HomeMy WebLinkAboutBLD-23-004995 ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department .. r ,.
1146 Route 28, South Yarmouth, MA 02664-4492
508-398-2231 ext. 1261 Fax 508-398-0836 1 '' ,`
Massachusetts State Building Code, 780 CMR \�, ,'`e
Building Permit Application To Construct, Repair, Renovate Or Demolish
a One-or Two-Family Dwelling
This Section For Official Use Only e D
Building Permit Number: )- 3-( "1s Date Applies• R E C G I _
Building Official(Print Name) Signature MAnDate
SECTION 1: SITE INFORiMATION _- ' NG DEPHR MEN"
�UttDl
1.1 P,ZroZnerty Add.rkis.:, .�. 62scy 1.2 Assessors Map &Parcel Number By
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,I54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Publit4] Private C] Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yesCl
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Recor h��h`p` Ykiasm 0 J ;\, to A OZ ( b LI
�A'�N Lt�I�l�s`CE�t— h J `" Va
Name(Print) City,State,ZIP
36 EP "-Ze y 13k3. 33y-a33k. 0ZKw�tIN► e AM—. L0.41
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK"-(check all that apply)
New Construction 0 Existing Building Owner-Occupied4 I Repairs(s)\' Alteration(s) 0 Addition 0
Demolition Accessory Bldg. 0 Number of Units ( Other 0 Specify:
Brief Des ription of Proposed rk'-:
-'-tom 1Z• otom+ t .51t4t, th‘toa lZsRAOC4AV*^/1-
SECTION 4: ESTIMATED CONSTRUCTION COSTS .._
Item Estimated Costs:
(Labor and Materials) Official Use Only `-_',,vv D
I.Building $ 3 C. 0 p 0 1. Building Permit Fee:$ i SC1 Indicate how fee is detgrmipp� (�
873
2.Electrical $
t RI Standard City/Town Application Fee ICY IN 22 202r
0 Total Project Cost3(Item 6)x multiplier x .__. //�'
3.Plumbingf [DING DEPARTMENT$
4.Mechanical (HVAC) $ List: 3 rj,0 Ot pt---
5.Mechanical (Fire
Suppression) $ Total All Fees:$ __
Check No. Check Amount: Cash tint: .I
6.Total Project Cost: $ .3 s- 000 0 Paid in Full in Outstanding Balance Du : 1 S \a3
�ao
3
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS 0q-11.9-1 (O'lt`'Z3
GS— d ` f n ,L, License Number Expiration Date
Nam of CSL Holder
O DSI List CSL Type(see below)
No.and Street Type Description
Z'.1 N\ S < U > Unrestricted(Buildings up to 35,000 cu.ft.)— tJ Restricted 18c2 Family Dwelling
City/Town,State,ZIP lvl Masonry, 0Z3 El RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
?al•3 IZ•?19°l Kr -if a cw I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 11 14 683 `2t\2 y
b HIC Registration Number Expiration Date
EilC,Ce5P n_Ngae,or HIC Regis t Name` P
C C �oaeLLi lvro L'lZnM'f e2ST C .
• C.°I N
No,and Street Email address
43 6 1,.)pata fTvAt A't �'19 `?-Si Z• '7'1611
City/Town,State,ZIP p7...-r'j�C7 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 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
to act on my behalf, in all matters relative to work authorized by this building permit application.
t...Lf.AttrZ \ 312/ z_3
Print Owner's Name
am (Electronic Signature) Date
• SECTION 7b: OWNERI OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
co fined in this a 'on 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.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
er u, ,.,_ Department of Industrial Accidents
mac_. Department
Congress Street, Suite 100
j,
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): ){S \ . 1�"1VA Q�t,�� Ov
Address: Z 63 (->,
City/State/Zip EMA hone - 77R `\
Are you an employer?Check the appropriate box:
Type of project(required):
l`k I am a employer with -3 employees(full and/or part-time)."
"""^^^CCC 7. Q New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
•
any capacity.[No workers'comp. insurance required.]
93.0 I am a homeowner doing all work myself.[No workers'comp. insurance required.]t Demolition
4.0 I am a homeowner and will be hiring contractors to conduct all work on m YP property.e I will 10 Ell Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11•Q Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5.0 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.Q Roof repairs
6.Q We are a corporation and its officers have exercised their right of exemption per NIGL c. 14.Q Other
152,*1(4),and we have no employees. [No workers'comp.insurance required.]
*Any applicant that checks box:1 must also till 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: OQAC\L S GCS ,Ji 10 r4O EM o cr
Policy#or Self-ins.Lic.4: \ SOO ' ()yZ-1' ZfDU-A Expiration Date: CA h 123
Job Site Address: 3i5 City/State/Zip: y-AQNMOu T N 'MA. 071.06 l'I
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 doh r t y«n to nd alties of perjury that the information provided above is true and correct.
Signature:
Date: 3)(2.3
Phone 4: 1&( \-7—— 1
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License 4
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#:
o''Y`N TOWN OF YARMOUTH
BUILDING DEPARTMENT
o 49k. ' H 1146 Route 28,South Yarmouth,MA 02664
`.-1"3`�a 508-398-2231 ext. 1261 Fax 508-398-0836
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`theem proposed work/demolition to be
conducted at c .�\
Work Address
Is to be disposed of at the following location: 1 K,(P'A- C.9Q
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
C , ction 150A.
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Signature of Application Date
Permit No.
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REMODELING
Li MT
GROUP INC.
OWNER AUTHORIZATION FORM
Statement of Ownership (I) Kathleen Rinaldi property owned of
38 Early Red Berry Lane authorize Ray Rosano of
RST Remodeling Group to perform work as authorized agent/contractor on
above property
Name of Authorized Agent/ Contractor_ Ray Rosano of
RST Remodeling Group
Owner's Signature K ' +L /6:0.t ZZ:
Date 3/011202 ---
Office Phone: 781-312-7799
Office Fax: 781-924-1341
1 of 1 3/6/2023, 12:45 PM
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�� CERTIFICATE OF LIABILITY INSURANCE 022 12023
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE GOES 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 poticy(ies)must have ADDITIONAL INSURED provisions or be endorsed
It 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 ley of such endorsement(s).
PNOOUCER )CnAMENTACT
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Dowling inswara,,1yas1,y,if n {''HONj��-F.rr. r'Ii3'n,2 ... 1 FAX
C.1bk (781)380-87a9
44 Adams Street bdtinnadowkngins.com
PO.Box 850982 MtIRER(s)AFFORDING COVERAGE NAIL a-.
Braintree MA ir.'r -O002 wawa R A Green Mountain inn co 20880
NM/RED IrISttmm,a. Arbeoa Protection insurance Company 41300
Rst Remodeling Group Inc imam,c A.Asx:iater Empinyers Insurance Company
238 Water St INSURER
PO Box 2(12 INSURER F.- -
Pembroke MA 02350-I025 mama F
COVERAGES CERTIFICATE NUMBER: Rsn ikti 2127/23 BO REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE I UH I HE POLICY PERIOD
INDICATED NOTWITHSTANDING ANY REQUIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERIIFICAtE MAY BE ISSUED OH MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCI LOTIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
TYPE Of INSURANCE —�JE>�If.___..____--POLICY POLICY EFF POLICY EXP --- LIMITS"(VD —_.— —_-------+tMNOOFYI'YY1 PWIOO/YYYY)
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE f 1.000.000
CIAI/AS MADE }^r;t 6i PREMISES MISES E necnnencei f AMAGE liJ RENTED 50.000
ME0 EXP(My aee person) f S'°°°
A 7004S%4!3 00/07,2022 00/0/r2023 PERSONAL&ADV SOUPY f I.000'000
GEHL AGGREGATE LIMIT APPUES PER GENERAL AGGREGATE f 2'000.000
X POLICY' , o LOC FOUO1C15 COMP OPAGO f 2'1:3°°'0
OTHER f
�pMgINEO SINGLE UNIT AUTOMOBILE LMBN.TTY _ .... (Ea agcadee) 1,000,000
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B OWNED SCHEDULED 1020080489 0&'14/2022 08/14/2023 (CONY INJURY iV. ...cadent) t
AUTO(OILY AUTOS
X HIRED X NON.NON-OWNED
S PERTY DAMAGE
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UMBRELLA LIAB OCCUR EACH CVO RRRENCE f
EXCESS LUB CLAIMS-MAUL AGGREGATE f
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(field deny In MIS E L DISEASE EA EMPLOYEE. f 500A00
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CERTIFICATE HOLDER CANCELLATION
3)I0u1 U ANY OI tIll.ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
IRE EXPIHAIION DAIS IHEREOF.NOTICE Will BE DELIVERED IN
Kathleen RN/akk ACCORDANCI WITII THE POI ICY PROVISIONS
78 Early Red Berry Lane
AIiritota Fn REPAIRER TAFNF
Vermouth MA ,vote �
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O 1988-2015 ACORO CORPORATION Alt rights reserved
ACORO 25(2018/03) The ACORD name and logo are registered marks of ACORD
I of 1 'I/')9P)fl•7.1 1•CD OhA
THE COMMONWEALTH OF MASSACHUSETTS
ZL� Office of Consumer Affairs and Business Regulation
2' 1000 Washington Street - Suite 710
?j Boston, Massachusetts 02118
Home Improvement Contractor Registration
1
Type: Corporation
74683
R.S.T. REMODELING GROUP INC. Registration: 9/28/2
236 WATER ST. Expiration: 0 /28l2024
PEMBROKE.MA 02359 ,
Update Address and Return Card.
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the
HOME IMPROVEMENT CONTRACTOR expiration date. If found return to:
TYPE:Corporation Office of Consumer Affairs and Business Regulation
Flegijttlfdibn Expiration 1000 Washington Street -Suite 710
174683 09/28/2024 Boston,MA 02118
R S T REMODELING GROUP INC.
RAMON ROSANO
236 WATER ST. c .n i •,(4":ice/• 1~
PEMBROKE,MA 02359
Undersecretary Not valid without signature
Commonwealth of Massachusetts
Division of Occupational Licensure
Board of Building Regulations and Standards
Const.ctitkioritSkitm.rvisor
CS 097754 I t,pires: 10/11/2023
RAMON W ROSANO . :l
27 WEST ELM ST
PEMBROKE VA 023N
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Commissioner ;�ia IC FCmcsa..
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All dimensions size designations This is an original design and must Designed: 1/28/2023
given are subject to verification on not be released or copied unless Printed: 3/6/2023
job site and adjustment to fit job ^O^O applicable fee has been paid or job
conditions. 2020 order placed.
1' kathleen Recovery 2023-1-28_11h29 All Drawing#: 1 No Scale.
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All dimensions_size designations This is an original design and must Designed: 2/28/2023
given are subject to verification on not be released or copied unless Printed: 3/6/2023
job site and adjustment to fit job 2020 applicable fee has been paid or job
conditions. 1 1 order placed.
rinaldi bath All(no dims) Drawing#: 1 No Scale.
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