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Home My WebLink AboutBld-23-006006 RECEIVED APR 2 8 2t23 ONE & TWO FAMILY ONLY-BUILDING PERMIT << Town of Yarmouth Building Department g '�+�• C PA 1,TM E NT 1146 Route 28,South Yarmouth,MA 02664-4492 ,, '� - 508-398-2231 ext. 1261 Fax 508-398-0836 � 5 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: >._..2..1Laida)j, Date Applied: SDM5 -- ) Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers ►yy1 k)cv. ISt ala Rd C=Z "y 22. 1.1 a Is this an accepted street?yes X, no Map Number Parcel Number 1.3 Zor3ng 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 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 caner'of Record: o c \t c i G L+�� `I C Imot-h, 0.2.1D i Name(Print) City,State,ZIP LH 1 gOCILT—WAnd Rcl ti>7jt FZ .��i 3(>9 -2I -5.b 0 ch {th o u OhctnAl 1, No.and Street Telephone Email Address GOi'r SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied ❑ [Repairs(s) 0 Alteration(s) 'yt Addition ❑ Demolition 0 Accessory Bldg.0 Number of Units Other 0 Specify: Brief Description of Proposed Work ��}(' � Q, �( �1 W CLifl Yl.L*j CUIJ(YrOte Crpt.,OCOrt,S +(1k J fo.;)Ge,r cLnc1 C-c.c.i t e r r\• SECTION 4:ESTIMATED CONSTRUCTION COSTS. • Item Estimated Costs: Official Use Only (Labor and Materials) I.Building $ 'g000 1. Building Permit Fee:$;CO _Indicate how fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ 2, OOC' . ❑Total Project Cost! t m 6)x multiplier x 3.Plumbing $ Z t 000 2. Other Fees: $-Ll3 0 • 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ ,+ Check No. Check Amount: Cash Am 6.Total Project Cost: $ 1�1 i COO ❑Paid in Full I Outstanding Balance D : i\''\a?) SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) i1.11 CrCL �I i cVLY c li License �Nu SS rti I - Z5 Number Expiration Date Name of CSL Holder Po c cv. lQ List CSL Type(see below) LA No.and Street Type Description S OfvefAs c 1.1\0t U Unrestricted(Buildings up to 35,000 cu.ft.) City/Town,State ZIP R Restricted lit2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding S-eckbr-ez-z.z.._norrte,. SF Solid Fuel Burning Appliances 44L —2I2-- Io} con}ract-I neWqmetZt.cian I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date C Company Name or HIC Registrant Name S so Irez-zt, hu 1/4v.c.; 0 C•3o>t LOLP° O(ltrt i-t1 C onck.,.\.6cel No.and Street DY" 14) M i7?1,( -1. 14 -Z 12-10+i!b-' 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 No ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as • .`the subject property,hereby authorize SeC k-Sjr-Cat-- 4 t. ,ct on my alf,in all m rs r tive to work authorized by this building permit application. Print Ot • s Nam ectronic Signature) Date • CTION 7b: OWNER OR AUTHORIZED AGENT DECLARATION y entering my name below,I creby attest under the pains and penalties of perjury that all of the information coot ' ed' thpplica n• ie and accurate to the best of my knowledge and understanding. 1 I("dJz3 Pr' wners or Au rized 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 no: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 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 Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.govldia Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/Individual): s ...sgC-eZZ.i \- c Y . COnSMDG'-- CXl Address: PC) ?IYI LO(CC) City/State/Zip: S Of W Ciff, Yi rA o-z.. pio2 Phone#:-.4-4-y — -.i . — l0i-1 0-4- Are you an employer?Check the appropriate box: Type of project(required): I. I am a employer with ---2- employees(full and/or part-time).* 7. 0 New construction • 2.fI 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'camp.insurance required.]t 9. Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 El Building addition ensure that all contractors either have workers'compensation insurance or are sl I l.0 Electrical repairs or additions s proprietors with no employees. 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.0Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.t 13. Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other 152,§1(4),and we have no employees.(No workers'comp.insurance required.] *Any applicant that checks box#i 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. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site information. �^ Insurance Company Name: .LSO C 1(*-d \'0: -1..sc\SV‘I nt-e- Policy#or Self-ins.Lic.#:hiCC-500--50 :IAA;5 -- Z0 1-Z.l;- Expiration Date: I\12 / Z--c Job Site Address: L{Ll -r;CL 1.c,1cund Rd UN}- -2, City/State/Zip; N►�Sty(,4NCMGL {-h t-tF- CZ(Iy 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 Signature: 7174( y, id t.✓C Date: N/«/23 Phone#: 4 y -2-I Z— (o L-1L1- 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 CIerk 4.ElectricaI Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: §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 y L\ 9)0C1L \C 1cd Work Address Is to be disposed of oat the following location: tb S t\S Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. Alt/01/41A00/00/U I /it23 Signature of Application Date Permit No. r.; :;.9',, '. t' ,a ~y"'d y-',�',,y-, /�/-.''�l r,',,.." . :'i: .fir. .... ° ,rt s,, �•n µFZ, �Ei9,{yr,r ,eta a '.s "'. / /,, ,S" . �,.; x' am.y ." • %HSa•. ,,,7.,t.t t't eF'h�N';i�';, .:4',A.;;•1iie;,::T,+. ;,ii<Y„' f j,,. T�i'5,�'"� ,pt,,, ., •e-e „.. ..,. ��.. .. a v�ypa�V:NFfIL`i �„',:�w.r,r,•� .... AC� DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 12/5/2022 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 RogersGray,A Baldwin Risk Partner PHONE FAX 410 University Ave (A/C.No.Exti:800-553-1801 (Alc,No):877-816-2156 MAI Westwood MA 02090 ADDDDRESS: mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# _ License#:PC-514062 INSURER A:Selective Insurance Company of 12572 INSURED SEABHOM-01 INSURER B:Safety Indemnity Insurance Co 33618 Sea Breeze Home Construction LLC INSURERc:Associated Employers Insurance 11104 PO Box 660 South Orleans MA 02662 INSURER D: INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER:18(333132 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 TYPE OF INSURANCE ADDL SUBR,w , POLICY EFF POLICY EXP OMITS LTR INSD VD POLICY NUMBER _(MM/DD/YYYY) IMMIDD/YYYY) A X COMMERCIAL GENERAL LIABILITY S 2439103 11/2/2022 11/2l2023 EACH OCCURRENCE $1,000,000 CLAIMS-MADE I A I OCCUR DAMAGE TO NTED PREMISES(Ea occurrence) $500,000 MED EXP(Any one person) $15,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 _..,.,.,.._ POLICY I.. EC [ LOC PRODUCTS-COMP/OPAGG $3,000,000 OTHER: $ B AUTOMOBILE LIABILITY 5920906 5/20/2022 5/20/2023 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ — OWNED x 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$ $ C WORKERS COMPENSATION WCC-500-5023605-2022A 11/2/2022 11/2/2023 PER I OTH- AND EMPLOYERS'LIABILITY Y/N STATUTEJ ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101.Additional Remarks Schedule,may be attached If more space is required) 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. Provincetown Building Department 174 Commercial St Provincetown MA 02647 AU D REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD