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HomeMy WebLinkAboutBLD-23-10024 ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department r'"ort r 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- airily Dwelling This Section For Official Use Only Building Permit Number: SC 23-caa(03 Date Applied: RECEIVED t r- O 5 18- 1-40-08 2023 Building Official(Print Name) S ature SECTION 1:SITE INFORMATION g�iL01PJd nd.FAf�TMEN1 1.1 Pro erty Address: 1.2 Asse sors M p&Parcel Numbers sr 1.1a Is this an accepted street?yes )C no Map Nu ber Parcel Number 1.3 Zoning Informatioik_c 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 0 Private 0 Zone: Outside Flood Zone? — Municipal❑ On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' n� N.TR_Owner' tZ of ecor�dl KW CA&Kb.) V c 00Z-I Name(Print) City,State,ZIP 2 kbOSIG Cam ' 111 toss "V23 IQ kit No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK' (check all that apply) New Construction 0 Existing Building 0 Owner-Occupied ❑ I Repairs(s) Alteration(s) g Addition 0 Demolition ❑ Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed War Z: Q(2evikaos ez_ ( ( U1 i2-tV ' ( LM - L-Yl l,L Re ( tom Pc ol�J uQ `�- 62. 9tf tAJAc Kt-moo) `5Pti�2.l6Q_/( t i Sl`bleRvCt42 SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) �-�,'• 1.Building $ 1. Building Permit Fee:S` e, Indicate how fee is determined: 2.Electrical $ IliStandard City/Town Application Fee ❑Total Project Cost3(Item 6)x multiplier . . x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: • 5.Mechanical (Fire $ Suppression) Total All Fees:$ — Check No. Check Amount: Cash ount: . 6.Total Project Cost: $ - ❑Paid in Full NJ Outstanding Balance ue:4 to (1l1V • •• a U ;O. YA$4 • • • • 4 • k • ' SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) ketOti ItIZ4 ..) M l- License Number Expiration p to Name of CSL Holder I!_ C�� � List CSL Type(see below) U �—�2 No).and Street Description AWSTo S rj5 026tE$ 410 Unrestricted(Buildings up to 35,000 cu.ft.) _ City/Town,State,ZIP Restricted 1&2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding Grp /� SF Solid Fuel Burning Appliances '7ft f0 ( m a. w,,,6 .Q8✓'l I Insulation Telephone Email address D I Demolition 5.2 Registered Home Improvement�C—ontractor(HIC) k� Z y12/211` �) Y 1 cam`'n. HIC Registration Nu er piraon Da tIIC Comp�y Nam )�C�Regi trant Name �^� No.and Street rn e t MARSH Mi US 0 0 1 b.& `' ' 1 Email address 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 IL No 0 SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRA R¶LIES F 0 • BUILDING PERMIT I,as Owner of the subject property,hereby authorize �1 A to act on my behalf,in all matters relative to work auth ' ed by t is uild' g:ermit applicatio -Aenve Muni "- E Z� 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. LOIEN AA, 't 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.mass.aov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dps 2. When substantial work is planned,pr a the information below: Total floor area(sq.ft.) 15 g01 (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" THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washingt S reRt - Suite 710 Boston, Massachusetts _02118 Home Improvement t)ntractor Registration Z MP Z Mil.lir= ^' , -...� '" Type: Individual Is �" — jR-- 'egis'tration: 163999 LOREN M FOSTER r"„‘ 1t E*pitation: 02/04/2024 16 CLAUS WAY lie a .ammmisomr _ MARSTONS MILLS, MA 02648 , �4 j�/+j�w 45 7c w S Update Address and Return Card. 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: TYPE:Individual Office of Consumer Affairs and Business Regulation Registration— Expiration 1000 Washington Street -Suite 710 1q3 99 . 02/0— 4_ 4/202.4 Boston,MA 02118 'LOREN M FOSTER f" L► ,_ :..tt LOREN FOSTER S * /� `. V 1. 16 CLAUS WAY `$, 4,,,,,,,ra.e,l,(0,4. MARSTONS MILLS,MA 02; —y.,-, Undersecretary Not valid without signature 5/8/23,7:06 AM Details I Licensee Details Demographic Information Full Name: Loren M Foster Owner Name: License Address Information City: MARSTONS MILLS State: MA Zipcode: 02648 Country: United States _ License Information License No: CS-106874 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 8/31/2022 Issue Date: 4/11/2013 Expiration Date: 8/15/2024 License Status: Active Today's Date: 5/8/2023 Secondary License Type: Doing Business As: Status Change Reason: License Renewal Prerequisite Information No Prerequisite Information No Available Documents Commonwealth of Massachusetts e# I •Division.of Professional Licensure v s - . • J. Boardof Building Regulations and Standard Constr9ctro'� S# rrisor y !p CS 106874 t lc 1pires:08115/2022 LOREN M FOSTER ;'. 16 CLAUS WAY C MARSTONS MILLS MA 02648 ` I'OIS"i13 Commissioner c K" tr https://madpl.mylicense.com/Verification/Details.aspx?result=fa7e9188-7762-4734-b3cb-9c03fa135d9b 1/1 • '� The Commonwealth of Massachusetts �plor,=,.. l .Department ofIndustrialAceidents 1 Cong}'ess Street, Suite 100 ~ , =,' ?_�� Boston, MA 02114-2017 ,r'•'y www.mass.go v/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): F.P ( J( -tDik) Address: < A200k) CP<c City/State/Zip: 5, 'f O ZIY L - Rhone #: SO' fl7S Are you an employer?Check the appropriate box: Type of project(required): IJi am a employer with ISO employees(full and/or part-time).* 7. Q 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.E I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9 El 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.E 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.❑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. 14.0 Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box R1 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: Ar2a(k) vt6c- vt, Gab( U,--Li 1 esve- Policy#or Self-ins.Lic.#: Z )6 A Expiration Date: 1 1 \ Z©Z tf Job Site Address: 300 ' 1e- `S } 1� ( �' '�c�' �'ga W City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number 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 erjury that the information provided ab a is ue and correct. Signature: (Ni� � w C� /�— Date: 5 $ 2-"S Phone#: SCE UZS 6 ec--/I Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License r Issuing Authority(circle one): I.Board of Health 2. Building Department 3. City/Town Clerk 4.EIectrical Inspector 5. Plumbing Inspector 6.Other - Contact Person: Phone#: ® A'`er"-CCPR o CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. 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 RogersGray, Inc-Kingston Branch CONTACT NAME: 434 Route 134 LaPHONE South Dennis MA 02660-1601 _ c.No,Etc j;800-553-1801 FAX No):877-816-2156 E-MAIL ADDRESS: mail@r0 BrSgray,COm INSURER(S)AFFORDING COVERAGE NAIC# INSURED — INSURER A:Arbella Protection 41360 E. F.Winslow Plumbing&Heating, Inc. EFwINSL01 INSURER B;Arrow Mutual Liability Insuran 13374 8 Reardon Circle INSURER C: South Yarmouth MA 02664 INSURER D INSURER E COVERAGES INSURER F: CERTIFICATE NUMBER:1778671040 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE ROLICY 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. 1NSR' ADDL SU RI LTR TYPE OF INSURANCE IN�WVD POLICY NUMBER POLICY EFF POLICY EXP ---- A X COMh1ERCIALGENERAL ABILITY y 1 (MM/DD/YYYY)-(MM/DD/YYYY) LIMITS 18500069272 12/1/2022 12/1/2023 __ -I CLAIMS-MADE I X I OCCUR I EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED PREMISES(Ea occurrence) A 100,000 MED EXP(Any one person) $10,000 PERSONAL$ADV INJURY $1,000,000 GE_N'L AGGREGATE LIMIT APPLIES PER: — POLICY X]JECO7 X +LOC I ! GENERAL AGGREGATE $2,000.000 PRODUCTS-COMP/OP AGG $2,000,000 1 OTHER: A AUTOMOBILE LIABILITY $ Y 102007840205 12/1/2022 12/1/2023 COMBINED NGLE LIMIT ANY AUTO (Ea accident)SI $1,000,000 OWNED X SCHEDULED BODILY INJURY(Per person) $ l_— AUTOS ONLY AUTOS X HIRED NON-OWNED BODILY INJURY(Per accident) $ AUTOS ONLY I X AUTOS ONLY PROPERTY DAMAGE !i (Per accident) A x i UMBRELLA LIAB $ I— X I OCCUR 4620088355 12/1/2022 12/1/2023 t I EXCESS LIAB I EACH OCCURRENCE $2,000,000 _ _ CLAIMS-MADE I 1 DED I X RETENTIONS 1nJtnn AGGREGATE 52,000,000 B WORKERS COMPENSATION 2019A $ AND EMPLOYERS'LIABILITY 1/1/2023 1/1/2024 X PER OTH- ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N STATUTE ER IOFFICER/MEMBEREXCLUDED? N N/A E.L.EACH ACCIDENT $500,000 _ (Mandatory In NH) I!f yes,describe under E.L.DISEASE-EA EMPLOYEE $500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 1 Plumbing&Heating Contractor. Central Vacuum is a division of E F Winslow Plumbing&Heating Inc. When Required by Written Contract the Following Applies: General Liability-Additional Insured Ongoing(30AP2195 04 21)and Completed Operation(30AP2195 04 21) Primary and Non-Contributory Basis(30AP2195 04 21),Waiver of Subrogation(30AP2195 04 21) AWorkers utomobile-Additional Insured,Primary and Non-Contributory Basis,Waiver of Subrogation(26AP1034 11/19) sement#4) Exc ss/UmbrCompensation lla—s Additional insured followsi form over ion runderlying General Liability and Automobile Liability No Residential Exclusions 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. AUT T ORIZEDREPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-22301 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 U vT —7r conducted at 3c-r, \sL� D \42 t-r1-1 Work Address r-- Is to be disposed of oat the following location: lOv t � h' Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. UC)„_ Ocl k-z3 Signature of Application Date Permit No. ONE or TWO FAMILY— BULDING PERMIT APPLICATION REGULATORY APPROVALS NOTICE (A) Val2,'Y\0 t-� Address of Proposed Work: GuGL_ tSU4f\D (2-D OK) Scope of Proposed Work: CVSconfleY� 6 f4 N 7(2--1L 1F'1r k - Pcf2s-, Coil q_kiS c n o s Date: 5j Cs 23 Based on the scope of work described above, the applicant is required to obtain approval sign- offs from the following departments as checked-of below: Health Dept. —508-398-2231 ext. 1241 Conservation —508-398-2231 ext. 1288 Water Dept. —99 Buck Island Road, 508-771-7921 Old Kings HWY. Hist. Comm. —508-398-22631 ext. 1292 Engineering Dept. —508-398-2231 ext. 1250 Fire Dept. — Kevin Huck/Scott Smith, 96 Old Main Street, SY Note: Please call Fire Department for an appointment. 508-398-2212 Other Appropriate plans and/or application shall be provided to each departments checked-off above. Each of these regulatory authorities has their own requirements outside the jurisdiction of the Building Department. All applicable approvals shall be obtained prior to submitting a building permit application to the Building Dept. Thank you for your cooperation. Receipt Acknowledgement: _ Applicant's Signature Date Rev. Jan. 2019