HomeMy WebLinkAboutBLDR-23-10017- /1 / /2
ONE &TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department of "y .
1146 Route 28,South Yarmouth,MA 02664-4492 ,
508-398-2231 ext. 1261 Fax 508-398-0836
Massachusetts State Building Code,780 CMR
Building Permit Application To Construct, Repair,Renovate Or Demolish
a One-or Two-Family Dwelling
►3(..1)i�� _ Iblll- RECEIVED
This Section For Official Use Only
Building Permit Number: , 2 1-U., i( Date Applied: MAY 0 4 2O2
f ,ram c?4cs D- 3 I --_-_.._______
Building Official ti v I l 1at e N C tJ E PA R T M E N T
(Print Name) S gna ay.
SECTION 1:SITE INFORMATION
.
1.1 Pro erty s: 1.2 Assessors Map&Parcel Nu bers
14�vl` c — . ,ae'lcii
1.1 a Is this an accepted street?yes 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 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 tit Private 0 Zone: _ Outside Flood Zone? Municipal/0 On site disposal system 0
Check if yesl ,
SECTION 2: PROPERTY OWNERSHIP'
2 O v} ner'o ed: C
1144
Name(Print) V C ty 1
J Mon
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction 0 I Existing Building 0 Owner-Occupied 0 I Repairs(s) 0 Alteration(s) El rAddition 0
Demolition 0 I Accessory Bldg.0 Number of Units Other 0 Specify:
'ef escri 'on of Proposed Wor Z: ,,,,e _
1 a`
SECTION 4:ESTIMATED CONSTRUCTION COSTS,
Item Estimated Costs: Official Use Only
(Labor and Materials)
I.Building $ 1. Building Permit Fee:S j r(7 Indicate how fee is determined:
2.Electrical $ J11Standard City/Town Application Fee
❑Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ /� •
n
4.Mechanical (HVAC) $ List 3 OLVti I 1532_
5.Mechanical (Fire $ JCI
Suppression) Total All Fees:$ • p \�1�
Check No. Check Amount•
Cash unt: V 16.Total Project Cost: $ , 6150 ❑Paid in Full it Outstanding Balance Du - I I
5 bill/\L,
[glel
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervis icense{CSL}
\ J1E E 7 1�• /n� Li
Name ICSL Holder JC..- License Number Exp�i'` 'o Date
1 l![ ` I- List CSL Type(see below) 0
No.and Street Te Description
�, 4 Unrestricted(Buildings up to 35,000 cu.ft.)
Ci /Town,State,ZIP �� R Restricted l&2 Family Dwelling
M l Masonry
RC [ Roofing Covering
WS Window and Siding
SF Solid Fuuel Burning Appliances
ele hon� 7 � '� � I Insulation
p EmaiI ress D Demolition
. 5.2 Register ome Improvement Contractor(HIC) ` 9q-jn� O
oj,Vo t HIC Registration Number Ex rati Date
HI omi an i �oc trans Name
Y)N -!.: � �uyl l�,
ot Sect
AV. Aria ,, Email a .ress
C. /Town State, 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 6. 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
to act on my behalf,in all matters relative to work authorized by this building permit application.
•
Print Owner's 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.
1/400A.
,, b. PAA412,' 6
Print Owner' r Authorized Agent's Name(Electronic Signature) ate
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 rtvr 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.gov/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"
rt„3 f -$�
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. Division of lccupat ►na ..foe�isut'e ;- �•
Beard 'Of Cations en+ tatdar
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--03/03/20
,
C dQF
ACCOREP® CERTIFICATE OF LIABILITY INSURANCE 1DATE
TE( oDDIYYYY)
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
NAME:
DOWLING &O'NEIL INSURANCE AGENCY (HONEC. EM): (NCFAX,Not:
973 iyannough Road E-MAIL
P.O. Box 1990 ADDRESS:
Hyannis, MA 02601 INSURER(S)AFFORDING COVERAGE NAIC#
INSURER A: AmGUARD Insurance Company 42390
INSURED INSURER B:
W D PRICE INC
INSURER C:
231 MAIN STREET UNIT 335 INSURERD:
YARMOUTH PORT, MA 02675 INSURERE:
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 SUBR
LTR TYPE OF INSURANCE INSD WVD POLICY NUMBERIDPOLICY EFF POLICY EXP LIMITS
(MM/DD/YYYY) (MMDfyYYY)
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 0
DAMAGE TO RENTED
CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ 0
MED EXP(Any one person) $ 0
PERSONAL&ADV INJURY $ 0
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 0
POLICY PRO-
JECT LOC PRODUCTS-COMP/OP AGG $ 0
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
(Ea accident)
ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURYaccident)AUTOS ONLY AUTOS (Per $
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 _
AND EMPLOYERS'LIABILITY Y/N X STATUTE EERH
A ANYPROP OFFICER/MEMBEREXCLUDED?ECUTIVE N/A 500,000
NR2WC320149 10/28/2022 10/28/2023 E.L.EACH ACCIDENT $
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000
DESCRIPTION OF OPERATIONS 1 LOCATIONS f VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Employees: Full Time: 0; Part Time: 0 Governing Class Description: CARPENTRY-CONSTRUCTION OF RESIDENTI
CERTIFICATE HOLDER CANCELLATION •
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
W D PRICE INC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
231 MAIN STREET UNIT 335
Yarmouth Port, MA 02675 AUTHORIZED REPRESENTATIVE: 444/ /71
I
01988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
The Commonwealth of Massachusetts
11+ Department of Industrial Accidents
1 Congress Street,Suite 100
« _' = Boston, MA 02114-2017
www mass.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): ),(`�_„(0.,\A,6_
Address: \U_\`-kCji,
City/State/Zip: C ('jrA- lion#:
Are you an employer? eck the appropriate box: Type of project(required):
1. 1 am a employer with 0._ employees(full and/or part-time).* 7. ❑New construction
2.al 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. t 9. ❑Demolition
❑ ys [No workers'comp.insurance required.]
10❑Building addition
4.01 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 are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.0I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 1;,❑Roof re airs
These sub-contractors have employees and have workers'comp.insurance.t
6.0We are a corporation and its officers have exercised their right of exemption per MGL c. 14 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.
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: 60A0.,,
Policy#or Self-ins.Lie.#: 95U S9,>\LA Expiration Date:
Job Site Address: \C Melc City/State/Zip:
Attach a copyof the workers' compensation
on policy declaration page(showing the policy nu ber and expiration date). Caiv 1,,
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 u der the ains and penalties of perjury that the information provided above is true and correct
•
Signature: / MO Date: �� ' Dah
Phone#: 5D ► rL f.
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. 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 1 )\\,
Work Address
Is to be disposed of oat the following location: VD \) u
Wt\W-U2
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. 111, §150A.
14 ( Lt 13\fe)(6-S
Signa e of Application Date
Permit No.
Very truly yours,
Wesley Price
President/Owner
W.D.PRICE,Inc.
I have read and consent to the preceding engagement letter.
14-4•F/ i "--• [Signature Client/s] 9/16/2022 [Date]
/(7114 [Signature Client/s] 9/16/2022 [Date]
\ti• • ,. ?t'� [Signature General Contractor] 22.09.21 [Date]
1
4
' 0,81tifkitk-'
5DS
.5%-6
.j `7 =
YARMOUTH TOWN CLERK
� p; TOWN OF YARMOUTH `23MAR2PM3:59 REC
1146 ROUTE 28, SOUTH YARMOUTH,MA 02664-4451
k Telephone(508)398-2231 Ext. 1292-Fax(508)398-0836
1 RECEIVE iING'S HIGHWAY HISTORIC DISTRICT COMMITTEE
`' ` APPLICATION FOR
HNivi0. :., CERTIFICATE OF EXEMPTION
t,D ING,S HIE HWA•1 1
Application is hereby made for the issuance of a Certificate of Exemption under Sections 6 and 7 of Chapter 470 of
Acts of 1973, as amended, for the proposed work as described below and on plans, drawings, or photographs
accompanying this application.
Tune or print lealbiv: , t A�,�--� ]
Address of`proposed work: ICI WI J { 7l Jr fr Map/Lot#_ �'tr
Owner(s): 1 �. e WitenPhone#:l b0 / 1All applications bee ubmitted by wnaccompanied by letter from owner approving subm I of a lication.
Mailing address: Year built G� �'�`v
EmailV9C4,In } eeklk,Preferred notification method: hone Email
Aaent/Contractor: f-6 C.) WI>)�� S _ Phone#:
Mailing Addr . � (,p
Email: Preferred notification method: Phone Email
i ,on of Proposed Wo additional new attached Unmeant):
r-D --X7-3.-- \e‘\0‘\(3)sviL'aket- ,
-Tax ‘ou mu.
Signed(Owner or agent): Date:
A Owner/contractor/agent is aware that a pennk may be required from the Building Department.(Check other departments,also.)
This certificate is good for one year from approval date or upon date of expiration of Building Pemtit,whichever date shall be later.
For Committee use only:
Date: 9(711 A3 proved Approved with changes Denied
Amount oft}.1/0 Reason for denial: '
Cash/CK it: 1013113 _ c}
Revd by: L.Sr MAR 0 2 ?On
I' r"ARMOU lht
DiS►KING-.Z H1!CHINAY_...
Date Signed: V .� Signed: 71/-"/179.7: APPLICATION#: +75 E 01