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HomeMy WebLinkAboutBLD-23-004484 /00 ?-/ZZ/ 3 [r ° ' ' "" I : • - WO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department :.. o ...'r -. Fg 09 2023 11146 Route 28, South Yarmouth,MA 02664-4492 _ i 4 _ 508-398-2231 ext. 1261 Fax 508-398-0836 �`' BU LDING Utl'ARTMENT • Massachusetts State Building Code,780 CMR • �` By ----- mit Application To Construct, Repair, Renovate Or Demolish ., a One-or Two-Family Dwelling This Se tion For Official Use Only Building Permit Number: 61.,W 3--l 4ki, `C Date Applied: Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION • Wro p r ddre s• ' m 1.2 mole:el Efcgumbers 1.1 aaa Is this an accepted street?`- • yeses no Map Numbir (,•/Parcel Number P 3 Z in of oration: 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: (Ivf.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 yes❑ 1 SECTION 2: PROPERTY OWNERSHIP' (�(�, t,, Ykofal. k1�� n1� 1 W N e(Print) Ci { te,ZlA' 3P 1q,U�tl�Aia G:50;7)1+1 ' No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 I Existing Building 0 Owner-Occupied 0 I Repairs(s) 0 Alteration(s) ( I Addition ❑ Demolition 0 I Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2. SECTION 4: ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 1. Building Permit Fee:$j TO Indicate how fee is determined: 2.Electrical $ v;�`� 0 Standard City/Town Application Fee �6 0 Total Project Cost3 tem 6) multiplier x , ci0 3.Plumbing $ I 2. Other Fees: $ 4.Mechanical (HVAC) $ 2E* List: /‘1 1°1° 5.Mechanical (Fire $ Suppression) O Total All Fees:$6.Total Project Cost: $ ( Check No. Check Amount: Cash aunt:��'' 0 Paid in Full 0 Outstanding Balance D e: V (.4 ,. }t -a•4�a .. ...�..... •„, : v . a is i. d`s�y, •+„ - i s` "+ , ?i'x iT c"-r. °` « 4' . 1'Of: ,✓'(ate .. ? `i f r F k , A i. .', .P. t�, °c,. ,k'I . , `, ' • . zit cc I. r • _ i K_ S . It� _ ..,T }M t . n� } r �� r T, *} - i r' Erik " t R " : . >'1 Y -. Nam'. 5 4, _ i rx et fSt 1 k s Si k : 4 ' _ l • S y ‘ .gin ,. y �� 71 e,-. s SiCTIOla-5: CONSTRUCTION SERVICES 5.1 Construction Sup isor License(CSL) C`-1�)I(�� ofe A0a� ,w' (1 CQ. Licensee Number`er Q / Expirat n Name of CSL Ho er `bi �n �� List CSL Type(see below) "ToNo.an Street t�[w � e Description (' a „� ( Unrestricted(Buildings up to 35,000 cu.R)l/C/w6 ,R Restricted l&2 Family Dwelling Ci9.6fvlexiViA- rtpi own,State,ZIP M Masonry RC I Roofing Covering WS Window and Siding / SF Solid Fuel Burning Appliances 5:81.4nI),._Clanl1 ILiI �l I Insulation Telephone E tI addre D I Demolition 5..2ZVIP �'Registered Home Improvement� (� Contractor(HIC) �('�(,�-7fI 1 tO .? `X '-+� O I Ce ed HIC'R4egistrlaatiio'n umber Ex Kira on Date • 1 101 1 C;t�p�ny�Iame HIC Registrant Name Ce ' .and Street v mos. 5) i mail addr s Ci /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 A 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 \NI:D.A . to act on my behalf,in all matters relative to work authorized by this bu' ding permit application. 1, Print Owner's Gnn 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. 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)Progr'am), 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.sov/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" §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. 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 \ \j \\c, i wiL, La — Work Address Is to be disposed of oat the following location: Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. \J\i / PAmi, Signatur of Application Date Permit No. The Common wealth of Massachusetts Departfrtent of Industrial Accidents =�'+1� 1 Congress Street, Suite 100v. ` t_ Boston, MA 02114-2017 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: \L.Qt RO "\-- City/State/Zip: \ a57 Phone 74: 5.....)6 7LL/ 7 Are you an employer?Check the appropriate box: Type of project (required): L'\1 1 am a employer with ..1. employees(full and/or part-time)." 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. &I 'emodeling ' any capacity.[No workers'comp. insurance required.] 3.❑I am a homeowner doing all work myself. [No workers'comp. insurance required.]t g Demolition 0 4.-1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 1 ❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole I.1.❑ Electrical repairs or additions proprietors with no employees. 12.❑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. insurances 1 Roof repairs 5.E We are a corporation and its officers have exercised their right of exemption per MGL c. 14•❑Other 152,§I(4),and we have no employees. [No workers'comp. insurance required.] 'Any applicant that checks box 4-'1 must also fill out the section below showing their workers'compensation Ipolicy 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. A� `JK ,, 0,12 Insurance Company Name: `� ,��}}����!� Policy#or Self-ins. Lic.#: W bal-44 Date: &6 a,.s Job Site Address: ROVACT;a04..)f./...—,10."-e.,. City/State/Zip: M O,(V S Attach a copy of the workers' compensation policy declara on 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. Signature: \j\ 0 . P i'•.' Date:�t23.0 Z,C10 Phone 3Y 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: THE COMMONWEALTH OF MASSACHI SETT Office of Consumer Affairs & Busine, x r ' • y on HOME IMPROVEMENT CONTR TYPE: Corporation Registration Expiration 199794 10/07/2024 W. D. PRICE, INC. WESLEY PRICE :. : 161 MAIN STREET /tea `f,�� -YARMOUTHPORT, MA 02675 . Undersecretary { t rS I �""' 1, Commonwealth of Massachusetts VV? Division of Occupational Licensure Board of Building Re ulations and Standards 9. Cons oofV rvisor tp CS-104189 y:,,• spIres: 03/03/2024 WESLEY D P_ ICE 161 MAIN STREET :� 3' YARMOUTH 1 PRT MA 02676 fi +} _. N i-...1 lel Commissioner c a K. EV&'IcL11 ., ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 07/13/2022 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 Caitlin Regan NAME: Dowling&O'Neil Insurance Agency PHONE (800)640-1620 FAX (A/C,No,Ext): (A/C,No): 973 lyannough Road E-MAIL cregan@hilbgroup.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Hyannis MA 02601 INSURER A: James River Insurance Company INSURED INSURER B W D Price Inc INSURER C: 231 Main Street,Unit 335 INSURER D: INSURER E: Yarmouthport MA 02675 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2271319676 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 HA✓E BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100,000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) S 5,000 A 001050672 07/09/2022 07/09/2023 PERSONAL&ADV INJURY $ 1,000'000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO 2,000,000 JECT LOC PRODUCTS-COMP/OPAGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) S 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$ S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) Et DISEASE-EA EMPLOYEE $ If yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I 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 endorsements.Nothing contained in the Certificate of Insurance shall be deemed to have altered,waived,or extended the coverage provided by:he policy provisions 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. 01111.11.11110. AUTHORIZED REPRESENTATIVE MA 02670 © s ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD .0042. " - - .: • ++Sa` y.F wYm e)d(..+M+i:A Ya , . ,. `h .. K . y e • zt a , • • • • • • • • • • ObillItaft f G fir:..-.. .._..,._,-..,.�.�. M_._..:.__.-...,...,..... ::.�:'... .. .. y 4 2'r Al�� DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 12/27/2022 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 NAME: DOWLING & O'NEIL INSURANCE AGENCY PHONE - FAX 973 lyannough Road EMAIL°'Exq: (NC,No): P.O. Box 1990 ADDRESS: Hyannis, MA 02601 INSURER(S)AFFORDINGCOVERAGE NAIC# INSURER A: AmGUARD Insurance Company 42390 INSURED INSURER B: W D PRICE INC INSURER C: 231 MAIN STREET UNIT 335 INSURERD: YARMOUTH PORT, MA 02675 INSURERS: 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. IS POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER LIMITS (MMIDD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 0 DAMAGE TO RENTE CLAIMS-MADE OCCUR PREMISES(Ea occur ence) $ 0 MED EXP(Any one person) $ 0 PERSONAL&ADV INJURY $ 0 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 0 POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 0 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION S $ WORKERS COMPENSATION X ,STATUTE ERH AND EMPLOYERS LIABILITY ANYPROPRIEfOR/PARTNERIEXECUTIVE NN R2WC320149 10/28/2022 10/28/2023 E.L.EACH ACCIDENT $500�000 A OFFICER/MEMBEREXCLUDED9NIA - (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500 000.... If yes,describe under ;DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Employees: Full Time: 0; Part Time: 0 Governing Class Description: CARPENTRY-CONSTRUCTION OF RESIDENTI CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE W D PRICE INC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 231 MAIN STREET UNIT 335 Yarmouth Port, MA 02675 AUTHORIZED REPRESENTATIVE: ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Q :; ,r TOWN OF YARMOUTH ° HEALTH DEPARTMENT PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET a. To he completed by Applicant: Building Site Location: \CA W‘d 1 .o t_C IV, 1C 1 OCut. j Proposed Improvement: cL, TI'+ ) 1 CU d (41 ' Applicant: WY).?‘).?j 1C0 k L 'j Tel. No.: H�yr . cc� 5 Address: �� ( Pt�,c4,1 C„1 qa).,,,goSk‘-e5L..±,i/vo ate Filed: ,3 **If you would like e-mail notification of sign off please provide e-mail address: Owner Name:-T k °LA 11..Q \AC.10s .V\ l —7 7 Owner Address: 11 W � �(/ �(L�? � 6.��,,$� Owner Tel. No.: I 1 \UN/ {faid5). RESIDENTIAL AND/OR COMMERCIAL BUILDING HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements For Septage Disposal and other Public Health Activities. • Please submit three (3) copies of plans, to include: (1.) Site Plan showing existing buildings, water line location, and septic system location; (2.) Floor plan labeling ALL rooms within building (all existing and proposed) — Note: Floor plans not required for decks, sheds, windows, roofing; (3.) If necessary, Title 5 application signed by licensed installer with fee. REVIEWED BY: DATE: PLEASE NOTE COMMENTS/CONDITIONS: / 7 7- / -s