Loading...
HomeMy WebLinkAboutBLD-23-001485 i REQEIVFD LSED 2 0 2022° E & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department of y 1146 Route 28,South Yarmouth,MA 02664-4492 ��, BUILDING DEPARTMENT 508-398-2231 ext. 1261 Fax 508-398-0836 ... By:-- -- Massachusetts State Building Code,780 CMR Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number:ill h" 1:3- 001 c6 c Date Applied: jl� )(1:1( --. �� Building Official(Print Name) Si attire Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers I g`i S rt.v£&t2.kFLN / W.yAttNOfl14 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,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: a� Public Private CI — Outside Flood Zone? ' Municipal 0 On site disposal system OS( Check if yeskr SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: C/2/4-« 4 - "c . V n). .iz 44 l;J, YA 2/%4 o 0 n1 , M,4 U ..673 Name(Print) City,State,ZIP / 8`1 Si`-tvRLF',4F LAwE g78-Z96-222q VAN(DEtzAA(o�l o�G-rtirtit.,coAi iti No.and Street Telephone Email Address 1 SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) 1 3* 1°' New Construction 0 Existing Building% Owner-Occupied j8'I Repairs(s) 0 Alteration(s)jlirl Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2: = ;-- _ .. = ,�- --I D F/Zs-M A,A rr C. FA 2 H" c-P Pi A-TL-t r A� X l S T/n/c— fS F 2 p N" /-,�.N X PA&J A 6 x, S 7-,.0 cr- 4-0 S : 7- SEP 2 6 ,022 SECTION 4:ESTIMATED CONSTRUCTION COSTS. -- • BUILDING DEP RTMLNT Estimated Costs: By: -- ------ -a Item Official Use Only (Labor and Materials) 7 1.Building $ 2, p c.) o 1. Building Permit Fee:$,tip Indicate how fee is determined: 2.Electrical $ Q 0 Standard City/Town own Application Fee , ❑Total Project Cost3(Item 6)x multiplier x �J 3.Plumbing $ 2. a S-_C i '- .l02 �/ (�� 0 Other Fees: $ v� . 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ t Suppression) Total All Fees:$ ' •/Check No. Check Amount Cash ' .unt:_,_ 6.Total Project Cost: $ L i 0 0 0 ❑Paid in Full 0 Outstanding Balance Du : /P. , SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) G /2.O 56 8 O;IJ 9 -1U1 A 5 r 1D License Number Expi tion D Name of CSL Holder (f " #7 A 2 T/5/4 N WA- `f List CSL Type(see below) No.and Street , Type Description r v 2e s-1-1 �E/ n�t A 0 2(o Li U Unrestricted(Buildings up to 35,000 cu.ft.) City/Town,State,ZIP l R Restricted l&2 Family Dwelling M Masonry A-,v trd(L1 t C&r p zi.,.. i RC Roofing Covering WS Window and Siding 17- 5)--��Su 3 SF Solid Fuel Burning Appliances RwFR bAttcAQPEN iYL7ocri nniv. I Insulation Telephone Email address COM D Demolition . 5.2 Registered Home Improvement Contractor(HIC) IAN yZ l i> I B7ioo o vszY HIC Company Name or HIC Registrant Name HIC Registration Number pira on Date • 1 2 M 002tAi t,- ti� No.and Street `"U CA a it d rrss G-M�iIL,COM O ✓ TA X/ -a/vt o O-Nt//1I/�� 6(7_$32 t(5-t{3 Email address City/Town,State, \ 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 0 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 .1/1 `'Q% i� — 1t ,J QYi)c4 Q. C Qrt1/4-T'c� to act on my behalf,in all matters relative to work authorized by this building permit application. 1 I j.J I 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. \Ci/x i Ci R V 01,-1,1 .-sLir&__ y -r0 -,A-0.?.)- Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: I. 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.2ov/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 _** �—_' 1, Department of Industrial Accidents e= 1 Congress Street, Suite 100 •=s•Imi � Boston, MA 02114-2017 5..�''y 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): Lei ,.J teF I /) Address: 11 7 ,,1 2 r I SA-F./ 0Z(9Yy City/State/Zip: F es--; c.E MA Phone #: ( 17- 33�- y S Lf Are you an employer?Check the appropriate box: Type of project(required): 1.11 I am a employer with employees(full and/or part-time).* 7. ❑ New construction 2.1ZI am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself. [No workers'comp. insurance required.] 9. [' Demolition 10 ❑ Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will . ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp. insurance.1 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑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. tContractors 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: 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 hereby certify/under th ',is and penalties of perjury that the information provided above is true and correct. Signature: � Date: - ,10 d Phone#: 6/ '7p (3 - yS,/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#: Commonwealth of Massachusetts THE COMMONWEALTH OF MASSACHUSETTS � C Division of Occupational Licensure Office of Consumer Affairs&Business Regulation Board of Building Re ulations and Standards HOME IMPROVEME�V�,CONTRACTOR TYPE EritCON; Con t t-. 4 Regstratton Ex* rii•n spires:03/19/2024 7100 04/0' r2.4 CS-110568 r t AN REID IAN REID ,.'N0 p AN RIVERDALE C flPENTRY fir' 47 ARTISANIfAYI p c FORESTDAL''�MA , AN REIDt ? �7 12 MOORING LANE , ,,,da(/ a'1O(iVd.i-.; SOUTH YARMOUTH, MA 02664 ' ` Undersecretary OvTr7tiS5io:Cr v:0 K. `. `• Construction Supervisor Registration valid for individual use only before the expiration date. If found return to: Unrestricted -Buildings of any use group which contain • Office of Consumer Affairs and Business Regulation 1000 Washington Street -Suite 710 less than 35,000 cubic feespac cubic meters)of enclosed' Boston,MA 02118 C -----7 I Not valid without signature Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this licensev/dpt Call(617)7273200 or visit www ��woomiN IANREID-01 TINAJIA A�ORO CERTIFICATE OF LIABILITY INSURANCE I DATE(MM/DD/YYYY) 9/1912022 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 ri!hts to the certificate holder in lieu of such endorsement(s). PRODUCER I CONTACT NAME: Deland,Gibson Insurance Associates,Inc. HON No,EXt (781)237-1515 FAX T 36 Washington Street lt (A/c,Nola( 81)23T-1805 Wellesley Hills,MA 02481 Misg,Info@delandgibson.com INSURER(S)AFFORDING COVERAGE NAIL S INSURER A:Safety Insurance Company 39454 INSURED INSURER B: Ian Reid INSURERC: 47 Artisan Way INSURER 0: Forestdale,MA 02644 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. INSR ADM OF INSURANCE AD SUBR T POLICY EFF POLICY EXP - _-- LTR WSD WVD POLICY NUMBER I(MMIDINYYYY),IMM/DD/YYYYI LIMITS A X oOMMERCIAL GENERAL UABILT/ EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE r X1 OCCUR BMA0025987 10/28/2022 10/28/2023 DAMISET(Ea NTED e) $ MED EXP(Any one person) $ 10,000 1 PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE ilea APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JEI:T I I LOG PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY (Ea as COMBINED LIMIT $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY _AUTOS BODILY pR INJURY(Per accident),$ I AUTOS ONLY AUTOOS ONLY (Pat"aG ) $ $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION - P � AND MAPLOYCRB'LIABILITY YIN _ ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? I I N/A (Mandatory in NH) It yes,describe under EL DISEASE-EA EMPLOYEE$ DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it more space is required) Location Address:47 Artisan Way,Forestdale,MA,02644 $3,647 BUSINESS PERSONAL PROPERTY LIMIT$500 DEDUCTIBLE Property coverage is on a Replacement Cost basis,Special Form,Equipment Breakdown included Endorsement VB14007/99 is included and commonly referred to in the insurance industry as'all In'coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Janice VanDerAa THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVEVEE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD §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 I VI S 1 U E F t-Prfr\L/ w M o t>7 / M 4 Work Address Is to be disposed of oat the following location: A 6,444vV - "'�i( -' s ✓ S} 'ut'� Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. „10 - ao a-)- Signature of Application Date Permit No. i tft-•\ `...,I , .....is2 14, t_ ,....1 : 1 4' Om \--/*-, 0. (EX TING) t-,5,s ie L _ i>Nrn '`' �' (EXISTING) Nh _. 2 N r n • , cox to o° rn 0 _1 f tl z 1 .. 5\--i i - ‘ ;i 1 i F + .. -