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HomeMy WebLinkAboutBld-23-005210 Maar-TWO FAMILY ONLY- BUILDING PERMIT R EJC E I V E D Town of Yarmouth Building Department illiti 1146 Route 28, South Yarmouth,MA 02664-4492508-398-2231 ext. 1261 Fax 508-398-0836 ' AR Q 0 Ww Massachusetts State Building Code, 780 CMR ZI! I_ Bui ng ermitApplication To Construct, Repair, Renovate Or Demolish II NCa DEPARTMENTmil'/ BU Q a One-or Two-Family Dwelling er:�J This Section For Official Use Only - Building Permit Number: 6 U)-3-01}- Date Applied: I� rs 0isal� �� 3-�� d-3 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION • 1.1Prope ty Address: 1.2 Assessors Map&Parcel Numbers�/ Z 18 Comp St. v-y ii: Xi/i4oi,11, 1.1a Is this an accepted street?yes x 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' 2.1 Ow er',�oof Record: Ma deign c 411, tees/- 7'f-,wuv Th H4 .02`7 3 Name(Print) City,State,ZIP Zy? easy 5/ra ' AS f/- / Cob 33f-3/// Ail/l7D4Gkv ft%C° aO ) . 64141 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 1 Existing Building 0 Owner-Occupied 0 l Repairs(s) ❑ Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: HBrief Descriptio of P dosed W rk2: Iwo A'A L�a , — c . MOW v� tw VAILI 7#14.1 1V 4 'Cl✓ To, , /ice,/ c mod✓ SECTION 4:ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: )e Official Use Only (Labor and Materials) o 1.Building $ I a/ o D 0 1. Building Permit Fee:S tio _Indicate how fee is determined: gib 2.Electrical $ �Cw Standard City/Town Application Fee i ❑Total Project Costa(Item 6)x multiplier RExC .EIVED 3.Plumbing $ GO U 2. Other Fees: $ � List: Y 4.Mechanical (HVAC) $ MAR 2 2 20 3 5.Mechanical (Fire Suppression) $ Total All Fees:$ d 1) U LDING DEPART MEN Check No. Check Amount: a4 Amount. 6.Total Project Cost: $ / S 000 0 Paid in FullOutstanding Balan iTe-:—gr— A 0 J riC I"; MA Of SECTION 5: CONSTRUCTION SERVICES 5..1�``Construction /S,upervisoorr License(CSL) G-f w ('O/,O Q r /A.VZ-t/ `ki-1) iu (V o tt L License Number b !3 Expiration ate Name of CSL Hblder 3 (hi /;I 10 u✓ ]j`"Ga��/ List CSL Type(see below) No.and Street (,' {'` Type Description U Unrestricted(Buildings up to 35,000 Cu.ft.) City/Town,State,ZIP 4� f�� O26 7 3 Restricted Iei2 Family Dwelling NI Masonry RC Roofing Covering • WS Window and Siding 1 '//� � '/ SF Solid Fuel Burning Appliances 36!/-J/1/ 11114h e /�ft/�It+u i/ I Insulation Telephone Email address (O(44 D Demolition 5.Registered Horrte improvement Contractor(HIC) / 7/zc6 3//4 //5- !Mite //J?v((/�'`t,i HIC Registration Number Expiration/Date HIC Comp • ame r Registran e / icJ Jf Ti" xvv �vk /<,,(/401Si Q/4/i+-'(, (0t4-, o.an Str�e�� Email address cl %(�iictav`t t dz47.1 5 7 36 V:3/// 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 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 t 'A'/J f'j1/4.- /Ci in!y to act on my behalf, in all matters relative to work authorized by this building permit application. Pittt S,4Vi 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.aov/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 I l Department of Industrial Accidents 071111= 1 Congress Street, Suite 100 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): I`(LII',L(f �j//i 'dlv,. T r . Address: 6 0 3 A/o f J / vv 0 I koc&c', City/State/Zip:46 f /Geni ✓14 /1 e26, 3 Phone #: S 07 .s L,.3/1/ Are you an employer?Check the appropriate box: Type of project(required): 1.164 am a employer with d employees(full and/or part-time).* 7. El New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8.X Remodeling any capacity.[No workers'comp. insurance required.] 3.E I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. El Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on m YProPrtY� e I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 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.t 13• Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 1 4•❑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. 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: �4�j ericut„ 2 it/C I ilitirA Pax. 614-0,att 1 Policy#or Self-ins.Lic.#: 6 Z.Z (.l to k 337 y76/ Expiration Date: 9/Z} Z Job Site Address: z edt hjt p SInc f �pt/ 1/-'1 City/State/Zip:MI I-/0 0+6 4 /tA- Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration late). C2C 7 3 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify i i r the pains and penalties of perjury that the information provided above is true and correct. Signature: , - 3//(' Z� Date: Phone#: So r .3rp 3P / Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: • TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261 Fax 508-398-0836 Office of the Building Commissioner BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G. L. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section 111/5 I hereby certify that the debris resulting from the proposed work/demolition to be bbe �f conducted at 2V / ,A7 57,7 / (41 f - U y % t J't��/ /G�� 0Altig Work Address Is to be disposed of at the following location: //"frititul4 451//-54 Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. 33 V4 3 Signature of Applicant Date Permit No. ; SECTION 5 CONSTRUCTION SEIMICF j tj 4 3.1 �C Construction IF",it 5a, rrv4I.ieease(C5L} t i2 f#1 ' d/3 r �,ia i L ki -. Al,t:�N it ;.' t.itemse NturiuT w"xpiratic*Dior eaLi /2, lt6v t"a > 4t i4 '�,� T .. i SE 7 /Ciitaa ;e Az. fat,.r t i i ' . F 8 +}rat i�rr. ....., 1 r;, t,t;a r 1711:1 ' Lv t`t •, De tii> .. Registered Ho cn 1rrtQrareu�eot C +atrartns ; 1iC) r i ' reentict h rr /3 ? _- i-jrits s i'ta Co 'a:'+ t D f, P. _t t`4 :1'.1.k,. .ttol 77-Wti t 3L E _ r ._ rand =zAI— } 1 bro. .p�. ,�tw} � ...0 23 1 -fit'_.3rtl' _.>,+ r. t �.I"YD'rCrit`1.Stat.L D T... i t t"'Iw?.:Ic ...t.,..t SECrIOr i: \4 t7�RKERti'COMIPENSA flON INSURANCE AFFIDAVIT(M.(.I» !{'.§ ,.5Ci6) J!! . 'tK Ceke:$C'l>ti7y° *7:'. 7 .r.ult3al:.l 1/1A-it ti.ii.I be co/RW.6%0.4:czc.1 .:,c.,eiic:with ttur 37,7 trait.:. .. :2::::7.. k 1 dts a ffdzvxt w ,n:i r s'.r i/I of the IkS�r�ltxce of*e h/414L" perm; ; S ,a i Affidavit Atta;:beir Yea 111. ; SECTION%a:OWNER AUTf1O11JJ s.1 to►v t 0 BE COMPLETED WHEN 4 O '+ ER'SAGErcr oR c:t)`I ItIX lo14. A.t°t°t. xt� i ft Rtf DL G Ptlturr ,. 3« + a14`f.' Z'x.7'Q !'t't,tttr°Tt..!?t+`x#1; Y' _ _ � i+t'2f;1'V JiK' ` ' to - ,rna healf is a e. :- :a . e. to wtIt otaf on by hull,- :.-.a mitt 4 licallex. _� 1 ax-ft- .....) 6t4ti,i s , 3�i6��0 3 ]e tiF.t Iii»r :01t'4l;it'OR AVE HOMED AGENT' L'i�T'D �R 4TIU Y i J. entet-e tr.,t:;0.14.h.:dv:v.I ert y atTest timia Zss u", i= Lt::.3etie'pl.=et.;tsrs th.41°ail o.`thc CC Coattintd it itt,5 a t-itc�tuitt:1 true$.id accurate totter tieg 45 to)"kt2E;;tiiL.:.:.;,YLw L_'itiCfSt3ti[ oil • Neatk}4=:"tstA.u+ortzL? i'<Ci=xkE C:£D�tu .Dtt' BLit) — `` x-Si __ _l Art 0o.rtur% attars�`. :. rn t tzt dk hiw1 . t�sak. a-0.Y, fares az�regts'ecol hornCoct os ; ta.‘:regis€ered ra the li;-, 1-. :ftr ours tot I.HIC F . i, w It t .e.acne tft the t it rnr.r i:the i i4 a,ogeonT-';:let 1M.u'ttei... li wv;et,•a s,eos.. Infortnat ein tr.L L .-.-at edriti Staperviser Ltc -l•.•.:i . ,•_ i4.ittd at.wv.;:.,;? ; .u'tric When substatz,t ' 4-7 x i ;iaq.Pted,pro. o the iufi n3 ttot b tro,' Total toot-area:•- . i iuclu *one,f.t;sited ba tertrar.- its.cs tie643 or porch) - GYais living au;-i ___ ____ ___. Habitant room•count i Number offrr'plau, Ni)fT:ber of twit c'ep': t Type ttfbi °yStent " ' ___. Wit; > 'p.I �++.ei s .y� 1a. -Total Fraj eCt Square E uit a{, `may slai '„'t• ;rojeu t.:t.�st' .ACo CERTIFICATE OF LIABILITY INSURANCE DATE(MIWDDIYYYY) 03/06/2023 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 Alan Burstein NAME: Peter M.Bakker Agency,Inc. PHONE 378-2700 FAX (A/C. o.Extl: c,No): 302 West Main St E-MAIL alan.burstein(goptisure.com 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 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POUCY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL UABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 500,000 CLAIMS-MADE XI OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 B MPJ7842M 04/06/2022 04/06/2023 PERSONAL BADVINJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY E� LOC PRODUCTS-COMP/OP AGG $ 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 UAB _ OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH X PEATUTE AND EMPLOYERS'LIABILITY YIN A ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N/A UB-8H337476-22 09/25/2022 09/25/2023 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/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 Tom Cardone ACCORDANCE WITH THE POLICY PROVISIONS. 21 Lakewood Rd AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 ( �" } ©1988-2015 ACORD CORPORATION. All rights reserved ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD • Commonwealth of Massachusetts in( Division of Occupational Licensure Board of Building Re ulations and Standards If' Cons ion Svisor CS-001895 f :pires:01/13/2024 CHRISTOPHER T KENNEY 603 WEST YARMOUTH RD WEST YARMOJITH MA 02673 n `�' Commissioner q as f. T1Cc77Lr- 1�2P �G�fivno-zmpea e oi/eir.4c)-• fZCG4e/4- Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation KENNEY BUILDERS INC. Registration: 181256 603 WEST YARMOUTH ROAD Expiration: 03/16/2023 WEST YARMOUTH,MA 02673 . Update Address and Return Card. SCA 1 1S 20M-05/17 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 n,.of GG.�aGfi i" WEST YARMOUTH,MA 02673 Undersecretary Not vali Wltho signature