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HomeMy WebLinkAboutUntitled COMMERCIAL ONLY— BULDING PERMIT APPLICATION REGULATORY APPROVALS NOTICE 4 trio cif//.5-EA S IQ e Ili A5 e, Address of Proposed Work: 135 SOUTH SHORE DRIVE UNIT 34 ( FREE STANDING COTTAGE) Scope of Proposed Work: Renovation of FULL bathroom keeping same floor plan. Interior work only of replacement of wall board after removing tile from walls. Date: (3. 1) • 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: NA Health Dept. —508-398-2231 ext. 1241 NA Conservation—508-398-2231 ext. 1288 NA 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. Receip Ac d8ement: CARLOS H FIGUEIROA 'App ant's Signature Date Rev.Jan. 2019 • • .:: T _,.. ,. ....,..r. .., . ....• . t., L4-.�. 3 --N 0 T `e • A ` ' A N � O G . I A L: - - C I•.A !' ' d C O P Y C . ! pG .Q • {1 !! tr7 ''��- K•'N O T N O T.....0/. • I t r- A N ' v A N r f t-t-- n O .F F I C I A "�la >c F I C L -` <; ` y� v OPY COP ( 7 8w �2R fcm. j .� �' lil Tll/_c ` wt. t4. `y Al 1 1 q`lie: 4.i' , .. ,•. . i 1 Asa •• rt. v "An- t ::4} \ • ): `An.. rrilb.m 2 . 6 ". t Q 44 ; 4.�p•.. 2 ' 'A .._i J �a,i' 0 i.f, _ 3 b ;� 13tt;p QopM • P S ; / I%.r111.l 07 7;1 .w.t..., ;Ii e - R EVIED FOR EL,LD,�,,,AND ZO1.l.;C C0OP Of %N i ANTE. ERRORS OR O!:,,',?;SS'0',3 GO P:C1"f, LSE E T <t; At r L;CA VT FROP,1 THE RcSr 0%S!,?LITY 0 'A5 EilIL COMPLIANCE. -.� �t. DATE: 1�-�� =r: C.c> 1 a q..L �w w C .G C�r c i. .� YARNOuTH S LA*ILK. VN .LAGS. G40*J04Mlylu, iiut�.omia. "0 u+.1rr 34 Z 64ouTN' YARI 1 04.1TH• 44A.ill4.. AuauAT 2.4 i9 i4 :i• ct z.s c 1� G;'.:. • Sru►►. . f as Yts'T k i? - !Ca.error-nark-Tr•1 is PL Au 544mArs bt.a ,. O utulr 3 4- se,.Ja c4a.,v¢YGp A..10 111C-IMMC.D, i..Ly Al)Jo',J I&J i u 4..ma, Au ca'rum- rr ct..w ALI i> - ACaJ ATE.1.Y CLJ'lcrsTl•6C. 1.J.N?bt1TLoc./mm.1{1)4mas.164- - A1�OQati..Aar...., ; MA�..t iw1TQJ►wlCf� Iwo {MMiXtp(A�: WS#iw Ow. "LEA. 'S . a.1 �`�+ ' �.•- AGGf b1<. A.i tttlu.-T. sy i ''''71 I t• •le$4 1 Cr}q� \ �.� ¢''r_ • ,f.A `�i�lal►7-e,rwll�.f . .lai . `,�, ,u dam:; .. . a , ifej7(k4 /7 IC( F'Y., BUILDING PERMIT APPLICATION --------------- . a �0 APPLICATION TO CONSTRUCT REPAIR, RENOVATE, CHANGE THE USE,OCCUPANCY �l 1.-..4 OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING OF,Town of ''Yarmouth Building Department MATT�.0 PI ,A'. 1 I-Ifi Route 28 • Yarmouth, MA 0266-1-1-492 Tel: 508-398-2231 ext. 1261 Fax 508-398-0836 �Q✓l Office Use Only Planning Board Information Assessors Department Information: Pe mtt Na.23-COA2.%Date Plan Type- Map Lot Permit Fee $ 15�! Endorsement Date I C 3 Li Recording Date New Deposit Rec'd. $ 3 5:aate 111�/2' Plan No. 1.4 Property Dimensions: 7 �� I Net Due ! Jother d•t• d� 1 y Lot Area(st) Frontap I nt Pnwarage F CE -1 D This Section for Office Use Only �, Building Permit Number. Data Issued: Certificate of O i N- 2023 Signature: /_ p cY I Building 0 'ai Date is Is not RI 111 ntAfliti PARTMF4T Section 1 - Site Information BY — 1.1 Property Address: 135 SOUTH SHORE DRIVE UNIT 34 1.2 Zoning Information: COTTAGE) R-3 RESIDENTIAL CONGO Zoning District Proposed Use 1.3 Building Setbacks(ft) " (NO CHANGE NA) L 4,,V,p 0 Front Yard I Side Yards - I Rear Yard Required Provided Required j Provided Required 1- Provided I 1.4 Water Supply(M.(1.L c.40.S 54) 1.5 Flood Zone Information: Comments Public Private Zone: BFE Section 2- Property Ownership/Authorized Agent' • 2.1 Owner of Record; NANCY MILLER ANDRIC TRUSTEE 5 NIPPENICKET TRAIL SOUTH EASTON MA 02375 Name(print) Mailing Address: S'avgAn4`liiett 4L4'144 yi La t eti 508-207- 3887 NANDRIC@COMCAST.NE Signature Telephone Telephone I / 2.2 Authorized Agent:1 Email Address: CARLOS H FIGUEIROA • 348 CAMP STREET UNIT F2 Ham*(print) Mailing Address: 608 237 9592 CHFIGUEIROA2002@HOTMAILCOM Signature Telephone Fax Email Address: j Section 3 - Construction Services 3.i licensed? Ds Supervisor. Not Applicable D CARLOS H r-�t�u�r��i�' SEE ABOVE AGENT AND SUPERVISOR SAME License Number Addre � 104107 08-237-9592 CHFIGUEIROA2002@HOTMAI. CWeiration Date S natu Telephone Email Address: 08-25-23 y3.2 Registered Home Improvement Contractor:I j Company RENaM1ODELING INC INotApplicabfe ❑ (I Address Registration Number j 20 CAPTAIN NOYES ROAD SOUTH YARMOUTH MA 02664 153792 Eiration Date I Signature Telephone 01/07/2023 • Section 4-Workers'Compensation Insurance Affidavit(M,G.L c. 152 5 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 5- Professional Design and Construc:ion Services-for Buildings and Structures Subject Ito Construction Control Pursuant to 780 CMR 116(containing more than 35,000 c.f. of enclosed space) Section 5.1 Registered Architect Not Applicable D }Name(Registrant): Registration Number Address Expiration Date Signature Telephone r I I Section 5.2 Registered Professional Engineer(s) Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date i Hams Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility IAddress Registration Number Signature Telephone i Expiration Date I ` l Name Area of Responsibility Address Registration Number Signature Telephone l Expiration Date Section 5.3 General Contractor C & F REMODELING AND CARLOS H. FIGUEIROA Not Applicable ❑ Company Name CARLOS H FIGUEIROA Perspit8fl t¢U1 nSOUTH YARMOUTH MA 02664 Address Uss �1 508 237 9592 Signature Telephone l 1. LPr(3o ✓ orJj , Section 6 - Description of Proposed Work(check ali applicable)I New Construction D l (for multiple family only) No.of Bedrooms (for multiple family only) No.of Bathrooms Existing Bldg. D" Repair(s) l7 I Alterations 0 I FREE STANDING CO IAUE) D Addition ii Accessory Bldg. ❑ Type !Demolition J Other Specify:p fy: I � Brief Description of Proposed Work: RENOVATION OF EXISTING FULL BATHROOM WITH NEW WALLBOARD AFTER REMOVAL OF TILE FROM WALLS. INTERIOR WORK ONLY WITH VANITY AND TRIM, NEVV FLOORING, FIX I UNES, I RIM. t'1N1NT.NG PLUMBING AND ELECTRICAL DONE BY OTHERS IF NECESSAN( NOTE BUILDING PERMIT 22-005596 FROM 4/15/22 WAS FOR ANOTHER BATHROOM IN THIS C:U O ) 'Section 7- Use Group and Construction Type] Building Use Group(Check as;applicapable) Construction Type A ASSEMBLY D A-1 D A-2 D A-3 D IA ❑ B BUSINESS I D A 4 D A s D 19 D 2A D E EDUCATIONAL 1213 D D F FACTORY D F-1 D F-2 D 2C D i H HIGH HAZARD D + 3A I I INSTITUTIONAL j D I-1 D 1-2 D 1-3 D 38 D M MERCHANTILE D 4 D J R RESIDENTIAL D R_1 D R-2 D R-3 0 5A D S STORAGE I D U UTILITY I D - �1 D 5-2 D s8 D SPECIFY: M MIXED USE I D SPECIFY: S SPECIAL USE , D SPECIFY: I Complete this section if existing building undergoing renovations,additions and/or change in use. 'Existing Use Group: RESIDENTIAL CONDO Proposed Use Group: NONE I Existing Hazard Index 780 CMR 34 Proposed Hazard Index 780 CMR 34 Section 8 Building Height and Area Building Area Existing(if applicable) Proposed Number of floors or stories irclude basement levels Floor Area per Floor{sf) Total Area All Floors (sf) Total Height (ft) 'Section 9 - STRUCTURAL PEER REVIEW (7B0CMR 110 11) Independent Stuctural Engineering Structural Peer Review Required Yes No SECTION 10a OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNS" • - • :` - !k TRACTOR APPLIES FOR BUILDING PERMIT SEE ATTACHED , 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. Signature of Owner Date • SECTION 1Ob OWNER/AUTHORIZED AGENT DECLARATION I, CART OS F-1 FIGUEROA AGENT AND CONTRACTOR 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. CARLOS H FIGUEIROA • Print Name •12/17/2022 • n e of Owner/Agent Date !Section 11 - ESTIMATED CONSTRUCTION COSTS Item • Estimated Cost(Dollars)to be completed by permit applicant 1.Building 3,500.00 2 Electrical 3.Plumbing/Gas 4.Mechanical(HVAC) 5.Fire Protection • 6.Total=(1+2+3+4+5) 7.Total square Ft.)tor xtawSrn s a abddaone) ! $3,500.00 Check Below ❑ Conservation-Commission Filing (if applicable) ❑ Old Kings Highway&Historical Commission approval (if applicable) STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION FOR A BUILDING PERMIT Date: /Z-/1- I a 22, 1,NANCY MILLER ANDRIC Trustee own the property at 135 South Shore Drive Unit 34 in South Yarmouth ,MASSACHUSETTS I have authorized C& F Remodeling and Carlos H.Figueiroa to act as my agent to apply and obtain a building permit from the Town of Yarmouth Building Department in accordance with 780 CMR the Massachusetts State Building Code. SIGNATURE OF OWNER NANCYANDRIC %1" OWNER'S ADDRESS 5 Nippenicket Trail, Easton, MA 02375 OWNERS EMAIL: NANDIC@COMCAST.NET OWNER'S TELEPHONE 508-207-7887 C&F Remodeling inc and Carlos H.Figueiroa: address 20 Captain Noyes South Yarmouth MA COMMERCIAL ONLY— BULDING PERMIT APPLICATION REGULATORY APPROVALS NOTICE )1,44Mau1//S4 5f4a ✓i/ it Address of Proposed Work: 135 SOUTH SHORE DRIVE UNIT 34 ( FREE STANDING COTTAGE) Scope of Proposed Work: Renovation of FULL bathroom keeping same floor plan. Interior work only of replacement of wall board after removing tile from walls. Date: lb( (3._ 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: NA Health Dept. —508-398-2231 ext. 1241 NA Conservation—508-398-2231 ext. 1288 NA 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. Receip jAc. *• . -dgement: �I � CARLOS id FIGUEIROA 'App ant's Signature Date Rev. Jan. 2019 /4C�® DATE(WOO/MY)`� CERTIFICATE OF LIABILITY INSURANCE 05/24/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY.4ND 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 Jenn Harney NAME: Leonard Insurance Agency,Inc PHONE (508)428-6921 FAX (508)420-5406 (A/C.No.Esti: (A/C,No): 683 Main Street E-MAIL ienn enc g y leonarda .com ADDRESS: @ Suite B INSURER(S)AFFORDING COVERAGE NAIC B Osterville MA 02655 INsuRER^: Evanston Insurance Company 35378 INSURED INSURER e: The Commerce Ins.Co. 34754 C$F Remodeling Inc. INSURER C: Associated Ind.Of MA-ARWC 26158 INSURER D: 20 Captain Noyes Road INSURER E: South Yarmouth MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: 22-23 Master 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. TN$R ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDD/YYYY) (MM/DDIYYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100,000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 A 3AA559242 04/15/2022 04/15/2023 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 PRO- POLICY JECT LOC PRODUCTS-COMP/OPAGG $ 2.000,000 OTHER .$ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ 250,000 B OWNED X SCHEDULED RVM277 01/18/2022 01/18/2023 BODILY INJURY(Per accident) $ 500,000 AUTOS ONLY AUTOS PROPERTY DAMAGE $ 250,000 NON -OWNED HIRED 'se O Y X AUTOS ONI Y (Per accident) Medical payments $ 10,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER vIN 1,000,000 C OFFICERANY PROPRIETOR/PARTNER/EXECUTIVE MEMBER E N N i A WCC-500-5018589 2022A 04/30/2022 04/30/2023 E.L.EACH ACCIDENT $ In NH) EXCLUDED 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 1,000,000 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) 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 POUCY PROVISIONS. AUTHORIZED REPRESENTATIVE MA 02601 15-� t- /1 1� ' �'t-" I VV ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration u rM Type: Corporation C F REMODELING INC s 1 111.111,Ab . Registration: 153792 Expiration: 01/07/2025 20 CAPTAIN NOYES RD. 5 S.YARMOUTH, MA 02664 . o .16 �'1.10� 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:Corporation Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street -Suite 710 153792 01/07/2025 Boston,MA 02118 C&F REMODELING INC 7-1 pl CARLOS H.FIGUEIROA r3'- 20-CAPTAIN NOYES RD. '<ed•W6i. S.YARMOUTH,MA 02664 Undersecretary Not valid without signature •• .. 70 l'. : "'''„' LS 3 • ✓ La.3. as '�N O T `e A ` ' A N J . COPY C i ! • w; < T• M N O T N OT `1 19 AN AN I i : n O .FFICIAL-'"'Na JF IC L -_ '-: COP 4•.0PY. \ `.. ................. .i t.,r • . r'l kl ; : I ip tt a • $ r3ha� EOM • • el' ^' V. II t - �"'ED FOR Ei;!LD!!;5 AND CODECI `:iPt x APB . ERRORS OR O?,-;sS'0'dS DO N t FEL ET All GCANT FROM THE R�EFG�;S!O U � TY OF'AS�JIL s • COMPLIANCE. Is.-I,,• DATE: q-11. • C' ,.L. .G CFFCIAL YAQNou'rN $LA*Ib(. v�.*4$. C MoiikVU'di y.* itu11 $PJa. 0- u+Jrr , 34 1 .ra (ticsuTN' YokiLmouTN,'MAAI►. F. "GAO—IL Imo. 6' Auauer ZA.IQt4 c; Z•S S of; =; L,�.u� su scut. Ct 7q.. T 4'.r I 4TiloY T►W Ticea PLAW f4IO,W5, b..ab• p i' LJ/,11T 34 KJtJG CAMv+GYGt+ AIJO THE. IMf DIATLLY ADJonJIa ka u►.;R`L, 4WD Ni-.AT rr it..'- ' A&4D Ac.cue.A-ru.Y DtLn T+•I PiE. I.A.,TOItT�LA *, o�.1 cbI MOJ.1%. ADc Qtr...ALEA, •••• MAI,J �,,p/T'Q, g. *a.10 I' teiWtA•7c. CO iwIQ ALLA �S ,ir,. �tAC•C-L�, Li �4,.T. , Cw�► YHarr � t jA,� C. . '`L r +:1•IIL rrC✓3 •` II `!�i ' - �,l�t'J iliMM • . 04-•-'-9,,e BUILDING PERMIT APPLICATION ---------------- • �c) APPLICATION TO CONSTRUCT REPAIR, RENOVATE, CHANGE THE USE,OCCUPANCY OF, Q `c OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING. Yp_ rra`cncts' `r Town of Yarmorith Building Department c�` 1146 Route _S • Yarmouth, MA U2664-4492 Tel: 508-398-2231 ext. 1261 Fax 508-398-0836 Cam- Jtfice Use Only Planning Board Information 1 Assessors Department Information: Pe Permit ho.�3-4 ate Plan Type Map lot I Permit Fee $ I 5-0 Endorsement Date w '1 f C _3 "/ _ Recordin5 Date New I Deposit Rec'd. $ 3 7. ate //Cf2 1.4 Property Dimensions:N Plan Na. a-� f Net Due `' I° -1 ther C e ti' J d\C)\ 1! Lot Area(sf) Frontag This Section for Office Use Only —� . I V D Building Permit Number. Data issued: I • Certificate of Oct p �23 I Signature: _ r% / / BuildingO cis! Date is !snot Rul1 n��pARTM NT [Section 1 - Site Information, °y 1.1 Property p rty Address: 1.2 Zoning Information 135 SOUTH SHORE DRIVE UNIT 34 COTTAGE) R-3 RESIDENTIAL CONDO Zoning District Proposed Use 1.3 Building setbacks(ft) - (NO CHANGE NA) C.cliki D a Front Yard j Side Yards ' Rear Yard Required Provided Required j Provided Required quired 1 Provided I 1_4 Wateri BupPhr(11 1.L-a-40.3 54) 1.5 Flood Zone information: Comments Public Private Zone: BFE • Section 2 • Property Ownership/Authorized Accent 2.1 Owner of Record: NANCY MILLER ANDRIC TRUSTEE 5 NIPPENICKET TRAIL SOUTH EASTON MA 02375 Name(print) Mailing Address: 3'cgAn4;. 1ect. Ai.) 144,/ za II eP• i 508-207- 3887 NANDRIC@COMCAST.NE Signature Telephone Telephone T Email Address: 1 2.2 Authorized Agent:l CARLOS H FIGUEIROA 348 CAMP STREET UNIT F2 Name(print) Mailing Address: 608-237-9592 CHFIGUEIROA2002@HOTMAILCOM I Signature Telephone Fax Email Address: ! Section 3 - Construction Services 3.1 l teOnasd?I ilEif f Supervisor. Not Applicable ij CARGOS h U SEE ABOVE AGENT AND SUPERVISOR SAME License Number -X Addre t 104107 '� 08-237-9592 HFIGUEIROA2002 HOTMAI. C C @ iVpiration Date S' natu e Telephone Email Address: Oa 25 23 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 ,• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): CARLOS H FIGUEIROA C&F REMODELING Address:20 CAPTAIN NOYES ROAD City/State/Zip:SOUTH YARMOUTH MA 02664 Phone#:508-237-9592 Are you an employer? Check the appropriate box: Type of project(required): 1.E 1 am a employer with 2-4 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ i am a sole proprietor or partner- listed on the attached sheet. 7. ® Remodeling 234T1J °oti ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' P h' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] fi c. 152, §1(4),and we have no employees. [No workers' 1321 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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 i.s providing workers'compensation insurance fur no'employees. Below is the polic►'and job site information. Insurance Company Name:ASSOCIATED IND. OF MA ARWC Policy#or Self-ins. Lic. #:WCC-500-5018589-2022A Expiration Date:04/30/2023 y4 erlat)1W SE,iii,r Di/l g Job Site Address: 13 C 5°u Zcr 5 4 ° 1 p'. Uri. 3 y City/State/Zip: f 1/4/Pisorsii 1-14 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that 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 perjure that the information provided above is trite and correct. Signature: Date: a-h0/22— Phone# 508-237-9592 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority(check one): i❑Board of Health 212 Building Department laity/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.DOther Contact Person: Phone#: §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-223!1 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 135 SOUTH SHORE DRIVE UNIT 34 Work Address Is to be disposed of oat the following location: TOWN OF YARMOUTH LANDFILL Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. 12/17/2022 Signature of Application Date Permit No. Property Location 135 SOUTH SHORE DR UNIT 34 Map ID 19/1/C34// Bldg Name State Use 1020 Vision ID 1124 Account# 1124 Bldg# 1 Sec# 1 of 1 Card# 1 of 1 Print Date 8/12/2021 2:47:18 PM CURRENT OWNER - TOPO UTILITIES STRT/ROAD LOCATION CURRENT ASSESSMENT MILLER JOHN L SR TLevel 'fPublicWater —1—Paved Recreational Description Code Assessed Assessed 815 6 Septic 7 Waterfront RESIDNTL 1020 317,800 317,800 5 NIPPENNICKET TR SUPPLEME'VTAL DATA YARMOUTH,MA Alt Prcl ID 15/E005/34// VOTE MISC 171 VOTE DAT SOUTH EASTO MA 02375 CHANGES PRIVATE BETTERM PLAN NU VISION ZIP CODE 2664: GIS ID M 307207 821950 Assoc Pid# Total 317,800 317,800 RECORD OF OWNERSHIP BK•VOLJRA GE SALE DATE / VAT SALE PRICE VC PREVIOUS ASSESSMENTS(HISTORY) MILLER JOHN L SR 347914 0 10-23-1984 U I 0 Year Code Assessed Year Code Assessed V Year Code Assessed MILLER JOHN L SR 0 I 0 2022 1020 317,800 2021 1020 289,000 2020 1020 251,500 Total 317800 Total 289000 Total- 251500 EXEMPTIONS — DER ASSESSMENTS This signature acknowledges a visit by a Data Collector or Assessor Year Code Description Amount Code Description Number Amount Comm Int APPRAISED VALUE SUMMARY Total 0.00 Appraised Bldg.Value(Card) 315,400 ASSESSING NEIGHBORHOOD Appraised Xf(B)Value(Bldg) 2,400 Nbhd Nbhd Name - B Tracing Batch Appraised Ob(B)Value(Bldg) 0 0001 NOTES Appraised Land Value(Bldg) 0 YARMOUTH SEASIDE VILLAGE Special Land Value 0 hG (1)BR-LR COMBINATION+ Total Appraised Parcel Value 317,800 MOTEL CONDO BLD 0 UNIT#34 (1)BR Valuation Method C &34A CI=2.96% KITCHEN GAMBREL ROOF Total Appraised Parcel Value 317,800 BUILDING PERMIT RECORD VISIT/CHANGE HISTORY Permit Id Issue Date Type - Description Amount Insp Date %Comp Date Comp Comments - Date Id Type Es Cd Purpost/Result 998891 11-15-1993 950 100 REPLACE W 03-31-2020 WD 54 Field Review 01-30-2014 DK 01 Measur+lVisit 01-30-2014 DK 02 Measur+2Visit-Info Card I 01-01-2014 BH 01 1 CY CYCLICAL 2014 06-02-2004 GM 00 Measur+Listed 09-27-1995 JF 00 Measur+Listed 03-15-1994 nR 07 Maasnu4nf/f1r Info takan at LAND ' VALUATION SECTION B Use Code Description Zone Land Type Land Units Unit Price Size Adj Site Index Cond. Nbhd. Nbhd.Adj Notes Location Adjustment Adj Unit P Land Value 1 1020 CONDO MDL-0 0 SF 0 1.00000 0 1.00 0000 1.000 0.0000 0 0 Total Card Land Units Or BF Parcel Tota Land Area.bY0O Total Land Value 0 Property Location 135 SOUTH SHORE DR UNIT 34 Map ID 19/1/C34// Bldg Name State Use 1020 Vision ID 1124 Account# 1124 Bldg# 1 Sec# 1 of 1 Card# 1 of 1 Print Date 8/12/2021 CONSTRUCTION DETAIL CONSTRUCTION DETAIL(CONTINUED) Element Cd Description Element Cd Description Style: 60 Cottage Condo Model 05 Res Condo Grade 06 Excellent Stories: 1 1 Story Occupancy 2 CONDO DATA Interior Wall 1: 05 Drywall/Sheet Parcel Id 103626 I C 1303 Owne 0.0 BAS Interior Wall 2: 06 Cust Wd Panel Yarm Seaside jB 1 IS 5 f629 sf) Interior Floor 1 05 Vinyl/Asphalt Adjust Type Code Description Factor% Interior Floor 2 14 Carpet Condo Fir 02 >400SF 120 Heat Fuel: 04 Electric Condo Unit 100 Heat Type: 02 Floor/Wall Fur COST/MARKET VALUATION AC Type: 01 None BuildingValue New 394,230 Ttl Bedrrns: 2 Bedrooms Ttl Bathrms: 2 2 Full Ttl Half Bths: Xtra Fixtres Year Built 1945 Total Rooms: Effective Year Built Bath Style: Depreciation Code G Kitchen Style: Remodel Rating Year Remodeled Depreciation% 20 Functional Obsol 0 Ext.Comment 0 Trend Factor 1 Condition Condition% Percent Good 80 RCNLD 315,400 Dep%Ovr Dep Ow Comment Misc Imp Ovr iV 1 .. •'S' , •i.• ,r.. r ' 4 \ ' i ,•t +.9. Misc Imp Ow Comment •• ' r► Cost to Cure Ovr + 'a► Cost to Cure Ovr Comment . q r >i i OB-OUTBUI DING&YARD ITEMS(L)/XF-BUILDING EXTRA FEATURES(B) P . r Code I Description J UB 1 Units (Unit Price 1 Yr Bit I Cond.Cd I %Gd jGrade I Grade Adj" Appr.Value f , FPL1 FIREPLACE 1 B 1 2200.00 1995 80 0.00 1,800 -'4'' ' ' "ilk* "M FPO EXTRA FPL 0 B 1 800.00 1995 80 0.00 600 '� . . _ / / r' ti . , h e N. h' ;f�� r ! y' _ r-. • 1 (J y [ BUILDING SUB-AREA SUMMARY SECTION Lt i C C I i'• LJ L 1 I I Code Description Living Area Floor Area Eff Area Unit Cost Undeprec Value , BAS First Floor 629 629 629 616.18 387,575 Ttl Gross Liv/Lease Area 6291 6291 6291 I 387,575 r-1.. e 1 ._._—. ,. t }. . -- - - - -- ... ; .... f ' - . . f 1 - , • . , . * 1 ' - ,.'7.„-- e'•Lk-,..k;,-,_ -v.-',- ';',. 4ir•:',AFt...-.4.-7L,..;.,..?17.t, :. -•-.,i-. , -Tr '-._i.-,,,..`''' , : !.",` ...-',4 -,.'z:•.:,r'. ' ...-' :,,,,44.t. 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