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HomeMy WebLinkAboutBLDR-2312760 ONE & TWO FAMILY ONLY- BUILDING PERMTT Town of Yarmouth Building Department 1146 Route 28,South Yarmouth,MA 02664-4492 -lti/e* \ 508-398-2231 ext. 1261 Fax 508-398-0836 i 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 c E ' V C Building Permit Number: Lb IL— 07 c Applied: ,w- -RA1s 6''6-,‘3 ruN2o23 Building Official(Print Name) ign tore Date SECTION 1:SITE INFORIVIATION BUILDING DEPARTMENT r iY - 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers f i_I L L a.k e , Yaikoutly t it 1,.1 J 2- 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: Zone: _ Outside Flood Zone? Public 0 Private 0 Check if yes❑ Municipal❑ On site disposal system 0 SECTION 2: PROPERTY OWNERSHIP` 2. Owner'of Re ord: Name(Print) City,State,ZIP No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ I Existing Building❑ I Owner-Occupied ❑ I Repairs(s) 0 Alteration(s) El I Addition 0 Demolition ❑ Accessory Bldg. 0 Number of Units Other ❑ Specify: Brief Description of Proposed Work': CC t, -(►1.;fi.l,LC1 ties, 4 pL& irc ce, SECTION 4: ESTIMATED CONSTRUCTION COSTS. Estimated Costs: Item Official Use Only (Labor and Materials) . 1.Building $ 1 50 0_ I. Building Permit Fee:S It. () Indicate how fee is determined: ®I Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ ,,/� 4.Mechanical (HVAC) $ List: .3j-r 0a '�lj/,�'J�R 1 ' 1�\�} 5.Mechanical (Fire $ ... . . � Suppression) Total All Fees:$ Check No. Check Amount: Cash unt:J -T . 6.Total Project Cost: $ 11 g(7 A, ID Paid in Full IC Outstanding Balance ue: C J 5ti9� SECTION 5: CONSTRUCTION SERVICES 5.1Construction Supervisor License(CSL) l/0 i i o f O r t✓ (IN(IP License Number Exp ration Date Name of CSlolder 3,3 t l a ` (ttrr et List CSL Type(see below) No.and Street Type Description /� U I Unrestricted(Buildings up to 35,000 Cu.ft.) Aci Yarik,o(AA-, /16 0 a�/,Y�� R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry . 0 P._3 9 4_ n/32 • RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances Pu rc Qui/ (r( l.c, r^p nn) I Insulation ephone f (✓ Email address D I Demolition 5.2 Registered Home Improvement Contractor(HIC) J ri Orr e '1/co/os/ C HIC Registration Number Ex irat on Date HIC Corrippniy,NamettHIC Regis Name akkut Lit rr 6orga6/6 (nu d Street p J Er4.il address cf. YanUirEkCity/Town, State,2'P Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFF DAVIT I.G.L.(D' c.1.52.§ 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 G COrc e , ail l f/ I n.C, to act on my behalf,in all matters relative to work authorized by tbislbuilding permit application. 6aJ'e d'ee a. euckt° / 1,3j23 Print Owner's Name(Electronic Signature) Dat • 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. G ee r e Z ct,v(j G 101,2,3 Print Owner(or Authorized Agent's Name(Electronic Signature) Da 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 I-IIC Program can be found at www.mass.cov/oca Information on the Construction Supervisor License can be found at www.mass.aov/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" o�'Y`gR TOWN OF YARMOUTH o BUILDING DEPARTMENT o yt 1146 Route 28, South Yarmouth, MA 02664 MATTA 508-398-2231 ext. 1261 Fax 508-398-0836 �OWYito� I Q BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G.L. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section 111.5, I hereby certify that the debris resulting from the proposed work/demolition to be conducted at (L 'QsK 1/ Ir(,r ti..(S a th,pnre Work Address Is to be disposed of at the following location: d� FXC n Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. I 1,21 ZJ Signature of Application Da e Permit No. The Commonwealth of Massachusetts 1ill1= G Department of Industrial Accidents ;1e► 1 Congress Street, Suite 100 Boston,MA 02114-2017 •�t 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): G eo e. 3wt r1 I tc. Address: 33 No r tL ltaun, J'trat City/State/Zip:A(.t tlik. y(I,ru..0al-kJ to Oc.G 4Phone#: y of,`7,q -or a Are you an employer?Check the appropriate box: Type of project(required): 10 am a employer with 13 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 8. aRemodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 10 Q Building addition 4.❑I 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 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q 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. tContractors 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. �/1 Insurance Company Name: A JJJO 0(At((L Tit (L Ptr( l>.V E &t! ,i.ra.h.0(, Policy#or Self-ins.Lic.#: () C 1 5 OOI O I J 9 Q a.©V1 Expiration Date: 3 I SI g. Job Site Address: a M L LL �,ax L City/State/Zip: Ya YI n.OtJl.l.ho art 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Cp Ji 0/3 .3 Phone#: 'Op- ')1G -1460 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other_ Contact Person: Phone#: June 13, 2023 Town of Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 Re: permit authorization for: 2 Mill Lane Yarmouthport, MA 02675 I, Andrew Maker, as owner of the subject property, hereby authorize George Davis, Inc. to act on my behalf,in all matters relative to work authorized by this building permit application form for the above referenced property. 6 f 0/24Z• z, ignature Date Print Name Z \i 11 L.a.n e .0 Y `T" 4 Mh It':' 1 . •\ 'i ; ,i'"t i i • It:SZ:11, i ' I I 1 :1" :$.1- . `# f':` S s r 4 f cl ,-1-...!1 ';',AS . :;' ,g ` ii.\ _ ,, , w, ,..: . 1K. � + Ig = 1 W' ► I I r as , i ... k r. #111ti '.'.1 .l' . M! I i N 7 g.. ^ • gar v '. .it•,:;',',„ -::,,,,... 4 . .: :11 ,-.4., 4 . 4 i .s: , , ‘,, ..? i . , • - ,;., l _i. \\ , ''.*- Ikt 1 y t+F . ii z. li i ,,, . ,,,,,, i 1 3 r 1 ,#d , i., . ,. L • r yY (i7 ; (i 1"'" lit r' 1 ' �aJ(& C9 0,1v.,j5)- �0? .•. \.,: �� *. + y ' •,,, \ or ,,, ,,„ ,.. 1 � ,�� dr-*A \ 111 \„ I F . WiiIY • 1 , r5.tp, , _ .. .` f 4' t i . 1 - .:. t -: i'. ,4. ..;,. 4.., ... \. y,,,, A R ''s;/ I'i , -: , z t Ali.; ' l 't r ti- f. • } �� i• t, . '', e: ' ,i, :`.- 4 .. ,.. .,. ,, , .e .` ,i ,;i.,,i,,,, \ . ti, . . •�/ • � " . 47 I 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: tr Office of Consumer Affairs and Business Regulation T�reF::�o`tporaUot� 9 Registratidnm.. -Expkrahon 1000 Washington Street -Suite 710 (6� 332U Boston,MA 02118 GEORGE DAVIS,INC., k:l14. GEORGE F.DAVIS i ` ;r~ i�? 33 NORTH MAIN STREEJ, =� � ,+ ��,X,,,,'�,. ,�Gfo,�i" SOUTH YARMOUTH,MA`06, Y;ti,r Undersecretary Not valid without signature 41 Commonwealth of Massachusetts Construction Supervisor ® Division of Occupational Licensure Unrestricted-Buildings of any use group which contain Board of Building R.e ulations and Standards less than 35,000 cubic feet(991 cubic meters)of enclosed Constid IS`4kervisor space. CS-056130 Bard res:03101/2025 1 GEORGE F DD1V1S 33 N MAIN SV SOUTH YARIdpUTH'. ,> •4. OIJ�d?O 3 rifFailure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Commissioner clad Y611 ita. For information about this license Call(617)727-3200 or visit www.mass.gov/dpl A CCPR L CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 3/7/2023 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(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: RogersGray, A Baldwin Risk Partner PHONE _ FAX 410 University Ave (A/C.No.Ext): 800-553-1801 (A/C,No):877-816-2156 Westwood MA 02090 ADDRESS: mail@rogersgray.com INSURER(S)AFFORDING COVERAGE - NAIC# License#:PC-514062 INSURER A:Western World Insurance _ 13196 INSURED GEORDAV-01 INSURER B:NGM Insurance Company 14788 George Davis, Inc. 33 North Main St. INSURER C:Associated Industries Insuranc _ 23140 South Yarmouth MA 02664-3437 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1602357243 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 POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY NPP8016556 1/12/2023 1/12/2024 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED _ CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $100,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY PRO- JECT LOC PRODUCTS-COMP/OPAGG $2,000,000 OTHER: B AUTOMOBILE LIABILITY M9M28491 10/26/2022 10/26/2023 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED x SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ C WORKERS COMPENSATION WCC50050143902023A 3/5/2023 3/5/2024 X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y N ANYPROPRIETOR/PARTNER/EXECUTIVE N NIA E.L.EACH ACCIDENT $500,000 OFFICER/MEMBEREXCLUDED? (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/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 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. Evidence of Insurance AU D REPRESENTATIVE i 7/ D ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD