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HomeMy WebLinkAboutBLD-23-002577 , R..E;cEINED • oYFR BUILDING PERMIT APPLICATION NOVQ a i e APPLICATION TO CONSTRUCT REPAIR, RENOVATE, CHANGE THE USE,OCCUPANCY OF, 0 E; OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELUNG. BUILDING D • .a)10 T.� Tulrit of Yarmouth Building Department By. a 1 146 Route 28 • Yarmouth. MA O2664—E492 Tel: 508-398-2231 ext. 1261 Fax 508-398-0836 — Office Use Only Planning Board Information Assessors Department Information: Perri Lt o.23'n57/ Date Plan Type Map Lat PermitEndorsement Date Fee $ ),t ) Deposit Rec'd. $/"I �1 Recording Date New U� CI bate Plan No. 1.4 Property Dimensions: I Net Due S 1 c10 Jother Lot Area{sf) Frontage(ft) Lot Lot Coverage Building Permit Number. This Section Office Use only I Date Issued: Signature: //,/ _ Certificate of Occupancy I Bw g Official • Date• is Is not required Section 1 - Site Information I 1.1 Property Address: � 1.2 Zoning Information ^NAV av ' i/t,� Zoning District Proposed Use 1.3 Building Setbacks (ft) . Front Yard Side Yards Required Rear Yarn eQ Provided Required I Provided Required I Provided 1.4 Water Supply(Iµ.Q.L c.40.S 54) 1.5 Rood Zone information: Comments Public Private Zone: BFE - Section 2 - Property Ownership/Authorized Agent 2.1 Owner of Record: 9111 I.19 Z DEC 0 2 I II Name(print) �I"( Mailing Address: 44 BUILDING DE 564 449 —0� Psb• 41PSignature Telephone ems` -- --.- ARTgr,-NT 1 Telephone —_ / (2.2 Authorized Agent: Erna' - s' Hams(print) Mailing Address: Signature Telephone Fax Email Address: Section 3 - Construction Services . 3.1 Licensed Construction Supervisor. Not Applicable .1 IV - h 6.4 License Number AddiLJ1 `U 4G, Z9 � . j j7 — 4 h-5- evi v hA y. 0 r 7 Expiration Date Signature Telephone Email Addre s: g84?oo.L..Em 4. Z7(:). Zi ' �- . tion 6 - Description of Proposed Work (check all applicable)I i New Constructionfamily -I_ ❑ (for multiple onl y) No.of Bedrooms l (for multiple family only) No.of Bathrooms ' i Existing Bldg. a I Repairs) ❑ I Alterations ❑ I Addition ❑ I Accessory Bldg. ❑ Type I Demolition Other S J Specify: Brief Description of Proposed Work: f Nltir c lei list .t' M -o weic--- '`J t^J i/ra r. - Ic- n_1 7_ . l I Section 7- Use Group and Construction Type I Building Use Group(Check as appficapable) ( Construction Type A ASSEMBLY ❑ A-1 ❑ A-2 ❑ A-3 ❑ to ❑ A-4 ❑ A-5 ❑ 1 B ❑ B BUSINESS ❑ ❑ 2A E EDUCATIONAL ❑ 0 F FACTORY I F-1 ❑ F-2 ❑ 2C ❑ H HIGH HAZARD 1 ❑ 3A ❑ I INSTITUTIONAL 1 0 I-1 0 1-2 0 1.3 0 SB 0 LAMERCHArrriLE ( ❑ 4 R RESIDENTIAL I❑ R-1 ❑ R-2 ❑ R-3 (] sA ❑ S STORAGE I❑ S-1 ❑ S-2 ❑ SB U UTILITY ❑ SPECIFY: M MIXED USE ❑ SPECIFY: S SPECIAL USE I ❑ SPEC WY: Complete this.section if existing building undergoing.renovations;additions and/or change in use_I Existing Use Group: Proposed Use Group: Existing Hazard Index'780 CMR 34 Proposed Hazard Index 780 CMR 34 !Section 8 Building Height and Area I Building Area Existing(ii applicable) Proposed Number of floors or stories include basement levels Floor Area per Floor(sf) Total Area All Floors (sf) Total Height (ft) Section 9 - STRUCTURAL PEER REVIEW (780CMR 110 11) I Independent Structural Engineering Structural Peer Review Required Yes No l SECTION 10a OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT --77,, // /CA) , as Owner of the subject property, hereby authorize R&.(ttACJft t7 \g‘/ C. L-O ' r y "'�-'�` j ltk; to act on my behalf, in all matters relative to work(autho authorized by this building permi: application. 91: ' i 0k0`ZZ Signature of Owner Date 1 • ' 3.2 Registered Home Improvement Contractor_ Company Name Not Applicable ❑ i Address Registration Number I E,.. iratbn Date Signature Telephone • +Section 4-Workers'Compensation Insurance Affidavit (M.G.L c. 152 S 25C(5) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure Ito provide this affidavit will result in the denial of the issuance of the building permit. f Signed Affidavit Attached Yes No !Section 5- Professional Design and Construction Services-for Buildings and Structures Subject to Construction Control Pursuant to 780 CMR 116(containing more than 35,000 c.f. of enclosed space) 1 Section 5.1 Registered Architect Nol Applicable ❑ 1 Name(Registrant): Registration Number Address Expiration Date Signature Telephone Section 5.2 Registered Professional Engineer(s) Name Area of Responstaity IAddress Registration Number I Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number I Signature Telephone Expiration Date Name • Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Section 5.3 General Contractor (,iJ .t/9 (y-•4-lr k2j otcl I r id„ Not Applicable ❑ Company Name Person Resp ible for Construction Address Signature Telephone . • i SECTION 1 Ob OWNER/AUTHORIZED AGENT DECLARATION I iwtalr1-9 , as Owner/Authorized Agent hereby declare that the statements and information on the forgoing application are true and acurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name / j Signature of-Owner/Agent Date ;Section 11 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cast(Dollars)to be completed by permit applicant 1.Building 2 Electric 3.Plumbing/Gas ' 4.Mechanical(HVAC) �5.Fire Protection 6.Total=(1+p+3+4+5) 7.Total Square FL(rsnm=taws&moons) Check Below ❑ Conservation-Commission Filing (if applicable) ❑ Old Kings Highway&Historical Commission approval (if applicable) The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 Vey ww».mass.gov/dia \\orkers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):Raymond Wyatt Address:1410 N. 5TH ST City/State/Zip:HARTSVILLE,S.C.29550 Phone#:508-887-3555 Are you an employer?Check the appropriate box: Type of project(required): 1.❑1 am a employer with ___employees(full and/or part-time).* 7. El New construction 2.Q I am a solc proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]' 9. El Demolition 10 0 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or arc sole 11.❑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. 13.❑ p ROOf repairs These sub-contractors have employees and have workers'comp.insurance.: 6.D 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. I.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: M A Q \ \\ C.L - \ N S V .'( (.� C 2 CCD M P(� Policy#or Self-ins.Lic.#: M�C O 206 2 J 7 -01 Expiration Date: /0/12/.20 2 Job Site Address: Li 6 M A\ N c fi, /A r C o v City/State/Zip: l I A 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 fy under the and penalties of pedury that the information provided above is true and correct Signature: Date: la.l&.— Phone#:508-887-3555 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#: The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 ~•`7* www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Apolicant Information Please Print Legibly Name (Business/Organization/Individual): 64,-%rG Ca ' i NC, Address: 214 CA-1'( _cf - City/State/Zip: 01 Phone #: 774 61%L-6 7 Are you an employer? Check the appropriate box: Type of project (required): i.%f am a employer with ' employees(full and/or part-time).* 7. New construction 2.L.I am a sole proprietor or partnership and have no employees working for me in 8. ( ( Remodeling any capacity. [No workers'comp. insurance required.] 3. I am a homeowner doingall work myself 9. Demolition ys [No workers'comp,insurance required.] 4.11 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.f l Electrical repairs or additions proprietors with no employees. 12.n Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13. Roof repairs These sub-contractors have employees and have workers'comp. insurance.: 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c_ 14.El Other 152,§1(4),and we have no employees.[No workers'comp. insurance required.] °Ally 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: v\l/�('r L N1H c, Policy# or Self-ins.Lie.#: M\At 07.0(7 2 2j. _C)1 Expiration Date: 16- (Z' 727 Job Site Address: 41( tiv'1�,:i1J 'z City/State/Zip:\�giL)oi,' 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:1( Date: /C.)/ _(")/z2 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/Tovvn Clerk 4. Electrical 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 A'6 MA11v � Work Address Is to be disposed of oat the following location: Said disposal site shall be a licens d solid waste facility as defined by M.G.L. Ch_ 111, §150A. Signature o pplication Date Permit No. )--*'"'ns) ® DATE(MM/DD/VYYY) ccRI A ' CERTIFICATE OF LIABILITY INSURANCE 10/24/2022 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). CONTACT Olivia Porter PRODUCER NAME: Berlin Insurance Group PHONE ( ) (A/C,No):508 459-1226 FAX (A/C.No.Ext): 61B MILTON ST E-MAILADDRESS: serviceteam@berlininsurancegroup.com INSURER(S)AFFORDING COVERAGE NAIC# WORCESTER MA 01606-2819 INSURER A: MARKEL INS CO 38970F INSURED INSURER B: CUELLO CONSTRUCTION INC INSURER C: 24 CATHARINE ST INSURER D: INSURER E: WORCESTER MA 01605-2710 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. INSR ADDL SUER POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE JNgD WVD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO JECT LOC PRODUCTS-COMP/OP AGG $ 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- AND EMPLOYERS'LIABILITY STATUTE ER Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBER EXCLUDED? N N/A MWCO206237-01 10/12/2022 10/12/2023 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) 416 Main St,Yarmouth MA 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. 416 Main St,Yarmouth MA AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE MARKEL Original Printing Issued October 17,2022 Standard NCCI Carrier Code:22616 Type:Stock Policy Number: Markel Insurance Company MWCO206237-01 10275 West Higgins Road, Suite 750 Rosemont,IL 60018 Renewal of Policy: Rewrite of Policy: Fein#/Risk ID#: 871712070/ 1.The Insured's Name and Mailing address: Cuello Construction Inc DBA Name: 24 Catharine St SIC CODE: 1751 Fl 3 Worcester, MA 01605-2710 774-810-0407 Other work place not shown above:See Attached Location Schedule Type of Corporation entity: 2. The policy period is from 10/12/2022 to 10/12/2023 [12.01 AM Standard Time]at the insured's mailing address. 3. A.Workers Compensation Insurance:Part One of this policy applies to the Workers Compensation Law of the states listed here: MASSACHUSETTS B.Employers liability Insurance:Part Two of this policy applies to work in each state listed in Item 3A. The limits of our liability under Part Two are: Bodily Injury by Accident: $100,000 each accident Bodily Injury by Disease: $500,000 policy limit Bodily Injury by Disease: $100,000 each employee C.Other States Insurance:Part Three of this policy applies to the states,if any,listed here AL,AK,AZ,AR,CA,CO,CT,DE,FL,GA,HI, IL,IN,IA,KS,KY,LA,ME,MD,MA,MI,MN,MS,MO,NE,NV,NH,NJ,NM,NY,NC,OK, PA,RI,SC,SD,TN,TX,UT,VT,VA,WV and WI D.California Endorsements and Schedules Other State Endorsements and Schedules: MDWC1001,Schedule of Premium Information(New for 9/1),Location Schedule,MWC 1201,WC000000C,WC000310,WC000406A, WC000414,WC000414A,WC000422C,WC000425,WC 20 03 01,WC 20 03 02 A,WC 20 03 03 D,WC 20 04 01,WC 20 04 03,WC 20 04 05, WC 20 06 01 A,WC 20 06 04,MJ W C 1000,MIL 1214,MPIL 1083,MPIL 1007 01 20,MAWC 008 01 16 4.The premium for this policy will be determined by our Manual of Rules,Classifications,Rates and Rating Plans.All Information required is subject to verification and change by audit. Minimum Premium:277.00 Deposit Premium:$421.00 Total Estimated Annual Premium:$2,725.00 Pay plan:10-Pay-15% Producer:Berlin Insurance Group LLC Countersigned By: 61b Milton Street 508-459-1226 Worcester,MA 01606 Date: 10/17/2022 Servicing office: Markel Service,Inc.,(888)500-3344 Central Park Plaza,222 South 15th Street,Suite 1500N Omaha,NE 68102-1680 (See extension of information page for class code,rate and premium detail) THIS INFORMATION PAGE WITH THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY AND ENDORSEMENTS,IF ANY ISSUED TO FORM A PART THEREOF,COMPLETES THE ABOVE NUMBERED POLICY MDWC 1001 02 20 1 11111111111111111111111111111111111111111111111111111111111 of 35 IIIIIIBIIIIHINIIIIIIVINIIIIIIIIIIUI I1VIIIIIIIIIIIIIIII 007707-014627-54834941-10172022 MWCO206237-01 • ,..b �'y. �r M1 to U) , i ri, pax j� ( f o '§ . .r _' ,y r. z . ti r 9u -4'� +� a y y F � ., ,„., X R , i 1 0L �Nt'� •� t AA eita 0 P. (4 ( 11■■ r yy , i a T 7 , i . .,,,,.., ' • : w gA y . y( ♦ T r , ss ` • . �i/add ry �'f'", 4 �i .tee ' • rye ;i & . 0 ,i- zaY > wr 0