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HomeMy WebLinkAboutBLD-23-001252 „ A ��,��� 3 Office Use Only o, _Ro CE�"” - D Permit#612a (0 . - / [ el la2-- �.- _.._..RECEIVE^n -:�Amount !D.U ` NATT;CH f3[•� IX L . °"°°•°'t°"p Ejd SEP L Permit expires 180 days from f issue date C �� d /�52 BUILUI G DEPARTMENT EXPRESS BUILDING P APPLICATI 0 IN. . C E I V E D TOWN OF YARMOUTH Y outh Building Department - z��2 /-P *,cp, 1� 1146 Route 28 ` 1 South Yarmouth, MA 02664(508 ) DEPA ✓✓✓ By. RIME 398-22 31 Ext. 1261 CONSTRUCTION ADDRESS: / a-3 I tie,- 5/ 5 Y b /L ASSESSOR'S INFORMATION: Map: 2 L Parcel:49 OWNER: U a C C/ f 1`lor )/ L)c,,A•cY 1 as / /0 f fc / e -NAME PRESENT ADDRESS TEL. # oi '7— 7/ y a c v CONTRACTOR: A t, o.+iLie—'y &/ Lay,S' ) A..1 60,3 U , Y kg. �.. `"5G' `a/ 3/I / NAME MAILING ADDRESS TEL.# Residential ❑Commercial Est.Cost of Construction$ --OOD t 60 Home Improvement Contractor Lic.# / " to _a Construction Supervisor Lic.# C-5'-- 0 CS / &" 7,9 Workman's Compensation Insurance: (check one) �/ ❑ I am the homeowner�c❑ I am the sole proprietorpproprietor / 31I have Worker's Compensation Insurance Insurance Company Name: h f'4 1-' U ci A to Worker's Comp.Policy# G 2 z• cr/3 tit 3,7 4/7C 4 7 "f0 4 1 4 WORK TO BE PERFORMED Tent Duration /i L(Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: Ai)) C3 j ( a S/O C5.l j Location off Facility I declare under penalties of perjury that the statements herei contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or revocation of my license or pros ution under M.G.L.Ch.268,Section 1. /// Applicant's Signature: t Date: /a,3 A gs2..._ Owners Signature(or attachment) iris, 2.77,..... Date: /.� '1 2 00 Approved By: Date: /// � Building Official(or designe MAIL ADDRESS: Zoning District: Historical District: ❑ Yes 0 No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes 0 No 10 Yes ❑ No. eranoriweaztri ot Mcicrt Drew=of Occupatcalat acarc or aug ding Fir.Aul=iar,-..;,1‘41, tAz tirek, ‘':CriStafttleAtaiNtlf • CS-00160b 0113:2024 CHRISTOPHER T KENNEY 7; 64)3 WEST YARMOUTH R 77. emoN WEST YARMOUTH MA eters , 1(.41" (.(:(1//////11.7/441(v/7;:// Office of Consumer Affairs and Business Regulation 000 Washington Street-Suite 710 3oston. Massachusetts 02118 Home improverrent Contractor Registration Type: CcToCcaliCe RqIi4gratton: KE.NNEY EUILDERS ITCExpitatiOn- 0.3,16120V 603 WEST YARMOUTH ROAO WEST YARMOUTH.MA M7.3 Updatt Addrerz.arra Return C Cr : Qrgc fCoosu tries 4Ltratis eut4bums Raga/tattoo HOWEMIPROVEMENT CONTRACTOR Registration valid for individual ute only TYPE:CerpotatiYi hefty*-Ma expiration d it foam!return tot Reoirattort Emit—Alio Office of Consumer Affaira and Rusin Reotiation 87.:1A, 174 1000 Wotern Street•Suite 710 Roseon,MA 02110 ALti.41.2( fit3NC t.7,1-P4707,1-i•E9 PiNrY• E13.72,W CS r YAIMOLi I ROAD Not vall le sig re yARmoi.,11-f.MA it267? Undersecralry ` : The Commonwealth of Massachusetts _ Department of Industrial Accidents =nAl_ 1 Congress Street, Suite 100 vn as I Boston, MA 02114-2017 5.•� www.mass oov/dia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): ,73 Address: D 3 lvec7 Yi9fri �1( J40 City/State/Zip: t -)4A 1VA,. c'.2C,73 Phone #: ' ,coo:_ 36' - -3( Are you an employer?Check the appropriate box: Type of project(required): l.[I aam a employer with 3 employees(full and/or part-time).* 7. Ei New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling 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 ❑ Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that ail contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑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.: 6.0 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. :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: (Tdc,!�i, 4A—, I4 6 /..r j•-•— Policy#or Self-ins. Lic. #: 6 z Q Ls./¢ 3 37`I 6,7( Expiration Date: 1,2,3/ a2o2. Job Site Address: / fA (v« 5/ / �-� / i City/State/Zip: . >4,1I'rcG 77" 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 a ' penalties of perjury that the information provided above is true and correct. Signature �� � j Date: / 0`7,3 07 2_.. Phone a#: 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#: DATE(MMIDD/YYY)fJ ACCRD CERTIFICATE OF LIABILITY INSURANCE 11/11/2021 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 POUCIES 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 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 CONTACTNome Matthew Sumares COCHRANE&PORTER INSURANCE AGENCY Pmc HCMEExt. (781)943-1682 ; No,; E-MAIL ADDREss: mriddell(gbakkerinsurance.com 981 WORCESTER ST INSURER(S)AFFORDING COVERAGE NAIL* WELLESLEY MA 02482 INSURERA: AMERICAN ZURICH INSURANCE COMPANY 40142 INSURED INSURER B: KENNEY BUILDERS INC INSURER C: INSURER D: 603 WEST YARMOUTH ROAD INSURER E: WEST YARMOUTH MA 02673 INSURER F: COVERAGES CERTIFICATE NUMBER: 715550 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 SHOVNN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR _ POLICY EXP YY) LIMITS LTR TYPE OF INSURANCE 1NSD�y POLICY NUMBER wi F r w(MMID COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE I OCCUR DAMAGE TO RENTED PREMISES(Ea ooaarence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE UMIT APPLIES PER GENERAL AGGREGATE $ POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS _AUTOS N/A BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS (Per accident) $ $ UMBRELLA UAB _ OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION S $ WORKERS COMPENSATION _ AND EMPLOYERS'UABIUTY YIN XSTATUTE PER ER ANYPROPRIETOR/PARTNERIEXECUTIVE EL EACH ACCIDENT $ 500,000 •A OFFICER/MEMBEREXCLUDED? NIA We WA 6ZZUB8H33747621 09/25/2021 09/25/2022 (Mandatory in NH) EL DISEASE-EA EMPLOYEE S 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 0613,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Iwdlworkers-compensationJinvestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Dennis ACCORDANCE WITH THE POLICY PROVISIONS. 685 Route 134 AUTHORIZED REPRESENTATIVE South Dennis MA 02660 Daniel M.Cro4lr, y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD /R(31.i /01,ei--, si W o YRR OWN OF YARMOUTH BUILDING DEPARTMENT O . -y; MA47,.„ Es 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 261 BUILDING DEPARTMENT TOTAL DEMOLITION SIGN-OFF FORM State Building Code (780 CMR) Chapter 33, Section 3303.6-Service Connections "Before a building or structure is demolished or removed, the owner or agent shall notify all utilities having service connections within the structure, such as water, electric, gas sewer and other connections. A permit to demolish or remove a building or structure shall not be issued until a release is obtained from the utilities, stating that their respective service connections and appurtenant equipment, such as meter and regulators, have been removed or sealed and plugged in a safe manner." "All debris shall be disposed of in accordance with 780CMR 111.5." Building or Structure Location: Map: 3'/ Lot: 312 Owner's Name: ,j a //yOI Q.- Address: Phone: Contractor's Name: c Au,,,7 1.3 Address: Phone: Eversource: Date: By: Title: National Grid: Date: By: Title: Water Dept.: Date: 77f- 1 9.Z1 By: Title: Board of Health.' Date: Y i Ia '-1I By: Title: Condition: Fire Dept.: Date: Cf �✓ ,�y`$--.��r 9, By: Title: rThs o DDate:7)/ ) i 3 62tVW 34_ nm iv) S ISM Fx 1 I �� By: LiSz She"/ Title: C11�Ft 1115-bbi_ c Date: a 3 .7 ,2 -5I By: Comeast: Date: 3/15 CA, r e—e. cx:1-Ydkii .. o Town of Yarmouth Conservation Office 0� - mouth.ma.us MATTA 11 , lx Conservation Commission Building Permit Sign-off Application TO BE FILLED OUT BY BUILDING PERMIT APPLICANT: Building Site Location: / 6 3 / i pt. J I 5 Ys f, Map# �! Lot(s)# tt, ,07 — Property Owner: (/"'€- 6 I f'ld P l Date filed: *Applicant: J( al &V�-<-• Applicant Address: fl Dail g e / /1,54 AI r'.45 l IV Pc Email Eirt�i)�_ c r 6 7/y41 /. Cr; 1 Telephone: 6 /7" %l .- 0 0 8- Please Note:By submitting this application the applicant grants permission to the Conservation Office to enter the location to conduct a site visit(if needed). Proposed Project Description: — /.<e fre6 Vc X I S l', , / H e_ Site Plan Title/Date: i 1-t pit., et 1S r, Sou In 5 5 1 0 - 7-2. TO BE FILLED OUT BY CONSERVATION ADMINISTRATOR: Does the proposed project require a permit? Refer to: SE83- 2; r or DOA permit Comments from Conservation Commission: Approved Conditionally Appro Rejected Conservation Commission Sign-off Signature: Date: 01 -( - Z2 *TO APPLICANT: All work-related debris shall be taken offsite or disposed in a legal upland location. At the end of each day, the area shall be clean and no debris shall be in the Resource Area. If work is permitted under an Order of Conditions, please arrange a pre-construction site visit with the Conservation Administrator. At the time of site visit, the MassDEP File Number sign must be installed, along with the erosion control/work-limit line. A copy of the Order of Conditions must remain on-site during construction. Please refer to the Order of Conditions for further details. 1 ' A ir TOWN OF YARMOUTH 113 .', r HEALTH DEPARTMENT 3 0.4 PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET To he completed by Applicant: Building Site Location: / FN5 �` Proposed Improvement: ae Svf d e a PI�L t�I'��,` icJ Applicant: C -e u /j c` 5(0 /fdc- S / /J L, i Address:£0,3 I )//4 n/YUU- / // Date Filed: V.73/.7 Q_ **lfyou would like e-mail notification of sign off please provide e-mail address: Owner Name: 1/© - , / Pj o Owner Address:L/ „l __ Owner Tel. No f0(7- 7/ 7., ado e A5 lti / / aJ RESIDENTIAL AND/OR COMMERCIAL BUILDING HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements For Septage Disposal and other Public Health Activities. Please submit three (3) copies of plans, to include: (1.) Site Plan showing existing buildings, water line location, and septic system location; (2.) Floor plan labeling ALL rooms within building (all existing and proposed) — Note: Floor plans not required for decks, sheds, windows, roofing; L (3.) If necessary, Title 5 application signed by licensed installer with fee. REVIEWED BY: DATE: ( h C COMMENTS/CONDITIONS: PLEASE NOTE VC-C- 0<12— C • roc/Cr cam.. P