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HomeMy WebLinkAboutBLD-23-004895 y P�131/s"/2 3 ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department ;• 'oF- v' 1146 Route 28, South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508-398-0836 .. it. Massachusetts State Building Code,780 CMR Building Permit Application To Construct, Repair, Renovate Or Demolish ::: �:;s.••' a One-or Two-Family Dwelling 1 This Section For Official Use Only Building Permit Number: 61,10 23_ decals— Date Applied: \)f• Spec S — 3 -14-60 Building Official(Print Name) ignature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 1.1 a Is this an accepted street?yes d 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 El Private 0 _Zone: Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'' f Record: 1%:v- `. I ) ttboRo� l h , AAA Orts Name(Print) City,State,ZIP gS c(cSu.4 Gl(L- C 17• St3-Us- 31N1 641111 U 401.co No.and Street Telephone Email ddress SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 I Existing Building&. Owner-Occupied 0 1 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 I Accessory Bldg. 0 Number of Units Other ❑ Specify: Brief Description of PrAp osed Work2: p,} i 1 2 4.,,;,4-e..,t , /Lew es kA4 .404 401.5 csiWI 61414 tteM buck i.e., SECTION 4:ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: Official Use Only ' Q (Labor and Materials) 4� 1.Building $ 3,dlpp 1. Building Permit Fee:$ OO _Indicate how fee is dete s....�: Standard City/Town Application Fee r O�> K 2.Electrical $ Ci 000 `�, 0 Total Project Cost (It 6)x multiplier__ fo 3.Plumbing $ �Odv 2. Other Fees: $—3 3 % a. *,i• 4.Mechanical (HVAC) $ List: ti fir`` t 5.Mechanical (Fire -$ Total All Fees:$ 01/ Suppression) Check No. Check Amount: Cash ount: ,,'` s IT 6.Total Project Cost: $ 13 010 0 Paid in Full lin Outstanding Balance D e: • SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) cY_01`(05`I8 th(�Iy J'«3 l2Z License Number ExpirafEion tip ate Name of CSL Holder tAiii41.0sIvN AVc List CSL Type(see below) tj No.and Street Type Description �j• t/k(LA1�i t ./�A A OZ4 U Unrestricted(Buildings up to 35,000 Cu.ft.) /'� Restricted 18c2 Family Dwelling City/Tod0]7vv n,State,ZIP M Masonry RC Roofing Covering WS Window and Siding 7 ^2 .? J�e Q it k •Co SF Solid Fuel Burning Appliances Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 1 ,,fi Iarws " tit, HIC Registration Number Expiration Date BI Coptpany(Name or H;.0 Registrant Name No.nd Street izia / ` J�"C CA• "1 y1 b. C� yha Asti024(.4 S _7G0_1-612 J 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 0 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 ,AA- '�ii ut.A_ to act on my behalf,in all matters relative to work authorized by this building permit application. /1 yi e Pr Owner's Name ectronic Signature) / ate • 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. ylye) Pft I er's or Aut rized Agent's Name(Electronic Signature) e 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.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 11,_„-,1,_ Department of Industrial Accidents _O)= 1 Congress Street, Suite 100 q= .=_ NBoston, MA 02114-2017 �,m ,••'y www.mass.go v/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): �4,t'�S U kp Address: k As Atpc City/State/Zip: S. yew.* i. d264( Phone #: SOB —7(oo -Z jZ= Are you an employer?Check tie appropriate box: Type of project(required): I.0 I am a employer with employees(full and/or part-time).' 7. New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in ca aci 8. �c Remodeling an y p ty.[No workers'comp. insurance required.] 3.❑I am a homeowner doing all work myself. [No workers'comp. insurance required.]r 9. ❑ Demolition 4 am a homeowner and will be hiring contractors to conduct all work on my property. 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. 12.0 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.: 13.0 Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 1 4•❑Other 152,§I(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box:l 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: Policy g 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 the pains and penalties of perjury that the information provided above is true and correct. r5.....„1 Signature: Date: —3/q/(2-� Phone#: 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 Phone t:Contact Person: o� YAR TOWN OF YARMOUTH u01BUILDING DEPARTMENT -<i �''a 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261 HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DATE: / JOB LOCATION: Y kJ 14 l . ‘./k2Mo NAME STREET ADDRESS SECTION OF TOWN "HOMEOWNER" J►. 13q (on 51 SX.S NAME I HOME PHONE WORK PHONE PRESENT MAILUG ADDRESS 3S Ltc d.-' Ctp- it a(Lksci ti µt- o 174-2 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 requirements and that he / she will comply with said procedures and requirements. _t_7021,47 HOMEOWNER"S SIGNATURE APPROVAL OF BUILDING 01-1-1CIAL 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 yes, 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 Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent h:homeownrlicexemp 1 1 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 conducted at y Olfle 22 lJ . tikg-M4„ i Work Address Is to be disposed of at the following location: S 4 £4co Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. 3/iy73 Signature of Applicant Date Permit No. •• 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia 3/10/23, 1:05 PM Mail-Sears,Tim-Outlook 4 Whale Rd Sears, Tim <tsears@yarmouth.ma.us> Fri 3/10/2023 1:05 PM To:jimbarry19@aol.com <jimbarry19@aol.com> James, I have reviewed your application and your address is listed in Marlborough. You do not qualify as a homeowner under the building code and will need a licensed contractor to apply for the permit. Section 110.R5 Definitions. Homeowner. Person(s) who owns a parcel of land on with he or she resides or intends to reside, on which there is, or is intended to be, a one-or-two family dwelling, attached or detached structures accessory 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. This email is considered a written denial of your permit application per Section 105.3.1 of the Massachusetts State Building Code. Section 105.3.2 states in part that "an application for a permit for any proposed work shall be deemed to have been abandoned 180 days after the date of filing, unless such application has been pursued in good faith" You may appeal this denial to the Building Code Appeals Board in accordance with M.G.L. c. 143 §100, within 45 days of this notice. Timothy Sears CBO Deputy Building Commissioner Town of Yarmouth 508-398-2231 Ext. 1259 04r) mailto:tsearsPyarmouth.ma.us RECEIVED MAR 1 nt 2023 BUILDING DEPARTMENT By. https://outlook.office.com/mait/sentitems/id/AAQkADE3MDQ5NWZmLTkOYzItNDIwNi1 iMDQxLWNkMGQyNmE4NzE5NAAQAFScehKeA6RMo8gj1 xqN... 1/1 r ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department of 1146 Route 28, South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508-398-0836 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: f3 L1)-2, —Mat- Date Applied: RECEIVED Building Official(Print Name) Signature Date _ _.._- SECTION 1:SITE INFORMATION FEB 2 4 2023 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers � � �y /28. 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: Public id Private❑ Zone: — Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: CZ67-j admit v� ya.,,,oJ AAA-Name(Print) City,State,ZIP Q Z G I7'Sl3-S S' �,r.�3e ft) I`� Cad.ad.,No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) ❑ Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2: Aix.) V.040. „fi f tt J, 2._ Ca e1* - V � , ctio,kte !:Kure,,- V SECTION 4:ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 5yrow. )fin I. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ /Di'o'J' r ❑Standard City/Town Application Fee ❑Total Project Cost (Item 6)x multiplier x 3.Plumbing $ ', tb0 2. Other Fees: $ �- 4.Mechanical (HVAC) $ , List: oZ,3 51 5.Mechanical (Fire Suppression) $ Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ Do* 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL Type(see below) No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) City/Town,State,ZIP R Restricted 1&2 Family Dwelling M Masonry RC Roofing Covering • WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name No,and Street 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 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 ��I C��60^- to act on my behalf,in all matters relative to work authorized by this building permit application. S1Gm5 OVA? Print Owner's Name(Elec nic 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. � s � Y�i0 � Print Owner's or uthori ed 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 I:ot 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.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 = _ Department oflndustrialAccidents ';��1ar1= 1 Congress Street, Suite 100 l!c Boston, MA 02114-2017 r;s�•'•I 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). Address: 9/ it.)64,, (Z ` City/State/Zip: k....›,Vhp, f ciiy,-2•3 phone #: Are you an employer?Check the appropriate box: Type of project(required): l.❑I am a employer with employees(full and/or part-time).' 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp. insurance required.] 8. [ Remodeling 3.0 I am a homeowner doing all work myself[No workers'comp. insurance required.]t 9. ❑ Demolition 4. I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.® 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 1�. Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL 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 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 the pains and penalties of perjury that the information provided above is true and correct. Sisnature: Date: 2/2 Y/23 Phone#: fj17 -5.3;COW 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#: R • TOWN OF YARMOUTH + 'fir; of _� -°1 BUILDING DEPARTMENT �� :�^=,;s, • 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261 HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DATE: ry aq : JOB LOCATION: " whale - w, Ytt k NAME STET ADDRESS SECTION OF TOWN "HOMEOWNER" r«03 autc.1 `17- 73-Sar GO 573 sat NAME HOME PHONE WORK PHONE PRESENT MAILING ADDRESS 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 requirements and that he / she will comply with said procedures and requirements. HOMEOWNER"S SIGNATURE ��,(,, APPROVAL OF BUILDING Ol' ICIAL 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 yes, 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 Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement. Check one: Si ature of Ow-�er or Owner's Agent Owner Agent h:homeownrlicexemp 1 1 I 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 conducted at (/)4.4 yfrk g-roc4 Work Address Is to be disposed of at the following location:lj £)q Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. 2/z y Z) Signat a of Applicant Date Permit No. _ r 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 Registration Expiration 1000 Washington Street -Suite 710 186647 12/18/2024 Boston,MA 02118 UNITED KITCHEN 8 BATH DESIGN INC //)) JAMES BIRD 1 HUNTINGTONAVEM, � �. SOUTH YARMOUTH,MA 02664 1' J Undersecretary Not valid without signature V Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Re ulations and Standards Consktit ioonfS rvisor �ti_ .F CS-096548 _--.4 61cpires:01/26/2024 JAMES M BIEID 1 HUNTINGTON AVENUE SOUTH YARfVIOUTH MA 02664 ?; Commissioner doealK. pCrr,t1i,t0., q.AvW DATE(MM/DDIYYYY) ACCPR EP CERTIFICATE OF LIABILITY INSURANCE 03/14/2023 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 Christian Barber,CIC NAME:TA The Oceanside Insurance Group PHONE (508)775-0500 FAX (508)790-7955 (A/C.No.Ext): (A/C,No): E-MAIL ADDRESS: 52 West Main Street INSURER(S)AFFORDING COVERAGE NAIC# Hyannis MA 02601 INSURER A: Safety Indemnity 39454 INSURED INSURER B: Associated Employers Ins CO United Kitchen&Bath Design,Inc. INSURER C: 1 Huntington Ave INSURER D: INSURER E: South Yarmouth MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2331409573 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 POLICY NUMBER (MM/DD/YYYY) (MM/DDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RETE CLAIMS-MADE X OCCUR _PREMISES(Ea occur ence) $ 100,000 MED EXP(Any one person) $ 10,000 A BMA0025969 10/26/2022 10/26/2023 PERSONAL&ADVINJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 JE LOC PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY 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 LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH X STATUTE ER AND EMPLOYERS'LIABILITY Y 1 N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 B OFFICER/MEMBER EXCLUDED? N NIA WCC-500-5016602-2022A 10/28/2022 10/28/2023 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 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) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsement of the policy. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions.This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This is to certify that the policies of insurance listed have been issued to the insured named above. JOB LOC:4 Whale Rd,W Yarmouth,02673 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE S Yarmouth MA 02664 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ACo® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 03/14/2023 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 Christian Barber,CIC NAME: The Oceanside Insurance Group PHONE ,Ext) (508)775-0500 FAX No): (508)790-7955 E-MAIL ADDRESS: 52 West Main Street INSURER(S)AFFORDING COVERAGE NAIC# Hyannis MA 02601 INSURERA: Safety Indemnity 39454 INSURED INSURER B: Associated Employers Ins CO United Kitchen&Bath Design,Inc. INSURER C: 1 Huntington Ave INSURER D INSURER E South Yarmouth MA 02664 INSURER F COVERAGES CERTIFICATE NUMBER: CL2331409573 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 POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE RETED CLAIMS-MADE X OCCUR PREMISESO(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 10,000 A BMA0025969 10/26/2022 10/26/2023 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PE° LOC PRODUCTS-COMP/OPAGG $ 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 LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION X STATUTE OTH- ER AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 B OFFICER/MEMBER EXCLUDED? N N/A WCC-500-5016602-2022A 10/28/2022 10/28/2023 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500'°00 If yes,describe under 500,000 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) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsement of the policy. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions.This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This is to certify that the policies of insurance listed have been issued to the insured named above. JOB LOC:4 Whale Rd,W Yarmouth,02673 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE S Yarmouth MA 02664 6:Zee_ ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ( )/11, coN“,tk ii•Octice." a qA\ioc„i ( 6,AV li\ ks\tvsL 1PLI- ii THE UILr DATE:3-lif401 _4 , ,