Loading...
HomeMy WebLinkAboutBLD-23-001611 m u le-it 91Z- /2 ONE & TWO FAMILY ONLY- BUILDING PERM E G1V E D Town of Yarmouth Building Department 1146 Route 28,South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508-398-0836 f' Massachusetts State Building Code,780 CMR gU1LD1 r ..? NT \_ _ _/ Building Permit Application To Construct, Repair, Renovate Or Denz. i ll a One-or Two-Family Dwelling This Section For Official Use Only ! Building Permit Number:56D-a3-6)fQ/m Date Applied: ti 2 ?— Buildin cial(Print Z ign re Date SECTION 1:SI E INFORMATION 1.P ope=dress: 1.2 Assessors Map&Parcel Numbers 49 1.1 a Is this an accepted street?yes I 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❑ On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of a ord: lei go-. Ka(o._t-'z.t c\ ,S Ya.r-moo M4 Oa Lo 13 Name(Print) City,State,ZIP Li ,e..e._,V A - 851-ill- b-19(0 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check ll that apply) New Construction 0 Existing Building❑ Owner-Occupied 0 I Repairs(s)(check/all 0 I Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Desckipti of Proposed Work!: Artri, Q -ry-N--t f..f." q,,,_,� i__,- SECTION 4:ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $4y O d. 00 1. Building Permit Fee:$4314andicate how fee is determined: 2.Electrical $ 0 Standard City/Town A plication Fee 0 Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 6 a 3d'doZ.27-- 5.Mechanical (Fire Suppression) $ Total All Fees:$ ( � Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ "f(,fig"a. 00 0 Paid in Full 0 Outstanding Balance Due: 1 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) sue„ ,, lu 04 be›-e- o� I :1�� Name of CSL Holder . ' / / License Number Expiration Date f_4 1 Q0_ (J�, ,: n /? /� r List CSL Type(see below) U o.an Street `i "J.7r' �1ff�bxn (:�,�(,�� Type j Description "rg,-.4.,,... yt /`/ .1-- 64)190 U ; Unrestricted(Buildings up to 35,000 cu.ft.)_ City/Town,State,Z1P R Restricted 1842 Family Dwelling M Masonry iRC ; Roofing Covering WS Window and Sidine .� �.y SF Solid Fuel Burning Appliances t /g /7 3 g7 ,.ec,fr/ - ,+=k GSvA..✓n,4.-- I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contactor(HIC) 1&a J rapr, LL-. < f/A" J'C /,.( s-e- ...el / f i3/2olt� _'IttllBii f ` HIC Registration Number Expiration Date C Company Name or C Registrant e 65S mitt,mitt, . cA. L d No. d Street _Q��r g fS�SJ>`.tyZ-t a-^- - �1.4 O et. �i7r-74 3 -?Ys/ Email address City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION LYSURANCE 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 lssua e of the building permit. Signed Affidavit Attached? Yes No C 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 Sv h,n,�„n ""., 1 1se �rur(... to act on my behalf,in all matters relative(Lç, & to work authorized by this building permit application. # ( ( ,4 eJ— 0 g ZZ Print Owner's Name(Electronic Signature) A.31?-6 Da • SECTION 7b: OWNER'.E Rr 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. 0 ei / 3�a6 Print Owner's or Auth rtzed AQ 's Name(Ere ature) D ite 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.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 hald'baths Type of heating system Number of decks/porches Type of cooling system Enclosed . Open 1 3. "Total Project Square Footage"may be substituted for"Total Project Cost" 1 §TOWN OF YAttMOUTH 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. 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 Li Gl d '1�.-v��� '4(4 dad 3 Work Address Is to be disposed of oat the following location: (9 t.S f y i fZ /Sevo Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. 1 - i �? e Signatuie of Applicati ate Permit No. _______—....,,‘ SUNRINC-02 TWANG AC-ORO CERTIFICATE OF LIABILITY INSURANCE DATE(MM(DD/YYYY) ki.----- 9/10/2021 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. I If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate do_es not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Walter Tanner NAME: Alliant Insurance Services,Inc. PHONE FAX 575 Market St Ste 3600 (A/c No,Exii (A/C,No). San Francisco,CA 94105 gppRkSs,• Walter.Tanner@aliiant.com INSURER(S)AFFORDING COVERAGE NAIL# INSURER A:Navigators Specialty Insurance Company 36056 _ _ INSURED INSURER B:James River Insurance Company 12203 Sunrun Installation Services,Inc INSURER C:American Zurich Insurance Company 40142 775 Fiero Lane,Suite 200 Ph#805-540-7643 i INSURER D: San Luis Obispo,CA 93401 INSURER E: 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. INBR ADOL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE I INS . POLICY NUMBER MMIDDIYYYY) IMM/DD/YYYY) LIMITS A XI COMMERCIAL GENERAL LIABILITY2,000,000 __ _ EACH OCCURRENCE _ $ __ CLAIMS-MADE X OCCUR LA21 CGL230321IC 10/1/2021 10/1/2022 DAMAGE TO RENTED 1,000,000 _- PREMISES(Ea occurrence) $ MED EXP(Any one person)_---$ _ 5,000 PERSONAL&ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2'000,000 X POLICY X 'JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 X OTHER:Retention:$100,000 Per Project Agg $ 10,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT .. _(Ea aceid rt $ ANY AUTO __ BODILY INJURY(Per person) $ OWNED - SCHEDULED AUTOS ONLY __ _AUTOS BODILY INJURY_(er accident) $ RED pyy p DAMAGE — - ----. —_:AUTOS ONLY _ —AUUTOS ONLY '''-Ter aacciident) $ --- —— — ---- — - - - -- - --. $ B UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 4,000,000 X EXCESS LIAR CLAIMS-MADE 001072261 10/1/2021 10/1/2022 AGGREGATE $ 4,000,000 DED RETENTION$ $ C AND EMPLORKERS YERS'LIABILITY Y/N ON X STATUTE_- —. ERR ANY PROPRIETOR/PARTNER/EXECUTIVE WC614287600 10/1/2021 10/1/2022 1,000,000 C R EXCLUDED', N NIA E.L.EACH ACCIDENT $ - andatoryin ) -- _E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation Policy WC614287600 Deductible:$1,000,000. Re:Permitting within jurisdiction. i CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1146 Route 28 ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 02664-4492 _ AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center ‘P., 2 Avenue de Lafayette, Boston, MA 02111-1750 j' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Sunrun Installation Services/ Stephen Kelly Address:225 Bush St STE 1400 City/State/Zip:San Francisco CA 94104 Phone#: 978-793-7881 Are you an employer?Check the appropriate box: Type of project(required): l.® I am a employer with 50 _ 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New❑ construction listed on the attached sheet. 7. ❑ Remodeling 2.❑ I am a sole proprietor or partner ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in anycapacity. employees and have workers' p ty• 9. ❑ Building addition [No workers' comp. insurance comp. insurance., required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL I2 ® Roof repairs insurance required.] + c. 152, §1(4),and we have no employees. [No workers' 13.11] Other comp. insurance required.] *Any applicant that checks box#l 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. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: American Zurich Insurance Company Policy#or Self-ins. Lic.#:WC614287600 Expiration Date: 10/01/2022 Job Site Address: 7 (� Ake-- City/State/Zip: VAefi x Z) 6,t4 73 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 be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify under the pains and penalties of perjury that the information provided abov is true and correct. Siunature: „oaf Date: dy�023O J- Phone#: 978-793- 881 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): 1❑Board of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector 5Ek'lumbing Inspector 6.0Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants —�— Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and,if necessary, supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information (if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center, 2 Avenue de Lafayette Boston, MA 02111-1750 Tel. (617)727-4900 or 1-877-MASSAFE Fax(617)727-7749 Revised 7-2019 www.mass.gov/dia Commonwealth of Massachusetts Construction Supervisor Division of Professional Lfterlsure UrxesbictEd -8uildktgs of any use group which contain Roan/of Building Regulations and Standaros less than 36,000 cubic tM 1�1 cubic mNers� of eci los,ed ortis;rutt��fiILi5p4lyisor space' CS 040622 C,,plres:08/01:2023 STEPHEN A ALLY 18 PARKWAY'ROAD STONEMAM ail 0211111 Failure to possess a current edition of the Massachusetts Commissioner {r„ State ButWweg Code is cause for revocation of this license, For htormatlorl &bait this license Call(617)727-3200 or visit vrrwmass-govtdpl THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street-Suite 710 Boston,Massachusetts 02118 Home Improvement Contractor Registration t Type Supplement Caro SUNRUN INSTALLATION SERVICES INC I i�j Registration 780720 Expiration 10'13/2024 21 WORLDS FAIR DR `—\ SOMERSET.NJ 08873 Update Address end 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:Supplement Card Office of Consumer Affairs and Business Regulation gffiffAtTApp untwist, 1000 Washington Street•Suite 710 180120 10/13/2024 Boston,MA 02118 SUNRUN INSTALLATION SERVICES INC. STEPHEN KELLY • 225 BUSH STREET � f„y(2;;,,�.�, c SUITE 1400 SAN FRANCISCO,CA 94104 Undersecretary vale without gnatu re Stephen A Kelly 695 Myles Standish Blvd Taunton MA 02780 TEL: 978-793-7881 Email: eastmapermits@sunrun.com