _(Ea accident) ANY AUTO BODILY INJURY(Per person) ',$ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) I$ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER OOTH STATUTE AND EMPLOYERS LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT I$100,000 A OFFICER/MEMBEREXCLUDED? N NIA N9WC772492 09/09/2022 09/09/2023 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE[$100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$500,000 Professional Liability (Errors& Per Occurrence/ Omissions): Claims-Made Aggregate DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Betty Jacovides ACCORDANCE WITH THE POLICY PROVISIONS. 248 Camp St B5 AUTHORIZED REPRESENTATIVE South Yarmouth, MA 02673 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD §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. 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 1�b7� � STi S cA ZPS-�- c���.�.o�j N 0061 Work Address —� Is to be disposed of oat the following location: )dh,Vou j f 1 S�oS Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. /o5/aa Q Signature of Application Date Permit No. • t sC U- t40 4(S t:. 1:71. '40444 d4. 248 Camp Street West Yarmouth Mass. 02673 October 6, 2022 Betty Jacovides Foxwood B-5 248 Camp Street West Yarmouth, MA 02673 Dear Betty, The Board of Trustees is in receipt of your request to replace/ perform work within your unit at Foxwood Condominium in accordance with the rules and regulations or by-laws of the condominium association. After reviewing the work requested,the following is provided: WORK TO BE COMPLETED: • 7— Double-Hung Windows (new construction) • 1 —Bay window DOCUMENTATION: 1. A copy of the Contractor's PROFESSIONAL license HAS been received. 2. Copy of the building permit HAS NOT been received. 3. A copy of the certificate insurance naming FOXWOOD CONDOMINIUM as an additional insured HAS been received. 4. Proof of workman's compensation HAS been received. CONDITIONS 1. Copy of Certificate of Insurance listing Foxwood Condominium Association as an additional insured. (must be received 3 days prior to work start date) 2. Copy of building permit(can be provided the work start date) 3. Trim to be Azek or equivalent 4. Trim to `3e face nailed with stainless steel nails OR counter sunk screwed with plugs. 5. Two business day advance notice of work start date. 6. Carpenters ID verification(done at start of work) 7. Windowsills must be installed on finished work. 8. Work area to be left in free of debris. 9. All materials to be taken off the property and not placed in dumpsters on the property STATUS: CONDITIONALLY APP O I D—Subject° to .-2 as listed Should the work completed and/or item installed not conform to this submission, the board of trustees will require removal/correction to comply with this approval. If you have any questions, please contact Shaun Horan at 508.775.6880 or John Pupa at 508.420.0047. Cordially, John J. Pupa Business/ Financial Manager Foxwood Condominium RTA_CABINET STORE Kitchen & Bath Measurement Form Please use this space to indicate measurements of all walls, windows, doorways, appliances and obstacles. Be sure to note the location of any gas and plumbing lines that need to be taken into consideration for your layout. i ( wL3 ) 4 _ 14.4,t _ N 5‘1 i d4j1 . i I fixf.,e _ L.„, WiwooMl j i 3 ,..... 1 I i i I ----1----TET7TWO F R BUILDING AND ZO;,iI G CODE CCIv"PLI' ANCE, ERRO S OR 0MM SSIONS DO NOT RELIEVE THE ADPLICANT I' OM THE RESPONSIBILITY OF"AS Bar Imo, C DtdPLIANI:Ff . IIN ,. it„c_— DATE:I U ia.O= ♦ .� J I ��i I BUILD 0 ICIAL I ( i 1....t. 't3 t ' i i ♦ t I i f j { 1 I I i I I t ! f I I i E 1 I f (wtWi)k I i VICI .,) 14•IiVC5 4Iohl(, �� ij000. (ov www.rtacabinetstore.com design@rtacabinetstore.com 1800-580-5535 I fax: 215-392-5466