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Home My WebLink AboutBLD-23-004591 • t Ptif Z P7720 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 ■ 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: 2 L-6--7,34-1 ,c-C1( Date Applied: 1i''N C) -- 14-)43 Building Official(Print Name) i ature SECTION 1:SITE INFORMATION R E ,.: ,,,,i. i. V:f D . 1.1 Property Address: 1.2 Assessors Map&Parcel Num rs /J`/-5,0Z//h k_5 r'ci /7vr 3/ FF . 6 2g23 1.1 a Is this an accepted street?yes no Map Number Parcel u er 1.3 Zoning Information: 1.4 Property Dimensions: BUILDING IJL r,t;RTfv1ENT ay 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 Zone: _ Outside Flood Zone? Private❑ Check if yesQe" Municipal❑ On site disposal system 517� SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: /17/1.(d/h!'/- ✓e,!n!!�S .-5Gti/h c.$e- i>//CI d-4 S/ Name(Print) City,State,ZIP y'r.z,•'7Olc - rV Jaf//// --$I, c' No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) 'Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work2: i '/ Jr 1-1" 31 SECTION 4: ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 150 1. Building Permit Fee:$ "SG2 Indicate how fee is determined: 2.Electrical $ / Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ ,3 570 4.Mechanical (HVAC) $ List: q Jl'' 5.Mechanical (Fire Suppression) $ Total All Fees:$ ' - 'Ca Check No. Check Amount: Cash Amo n \ 6.Total Project Cost: $ 650 0 0 Paid in Full EliOutstanding Balance Due: 15 n SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 1r las ,,.-5 ; nn Qed3i_�D5 ,x n ". 0-2 _i_— T_ / / �� ) License Number Ex nation ate Name of CSL Holder A a ox. /`/O List CSL Type(see below) No.and Street Type Description .143�Sit !!"' /7/, a2 6 /.9 U Durestricted(Buildings up to 35,000 cu.ft.) City/Town,St ZIP - R Restricted 1&2 Family Dwelling M Masonry • f }1ei-a RC Roofing Covering �� /� WS Window and Siding 5 7 d 2 e 1 qr ' rn ill y SF Solid Fuel Burning Appliances I ° I ' Insulation Telepho Email address ,c0.7 D 1 Demolition 5.2 Registered Home Improvement ContractoKHIC) HIC Com y N e or HIC Re 'strant ame MC Registration Number pi Date sl nX /. ,3 , Na.and Street / rb2 ✓t'e v/ai6r/-e:Oc 7Gr,/<0,7 .P2 ci- /! /�,� /)9W37/-Q ecj.1LQ0040 Email address City/Town,State,UP' (f l`� 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 ❑ . 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 �lJclrYerJ /jz✓Uob`41/ to act on my behalf,in all matters relative to work authorized by this building permit application. •C/<<./Ae% (✓dins .2/7 ,zO ZL5 Print Owner's Name(Electronic Signature) ate ` SECTION 7b:OWNERI 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. I/fai6,v /', ' c 2/71 a2 Print Owner's or 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 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.Inass.gov/oca Information on the Construction Supervisor License can be found at www.mass.sov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,d c s or porch) Gross living area(sq.ft.) /J/,f Habitable room count Number of fireplaces ' Number of bedrooms Number of bathrooms Number of half/baths Type of heating system �i i� Number of decks/porches Type of cooling system_ Enclosed 43//Tc /-Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" c ems- 0 6tilt CA1)-(iL 5-J 7 '�0 - 6/d2 € 1 • The Common wealth of Massachusetts � 1=. t Department oflndustrialAccidents 1 Congress Street,Suite 100 = = Boston,MA021142017 y�'"r,`��.-71 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/EIectriciansfPlumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print LeaibIv Name(Business/OrganizatioMndivi dual): ' 4 l.- ,J z-z/' Address: '0, no,r /2JJ7 City/State/Zip: /7 ,5- �/42!'/-./)2,1 y9Phone#:(5-0 p j2.-07c)E5 Are you an employer?Cheek the appropriate box: Type of project(required): l.Q I am a employer with employees(full and/or part-time).* 7. New construction 1 m a sole proprietor or partnership and have no employees working for rat in any capacity.[No workers'comp.insurance required.] $• []Remodeling • 3.Q I am a homeowner doing all work myself.[No workers'camp.insurance required.]t 9. Q Demolition 4.Q I am a homeowner and will he hiring contractors to conduct all work on my property. 1 will I0 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 5_Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.0 Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.t 13.0 Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. l •Q Other 152,§I(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box AI must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ;Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. lithe sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: c6 c,J ,—- OQ,�I� r sue.y Policy#or Self-ins.Lic.#: ,-9/PT-C'0Dc32oevo Expiration Date: /6/...Z0_2(__F Job Site Address: /J (SO7./J L$> ' City/State/Zip:Jorl�/ c_Se?? Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration 749p,g Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to S1,500.00 � and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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 certifyunder th ains ndpenalties of perjury that the information provided above is true and correct. Sienatu ./ '-- Date: .2 -2 0-2- Phone tr: 'O�t529 " oQ Official use only. Do not write in this area,to be completed by city or town official City or Town: PermitfLicense# 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#: aC�ot DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 02ro6/23 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 CON FACT NAME: Deoliveira Insurance Services PHONE Exn: 508-477-3023 (Am,No): 508-638-6463 800 Falmouth Rd. ADDRESS: joe@dinsinc.com UNIT101-A Mashpee,MA 02649 INSURER(S)AFFORDING COVERAGE NAIC 0 INSURER A: UTICA FIRST INSURANCE INSURED INSURER B ANDREW TARABELLI INSURER C: PO BOX 1237 INSURER D MASHPEE,MA 02649 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. LTTRR TYPE OF INSURANCE .$0 eWVD POLICY NUMBER POLICY EFF POLICY EXP (MM/DD/YYYY) (MMIDD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE Ej OCCUR DAMAGE S(RENTED PREMISES(Ea occurrence) $ 50,000 MED EXP(Any one person) $ 5,000 A ART3000320840 04/06/22 04/06/23 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY n jE a n LOC PRODUCTS-COMP/OP AGG $ 2,000,000 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 LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ Byes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) HANDY MAN OPERATIONS AS DEFINED BY UTICA FIRST 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 ACCORDANCE WITH THE POLICY PROVISIONS. 1146 ROUTE 28 SOUTH YARMOUTH,MA 02664 AUTHORIZED REPRESENTATIVE NOAH HOLLAND 1 • §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-22* 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 /f9vro�l/�i' Work Address Is to be disposed of oat the following location: .4" (1C!!/,a.$ Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. qf2 Signature o Application / Date Permit No. Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Mastachusetts 02118 Home Improve Citractor Registration Type: Individual Registration: 157144 ANDREW TARABELLI Expiration: 04/15/2023 P.O.BOX 1237 MASHPEE,MA 02649 Update Address and Return Card. SCA 1 0 20M-05/17 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYE:Individual before the expiration date. If found return to: Regiw Expiration Office of Consumer Affairs and Business Regulation 157144 04/15/2023 1000 Washington Street -Suite 710 ANDREW TARABELLI Boston,MA 02118 ANDREW R.TA4ABELLI 55 RIVERSIDE ROAD,UNIT 1 ��/• MASHPEE,MA 02649 Not valid without signature Undersecretary • • y1 • Commonwealth of Massachusetts Division of Occupational Licensure Vr Board of Building Re viptions and Standards ConskAitiOn Aillv.)rvisor CS-031105 1.4 I EStpires:04/27/2024 ERNEST S VatG1 4 ',IV I:• PO BOX 110V. MASHPEE 144,0 ' t 4Pot.i.var.v33 Commissioner da,ik • •