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HomeMy WebLinkAboutBLD-23-005211 "'ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department y- • 1146 Route 28, South Yarmouth,MA 02664-4492 ! - 508-398-2231 ext. 1261 Fax 508-398-0836 tl'' ■ Massachusetts State Building Code, 780 CMR -, o re Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling I This Sectio For Official Use Only Building Permit Number: 8(,) - 3 iiirm ' Date Applied. Act 0052 C�-. ` vr" -3 4( a3 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: I. 1.2 Assessors Map&Parcel Numbers 1.1 a Is this an accepted street?yes 34 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: Zone: _ Outside Flood Zone9 Public Private❑ Check if yes Municipal 0 On site disposal system X SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of accord: / t 4.w i G4 1I1 it H a" �Ct Pc.$I Yrw?G �h HA 0 Zv 7 3 Name(Print) City,State,ZIP j Z'l' a *.p Sa 4f &i/3 6/5 - 6632. 3'otw oail sc 'i 1304% 14,t4t No.and Street Telephone Email Address I (QW, I SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 1 Existing Building 0 Owner-Occupied 0 Repairs(s)A Alteration(s) 0 Addition 0 Demolition X Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work': D4/i h14, A ut 6 FI°vet Q k 4 y c. £tpAir vid t Ivt e Slut hi I Ca% ft, � iu �� Tk),/*i,....,/ SECTION 4:ESTIMATED CONSTRUCTION COSTS. Estimated Costs: VcCr---* Item Official'Use Only(Labor and Materials) 41.Building $ 1. Building Permit Fee:$coo Indicate how fee is determine z l a n 2.Electrical $ Iv Standard City/Town Application Fee j w • il 0 Total Project Costa Itemnx multiplier . x 1 m' ►--,cz) ; — 3.Plumbing $ 2. Other Fees: $ DI _ i 73 4.Mechanical (HVAC) $ List: .-1 w� MI 5.Mechanical (Fire Z�� rn Suppression) $ Total All Fees:$ - x S 6.Total Project Cost: $ � f Check No. Check Amount: Cash Amo _b`a AV ❑Paid in Full I�Outstanding Balance Due: 5 31a1 ,,) V SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) Cif- //// es'-- 0d/8"c13- ///3/z`/ x.s /k.t nitt 17 License Number Expiration Date Name of CSL Holde U 60 3 Lh f Arvic/�,.f j �JB��,/� List CSL Type(see below) No.andStreet '1 �[ /1 Type Description gl /vhr/�e�, �� �� U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted 1,k2 Family Dwelling City/Town,State,ZIP • M Masonry RC Roofing Covering WS Window and Siding �0? j I f'Sill +� e r / SF Solid Fuel Burning Appliances CP' 10 7 `C(4A6,(ibi arJ tn+t i I Insulation Telephone Email address • CO."i. D Demolition 5.2 Registered Ho Improvement Contractor(HIC) /OjZ�, • (. Z em� b/�dcrs G` HIIC Registration'' nber Expirati n Date HIC Comp N e o C Registr t N /,3 tvt j'1 l�JLy7r a c�/�/1 a�1 . i 64 sU /A /� a •sal 'Cep /1 l � ft014\ ho and.Street // �•M� tjl X*64/if ^ /9/9 DZ4 73 SDI 3C V- .3/1/ L,��atl address 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 9[tL No 0 SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN pi,,,), OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1y, I,as Owner of the subject property,hereby authorize i ybl .f' 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.gov/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 Department of Industrial Accidents gir�i� 1 Congress Street, Suite 100 Boston, MA 02114-2017 - 4•`�� 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): Ke kli " aigieltv) 'KC - Address: t 03 Mil X1-10 ev/4Rokei thS / it/A,we //A 0 2i.7 3 City/State/Zip: �✓�s� yrf�alr Lj /4/4 U Phone #: 5-e7 zL'el-3/C/ J Are you an employer?Check the appropriate box: Type of project(required): I. I am a employer with 0 employees(full and/or part-time).' 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp. insurance required.] 8• Remodeling • 3.0 I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10//❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.: 13•❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other R(r41 ( 152,§I(4),and we have no employees.[No workers'comp. insurance required.] 1 pcMll.L. *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: A p1etrt_4 vt Z i'r/c 1 ..h W r i h.C{ 647Ahh It Policy#or Self-ins.Lic.#:6 z Z U b � � 33 7 y 7 / 7 Expiration Date: Job Site Address: ZY?' 4aarp 1#�4 1( City/State/Zip:Mf/ )%triopvft /VI Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Ole?.� 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 t er re pa• s and penalties of perjury that the information provided above is true and correct. Signature: Date: ,AA ? g Phone#: 5Q (J 3 V- 3/// 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#: 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 resultingL from the proposed work/demolition to be conducted at Z yr Cowl) 5/114-I tie S Y /r'kle'c'/1 /e7 Work Address Is to be disposed of at the following location: grote�� t �c',aoi '/ Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. I/ 3 70 Signature of Applicant Date Permit No. SECTION S: CONSTRUCTION SERVICES l 5.1 Construction Super�+tsnr License(C5L) �- /� p ! ii.?�0./V/ ill 3/2 V eh-s ,v jg,y%_ �(/ 1 Licen c Number Expiration Etats: Name o:cL ) old }, 60 /3 i L Aim :�!/ /iAeJ List CSL Type(zee below) V iCa and Smet L Type Description • V R U uildinas•on to 33.400 cu RLL /1if yt,-,•cv fit //4 c2G 7 _.._ R Restricted Ih2 Family Dwetnne CQQiTorortt,State,ZIP M Masonry RC Rooting Covering p �/ _-- /__._... WS ) Window sad Siding _ nees ICI L► �'�/7''3/l1 AA, Ar �L�I,.S eA f ! SF Saud Fug:Busting AppGa I /+�I ! Insulation Tel Email add= . (01.1 D -Deolol;i40 5.2 Registered Hom Improvement Contractor(NIC_) ,C f��"� ]l G/2:3 f �i/dux G O f hit'Regi:ration'• obrr Lxpi.•ati elate C f_o^tr44,o C Regist:Jp t N j ---..._. ! lea rss44J /Cr �__ �ddt� 1� 1 �1 .�tiz't o sn Stec JLI 1� / ��/ SIN ly,L^ 1 3' - 3/// �..:aa ad s City/Town, State. Z __. I eke-4"one rSECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G_L.e. 152.1 25C(6)) 1 Workers Con_persittun lasur.uxe affidavit trust be completed and subtnined with this application. Failure to provide this affidavit %ill result in the denial of the (sstt.�nce of the building perntt. i _ Sized Affiid..•i:Anacbed^ Yes .. . .. )1I1, No SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT �rK '{� 1,as Owner of the subject property,hereby authorize_ �7� � _1 � (V t , 4 to act on my behalf, in all t2za e rers. lative to work autbctriicd by this by; ling permit application 4i---6 4-147- f 6 A--4 I - e . 6‘.),(vvi- - .. Eti t" 's Name 4Eiecrra_t,:st; tar tie - SECTION 7b: OWNER'OR ALrFHORIZED AGENT DECLARATION 1 By entering my name below,I hereby axest unties the pains and penalties of perjury that all of the information contained in this apclication is true and accurate to the best of my knowledge and understanding. Pratt Owner's or Authori..:a A„ert's Macaw(Electronic Signature) Date NOTES: 1. An Owut i who obtains a building permit to do his/her Derr work or an owner who hires as unregistered cote actor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaraa y fund under M.G.I..c. 142A.Other Important information on the HIC Program can be found at tiw.•winass.Qovioca Information on the Construction Supervisor License can be f..j4 at www.To.3FL v 2. When substantial work is planted,provide the infortration below Total floor area(sq. ft.) __ n �,,(including g;urage, finished ba tent'attics,6eas or porch) Gross living area(sq. ft.) 1lal�i►able room count d Number. of fireplaces .„ Number of bedrooms __�_. Number.of batl,mom5 __ Nu ubct u:h f7baLtts Type of heating system w .4.1. Numberof decks/porches Type cf cooltrtl sys:ctn _ EnclosedOpen �.. 3 "Total Project Square Footage" may be substinated for'Total Project Case c-W 1-.. / -]_d \ ' \ . G� r-1.-' S a -- a (7 ' x t. p o T y ir .2 X/' ' \ 4( . I CLASS TEAHER Name Address Phone Email Check number , - . Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Re ulations and Standards Cons IonfS visor CS-001895 i cpires:01/13/2024 CHRISTOPHER T KENNEY 603 WEST YARMOUTH RD WEST YARMOUTH MA 02673 i s- . f Commissioner .jja. a t7Ze r0/74/220/M0effii c tir)c)-aC1114-eiij Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation Registration: 181256 KENNEY BUILDERS INC. Expiration: 03/16/2023 603 WEST YARMOUTH ROAD WEST YARMOUTH, MA 02673 Update Address and Return Card. SCA 1 0 20M-05/17 . K ,,,,,,'/f/Wi///</. /47•i-ai��iii///i Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 181256 03(16/2023 1000 Washington Street -Suite 710 KENNEY BUILDERS INC. Boston,MA 02118 CHRISTOPHER KENNEY .! 603 WEST YARMOUTH ROAD Li✓F"`f�' zG`s" Not vali WIthO signature WEST YARMOUTH,MA 02673 Undersecretary / 1 ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 03/06/2023 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY A.ND 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 polioy(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 Alan Burstein NAME: Peter M.Bakker Agency,Inc. PHONE (860)378-2700 FAX (A/C,No,Ext): (A/C,No): 302 West Main St E-MAIL alan.burstein@optisure.corn ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Avon CT 06001 INSURER A: American Zurich Insurance Comp 40142 INSURED INSURER B: Main Street America Assurance Company Kenney Builders Inc. INSURER C: 603 W YARMOUTH RD INSURER D: INSURER E: WEST YARMOUTH MA 02673-1459 INSURER F: COVERAGES CERTIFICATE NUMBER: CL233624254 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE EEEN 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 EIEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DDIYYYY) (MM/DD/YYYYL LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE IRTED CLAIMS-MADE X OCCUR PREM SESO(Ea occu r nce) $ 500,000 MED EXP(Any one person) $ 10,000 B MPJ7842M 04/06/2022 04/06/2023 PERSONAL&ADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER' GENERAL AGGREGATE $ 2,000,000 X POLICY JECT PRO LOC PRODUCTS-COMP/OPAGG $ 2,000,000 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) $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ �-WORKERS COMPENSATION PER O X STATUTE ERH AND EMPLOYERS'LIABILITY YIN 500,000 A ANY PROPRIETOR/PARTNER/EXECUTIVE N/A UB-8H337476-22 09/25/2022 09/25/2023 E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/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 John Calligan ACCORDANCE WITH THE POLICY PROVISIONS. 248 Camp St AUTHORIZED REPRESENTATIVE Unit H6 West Yarmouth MA 02673 , +r p jY . � t ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Q e_A- C1 L 47 v 2 6cAk f3d 6 LA) - 2 HA -- -7 7---' (2-n 7'17';!' V\S Floor L 0 v .1" Fo,r6,% 62 v 0 d ,� a 5/,. (Jci / l�%<'i2,o 4 Shepley 216 Thornton Drive Hyannis, MA 02601 Phone:(508)-862-6200 www.shepleywood.com E0003X 10105 D10375167743 S2 P9543685 0001:0085 ,...iiIIIIIIii.oi iiliiI dill iiih ai IIiiiii..IIiIiIiiIiiiIIiiIi n, CHRISTOPHER KENNEY KENNEY BUILDERS INC 603 W YARMOUTH RD WEST YARMOUTH MA 02673-1459 II 1111111111111 II