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Home My WebLink AboutBLD-23-005772 " ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department 1146 Route 28, South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508-398-0836 Massachusetts State Building Code, 780 CMR . o.m e Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: 13.(4.43_40. tkan_l/Date A ie • 1%'—/gam uilding cial(Print Name) Signature R '� P CC Dd4drr SE ION 1:SITE INFORMATION 1.1 Property Address: 1.2 sses rs Ma &Parcel Numbers �� Q23 S� AE.2l'S AvL� w''-IAQnOA 2 2._ 1.1a Is this an accepted street?yes no Map Number Parcel Numb r e UILDING DEW,a RTfVjE 1.3 Zoning Information: 1.4 Prgperty ensions: R E C E Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) \____ FIR 18 2023 Front Yard Side Yards Rear and is ILD►NG DEPARTMENT Required Provided Required Provided Required By rovi __ 30 30 30 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Floo Zone Information: 1.8 Sewage Disposal System: Public Private❑ Z ne: Outside Flood Z ? &(. I Check if yes❑ one Municipal 0 On site disposal system } SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Re d: N tss ,CM w- Yo& k-c-R Name(Print) City,State,ZIP 8� Aczes AVE -rat OSb n-VB No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building0- Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2:. k — IDAM N —'D 1w `-.•- SECTION 4: ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 1. Building Permit Fee:$/5-b Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: ad- -1 7 5.Mechanical (Fire Suppression) $ Total All Fees:$ / Check No. Check Amount: Cash Amount:1 6.Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due: I i SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) i�J�pN� M CO5T c� LitSLicenseNumber JatL Name of CSL Holder lb Gu S K List CSL Type(see below) No.and Street To Description M AP.b OIQS MILLS MA ooy8 AP Unrestricted(Buildings up to 35,000 cu. ft.) City/Town,State,ZIP Restricted 1 cfc2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding o 2. 1( MRC 2 &s tow . SF Solid Fuel Burning Appliances Telephone 7 CotA I Insuulation Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Company Name or HIC Registrant Name HIC Registraf n Number Ex Sirati n Date �Nb an Str (n�}t'l (Y7►'1�� ctANSLow co IA �r�I'� eet eet �'t((, j o,�t� It 56 6130 Z 1' 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 k- No ❑ SECTION 7a: OWNER AUTHOR IZATION TO BE COMPLETED OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING WHEN I,as Owner of the subject property,hereby authorize E F W(QS1..OK) to act on my behalf, in all matters relative to work authorized by this building permit application c.\ASOJ (2 I 4 I/ Print Owner's Name(Electronic Signature) D(vi to • 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 C..0 .--- ell (- k-/V ---- t z Print Owner's or Authorized Agent's Name(Electronic Signature) Da e 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.g.ov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) 16 R- (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" 1 Commonwealth of Massachusetts,DWisionof Profe9sionaf Licensure y. ' Board of Building Requlations and Standard9, Conski h 1 ., 4iiisor CS'-106874 � �� f' c�pires:08/15/2022 LOREN M FOATEIl I L MARSTONS 1b O , O °-naafi Commissioner dai Licensee Details Demographic Information Full Name: Loren M Foster Owner Name: License Address Information City: MARSTONS MILLS State: MA Zipcode: 02648 Country: United States License Information License No: CS-106874 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 8/31/2022 Issue Date: 4/11/2013 Expiration Date: 8/15/2024 License Status: Active Today's Date: 4/17/2023 Secondary License Type: Doing Business As: Status Change Reason: License Renewal Prerequisite Information No Prerequisite Information No Available Documents THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration ^' _= • W Type: Individual d =arwi egiSCration: 163999 LOREN M FOSTER ,,ti E piration: 02/04/2024 16 CLAUS WAY .. a MARSTONS MILLS, MA 02648 Min Q! 4 1114Ir C` ?w � v 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(Individual Office of Consumer Affairs and Business Regulation Re•istr.',., -_ Expiration 1000 Washington Street -Suite 710 '' =- 3 02/04/2024 Boston,MA 02118 =-v LOREN M FOSTER j '�. _ --, .` i LOREN FOSTER V , --- / (NA-16 CLAUS WAY C _ MARSTONS MILLS,MA 02648 '* & I `' Undersecretary Not valid without signature The Commonwealth of Massachusetts . Department of Industrial Accidents r _;er►l _.. ; 1 Congress Street, Suite 100 ' �_ Boston, MA 02114-2017 mum www.mass oov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): tt..)SLOW Address: coN) czr r City/State/Zip: �,YA V%1O SC Phone #: 39 Are you an employer?Check the appropriate box: Type of project(required): 1.1g2.I am a employer with 00 employees(full and/or part-time).* 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. El New Jelin uCtlOn any capacity.[No workers'comp. insurance required.] • [ $emOelig 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 Ej Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance.t 13.0 Roof repairs 6.0 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. (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: A 0v.) MuicAL U i Li 19 1 ) t #Policy or Self-ins.Lic.#: 20fa9 A Expiration Date:e: ( I' tz.0 zti Job Site Address: Si Ave (4).\A vi4 'l City/StS3 ate/Zip: Attach a copy of the workers' compensation policy declaration page(showing the pol cy 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 abo e is true and correct. Sisnature: (N/. Phone#: 030 2 '71 Date: (1 Z-2 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#: A`coRc! CERTIFICATE OF LIABILITY INSURANCE I DATE(MMI°°' ) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. 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(les)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 RogersGray, Inc-Kingston Branch CONTACT NAME: 434 Route 134 PHONE South Dennis MA 02660-1601 _Lac.No.EA);800-553-1801 (AArc,No):877-816-2156 E-MAIL ADDRESS: mail@rogersgray.COm INSURER(S)AFFORDING COVERAGE NAIC# _ INSURED INSURER A:Arbella Protection 41360 E. F.Winslow Plumbing&Heating, Inc. EFWINSL Ot INSURER a:Arrow Mutual Liability Insuran 8 Reardon Circle 13374 South Yarmouth MA 02664 INSURER C: INSURER D: INSURER E: COVERAGES INSURER F: CERTIFICATE NUMBER:1778671040 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE ROLICY 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 ADO-SU RI LTR TYPE OF INSURANCE INSD WVO POLICY NUMBER POLICY EFF POLICY EXP --- A X COMMERCIAL GENERAL LIABILITY y {MM/DD/YYYY) (MM/DDnYYY) LIMITS 8500069272 12/1/2022 12/1/2023 J CLAIMS-MADE X EACH OCCURRENCE $1,000,000 (__._ I I OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) S 100,000 MED EXP(Any one person) $10,000 PERSONAL 8.ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: ` I POLICY LXJ jECOT I X (LOC I GENERAL AGGREGATE S2,000,000 I PRODUCTS-COMP/OPAGG 52,000,000 OTHER: A AUTOMOBILE LIABILITY 5 Y 102007840205 12/1/2022 12/1/2023 COMBINED NGLE LIMIT ANY AUTO {Ea accident)SI 51,000,000 OWNED SCHEDULED BODILY INJURY(Per person) S AUTOS ONLY x AUTOS BODILY INJURY(Per accident) $ X HIRED NON-OWNED AUTOS ONLY I X AUTOS ONLY PROPERTY DAMAGE (Per accident) $ A , X UMBRELLA LIAS X S OCCUR 4620088355 12/1/2022 12/1/2023 EACH OCCURRENCE $2,000,000 EXCESS LIAR I CLAIMS-MADE AGGREGATE 52,000,000 I DED I X (RETENTION$won B WORKERS COMPENSATION 2019A _ $ AND EMPLOYERS'LIABILITY 1/1/2023 1/1/2024 X STATUTE FORTH ANYPROPRIETORIPARTNERiEXECUTIVE Y/N OFFICER/MEMBER EXCLUDED? I N I N/A E.L.EACH ACCIDENT $500,000 (Mandatory In NH) I(yes,describe under E.L.DISEASE-EA EMPLOYEE $500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Plumbing&Heating Contractor. Central Vacuum is a division of E F Winslow Plumbing&Heating Inc. When Required by Written Contract the Following Applies: General Liability-Additional Insured Ongoing(30AP2195 04 21)and Completed Operation(30AP2195 04 21) Primary and Non-Contributory Basis(30AP2195 04 21),Waiver of Subrogation(30AP2195 04 21) AWorkers utomobile—Additional Insured,Primary and Non-Contributory Basis,Waiver of Subrogation(26AP1034 11/19) ion(Endorsement#4) Excess/Umbrella—Additional Waiverensation— insured followst form over underlying General Liability and Automobile Liability No Residential Exclusions 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. AUT ED REPRESENTATIVE _7_,)444meeeil /adelf 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 508-398-2231 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 Acmes qfkeUC- . 0-67 Work Address Is to be disposed of at the following location: y f l��1 4j5 et_ Cj"4'ROr Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. \ 11 ( Signature of Applicant Date Permit No. 1 ag ea-10 Q- tirst)(41 L.-- i t t) P ),c __ . (41K------- "5 0 : cl? ,ow I 1 1 #k 1 ' I t r\a> 3 k i 1% ,„.. r-i UN ---Ir --- • ' 1 0... 9, c\ '. .. , › ; D ' C., • , ''. 1 . i 1 1*-...4.---- T•34. 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