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HomeMy WebLinkAboutBLDR-23-10018 (2) ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department 1146 Route 28, South Yarmouth,MA 02664-4492 � 508-398-2231 ext. 1261 Fax 508-398-0836 '" i �'+ s',�� Massachusetts State Building Code,780 CMR Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Fan 'y Dwelling rxJ)12.-2-3- I D(o1 This Sectiony� For Official Use Only Building Permit Number: P�U) l -� f3 Date Applied: If\-' cS ,� 14'n/33 Building Official(Print Name) ign re R E I E I N E D SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers MAY 04 2023 a6 "YY,zsTor ( .J ileake,OT H 1.1 a Is this an accepik Street?yell no Map Number Parcel Numb-r BUILDING DEPARTMENT By _ 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 Rear Yard Required I 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 Owner'of Record: 13 GA- c T 6, �R�la u�14 "Pn A. Oct 6641 Name(Print) City,State,ZIP 06 Nnns'.s-r-0_L ) 11$_G' 5 -_aRc-t- imp. carte No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction❑ Existing Building 0 Owner-Occupied 0 I Repairs(s) 0 Alteration(s)XI Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2: ( 8."Cif S) - SECTION 4:ESTIMATED CONSTRUCTION COSTS. Estimated Costs: "" D Item (Labor and Materials) Official Use Only E c E IV 1.Building $ 1. Building Permit Fee:S 1 ---(3 Indicate how feet deitermined: 9.cc," ��, MAY � 1�Standard City/Town Application Fee , 222023 2.Electrical $ Cl Ici \ 0 Total Project Costs(Item 6)x multiplier 3.Plumbing $ a 2. Other Fees: $ , \ "`U;/ .. 17�r,DEPART -NT 4.Mechanical (HVAC) $ Q List: 3,)OD vl - -_ 5.Mechanical (Fire Suppression) $ Total All Fees:$ f Check No. Check Amount Cash Amount: , Vd 6.Total Project Cost: $ 0 Cl Paid in Full QI Outstanding Balance Due: It L ' rill 5)/71g5 SCankid Si/7/Z9 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) N LaCT. P ac.k-{ . rr LLiicenseNumber„LE 66-y� Expiration at Name of CSL Holder List CSL Type(see below) k) No.and Street �i, Type Description civa Cy) Unrestricted(Buildings up to 35,000 cu.ft.) /TRowntSN0tate,ZIP ' 0 art 3 R Restricted 1&2 Family Dwelling 00yM Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances COI?, G waL.L-actIrr,ac Nabs,ogiTw,02- I Insulation Telephone eP EmaiI address D Demolition 5.2 Registered Home Improvement Contractor(HIC) t��c `macao�.c _L cab ),tea 5 CC Company Name or HIC Registrant Name d ) HIC Registration Number Expiration Date <I" 1�.P1' T ( MUt ►2(4lac�c� 1--t3r1NvailtA" No.and Street Email addr 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 .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 )a 1_�( w\.ci-t to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's ectronic 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: 1. 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 HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.zov/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" Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Re ulations and Standards Cons ionTSisl' visor CS-116646pires: 12/29/2025 WALACI P M CHA ! : 193 CAMP S P APT J5 i WEST YARMatITH M 73 Z: l b���I,LFrt.1�0' Commissioner c THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date, If found return to: TYPEi ridiviidual Office of Consumer Affairs and Business Regulation Registration expiration 1000 Washington Street -Suite 710 201015 02/22f2025 Boston,MA 02118 LACI PEREIRA MACHADO LAG MACHADO CAMP ST APT J-5 „t G(ak' J ST YARMOUTH,MA 02673 Undersecretary Not valid without signature • • §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 T,sT L.Y1 WorhAddress Is to be disposed of oat the following location: (6ak\„,,„ S a L Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. Signature of Date Permit No. �T' The Commonwealth of Massachusetts 1'�'lilfi►=. t Department of Industrial Accidents .:IRtI� 1 Congress Street, Suite 100 4=4,11Boston, MA 02114-2017 ,;, iwww.mrrss.gov/dfa Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY, Applicant Information Please Print Legibly Name (Business/Organization/Individual): -W Et gal>JTs Iv G 1,4t�`V. \ , R' ` c rY1 N Address: 3,j , ....-re 4 .Nir.\& Si. wr-t-i( (-A City/State/Zip: 1-4( a - --r s J .),.. 0,.60S. Phone#: Sc,g. G•c-1_c1.1..1.0 Are you an employer?ChM(the appropriate box: Type of project(required): I.gt l am a employer with a- employees(full and/or part-time).' 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp. insurance required.] 8• ®Remodeling 3.0 I am a homeowner doing all work myself.(No workers'comp.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 sole 11.[] ElectricaI 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 sheet. 12.❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurances I •❑Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per,MGL c. I 4•❑Other 152,§I(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. 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 ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: k up,......-r '-rF,gy\ a- Q VL ui ‘ C••TLdvn r Th Policy#or Self-ins.Lic.#: W c 90 Co 9'1 A Expiration Date: 05/ ,112 a 3 Job Site Address:,Q6" c-- 9( L a►AP City/State/Zip: '), ©a6€Lf Attach a copy of the workers' compenktion policy declaration page(showing the policy n mber 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 certify under the pains and penalties of perjury that the information provided above is true and correct. signature: (, L; eJ...e...,--,... W m 4 Date: c-T '" /(1)cN n 3 Phone#: .S o(Z,3-6G siJL O Official use only. Do not write in this area,to be completed by city or town off ciaL City or Town: Permit/License# . Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6.Other Contact Person: Phone#: __"""""1A A JOSESIL-03 JPOWERS /" W RlJ DATE RAM/DOW/TT) ‘.,.,.- CERTIFICATE OF LIABILITY INSURANCE 3/3/2023 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 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(les)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 License#1780862 1 c ACT John Powers HUB International New England t PHONE 'FAX 265 Orleans Road (NC"No,Est):(508)945-7866 :WC,No): North Chatham,MA 02650 E-MAII John.Powers@hubinternationai.com ADDR SSc, INSURER(S)AFFORDING COVERAGE NAIL# ._ ,INSURER A Selective Insurance Company of America 12572 INSURED INSURER B:Selective of the Southeast 39926 Mr Painting and More Inc ,INSURER C 320 Stevens St.Unit C1 ,INSURER D: Hyannis,MA 02601 INSURER E: 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. MISR; ADDLSUBRf _ _ POLICY EFF POLICY EXP LTR g TYPE OF INSURANCE INS°:WVD, POLICY NUMBER ,(MMtDD/TYYY1 (M JDO1YYYYI LIMITS A I X ,COMMERCIAL GENERAL UABILITY ' 1 000 000 EACH OCCURRENCE $ CLAIMS-MADE , X ,OCCUR S 2334823 4/10/2022 , 4/10/2023 ;PREMISES RENTED ante) $ 500,000 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1'040'000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY PP& , LOC 3,000,000PRODUCTS-COMP/OP AGG $':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) $ i UMBRELLA LIAB OCCUR ` EACH OCCURRENCE _,_ $ EXCESS LIAB CLAIMS-MADE, i AGGREGATE :$ DED RETENTION$ $ B WORKERS COMPENSATION PER OTH- ' AND EMPLOYERS'LIABILITY • Y IN STATUTE : ER, ANY PROPRIETOR/PARTNER/EXECUTIVE WC 9080976 5/23/2022 5/23/2023 500,000 FICERIMEM13sER EXCLUDED? ' N N/A EL.EACH ACCIDENT _ $ r (mandatory in NH) EL._DISEASE_EA EMPLOYEE $ 500,000 'If Ey TIN under E.L.DISEASE-POLICY LIMIT t$ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS f LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) 1 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. AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. 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