HomeMy WebLinkAboutBLD-23-006020 At
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U,LpING U6pHkTME�I._�
I ill�l ; &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 c,... .4-or
l,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:eL,D ki D JJ )7) Date Applied:
Building O aI(Print Name) • Signature
Date
SE ION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
v9 e_MAkiJ .L Pei i&r- .j,U,:-.
1.i a Is this an accepted street?yes e no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards I Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,i 54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 private 0 Zone: _ Outside Flood Zone?
Check if yes❑ Municipal 0 On site disposal system 0
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
C,/vrw I(E• i irl<. Ia rv,ek_ 432.,L.Name(Print) City,State,ZIP
al Ci4A:'Jri&L P2).-kT .irt.I JE col £St,ciA3c1 () L fr)/i.1Lr Ce,rV
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ I Owner-Occupied ❑ I Repairs(s) 0 I Alteration(s) ❑ I Addition 0
Demolition ❑ Accessory Bldg.0 I Number of Units I Other 0 Specify:
Brief Description of Proposed Work2: Li i R.:►-F T 1-1 t lac:r- _.t..s.L5;•4 L.L_ kJ r OF—EC.i~ *L.)¢27. •r.--
04 rt 4,t> , PAPP rt AZT_tra c n+5 hie r -F' rti A,_ ( .r {1.1•t rd r�L.
`PfrzR.P. .,T►=.'I ;klecr S„ i=LF4_<ta �i ► W enri P ,1 i . Ti G�.
! LL. rL. L zn 51,0J bit.S t-1 ., R t n�15. R rein ltj
�3s� Ron
SECTION 4:ESTIMATED CONSTRU ION COSTS.
Item Estimated Costs:
(Labor and Materials) Official Use Only
1.Building $ I. Building Permit Fee:S Indicate how fee is determined:
2.ElectricaI $ 0 Standard City/Town Application Fee
3.Plumbing $ ❑Total Project Ct st3(Item 6)x multiplier . x
2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) $ Total All Fees:$ •
6.Total Project Cost: $ Check No. Check Amount: Cash Amo 1
' <_ _ ❑Paid in Full 0Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
�T ri•F L' ry t i.? License Number Name of CSL Holder Expiration Date
(� Bd�t (� _�� List CSL Type(see below)_
No.and Street '`1 reg.) 7 02_i` 1 „
Type Description
62a A . i�nr*•ter rya �J.r l C�?, <-t U Unrestricted c u'.1 r to 35 000 cu. t.
City/Town,State,ZIP R Restricted l&2 Famil Dweltin
M - .,
RC Roofin:Coverin
8 rs 47'"z ne �, WS Window and Sidin_
-1 R 1 g yy 3 b 0 I Ct C5L 6)l�r�!C AS r:to.. SF Solid Fuel Snoring Appliances
Tel
..,a Email address l ion
Demolition
. 5.2 Registered Home Improvement Contractor(HIC) D
7' .J,�a_) 1 -r,la,a 1-1`1Z3 i i%1-ti73
HIC Co pay Name or HIC Registrant Name HIC Registration Number Exp tiva onon D ee
1C, PV1 Hl4. A,17.--- G.ltafvtr P _!a!- ,ck.A'i 'Li )
No.and Street I!.. 1r La ci r .ce F .:t Lei
C �u'� rr 1�► r, , '�g j g4=a .�iL. `20 Email address
Ci /Town,State,ZIP Tele hone rv, r. Ni-rzr
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 Owner of the subject property,hereby authorize T
to act my be in all relative to work authorized by this building
permit application.
Prig 's ame(e i i,'1: ' -, _ �t %L',i z 2s
e
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.
tr--:�i- 'bpi . � f �..1 / �7."I
Print Owner's or Authorized Agent's (Electronic Signature 2-3
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 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the H.IC Program can be found at
www.mass.gov/oc4 Information on the Construction Supervisor
2. When substantial work is planned,provide the informatio l License can be found at www�lZ
Total floor area(sq.ft.).)
Gross living area(sq. (including garage,finished basement/attics,decks or porch)
Number of fireplaces Habitable room count
Number of bathrooms Number of bedrooms
Type of heating system Number of half/baths
Type of cooling system Number of decks/porches
Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
• The Commonwealth of Massachusetts
-.artier / .Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mcrss.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): Sf'a t �,�..s e!= es."
Address: Pza &v i3 c ...1 ()IA, CY2 o2 ei`L# .0
City/State/Zip: (-?err-.pr�...1 N:4, 03W-1 Z Phone it: IR1 -24.1Li .24,, 30
Are you an employer?Check the appropriate box:
Type of project(required):
1.01 am a employer with_ 3 employees(full and/or part-time).'
7. ❑New construction
Q I am a sole proprietor or partnership and have no employees working for me in
any capacity.[No workers'comp.insurance required.] $• ❑Remodeling
3.0 I am a homeowner doing all work myself.(No workers'camp.insurance required]t 9• ❑Demolition
4.0 I am a homeowner end will be hiring contractors to conduct all work on my property. 1 wfli 10❑Building addition
ensure that all contractors either have workers'compensation insurance or are sole
MO•O 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 sheet12. Plumbing repairs or additions
These sub-contractors have employees and have workers'comp.insuramce.t 13. ppf repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c, I4.❑Other
152,§1(4),and we have no employees.(No workers'camp.insurance required.]
*Any apples that checks box#1 must also fii1 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
teontractors that cheek 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.
X am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: A_r r l ( i tTL,1i rj S_
Policy#or Self-ins.Lic.it: 4.0 Cea Q S i r-I 2 n 2 7 Expiration Date: i 1 /'-i /2�
Job Site Address: Sat Cl-1 new Ni Pc ;— J tZ i uc City/State/Zip: LLJ. mict C)24.i 3 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.
1 do hereby cer ify under the pains and penalties of perjury that the information provided above is-true and correct —�
Signature: Date: / 2.4-1 J23
Phone#: 1 k 1 k ,.2 3Ci
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#:
§TOWN of YARMOUTII
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 3q 4-1 1_ en r►.-r \Q I' 1
Work Address
Is to be disposed of oat the following location: �� t.t_1 cry _ slv�
re.) _frJ St i g:
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. 111, §150A.
zl / t rz.3
•ture of Applicatio Date
Permit No.
A`QRD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY)
04/17/2023
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 POUCIES
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 Elizabeth Spadea
NAME:
Brown&Brown of Massachusetts,LLC P NE Extl: (781)817-6818 FAX
No): (781)848-6100
980 Washington Street LASS: Elizabeth.Spadea@bbrown.com
Suite 325 INSURER(S)AFFORDING COVERAGE NAIC 0
Dedham MA 02026 INSURER A: Travelers Property Casualty Company of America 25674
INSURED INSURER B: Associated Industries of Massachusetts Mutual Insurance 33758
Bogue Builders INSURER C:
Po Box 134 INSURER D:
INSURER E:
Canton MA 02021 INSURER F
COVERAGES CERTIFICATE NUMBER: CL2341772338 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 A.'. r:• POLICY F _POLICY EXP
LTR TYPE OF INSURANCE INSO MID POLICY NUMBER (MMIDOIYYYY) (MMIDOIYYYY) LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1'�'�
GE-10 RENTED
CLAIMS-MADE p OCCUR PREMDISES(Ea occurrence) $ 300,000
X General Liability MED EXP(Any one person) $ 5,000
A 6809891N308 04/27/2022 04/27/2023 PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2.000,000
POLICY n JE T LOC PRODUCTS-COMP/OP AGG $ 2,000,000
OTHER: Employee Benefits $
AUTOMOBILE UABIUTY 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'JAB OCCUR EACH OCCURRENCE $
EXCESS LU1B CLAIMS-MADE AGGREGATE $
DED RETENTION$ $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY Y/N STATUTE ER
B ANY PROPRIETOR/PARTNER/EXECUTIVE N/A 10060259192022 11/04/2022 11/04/2023 EL.EACH ACCIDENT $ 100'000
OFFICERIMEMBER EXCLUDED?
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100'°°°
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)
Project Blue Point Realty Trust,West Yarmouth
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Town of West Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
-
BOGUE
Roofing and Remodeling
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Bogueronang1906*comeastnet Canton,MA 02021
Stephen Bogue (781)844-3630
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THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer/Walk$Business Regulation
HOME IMPROVEAMENtCONTRACTOR
TYPE: n"�iv dual .
Registration !„ Expiration
177236'°: i^,11_14/17/0 3
*STEPHEN E BOGUE Uf
a/B/A BOGUE ROOFING AND REMODELING
STEPHEN BOGUE III
77 ADAMS ST �'l
BRAINTREE,MA 02184
Commonwealth of Massachusetts
Division of Occupational Licensure
Board of Building Re ulations and Standards
Cons relkeivisor
• CS-073579 Liires: 07/17/2024
STEPHEN EftpVA
P.O.BOX
CANTON MA;
-O74.11d0'
Commissioner c1i n"c F-Y55.7ithi