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HomeMy WebLinkAboutBLD-23-004897 ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department f..--4- -i. -..__1146 Route 28, South Yarmouth,MA 02664-4492 i . \ e,1\ 508-398-2231 ext. 1261 Fax 508-398-0836 t Massachusetts State Building Code,780 CM �� ,l� R Building Permit Application To Construct, Repair, Renovate Or Demolish ; t: a One-or Two-Family Dwelling (� V D This Section For Official Use Only t A Building Permit Number: �j(.j 3-C—t 8 / Date Applied: i �'n� r)c U �eL } ^� BUILDING DEPgPT. �)l.• Al S "LJ'43 By MENT Building Official(Print Name) Sign re Date SECTION 1:SITE INFORMATION 1.1 Property Address: � 1.2 Assessors Map&Parcel Numbers rb s 9 ok-r W1o� U' 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 I 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 yes0 ' SECTION 2: PROPERTY OWNERSHIP' 2.1 ,Owner'of Record: , v i m nSG r1 C-'I c: Cn l U C r-C1 5`) 0''"r'-t (�G Name(Print) City,State,ZIP Z 3 & l c.l,tr t�t AC �(• No.and Street Telephone Email Address SECTION 3:DESCR PTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building Lir I Owner-Occupied 0 f Repairs(s) Fit` Alteration(s) e' I Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2: ZCil n Or.ir K. }-di erl SECTION 4: ESTIMATED CONSTRUCTION COSTS. R C E I V E D Item Estimated Costs: Official Use Only MAR ��yy (Labor and Materials) .lU23 I.Building $ 1. Building Permit Fee:$ �D Indicate how ifee s determined: INStandard City/Town Application Fee BUILDIN • f EPA TMENT 2.ElectricaI $ By 0 Total Project Cost3(Item 6)x multiplier 3.Plumbing $ 2. Other Fees: $ ,.'-,_y 4.Mechanical (HVAC) $ List: 9v,Q d 1JC )/32_ 6.Mechanical (Fire /< Suppression) Total All Fees:$ Check No. Check Amount: Cash oupt 6.Total Project Cost: $ 'Z5t060-bJ 0 Paid in Full l�Outstanding Balance ue: I 1 0 \��� A • 1., , pY wS 8 -,.. i C}A,4'��f<-, ,E� �i, b. - — .. - £ S is -. - , tF ` .r7t rT• *.r• , „ S bo �-v<� T }4...,. f vim t' k, w i. . .., _v s ' ^ilk' :', .. .. 1 !9 n k.,.t 4... + yx� E I. • 4 - - "`.. SECTION 5: CONSTRUCTION SERVICES 5.1 ConstructionC Supervisor License(CSL) ^sue J(O�v l �6 I I So 1 y�,US c) (LLiicense Number Expiration D;te�O Z3 Name of CSL Holder r 3 k I t t \h t ns-to T n s (-- List CSL Type(see below) No.and Street Type Description `1 O r,6 t A,( M,(1 0 I 6, U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted l&2 Family Dwelling p City/Town,State, M Masonry RC 1 Roofing Covering • WS Window and Siding Q► 2 a 1 SF Solid Fuel Burning Appliances -1 1.2S1'7' ' Adico,rC20(leg ova.(an I Insulation Telephone Email address D Demolition . 5.22 Registered Home Improvement Contractor(HIC) ZO/Z /Z5 G 3 ,leO I t14 k. eon sirci. 0A; HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name `Z3 ae21 Lk/C or 5„ ;.�d� 'S e ivoigu ,ri,, z36 ct(.Cfivti No.and Street •k,db 01 AV" p/ 776' (d 7 VSY lc-O/ Email 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 ❑ 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() it r t4 L e Li II t✓c,, . (� D c.4iJr to act on my behalf,in all matters relative to work authorized by this building permit applica ion. (-2 - A,k 1 ( " IJ1 4/2_ Print Owner's N ' C e(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. 2:DSCi-ne L. C4,1LtC r0 3/ Z 5 Print Owner's or Authorized Agent's Name(EIectronic 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.aov/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" • • _ F . , • • • • • �, • §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-22311 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 2c( e s i- ('c ,k i (( , r Iti16✓ Work Address Sd DSp Is to be disposed of oat the following location: Na_u S Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. 7 Sign re of Application Date Permit No. The Commonwealth of Massachusetts emosarQj�h Department of Industrial Accidents =s 1 Congress Street, Suite 100 Boston, MA 02114-2017 �•' www.mass.gov/diet Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY•. Applicant Information Cr'a--1 o)t-rG Please Print Legbly Name (Business/Organization/Individual). 3 k SC l 4 —0 C1 I a U p k r of Address: .2,3 U M"� C ) 7 2 C . City/State/Zip:S L- ( f'A,. ) Phone#: 6 / 7- / V Li Are you an employer?Check the appropriate box: Type of project (required): l.Q lam a employer with employees(full and/or part-time).* 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in ca act 8 ,�Remodeling • an y p ty.livo workers'comp. insurance required.] 3 1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t g L. Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will l0 C Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions proprietors with no employees. 12.C Plumbing repairs or additions 5.01 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 1 Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. I4.[1]Other 152,§I(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 anz an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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 do here under z ains id alties of perjury that the information provided above is true and correct. Signature: Date: Phone T: i — ys /v 0 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 i 5 BUILDING DEPARTMENT . { 1146 Route 28, South Yarmouth,MA 02664 508-398-2231 ext. 1261 HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DATE: JOB LOCATION: 29 O L/ ( C)✓L Q d NAME STREET ADDRESS SECTION OF TOWN "HOMEOWNER" C "--aa J la ( c oirro bei k' De Ol,ivrr. (,,'7 YS )/y 0 NAMR HOME PHONE WORK PHONE PRESENT MAIL tNG ADDRESS 23 (?i ck.i pc-,UJ.. ' S J0.-b-,n 6"/ 77 S.. • CITY OR TOWN STATE ZIP CODE The current exemption for `Homeowner' was extended to include owner—occupied dwellings of one or two units and to allow such homeowners to engage an individual for hire who does not possess a license,provided that such homeowner shall act as supervisor. (State Building Code Section 110 R5.1.3.1) Definition of Homeowner: Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is or is intended to be, a one or two family attached or detached structure assessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner;such"homeowner"shall submit to the building official,on a form acceptable to the building official,that he/she shall be responsible for all such work performed under the building permit. (Section 110 R5.1.3.1) The undersigned `homeowner' assumes responsibility for compliance with the State Building Code and other applicable codes, by-laws, rules and regulations. The undersigned 'homeowner' certifies that he / she understands the Town of Yarmouth Building Department minimum inspection procedures and uirements and that he I she will comply with said procedures and requirements. HOMEOWNER"S SIGNATURE APPROVAL OF BUILDING O14141CIAL INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch.142. Yes No If you have checked ves, please indicate the type coverage by checking the appropriate box. A liability insurance policy Other type of indemnity Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chaprer jo e\Mass. General Laws and that my signature on this permit application waives this requirement. 1 C, _ Signat e wner or Owner's Agent (Ee: ner Agent hhomeownrlicexemp • • III • • ,� � wx • • • • . . = • ACC1120® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 3/2/2023 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 Eastern Insurance Group LLC PHONE Select Department FAX 233 West Central St lac.No.Ext): 800-333-7234 Opt.3 (ac,No):781-586-8244 Natick MA 01760 ADDRESS: selectwork@easteminsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Northfield Insurance Company 27987 INSURED JUBEPDE-01 INSURER B:Arbella Protection Insurance Co 41360 Juberto P. Deoliveira Deoliveira Construction LLC INSURERC:American Zurich Insurance Co 40142 _ 23 Belcher Drive INSURER D: Sudbury MA 01776 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER:1742'7884 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. INSRPOLICY EFF POUCY EXP LT ADTYPE OF INSURANCE NDLSUBR 1MM/DD/YYYY) (MMIDDIYYYY►LTR INSD YYVD POLICY NUMBER LIMITS A X COMMERCIAL GENERAL LIABILITY WS517416 4/28/2022 4/28/2023 EACH OCCURRENCE $1,000,000 CLAIMS MADE X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $300,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ B AUTOMOBILE LIABILITY 1020074439 6/5/2022 6/5/2023 COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $100,000 OWNED x SCHEDULED BODILY INJURY(Per accident) $300,000 AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $250,000 AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ c WORKERS COMPENSATION 6ZZUB-6R04248-6-22 9/2/2022 9/2/2023 X PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? N N/A (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/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 ACCORDANCE WITH THE POLICY PROVISIONS. DeOliveira Construction 29 Oyster Cove Road Yarmouth MA 02664 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD A I, oil r .x- i"") ./\. N x-- 8---% V°P i 0" ri m h e 7\ W A- c. , i :::?. 0\0 t-, Tl U0 G "In,. 1 p O T7 0 S Cn — ITl -i m r ,./ cl\ -r • • • • rnz • • • • • • • • • •