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HomeMy WebLinkAboutBLD-23-002894 '' US I OnS )0nd cD(n IcaP Pell>mi-F 1 - TWO FAMILY ONLY- BUILDING PERMIT R G E Town of Yarmouth Building Department ...0........ ..... ,,i 1146 Route 28, South Yarmouth,MA 02664-4492 NOV 28 2022 508-398-2231 ext. 1261 Fax 508-398-0836 �t ... Massachusetts State Building Code, 780 CMR BUILDING DEPARItfi erntitApplication To Construct, Repair, Renovate Or Demolish _. a One-or Two-Family Dwelling This Section For Official Use Only B ' Permit Nu for 4 Db2gcH Date Applied: -� 0. r im Zj Z Building *PO. mt ame) Signature Date SECTION 1:SITE INFORMATION 1.1 i rroope ty Address: �� ONT' /IO3 4-/Ibr 1.2 Assessors Map&Parcel Numbers 5. y bt- 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 0 Private 0 Zone: Outside Flood Zone? _ Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2. 0 vr'o Sword: , ,Q(,�s� a coI Name(Print) S� City,State,ZIP �ue_�!J�/! 5' I i a4— I IOs No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units I Other 0 Specify: Brief scriptio roposed W e,.2: ; C 4 ..-asfAeapr. ,,' 1,1 çcri,ii i p"..4F 7. K.-,. -i'l , K7/.4 Sc. SECTION 4: ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ /Q 6.- --0 a• 1. Building Permit Fee:$ _Indicate how fee is determined: Ii 0 Standard City/Town Application Fee 2.Electrical $ N 4" 0 Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ g 0.t1° 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ • Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 0 Paid in Full ❑Outstanding Balance Due: t SECTION 5: CONSTRUCTION SERVICES 5.1 'Construction Supervisor License(CSL) L, ������� CS 0073/ Aiy�^ d . `i6A 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 cCam— M Masonry ,4 wic� MA Da./3 RC Roofing Covering I /0 WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Mt 64,02 Co ractor(HIC VIMHIC om any N e or HI Registrant N e / .� / -1STS HIC Registration Number Expiration Date xego No.gi treet Ili S6 Email address City/Town,State,ZIP Telephone j 7 r1 f 1 p1stSr�S'P f ��s, '�" 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 Issuan-of the building permit. Signed Affidavit Attached? Yes No ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. ,iliaelk-Aumet. - graft boClfrlesik-er. /141i r) mt 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: i 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor I (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration i 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 2- Number of bathrooms Z- Number of half/baths .- Type of heating system clime'L Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" 1 no LummunPveuttrt uj inussucnusettA . , . Department of Industrial Accidents Office of Investigations ''3) Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 l' '--7":5. =•`- WWW.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibh Name (Business/Organization/Individual):Benabby Inc d/b/a Disaster Specialists — Address: PO Box 480 9 Jan Sebastian Dr City/State/Zip: Sandwich, MA 02563 Phone #: 508-888-1113 — Are you an employer? Check the appropriate box: Type of project (required): I.0 1 am a employer with 18 4. Ej I am a general contractor and I 6. El New construction employees (full andlor part-time).* have hired the sub-contractors 2.El] I am a sole proprietor or partner- listed on the attached sheet, 7. —1 Remodeling ship and have no employees These sub-contractors have 8. — Demolition working for me in any capacity. employees and have workers' 9. LI Building addition [No workers' comp. insurance comp. insurance.t required.] 5. El We are a corporation and its 10.0 Electrical repairs or additions 3.El 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' 13.0 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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:Applied Risk Insurance Services Inc Policy#or Self-ins. Lie. #: 37-3982266-01-04 Expiration Date:6/1/23 Job Site Address: .Vi -b7,//4'e1,-/5/ City/State/Zip icy)(d, "/,,/c -hal: 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 he forwarded to the Office of Investigations of the DIA for insurance coverage verification. • I do hereby certify und , the pains and penalties of perjury that the information provided above is true and correct. Signature: .' /32-10 ----,/ ..,/ 7L :-_i y Date: ?' --.1.2 Z ' 7 SI 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(check one): 1E:Board of Health 2E3 Building Department 3.E3City/Town Clerk 4.E3 Electrical Inspector 5LJPIumbing Inspector 61:Other Contact Person: Phone#: per.r m_ Q z � �2 C7 5, Yr CZ 4-1 _ n I zz s *°CCU o cn To , m4r Qni om. o I N CO 0 4 0a w C� c Cl) I.)* - 0 �§ :a.• US co 1. gk. to ri°u� co 0 C) ca f33 to = f `z a Cs 3 aim S Rob •. � ct _ S. -4 crib'c n 18. 0 . 0 .Z;ioz ro ... 10 g C m 0ca " z c 3 w w.a 1 ACcRD® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 4kliniei 06/08/2021 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 Lynn Blanchard,CIC,CISR NAME: y FIAI/Cross Insurance PHONE (603)669-3218 FAX (603)645-4331 (A/C,No,Eat): (A/C,No): 1100 Elm Street E-MAIL Manch.Certs@crossagency.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Manchester NH 03101 INSURER A: Crum&Forster Ins Co 42471 INSURED INSURER B: Crum&Forster Indemnity Company 31348 Benabby,Inc.,DBA:Disaster Specialists INSURER C: PO Box 480 INSURER D: 9 Jan Sebastian Drive INSURER E: Sandwich MA 02563 INSURER F: COVERAGES CERTIFICATE NUMBER: 21-22 GL,BA&Umb 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 AUUL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER ,MM/DD/YYYY) .MMIDDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 �/ DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 10,000 A Y Y EPK135651 06/01/2021 06/01/2022 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X JROT 2 OTHER: LOC 0000PRODUCTS-COMP/OPAGG $ 0 Contractor Pollution- $ 1,000,000 AUTOMOBILE LIABILITY GC SMBINEOSINOLwkIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ B OWNED / SCHEDULED Y Y 1337489019 01/01/2021 01/01/2022 BODILY INJURY(Per accident) $ AUTOS ONLY /� AUTOS X AHIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY X AUTOS ONLY (Per accident) $ PIP-Basic $ 8,000 UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A X EXCESS LIAB CLAIMS-MADE Y Y EFX118021 06/01/2021 06/01/2022 AGGREGATE $ 1,000,000 DED X RETENTION$ 0 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Sedgwick Claims Management Services,Inc.and their Carrier Clients,agents,employees and directors are included as additional insured with respects to CGL,business auto,pollution and umbrella policies on a primary and non-contributory basis as required by written contract with named insured.CGL additional insured applies to completed operations.Waiver of subrogation in favor of the additional insured applies to CGL,business auto and umbrella policies as required by written contract with named insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Sedgwick Claims Management Services,INC. ACCORDANCE WITH THE POLICY PROVISIONS. 6440 Southpoint Pkwy AUTHORIZED REPRESENTATIVE �,,�(/�J Suite ono �� Lu�C Jacksonville FL 32216 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD • ACC) CERTIFICATE I ICh LIABILITY INSURANCE DATE(MMDDNYVY) 06/08/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Applied Risk Insurance Services, Inc. PHONE FAX 10825 Old Mill Rd (A/C,No,Ext): (877)234-4420 (A;C,No): (877)234-4421 E-MAIL ----- Omaha, NE 68154 ADDRESS: PRODUCER (877)234-4420 CUSTOatERID# INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A' Continental Indemnity Co. 28258 Benabby, Inc. INSURER B: dba Disaster Specialists PO Box 480 _-INSUflER.C:.. Sandwich, MA 02563-0480 INSURERD: INSURER E: CTL 1273 1664998 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 --- ;ADDLSUBR1 POLICYEFF 1 POLICVEXP --_- LTR TYPE OF INSURANCE INSR IWVD D/POLICY NUMBER (MM/DYYYY)4JMM/DDIVYYY) LIMITS GENERAL LIABILITY ! 1 'T' ---- I '.. ' EACH OCCURRENCE S. COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED ( PREMISES(Ea occurrence/ CLAIMS MADE OCCUR -- - MEOEXP(any one person) ! PERSONAL&ACV N)URY .... ---- — - GENERALAGGREGATE $ GEN:L AGGREGATE LIMIT APPLIES PER PRO- PRODUCTS COMP/OP AGG POLICY -. JECT !LOC AUTOMOBILE LIABILITY - - COMBINED SINGLE LIMIT ANY ALTO ,_1Ea accidentl ALL OWNED AUTOS BODILY INJURY(Per person) -'; S _. SCHEDULED AUTOS BODILY INJURY(Peracdden,/ $ HIRED AUTOS • PROPERTY DAMAGE (Per accident) $ NON-OWNED AUTOS • c - UMBRELLA LIAB', ',OCCUR EACH OCCURRENCE 5 EXCESS LIAB !CLAIMS MADE AGGREGATE I -- - -----_-- ,DEDUCTIBLE `�iI RETENTION 5 ! -- --. $ .._- ---- --- $ WORKERS COMPENSATION 1 !WC STATU- 0TH-;' AND EMPLOYERS'LIABILITY Y:N'. X TORY LIMITS_` .'=R.,,, 'ANY PROPRIETOR/PARTNER/EXECUTIVE; E EACH ACCIDENT S 1,000,000 AOFFICER/MEMBER EXCLUDED'? N I N A X 3 7-3 9 8 2 6 6-0 l-0 4 06/Ol/2021 06J01/2022 (Mandatory in NH) E L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes describe under SPECIAL PROVISIONS below ! E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS+LOCATIONS r VEHICLES(Attach Acord 101,Additional Remarks Schedule,it more space is required) The blanket waiver applies to all operations for Sedgewick Claims Management Services, Inc and others as required by written contract for whom the named insured has agreed by written contract to furnish this waiver. CERTIFICATE HOLDER CANCELLATION Sedgewick Claims Management Services, Inc SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 6440 Southplaimoint PMankwy Ste 200 BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED Jacksonville, FL 32216 IN ACCORDANCE WITH THE POLICY PROVISIONS, Attn: Project Manager AUTHORIZED REPRESENTATiV�� 1783118 ACORD 25 (2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved 11/28/22,9:52 AM Details Licensee Details Demographic Information Full Name: RICHARD J LENNOX Owner Name: • License Address Information City: SANDWICH State: MA Zipcode: 02563 Country: United States License Information License No: CS-055731 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 11/17/2022 Issue Date: 11/7/2010 Expiration Date: 11/7/2024 License Status: Active Today's Date: 11/28/2022 Secondary License Type: Doing Business As: Status Change Reason: License Renewal Prerequisite Information No Prerequisite Information No Available Documents https://madpl.mylicense.comNerification/Details.aspx?result=ee8d4ee9-b067-467f-ac76-4e466bb8f490 1/1 • Commonwealth t Massachusetts Dsvistori of Professional Licensure ...,- Board of Building R!,9otations and Standards Cons rrs`'ti+ ' ir'5p sor CS-055731 `.. sires: 1110712022 RICHARD J PO BOX 4 " If 4 � qf SANDWICH 044CCA, r ry Commissiondail 7 . ` fr�rxw, " . , ' Town of Yarmouth Sanitation Facility Credit Card Customer Account -- | Facility 8CCeSS will be allowed using a credit card Only. This application allows the Toxvn,s / credit card vendor to store the credit card information for speed and convenience Ot processing. |f approved an account # will be e-mail tO the address provided. F�[the Credit Card Holder Information: `- — La�tNarne'. |Haning�n First Name: @c� � -- / - - [ompanyName� !Disaster Specialists — iPOBox48U � Address i Address: Box � / - . | Zip Code: 02563 --- State:' MA | City: Sandwich ' ' PhoneNumber�JG0D-888'1113 Fax Number: 508'088'2951 � Email Address: / | Credit Card Type: ^ ^ ^~^^^/ �� ����� x� — ' Expiration ������ Expiration ��� u������� Month: �v� _| ��r Card #: 3783460718922252 Cardholder: Vicki M H2[r\OQtOO Termnsamd Conditions: Disposal will be allowed only ifa valid credit card isunfile, |f the Town of Yarmouth does not receive payment for the credit card transaction for any reason admittance to the facility will be suspended until payment is made. By signing below, I/we hereby agree that if the Town of Yarmouth is required to place any sum outstanding in the hands of an agency for collection, all costs of collection not to exceed 33-1/3%shall be added to the unpaid balance, whether or not legal action ixinstituted. Any Debtor/Applicant in default shall be liable for all attorney's fees and costs incurred by the Town of Yarmouth in collection of any balance past due. Once this application is processed by entering the information in the Payment Card Integration compliant credit card vendor's website the credit card number will be blacked out to eliminate access to the paper file resulting in an opportunity for the Town to retain the Credit Card information. The applicant is responsible for providing updated credit card information to the Town , prior to expiration. | � - ' Date Signature ,',,,,,',,/ - ' Printed Name Submit completed,signed form via e-mail to: n-,,bi yumnoutb.mu.om. O/brmuUir Town o[Yarmouth, 597 Forest Forest Rd,West Yarmouth,MAO2664. 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 //eV /,�jP6 Ug. 7 yf Zewavrit ,ogee Work Address Is to be disposed of at the following location: ,V4 f41(j717, ���¢/� S'•�. Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. Signature of Applicant Date Permit No. Unit 1 105 /. ,L 1HE 1 16' 10" - 1 ..:— : 1 ZyZ ia�l - = 14 1 i \ 16' 2" �-. f..; t uac ,_. . , 1 11' 3" 1 2' 7"—1-3' 2"—1-2'4" 1+1 10' 9" 2' 3"—' 2' 10"~~2' 2'1' cv, Living Room 0 loset I (o) Pantry (2tjbat closet )_ n IM M 1 r 1 1 I-2' 7" I 3'---,—_2' 8"—i oo" rt 1 5' 4".1' 811: 8' 6" ..—2' 6'��1 T Bedroom _ __\ 2"_ „ 8' F-,1 t 2- ) ;�o ' 3 , 1 , t ems! 1 i L r \ Bathr 10 m - 1 v-!Kitchen i_ Vloset 3 — L 7,...-- ) 0 ._,. __, ,\------ 1 , , 8' r ' 27' 8" 1 8 6 1 IT Unit 1 105 SWAN_POND-RPR_2 11/22/2022 Page: 10 Unit 1 103 1 1 1' 3" I 2' 7''-I ' 6,, I 8' 4" I g' 6" .n 10' 9" "-2' 3" ,'-' 5' 2" - 8' 8' L. NI ' loset I i.iS ) 14- Bathr Kitchen o` j_ .1' loser 2 L N "' 1 Bedroom i =� I _, ~ ~2' 7" J 5' 4" I 8' 6" I 00- v M 00 0 1 3'—I 2' 8"--1 T •2' 10"-'' -2' 2'1 �,� loset 3 ( ) Pantry (2i oat closetM.)Fn Ir Living Room 8 1 � 1 16' 2" il ,-, (na."PI.I- 1 16' 10" I M : L�J 401111.r.liairlir - Unit 1 103 SWAN_POND-RPR_2 I1/22/2022 Page: 9 R"rt fr • • • • • • .i. • Itv • - RECEIVED iiim DEC 211022 BUILDING DEPARTMENT OF.YRR BUILDING PERMIT APPLICATION By• -- t �c1I11111i � o APPLICATION TO CONSTRUCT REPAIR.RENOVATE CHANGE THE USE,OCCUPANCY OF — G OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING.. N S Teem uf\armm th Building Department ^ 1 146 Route' 28 • Yannouth. MA 0266-1—t492 Td: 508-398-2231 ext. 1261 Fax 508-398-0836 office Use On I Planning 9oard Information Assessors Department Information: PETrflif No. _ _3-1Lr Date Plan Type Map (mot Permit Fee $ (Endorsement Date / According Date New Deposit Fec'd. $ 1.4 Property Dimensions: I Plat No. Net Due $ Other Lot Area(sf) Frontage(tt) Let Coverage I rive Section for Office Use Only • Building Permit Number. Date Issued Signature: Certificate of Occupancy Building Official • Date is Is not required Section 1 -Site Infer nation i 1.1 Property Addreeen 1.2Zoning Swan Pond Village Apts. r InfomfaLorc 1100 Alewife Circle - Units 1103. 1 1UD Zoning District Proposed Use 1.3 Building Setbacks(ft) --- Front Yard Side Yards Rear Yard Required I Provided Required Provided Required Provided 1.4 Wader Supply(M.0..L c..40.S S4) 15 Flood Zone Information: Comment • Public Private Zone BFE Section 2- Property Ownership/Authorized A.ge . 2.1 PAsoISsciat s Mark Donahue 170 Newbury St. Boston, MA 0211p ✓ Name(print) 1 G'�� � 617-266-0044 Mailing Address: Signature Telephone mdonahue C{�l waboston.com Telephone 12.2 Authorized Agent Email Address: Ray Kenneally 170 Newbury St. Boston, MA 0211d Na s(pri7 /� Mailing Address: Sign�' 617-980-9440 rkenneally@weboston.com Telephone Fax Email Address I Sectiof}3'-Construction Services 3.1 Uesnsa Construction Supervisor-. Not Applicable Ray Kenneally 954 Canton Ave., Milton MA 02186 License Number Adger CS-097990 /� ai S17-98_0-9440 rkenneally a(�waboston.cor pig Date il--signature W Telephone Email Address: 5/19/23 p� i • • 3.2 Registered Home Improvement Contractor. Company Name Not Applicable Q Address Registration Number Signature Telephone 'gi2tion Date 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 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 Not Amicable❑ Hama(R•ciatrant): Address Registration Number Signature Expiration Data Telephone Section 5.2 Registered Professional Engineer(s) Nam* 'Ara d Resporsp®y Address Reyitraeon"""Dot Signature Telephone Evirat on Daze Name Area or Responsibility Address Registration Nutter Signature Telephone I Expiration oat Hama Area at Rcsporsr t5y Address I Registration Netter Signature Telephone Expiration Data Hams Area of Responsbt ty Address Registration Number Signature Telephone Expiration Date Section 5.3 General Contractor Not Applicable Company Nam* Person Responsible for Construction Address Signature Telephone 22 , ; Sect• ionr 6- Descri • ', New Construction ��of Proposed Work(check all applicable) ❑ (for multiple family only) No.of Bedrooms (for multiple family only) No.of Bathrooms—.._— Existing Bldg. ❑ Repair(s) ❑ Alterations ❑ Addition Cl Accessory Bldg. ❑ Type Demolition Other Specify_ Brief Description of Proposed Work: i • i C ISection 7-Use Group and Construction Type I Building Use Group as Check ( aPPric aPabie) I Construction Type A ASSEMeLy I❑ A 1 0 A-2 0 A-3 ❑ to 0 B BUSINESS Ai 0 A-5 ❑ to 0 ❑ 2A ❑ E EDUCATIONAL ❑ ❑ F FACTORY ❑ F-1 H HIGH HAZARD ❑ El F-2 0 3A 0 1 INSTITUTIONAL'❑ I-1 3A 0 M MEf:1CHANTiLE El ❑ 1-2 o 1"3 ❑ >8 0 R RESIDENTIAL ❑ R-1 ❑ R-2 ❑ R-3 0 SA ❑ S STORAGE ❑ s-I 1 u unity I❑ ❑ SPECIFY: M MIXED USE SPECIFY: I S SPECIAL USE I 0 SPECIFY: (Complete this.section if existing building undergoing.renovations:additions and/or change Iri use. Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34 Proposed Hazard Index 780 CMR 34 Section 8 Building Height and Area I Building Area Existing(if applicable) Proposed Number of floors or stories include basement*vets i 1-Floor Area per Boor(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 1 SECTION 10a OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, Mark Donahue ,as Owner of the subject property, / hereby authorize �J Ray Kenneally to act on my behalf, in a I mailers relative to Work authorized by this building permit application. 1 12/21/22 Signature of Owner Date 4 SECTION 1 Ob OWNER/AUTHORIZED AGENT DECLARATION ! 1, Ray Kenneally .as Owner/Authorized Agent hereby declare that the statements and information on the forgoing application are true and acurate,to I the best of my knowledge and belief. I Signed under the pains and penalties of perjury. Kenneally Print Name 12/21/22 Signatur f Ownerr/Agent Date Section 11 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be completed by permit applicant 11.Building a Electrical 1 I . 1 3.Plumbing/Gas 1 4.Mathanlal(1-iVAC)S.Are Protection 6.Tota1_(7.2.3.4.5) 1 7.Total Souare Ft.ow now v,.se .t.444onl Check Below D Conservation-Commission Filing (if applicable) ❑ Old Kings Highway&Histori l Commission approval (if applicable) • IA §TOWN,OR YA RMOUTH 1146 Route 2$;:South;Yarmouth, MA 02664 508-398-223 :;eat.t261-Fair 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 S ki/i4/ Fb/VT) UI C,LA6•;5 UNi f,s f(03 —105 Work Address Is to be disposed of oat the following location: D,St64-. 513go,41l. S'- Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. //o W/1 Signature of Application Date 23 - oolgq Permit No. t;ommonweaitn or Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Co nstructtbhitipe.rvisor Construction Supervisor CS-097990 expires:05/19/2023 Unrestricted -Buildings of any use group which contain RAY J KENNEALLY less than 35,000 cubic feet(991 cubic meters) of enclosed 954 CANTON AVENUE • • space. MILTON MA 02186 • lif,\'•I• 3�11,` Commissioner c cudi.Z f. iimii&. O Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Call (617) 727-3200 or visit www.mass.gov/dpl ACORD Client#: DATE TM CERTIFICATE OF LIABILITY INSURANCE 12/21/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND C:ONFERS NO RIGHT UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Raphael Oliveira AIAAAP PHONE (508)771-4600 DISCOVERY INSURANCE AGENCY LLC (A/C,No,Ext): 668 Main ST,#A HYANNIS,MA 02601 Phone: 508 771-4600 EMAIL aphaeldiscovery@gmail.com ( ) ADDRESS: Raphaeldiscovery@gmail.com INSURER(S)AFFORDING COVERAGE NAIC INSURED INS- URER A:ATLANTIC CASUALTY PLJ CARPENTRY INC INS- URER B: 76 WEST MAIN STREET#108 wsURER C HYANNIS, MA 02601 INSURER D:AIM MUTUAL INS CO INS- URER E: INS- URER F: COVERAGES CERTIFICATE NUMBER:000015 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO TALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRL ADDLI SUBR POLICY EFF POLICY EXP TR TYPE OF INSURANCE NSR VVVD POLICY NUMBER (MMIDDIYYYY) (MMIDDIYYYY) LIMITS A GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES(Ea ocurrence) $ 100,000.00 MED EXP Any one person) CLAIMS-MADE I ( OCCUR S 5,000.00 L261004216-2 8/11/2022 8/11/2023 PERSONAL&ADV INJURY $ 1,000,000.00 GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 2,000,000.00 K POLICY PROJECT[ ILOC B COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident) ANY AUTO BODILY INJURY(Per person) ALL OWNED SCHEDULED BODILY INJURY(Per accident) AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) C UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAR CLAIMS-MADE AGGREGATE DED RETENTION$ D WORKERS COMPENSATION x WC STATUTORY OTH AND EMPLOYERS'LIABILITY Y/N LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE N OFFICER/MEMBER EXCLUDED', E.L.EACH ACCIDENT _ AWC40070395842022A 6/3/2022 6/3/2023 $ L000,000.00 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000.00 If yes,describe under E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS below $ 1,000,000.00 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 MA-28,Yarmouth, MA 02664 RAPHAEL OLIVEIRA 1/1 ©1988-2010 ACORD CORPORATION.All rights reserved.