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BLD-23-004704
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't ^t'€'7;r4::,.# •• t..�N• <+uxl',- ',u ,.Sd r7{'vm ,�'��`k;Aq:4 .:,+� '"'s, 'M,,,,.y yr w,�,f $5ro•; S' a:..5,'�,.:d. a,. r.x tn;:�•» ryc•..','ay.s, e„� , r. , , 3.2 Registered Home Improvement Contractor. ' Company Nam. Not Applicable Q • _0 , Address Registration Number Expiration Date Signature Telephone Section 4-Workers'Compensation Insurance Affidavit(M.G.L c.152 S 25C(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit wiU result in the denial of the issuance of the building permit. 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) Section 5.1 Registered Architect Not Applicable 0 Hama(Registrant): Registration Number Address Expiration Date Signature Telephone Section 5.2 Registered Professional Engineer(s)I Hams Area of Responsiblity Address Registration Number Signature Telephone Expiration Data Hama Area at Responsibeity Address Registration Number Signature Telephone Expiration Date Name • Area of Responsibility Address Registration Number Signature Telephone Expiration Date Hams Area of Responsiti6ey Address Registration Number Signature Telephone Expiration Date Section 5.3 General Contractor 7 f c M.S4 r4A C4 r` D Al Not Applicable 0 Company Hams Person Responsible for Construction a a 3 �Dpw 4v £ Pao v,'aj, ,io Fcj vac,tfo Addre na Telephone • SECTIO 1 Db OWNER/AUTHORIZED AGENT DECLARATION • . I, / A/ Ti7 A/I D ?UM y/E? S , 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. • / ' 41/`t ON c.) tzOn-4 r s • Print Name egz.....2.„..ozi____-- .......--- _ 07/J Si of Owner/A� gent Date Section 11 - ESTIMATED CONSTRUCTION COSTS Rem ' Estimated Cost(Dollars)to be • completed by permit applicant 1.Building 4 /6i i(70'c.)0 ,2.Electrical 3.Plumbing/Gas 4.Mechanical(HVAC) . S.Fire Protection B.Totals (1+2+3+4+5) 4 d-01676 , 06 ' 7.Total Square Ft.pornw aeumuns&adtatas) Check Below ❑ Conservation-Commission Filing (if applicable) ❑ Old IGngs Highway&Historical • Commission approval (If applicable) • • • • cF.1- ' BUILDING PERMIT APPLICATION ' • 2/t °, APPUCATION TO CONSTRUCT,REPAIR,RENOVATE, CHANGE THE USE,OCCUPANCY OF, • fit.. C OR DEMOUSH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWEWNG. 1a ,,T„cM s .Z• Town of Y.trmouth Building Department »`�-� �La' 1146 Route 28 • Yarmouth, MA 02664—E492 Tel: 508-308-2231 ext. 1261 Fax 508-398-0836 Office Use Only Date Board Information Assessors Department Information Permit No. Date Types for Permit Fee $ Endorsement Date,_____ / Deposit Rec'd. $ pad Re'ording Date New Plan No. • 1.4 Property Dimensions Net Due $ OtherLot Area(sf) Frontage(It) This Section for Office Use Only Building Permit Number: I Date Issued • Signature: Certificate of Occupancy Building Official Dater is Is not required Section 1 - Site Information I 1.1 Property Address: 1.2 Zoning Informed= • Zoning District Proposed Use 1.3 Building Setbacks(ft) • Front Yard Side Yards • Rear Yard Required I Provided Required Provided Required Provided 1.4 Wats,Supply(na.tl.1..a Zone 40.S 54) 1.5 Rood Zo Informal.Informal= Conxnent c ti Pubg Private Zone: _ BFE _.___ . Section 2- Property Ownership/Authorized Agent I 2.1 Owner of Record: r f Name(print) Mailing Address: Signature Telephone Telephone / 2.2 Authorized Agent I Email Address: '4Al'-re)kJ [ 0 1 ;v1 4'e_ S vZ. M O ,4 v e. P. 12.L aG/4p Na prime ,.:(04/01 Mailing Address: rgnature Telephone Fax Email Address: j • Section 3- Construction Services 3.1 Licensed Construction Supervlson Not Applicable l] 1iv-rc'3 to i d Q y- a.l {� License Number �BBJ Add I S i eInO iri[ 4,�,.P4n c P 1. C7 i,t Cf ir, /! CS--ing077 /n 4611.% 4—.4o)--4 - 7?(/ 4-eS a f)f-0,L E Date ignature phone Email Address: l)/ /V c7..1 y4 ' •. Section 6- Description of Proposed Work(check all applicable)I New Construction ❑ I (tor multiple family only) No.of Bedrooms I (for multiple family only) No.of Bathrooms Existing Bldg.: I Repair(s) ❑ I Alterations ❑ I Addition 0 I Accessory Bldg. ❑ Type I Demolition I Other Specify: Brief Description of Proposed Work: • Section 7- Use Group and Construction Type I Building Use Group(Check as appicapable) Construction Type • A ASSEMBLY 0 A-1 ❑ A-2 ❑ A-3 ❑ to ❑ B BUSINESS aA� ❑ ❑ 1B CI E EDUCATIONAL. 0 2A F FACTORY 2B ❑ ❑ F-1 ❑ • F-2 ❑ 2C ❑ H HIGH HAZARD ❑ I INSTITUTIONAL ❑ I-1 3A ❑ ❑ 1-2 ❑ 1-3 ❑ 3B ❑ M MERCHANTILE CI - Ft RESIDENTIAL 4 ❑ ❑ BA ❑ R-2 ❑ R,3 ❑ SA ❑ U STORAGE1UTY ❑ S-1 ❑ S-2 ❑ 58 0 ❑ SPECIFY: -_ M MIXED USE ❑ SPECIFY S SPECIAL USE ❑ SPECIFY. (Complete this•section if existing building undergoing.renovations;additions and/or change iri use.] 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 ' Bulking Area Existing(f 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 11011)1 _ Independent Structural Engineering Structural Peer Review Required Yes No I SECTION 10a OWNER AUTHORIZATION-TO BE COMPLETED WHEN • OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT] I,r� . as Owner of the subject property, hereby authorize sr- F J'_ (�inn_STr? ; 0d,! to act on .( my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date A�RD CERTIFICATE OF LIABILITY INSURANCE DATE(MMVDDM/YY) 01/05/2023 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 pollcy(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 CONTACT Sandra Grossguth Lezaola Thompson Insurance (PJ„DN.E,,i; (401)434-7203 FAX No): 2761 Pawtucket Ave Ammon: sandra@lezaola-ins.com East Providence,RI 02914 INSURER(S)AFFORDING COVERAGE NAIC A INSURERA: Selective Insurance 12572 INSURED INSURER B: Selective Insurance 19259 T&J Construction, Inc INSURER C: 223 Don Ave INSURER D: East Providence,RI 02914 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 95985385-172647 REVISION NUMBER: 38 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 ADM SUER POLICY EFF POLICY EXP UMITS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (M (MMI M/DO/YYYY) DWYYYY) A X COMMERCIAL GENERAL UABIUTY S 2441887 03/19/2022 03/19/2023 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS MADE n OCCUR PREMISES(Ea occurrence) $ 500,000 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LBAIT P APPLIES PER GENERAL AGGREGATE $ 3,000,000 11( POLICY 1-1 JECT I I LOC PRODUCTS-COMP/OP AGG $ 3,000,000 I OTHER $ A AUTOMOBILE UARIUTY S 2441887 03/19/2022 03/19/2023 (�MBIN SINGLE LIMIT $ 1.000.000 ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY X AUTOS X AU TOS ONLY X ANUT S ONLY PROPERTY DAMAGE $ (Per accident) $ I UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ pi B WORKERS COMPENSATION WC 9084297 03/19/2022 03/19/2023 X STA uTE OTH- ER AND EMPLOYERS LABILITYN ANY PROPRIETORIPARTNERIEXECUTIVE Yr;' N(A E.L.EACH ACCIDENT $ 500,000 OFFICER/ME ER EXCLUDED? I IY(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE i 500,000 If ESCR yes dearnIPTION be under OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 D DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached N more apace Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Yarmouth MA ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE ��,�t t `_'') -f' !. " LA.;T''�i L.' •z.. ''"'" �� (SJG) i a��4t."�Lx �'" 01988-2015 ACORD CORPORI>CTION. All rights reserved. Arnim 9R 19A1R/OR1 Tha A(:ARf nsrem anti Innn aro name*anar(marks of Amen Print/set by C.I(:nn A1I/IR/9119' of AQ•M AM Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Regulations and Standards ConstottiVon WO5rvisor CS-109077 z ijires; 12/13/2024 ANTONIO J RNU .°11 t 223 DON AV g l et EAST PROVIe* Commissioner diaa Y3jEancQ�t The Commonwealth of Massachusetts _ Department of Industrial Accidents c, 1 Congress Street, Suite 100 �1 Boston, MA 02114-201747 www.mass.gov/dia 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): `1-I J Cc7 Address: 0..0)-2 a„/ Ave 1 L &- City/State/Zip: S. pat,U;rmt jZ r o c /4 Phone #: 110/ —t. S/ -- 7 U)/ Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with ] employees(full and/or part-time).* 7.2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑New construction any capacity.[No workers'comp. insurance required.] ,'®-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 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.Q 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 sheet 12.❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.* 13•Q Roof repairs 6.0 We 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: C Ve ? CIQ Policy#or Self-ins.Lic.#: 2/4 .2.q'7 Expiration Date: D__? Job Site Address: 4Co l( 9...7 g 1/le,T y 10Ot 4 yl City/State/Zip: wsi- YAr m®u44 Attach a copy of the workers' compensation policy declaration page(showing the policy number arid expiration date). Failure to secure cove a � )rage 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Si ature: Date: Phone#: O j— 4 Sl— 1$ h'/ 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#: