HomeMy WebLinkAboutBLD-23-005724 RECEIYARE & TWO FAMILY ONLY-BUILDING PERMIT
Town of Yarmouth Building Department
APR 12 2023 1146 Route 28, South Yannouth, MA 02664-4492
508-398-2231 ext. 1261 Fax 508-398-0836
BUILDING DEPARTMENT Massachusetts State Building Code,780 CMR WBy — Building Permit Application To Construct, Repair, Renovate Or Demolish
a One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: 13�.b,z3-tx a Date Applied:
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORi'lATION
1.1 Property Address: % ` ,J 1.2 Assessors Map &Parcel Numbers
1.1a is this an ajaepted street do 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:
Pubtici Private❑ Zone:_ Outside Flood Zone?
Check if yes❑ Municipal 0 On site disposal system 11(
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner,'of Record:
Name(Print) City,State,
C'\ti NOaVhii 110t -ItLI ►bill vni ', Z7 4) (iTexj 4 Co--)
No.and Street Telephone Email Address
SECTION 3: DESCRIPTIONP OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building D Owner-Occupied fl I Repairs(s) tel Alteration(s)Nin Addition ❑
Demolition ❑ Accessory Bldg. 0 Number of Units I Other 0 Specify:
A-,0 ell. c
Brief Description of Proposed Work': V r iti.VA Y' ctj .fin "? \_ 4
ic SECTION 4:ESTIMATED CONSTRUCTION COSTS. IC)Item Estimated Costs: 4%
(Labor and Materials) OfficialUse Only ��\,-
1.Building $ 1 b h ap. of) 1. Building Permit Fee:$ (j0 Indicate how fe ' d •miffed: 41j
2. Electrical $ `� b�`i+� rtiV" Standard City/Town,Application Fee _ ', O��
❑Total Project Cost' (Item 6)x multiplier t C ��
3.Plumbing $ �O604(fr 2. Oilier Fees: $ 3 '�V a,` �P ,v fp"
4.Mechanical (HVAC) $ bi'1• a U`' List: l
5.Mechanical (Fire
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unn Sression) $ Total All Fees:$
1 �� Check No. Check Amount: Cas Amount:__
6.Total Project Cost: $ ' ^D �V+ D Paid in Full *Outstanding Balanc:Due: 4 6
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SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) b ( (_ l 0$ f />/,'O6`' )
CS1 y 9 C6. 7 ( License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
-�� 1? '1 -e\\
No.and Street T e Description
(� e U Unrestricted(Buildings up to 35,000 Cu.ft.)
` 1(7X tj�-� Restricted 1&2 Family Dwelling:
City/Town,State,ZIP M Masonry
KC; Roofing Covering
�,rti jZ \ ( V 3)'" WS Window and Sidine
�{ SF Solid Fuel Burning Appliances
;66 7 6 y`74°) ?�1� .rma ' n \la.;rAtttllU , I Insulation
Telephone Email address D Demolition
5,2 Registered Horne Improvement Contractor (RIC)
HIC Registration Number Expiration Date
KC k C v Name o .IC Regis're\ �qe t 1 —)/ , 0 (3 /la
/4)2
No.and S t l` J 0 Email address
City/Town,State,ZIP Telephone SDI ` 9 S i t_ I Kl ey 1� ,\)
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(.M,G.L. e.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 Et No 0
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FORBUILDING PER.t11IT
I,as 01.vner of the subject property, hereby authorize u'L---. a'qe ` Pt-
,
to act on my behalf,in all matters relative to work authorized by this building permit application. /
11)
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER 1OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties ofpe l jU 1 y that all of the information
contained in this application is true and accurate to the best ofrny Imowledge and understanding.
!r1 1e.,.Yz uv;� > `11i01 7
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her ovm work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(RIC)Program), will LZQ 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.eov/oca Information on the Constntctlon Supervisor License can be found at www.mass.eov/dQs
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 ofhalflbaths
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"
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of Mw cou,
Department ofindustria!Accidents
, \ J Congress Street, Suite 100
• J Boston, MA 02114-2017
-.,, ,.f www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERNIITTING AUTHORITY,
Annlicant,Information Please Print Legibly
//^^
Name(Business/Organization/Individual): CC T-e..V 4r- C)v tom.
Address: V t 0 VP v
City/State/Zip: t 4,,A.Q Phone#: s 0,S )7
Are you an employer? Check the appropriate box: Type of project(required):
t.O 1 am a employer with I employees(full and/or parHime).* C)D New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling
any capacity.[No workers'comp.insurance required.]
3.0 I am a homeO\vner doing all work myself.(No workers'comp.insurance required.]t 9. D Demolition
10 D Building addition
4.0 I am a homeowner and wi!!be hiring contractors to conduct all work on my property. 1 will
ensure that all contractors either have workers'compensation insurance or are sole I 10. Electrical repairs or additions
proprietors with no employees.
12.D Plumbing repairs or additions
S.0 1 am a general contractor and I have hiied the sub-contractors listed on the attached sheet. 13. repairs
These sub-contractors have employees and have workers'comp. insurance.f Q Roof
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. OOther
152,§I(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 indi.raring 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 tftat is providing workers'compensation insurance/or my employees. Below is the policy and job site
information. (' aive-3
7Insurance Company Name: ‘in 1„ r4N S V.ACIWC,
Policy#or Self-ins.Lie.#: t1'W t,_ 4 60 1 O T' Expiration Date: ( f)� 1')..12:41:-
Job Site Address: c \'\t^ '1,\ �� � City/State/Zip: Tr)('\
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 certi under the pains and penalties ofperjury that the information provided above istrue and correct.
Signature: NVi� Date: t () .}
Phone#: S 0 k G
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):
I.Board of Health 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
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§TOWN OF YARMOUTH
1146 Route 28, South Yarmouth, MA 02664
508-398-22311 ext.• 1261 F x 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 Sr ti \'1 (,,fr ,-v.
Work Address
Is to be disposed of oat the following location: 51\
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. 111, §150A.
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Signature of Application Date
Permit No.
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Commonwealth of Massachusetts
171 Division of Occupational Licensure
Board of Building Rel rations and Standards
Constt{ion Srvisor
,J.
:S-049879 _ Spires: 05/22/2024
STEVEN L. MELLOR 4111
P.O.BOX 627'
CENTERVILLf MA 02632 ; ;(
Cc.....,:ss,. :c: s;;,
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE: Individual before the expiration date. If found return to:
Registration Expiration Office of Consumer Affairs and Business Regula
117610 05/12/2023 1000 Washington Street -Suite 710
STEVEN L MELLOR Boston, MA 02118
ipr?
STEVEN L. MELLOR ,
74 FROST LN �G /a,Gi" !Z 1
HYANNIS, MA 02601 Not valid without signature
Undersecretary 9
•
117 Commonwealth of Massachusetts
Division of Occupational Licensure
Board of Building Rego rations and Standards
Const ion S ervlsor
CS-049879 = ,tplres:05/22/2024
STEVEN L.MELLOR
P.O. BOX 627 j°
CENTERVILLE MA 02632
I
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
A.i.M. Mutual Insurance Company -
54 Third Avenue,Burlington, Massachusetts 01803-0970
(BOO)876-2765 NCCI NO 26158
POLICY NO. AWC-400-7035582-2022A
PRIOR NO. AWC-400-7035582-2021A
ITEtvt
1 The insured: Steven L Mellor
DBA: Mellor Building&Remodeling
Mailing address: P 0 Box 627 FEIN:--"0000
Centerville,MA 02632
Legal Entity Type: Individual
Other workplaces not shown above: See Location
2. The policy period is from 05/17/2022 to 05/17/2023 12:01 a.m.standard time at the insured's mailing address.
3, A. Workers Compensation Insurance:Part One of the policy applies to the Workers Compensation Law of the
states listed here. MA
B. Employers'Liability Insurance:Part Two of the policy applies to work in each state listed in item 3.A.
The limits of liability under Part Two are: Bodily Injury by Accident $ 1.000,000 each accident
Bodily Injury by Disease $ 1,000,000 policy limit
Bodily Injury by Disease $ 1,000,000 each employee
C. Other States insurance: Coverage Replaced by Endorsement WC 20 03 06 B
D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE
4 The premium for this policy will be determined by our Manuals of Rules.Classifications,Rates and Rating Plans.
All information required below is subiect to verification and change by audit
Classifications Premium Basis Rates
Code Estimated Per$100 Estimated
No Total Annual Of Annual
Remuneration Remuneration Premium
INTRA 000332485
INTER SEE CLASS CODE SCHEDU:F
Minimum Premium $575 Total Estimated Annual Premium $575
GOV GOV Deposit Premium $576
STATE CLASS
MA 5183 State Assessments/Surcharges
$13.00 x 4.1800% $1
This policy,including all endorsements,is hereby countersigned by — r -- 05/08/2022
Ajt iaiud Signature Date
Service Office: Mark Sylvia Insurance Agency
54 Third Avenue 404 Main Street
Burlington MA 01803 Centerville.MA 02632
WC000001A(7-11)
Includes copyrighted material of the National Council on Compensation Insurance.
used with its permission,
4/21/23,9:14 AM Mail-Sears,Tim-Outlook
2 Snug Harbor Rd
Sears, Tim <tsears@yarmouth.ma.us>
Fri 4/21/2023 9:14 AM
To:s.l.mellor@hotmail.com <s.l.mellor@hotmail.com>
Steven,
JI have reviewed your application and you need to submit a proposed floor plan, there is only the existing
one with the application.
Thank you
Timothy Sears CBO
Deputy Building Commissioner
Town of Yarmouth
508-398-2231 Ext. 1259
maiito:tsearsjyarmouth.ma.us
https://outlook.office.com/mail/sentitems/id/AAQkADE3MDQ5NWZmLTkOyzItNDIwNi1 iMDQxLWNkMGQyNmE4NzE5NAAQACJktiasb8lAiGEMj4k9c9... 1/1
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