HomeMy WebLinkAboutBLD-23-004414 ?kX 21\Lk\1'
ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department .._r
1146 Route 28, South Yarmouth,MA 02664-4492
508-398-2231 ext. 1261 Fax 508-398-0836 s' :..�' ■ `
Massachusetts State Building Code,780 CMR '`
Building Permit Application To Construct, Repair, Renovate Or Demolish
a One-or Two-Family Dwelling
This Secti n For Official Use Only ti► E (,. IC IVED
Building Permit Number: �(�'9 3- ' i\k, Date App ' d: FEBf
1--\ <;N � ,-� k l 3- �.3 0 7 Z023
Building Official(Print Name) Signature 81,, S. Da -D,4F41-Mr NI
SECTION 1:SITE INFORMATION
1.1 xoperty(,�( /Add Ass: i , / 1.2 Assessors Map&Parcel Numbers
• 03 b . _ .. _
1.1a Is this an accepted street?yes ,/ o Map Number Parcel Number
1.3 Zoning Information:'U k(-c. 1 0 1-- 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 J 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:
Zone: Outside Flood Zone?_
Public 0 Private 0 Check if yes❑ Municipal 0 On site disposal system 121
SECTION 2: PROPERTY OWNERSHIP'
. Own 'o Recpr
iea T; S- /id//GIST ftli/4l . 7 r k f f A91 L't2�' , AA l'l `5
(lie
me(Print) 7r6s5 City,State,ZIP
V66NZr7l
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction 0 Existing Building❑ Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 I Addition Cl
Demolition ❑ Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work2: U a.e - , )C -t t rl ..1.0 f\-i" Si�Ce /:�i.�CA u-
(O -&- t l S' O C ui T ICS ( 1 G t�>,S a -e il
�ur`dr t
} 1
SECTION 4: ESTIMATED CONSTRUCTION COSTS •
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 1. Building Permit Fee:$ I¶0 Indicate how fee is determined:
Standard CityiTown Application Fee
2.Electrical $ s
0 Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ -65 47
4.Mechanical (HVAC) $ List: 0/C/e- J u�
5.Mechanical (Fire — .$
Suppression) Total All Fees:$ �
C:zeck No. Check Amount: Cash ounf
6.Total Project Cost: $ �v/ 4 o a 0 Paid in Full El Outstanding Balance e: \\ ,
\\°
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
Name of GSt older License Number Expiration
11���,�/t/ Z. List CSL Type(see below)
No.end Street —
/l Type Description
d�f.S ry'//s 7/—'�� GG G IS' Li• Unrestricted(Buildings up to 35,000 cu.ft.)
Ciq+/Town,3teee,Zip R i Restricted 1dc2 Family Dwelling
tvl Masonry
RC I Roofing Covering
WS Window and Siding
r r SF Solid Fuel Burning Appliances
)'/,1 J'/ ".t%l P/ t ) 7' c� PP
Telephone `�Email address �� I DemInsolition
5.2 Registered Home Improvement Contractor(HIC) D Demolition
/ (t 113 (J /� ,',3 � f,,'/�f_
HIC ' tp y}tam or H1 HIC Registration Number Expiration Date/C (yit`.01) ,3� /C
No.ettp$ e _ ,�,'� l� Z( i)e/JC+. /ff71•lam'
// 7 � ��6�5 -y"L Y14'• /X1/
ty/Town,State, Email address
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 .:b'' No,. .fl
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WREN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize / _ 41 /t4 /.
•
to act on my behalf,in rs relative to work authorized by this building permit application.-
ppi catioar�t/L' �
/. t_ . 02/(lAI2(123
Print Owtr' 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.
/.S G•LU L_.)
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1• An Owner who obtains a building permit to do hisfaer own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will nor 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 ww� w.mas_s gov/dns
2. When substantial worlc is s -.i provide the information below:` , . C ,. ,,
Total floor area(sq.ft.) ( , S( �� •+. c (or poi c) /�1
Gross living area(sq.ft.)` (including garage,finished basement/attics,decks or pooch) a °_i 1
Number of fireplaces Habitable room count
Number of bathrooms Number of bedrooms
Type of heating system rC c l c , _7r1 Number of decksaths
Type of cooling system r�_ (c� Number of decks/porches
Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
)-6tn-? /S8rr ( let ri&soy+
§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 3 T Uilc% Ae-fc 2j /
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.
1Z .k., 3/. ZJZ 3
Signature of Application / Date
Permit No.
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
f Boston,MA 02114-2017
www.tnass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information /a/ Please Print Legibly
Name (Business/Organization/Individual): / • ,l" t .Lae\ � 7'rf/('}1G-)._ TAX
Address: ///Z � /") SI• �v � ��.�
City/State/Zip: J Mt o 26 S-S Phone#: S • L �8 7
7Q0J
Are you an employer?Check the appropriate box:
ry Type of project (required):
1.0 am a employer with r' employees(full and/or part-time).'
7. ❑New construction
2.T]I am a sole proprietor or partnership and have no employees working for me in
any capacity.[No workers'comp. insurance required.] 8• -R�modelin� •
3.0 I am a homeowner doing all work myself [No workers'comp. insurance required.]t 9. ❑ Demolition
4.E:1 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
11.0 ElectricaI repairs or additions
proprietors with no employees.
5.❑[am a general contractor and I have hired the sub-contractors listed pn the attached sheet. 12 ❑Plumbing repairs or additions
These sub-contractors have employees and have workers'comp. ins irance.r 13.0 Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per,MIGL c. 14.Q Other
152,§I(4),and we have no employees. (No workers'comp.insurance required.]
*Any applicant that checks box 041 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 End then hire outside contractors must submit a new affidavit indicating such.
(Contractors that check this box must attached an additional sheet showing tie 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 iirsurance for my employees. Below is the policy and job site
information. ,�' /
Insurance Company Name: 4. Z /"/ IyJtt&'L,
Policy#or Self-ins.Lic.#: G(.)C C • 5 O e) ' O .4 43d 2.0Z2,i Expiration Date: // Zc&J
Job Site Address: U25 itk 11. Ci !State/Zi �� j
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 an er he pains and penalties of perjury that the information provided above is true and correct.
Signature:" Date: /-d t <U
Phone#; . vN °i":2 d7. 7r(.l /
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 Cleric 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
0-fY t TOWN OF YARMOUTH
kT' - BUILDING DEPARTMENT
;^ ;,;=<< <d 1146 Route 28, South Yarmouth, MA. 02664 S08-398-2231 ext. 1261
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT: �.
DATE:
JOB LOCATION:
NAME STREET ADDRESS SECTION OF TOWN
"HOMEOWNER"
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 indivicual 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 OFFICIAL
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 ves, 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:horneownrlicexemp
Commonwealth of Massachusetts
Division of Occupational Licensure
Board of Building R = and Standards
r
Con t'�_ • isor
40,
CS-009889 47 _ ires:05128/2024
THOMAS A
POBOX7 „z
OSTERVILLI*A
Commissioner , 'tcr
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affai e'' Business Regulation
1000 Washing i- Suite 710
Bosto -- - -,- --e� 118
illiMIlillit Home Im•ro .�.,, -•- ,w��-L .- -- e•istration
5,
V, ...-. Type. Corporation
T.A. NELSON CONSTRUCTION CO., INC. e•�, -tion: 110216
/13/2
_-'-'" E .tion: 10/13/2024
P.O. BOX 749 -
OSTERVILLE, MA 02655 Orr
_ - "µ'�_
yr
`rMP 1. Update Address and Return Card.
THE COMMONWEALTH OF MASSACHUSETTS I
Office of Consumer Affaf&Business Regulation Registration valid for individual use only before the , ' ,
HOME IMPROVE r tcONTRACTOR expiration date. If found return to: f .
TYPE;041, moo Office of Consumer Affairs and Business Regulation i
Re is °EXptiiation 1000 Washington Street -Suite 710 I
11 61 , , 624 Boston,MA 02118 i E
T.A.NELSON CONS*_ -E.k,i a ,Pc.r, ' ( r
THOMAS A.NELSON +11' Vw; 1thOUt9flatUre
Unersectary No
1
IMWD
AC CERTIFICATE OF LIABILITY INSURANCE DATE
01/31/2o 3�)
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 Maureen Roderick
NAME:
Horgan Insurance Agency PHONE 5C8! 775 5830 FAX (508)775-6688
ttArc,No,Eat): (MC,Noy:
44 Barnstable Rd. ADDRESS: maureenr,c,corga^insurance cam
PO Box 250 INSURERIS)AFFORDING COVERAGE MAC•
Hyannis MA 02601 INSURER A: Evanston Ins CO
INSURED INSURER B Safety Insurance Co.
T.A Nelson Construction Co Inc INSURER C: A I.M Mutual
PO Box 749 -INSURER D:
INSURER E-.
Osterville MA 02655
INSURER F
COVERAGES CERTIFICATE NUMBER: 2022-2023 GL Auto&WC REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE.NSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR 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
LTRS TYPE OF INSURANCE IN D POLICY NUMBER IMMtDICD YYYY EFFI M OD1 YYPOLICY UNITS
(({ DIYYYYI
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1.000,000.
DAMAGE r0 REN1 tU
CLAIMS-MADE XI OCCUR PREMISES!Eaoccurrence) S 100,000.
_ MED EXP(Any one person) S EXCLUDE
A — MKLV1PBC002953 10/12/2022 10/12/2023 PERSONAL it INJURY $ 1.000,000
GEN'LAGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000.000
X POLICY n JE o II LOC 2,000.000.
PRODUCTS-COMP/OP AGG S
OTHER
AUTOMOBILE LIABIUTY COMBINED SINGLE LIMIT S 1.000.000.
— (Ea accident)
ANY AUTO BODILY INJURY(Per person) S
B — OWNED SCHEDULED 5922218 09/29/2022 09/29/2023 BODILY=NJURY(Per accident; S
_ AUTOS ONLY AUTOS
X HIRED X NON-OWNED sk PERTY DAMAGE s INCLUDED
AUTOS ONLY AUTOS ONLY I(Per acodene
S
UMBRELLA UAB OCCUR
EACH OCCURRENCE S
EXCESS LIAB CLAIMS-MADE AGGREGATE S
DEC, RETENTION S S
WORKERS COMPENSATION Nel PER OTH-
AND EMPLOYERS'LIABILITY YrN STATUTE ER
C ANY PROPRIETOR/PARTNER/EXECUTIVE ORrPARTNEEDXECUTNE (� NIA WCC-500-5026132-2022A 11/29/2022 11/29/2023 EL EACH ACCIDENT
$ 1.000.000
OFFICER/MEMBER EXCLUDED? ' .-
(Mandatory In NH) E L DISEASE•EA EMPLOYEE S 1.00Q000.
If yes.describe under
DESCRIPTION OF OPERATIONS below E I_ DISEASE•POLICY LIMIT S 1.000.000.
)ESCRIPTION OF OPERATIONS i LOCATIONS VEHICLES (ACORD 101.Additional Remarks Schedule,may be attached It more space is required)
7,ERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF.NOTICE WILL BE DELIVERED IN
Za::as;ar, Resice"ce. ACCORDANCE WITH THE POLICY PROVISIONS.
U e R':?t-r s RO
AUTHORIZED REPRESENTATIVE
Wes:Ya•m::.a MA 0?673 4
1988-2015 ACORD CORPORATION. All rights reserved.
%CORD 25(2016/03) The ACORD name and logo aro registered marks of ACORD
TO''.\"1 OF YARMOt(TV(
o WATER DEPARTMENT
10-t-I \ y 99 Buck Island Road
.us'TACNEESE West larmouth, ,CIA ()2673
'` �� Telephone: (508) 771-7921 • Fax: (508) 771-7998
BUILDING PERMIT APPLICATION FOR
WATER DEPARTMENT SIGN OFF
TRANSMITTAL FORM
BUILDING SITE LOCATION: (-- GL/7C , / dhr f /I _.._
PROPOSED WORK: �d'C�r.Sti/1 7k'D ac�go4 978 /lod, 7
Ode ltA�t(,� y OG� 1
APPLICANT: ��j// // I c1/01-J lip
' lV�ISLZ�_---
ADDRESS: ///2 4//.)_J7
TELPHONE: '6 W� /kV
RESIDENTIAL AND /OR COMMERCIAL BUILDING
Water Department: Determines Compliance of Water Availability and or existing location
I:neineerin� Department: Determines Compliance for Parking and 1)rainaize
Conservation Commission: Determines Compliance to Wetlands Act: i.e. If lot(s)border any type of
wetlands. streams. ponds, rivers. ocean, hogs, boys. marshland. ETC...
Icalth Department: I)etennines Compliance to State and Town Regulations, i.e.
requirements for Septage Disposal and other Public Health Activites
Fire Dcpartm° t: Determines Compliance to State and Town Requirements for Personal
Safety, Property Protections, i.e. Smoke Detectors, Sprinkler Systems,etc
Z � 2-;
:AP .ICANT SIGNATURE DA' E
FFICE USE: COMMENTS ON PERMIT APPROVAL. OR DENIAL.
�o u er 11) vol v&f
nor 201 z
I'XIEWED B W ER DIVISION(SIGNATURE) DATE
ONE or TWO FAMILY— BULDING PERMIT
APPLICATION REGULATORY APPROVALS NOTICE
Address of Proposed Work: . . ] (,frlclp. Xl. Pt. irk-
Scope of Proposed Work: /Idol 6 [ G,�f /A, li Itt/71/652/."8//14/1N
� i./
/L.W l' 9 r e. lir gdd <'S-7// ,
(LA of iud1 //l124, r /6,/u
Date:
Based on the scope of work described above, the applicant is required to obtain approval sign-
offs from the following departments as checked-of below:
Health Dept. —508-398-2231 ext. 1241
Conservation —508-398-2231 ext. 1288 ` 1
JWater Dept. —99 Buck Island Road, 508-771-7921 W�
Old Kings HWY. Hist. Comm. —508-398-22631 ext. 1292
Engineering Dept. —508-398-2231 ext. 1250
Fire Dept. — Kevin Huck/Scott Smith, 96 Old Main Street, SY
Note: Please call Fire Department for an appointment. 508-398-2212
Other
Appropriate plans and/or application shall be provided to each departments checked-off above.
Each of these regulatory authorities has their own requirements outside the jurisdiction of the
Building Department. All applicable approvals shall be obtained prior to submitting a building
permit application to the Building Dept.
Thank you for your cooperation.
Receipt Acknowledgement:
Applicant's Signature Date
Rev. Jan. 2019