HomeMy WebLinkAboutPermit TOWN OF YARMOUTH Building Department BUILDING
•
(508) 398-2231 ext. 1261 PERMIT
0 1 PERMIT NO BLDR-23-9982 JOB WEATHER CARD
ISSUE DATE August 2,2023
APPLICANT
Ted Bailey PERMIT TO
AT(LOCATION) 113 HIGHBANK RD,SOUTH YARMOUTH MA 02664 ZONING DISTRICT Bldg.Type
SUBDIVISION MAP BLOCK LOT 080.127 BUILDING IS TO BE: CONST TYPE USE GROUP
REMARKS Alterations per approved plan 780 CMR MSBC,9th Edition-Remodel bathroom(508-932-5447)
AREA(SQ FT) ESTIMATED COST$ PERMIT FEE$$90.00
CONTRACTOR
OWNER SAKOLSKY HOOPES GABRIELLE E
LICENSE#
BUILDING DEPT.BY PHONE#
ADDRESS 113 HIGH BANK RD
SOUTH YARMOUTH MA 02664-3131 THIS PERMIT CONVEYSf (� C,''A �
NO RIGHT TO OCCUPY ANY STREET,ALLEY OR SIDEWALK ORN Y PART THEREOF,EITHER TEMPORARILY OR
PERMANENTLY.ENCROACHMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE
APPROVED BY THE JURISDICTION.STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED
FROM THE DEPARTMENT OF PUBLIC WORKS,THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE
CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS.
PER R110 INSPECTIONS ARE REQUIRED FOR ALL APPROVED PLANS MUST BE RETAINED ON WHERE APPLICABLE SEPARATE
CONSTRUCTION WORK JOB AND THIS CARD KEPT POSTED UNTIL PERMITS ARE REQUIRED FOR
FINAL INSPECTION HAS BEEN MADE.WHERE ELECTRICAL,PLUMBING/GAS,FIRE
REFER TO DETAILED INSPECTION SCHEDULE A CERTIFICATE OF OCCUPANCY IS PROTECTION AND MECHANICAL,
FOR REQUIRED INSPECTIONS REQUIRED,SUCH BUILDING SHALL NOT BE SHEET METAL INSTALLATIONS.
OCCUPIED UNTIL FINAL INSPECTION HAS
BEEN MADE.
POST THIS CARD SO IT IS VISIBLE FROM STREET
BUILDING INSPECTION APPROVALS
•
WORK SHALL NOT PROCEED UNTIL PERMIT WILL BECOME NULL AND VOID IF INSPECTIONS INDICATED ON THIS
THE INSPECTION HAS APPROVED CONSTRUCTION WORK IS NOT STARTED WITHIN SIX CARD CAN BE ARRANGED FOR BY
THE VARIOUS STAGES OF MONTHS OF DATE THE PERMIT IS ISSUED AS NOTED PHONE 508-398-2231 ext. 1261, 1260
CONSTRUCTION. ABOVE.
.Il 2 3* DoS'-1 f)
7,340111 ONE & TWO FAMILY ONLY— BUILDING PERMIT
Town of Yarmouth Building Department oiF'-. r...
1146 Route 28,South Yarmouth,MA 02664-4492 .
508-398-2231 ext. 1261 Fax 508-398-0836 trtimot' ■
Massachusetts State Building Code,780 CMR
Building Permit Application To Construct, Repair, Renovate Or Demolish
a One-or Two-Family Dwelling
,[;A -z 3- 1 q This Section
For Official Use Only
Building Permit Number: J3 at Date Applied:
jr-, 5 - r ,,.1., 3 RECEIVED
BuildingOfficial
(Print Name) • 4-nature Date
SECTION 1:SITE INFORMATION APR 13 023
1.1 Property Address: /� 1.2 Assessors Map&Parcel Numbers
i _
3 1-hkr I- ruc eJ BUILDING DEP4 R ;y' `NT
1.1 a Is this a 1accepted street?yes no Map Number Parcel Numb EsY— ------
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
ti1ri- NiIw Nf9 Nj Nli7- , Alk—
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private CI Zone: — Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY O WNERSITIP'
2.1 Owner'of ecord
C�abrn & &ikolSK9 \leirri ru ma DZloco
Name(Print) City,State,ZIP
I/3 hknie Rd. ,9Z535` .ZG4/ 9 Sae Old
No.and Street Telephone Email Address Bit-'
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction CI Existing Building❑ Owner-Occupied 0 I Repairs(s) 0 Alteration(s) ❑ Addition 0
Demolition ❑ Accessory Bldg. 0 Number of Units 1 Other id Specify; I€t.pkuz . ,/wJiu )
B 'ef Description of Proposed Work2: p( ,,(XIS'fi fjJi6"vt ev" V'LIH.L (..4/ tl.LL�
,- VaL, J
SECTION 4:ESTIMATED CONSTRUCTION COSTS.
•
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ /„Q 8' 1. Building Permit Fee:$I'S O Indicate how fee is determined:
'
2.Electrical $ KKK Standard City/Town Application Fee
0 Total Project Cost3(Item 6)x multiplier x
3.Plumbing
$ [5-CO `_2. Other Fees: $ �/
4.Mechanical (HVAC) $ List: IaO. O int)/)-&G f 0 rth'r
5.Mechanical (Fire . 8-6"--6p®I S�4p y'7 \1�
Suppression) $ Total All Fees:$ ' -
r� Check No. Check Amount: Cash Amount:
1%Yp� ❑Paid in Full it Outstanding Balance Due: 9 t
6.Total Project Cost: $
,� W5dog 40/ O ( 7 sz /23 \�
§TOWN OF•YARMOUTH
1146 Route 28, South Yarmouth, MA 02664
508-398-22311 ext.••1:261 Fox 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
Work Address
Is to be disposed of oat the following location: Cakiki
/eaq wU-,
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. 111, §150A.
46/2.3
'gnature of Application (../ Date
Permit No.
,\ .,ne wmmunweassn of tviussucnuseus
l Department of Industrial Accidents
":: I--z. Office of Investigations
"x "' Lafayette Ca
'v Center
`l" =" 2 Avenuede Lafayette,`, ..z f, Lfa3' ,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):Theodore Bailey
Address:58 Delano Rd.APT 1
City/State/Zip:Marion Ma 02738 Phone# 508 932 5447
Are you an employer?Check the appropriate box:
1.❑ I am a employer with 4. ElI am a general contractor and I Type of project(required):
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
ship and have no employees These sub-contractors have
employees and have workers'
working for me in any capacity. 8. ❑Demolition
[No workers' comp,insurance comp.insurance•# 9. ❑Building addition
3.❑ required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
I am a homeowner doing all work officers have exercised their
myself. 11.0 Plumbing repairs or additions
[No workers'comp, right of exemption per MGL
insurance required.]t c. 152,§1(4),and we have no 12.0 Roof repairs
employees. [No workers' 13.11 Other Replace existing with new
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.
Insurance Company Name: >+cSin f Was...1h244dy
Policy#or Self-Ins`Lic.#: AI frep 44 a
-T 9 l Expiration Date: pZ�
Job Site Address:' .
City/State/Zip:_ _ _
Attach a copy of the workers'compensation policy declaration page(showing the policy number and'ejirati no 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.
.as hereby era),under the pains and penalties of perjury that the information provided above is true and correct
•
Sisrnature:
Dat :
Phone#: 508-932-5447
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):
IDBoard of Health 2D Building Department 31:City/Town Clerk 4.0 Electrical Inspector 50Plumbing
Inspector 6.[]Other
Contact Person:
Phone#:
Board of B and Standards
`.
•
V1
CS-1� * Fires:•10/01/2023
co
68[3EL/1NQ k F
AP 1
MARION MA
Commissi
4141114
AC Ro® CERTIFICATE OF PROPERTY INSURANCE DATE(MMiDD/YYW)
`--� 06/08/2022
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.
PRODUCER CONTACT
NAME:
PHONE (844)472-0967
tA/C.No.Ext1: (A/C,Nog (203) 654-3613
BIBERK ADDRESS: salessupport@biberk.com
P.O. Box 113247 PRODUCER
Stamford, CT 06911 CUSTOMER IQ
INSURER(S)AFFORDING COVERAGE NAIC#
INSURED INSURERA:Berkshire Hathaway Direct Insurance Compal 238130
INSURER B:
Theodore Bailey
58 Delano Rd Apt 1 INSURERC:
Marion, MA 02738-2011 INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
LOCATION OF PREMISES!DESCRIPTION OF PROPERTY(Attach ACORD 101,Additional Remarks Schedule,if more space is required)
Location: 58 Delano Rd, apt 1 Marion, MA 02738-2011
Bidg #001: Carpentry-7422101
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY 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 TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION
LTR DATE(MM/DD/YY COVERED PROPERTY LIMITS
YY) DATE{MM/DDIYYYY)
X PROPERTY BUILDING $ 0
CAUSES OF LOSS DEDUCTIBLES PERSONAL PROPERTY $
BASIC BUILDING - N9BP424491 04/28/2022 04/28/2023 BUSINESS INCOME $ 'rr
BROAD CONTENTS EXTRA EXPENSE $ *
X SPECIAL RENTAL VALUE $
EARTHQUAKE BLANKET BUILDING $ n/a
WIND
BLANKET PERS PROP $ n/a
FLOOD BLANKET BLDG 8 PP $ n/a
INLAND MARINE TYPE OF POLICY -
$
CAUSES OF LOSS
NAMED PERILS POLICY NUMBER $
$
CRIME $
$
TYPE OF POLICY $
BOILERBMACHINERY/ ' -
EQUIPMENT BREAKDOWN $
$
$
SPECIAL CONDITIONS I OTHER COVERAGES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required)
* ALS up to 12 months.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Theodore Bailey THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
58 Delano Rd Apt 1
Marion, MA 02738-2011
AUTHORIZED REPRESENTATIVE eoit
44,1-" Ski ff-----
®1995-2015 ACORD CORPORATION. All rights reserved.
ACORD 24(2016/03) The ACORD name and logo are registered marks of ACORD
Any
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
TYPE Individual
Registration Expiration
165792 11/18/2023
THEODORE J BAILEY
THEODORE BAILEY i2
58 DELANO RD APT 1 ,.4,,,,c.ora,(1',/relorii.
MARION,MA 02738 Undersecretary
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The Commonwealth of Massachusetts
—_--' = Department ofIndustrial
g gi-,it"— Accident) = s
1 e. _= Congress Street,Suite 100
... Boston
MA 02114-2017
.r0 www.mass.gov/due
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
A !leant Information
Name (Business/Organization/Individual); Please Print Leaibl
Address:
City/State/Zip:
Are you an employer?Check the appropriate box: PhoneQAe
er.
P Y '
1•0 1 am a employer with employees(full and/or part-time).* Type of project(required ;
2•0 I am a sole proprietor or partnership and have no employees working forme in )
New construction
any capacity.[No workers'comp. insurance required.]
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t $ Remodeling
4.0 I am a homeowner and will be hiring contractors to conduct all work on9. Demolition
ensure that all contractors either have workers'come my property, 1will 10 ❑Building addition
proprietors with no employees, compensation insurance or are sole
5.0 I am a general contractor and I have hired the subcontractors listed on the attached11 Electrical repairs or additions
These subcontractors have employees and have workers'comp.insurance.:
12.0 Plumbing repairs or additions
sheet,
6.0 We are a corporation and its officers have exercised their right of exemption per,MGL c. 14.0 Other repairs
152,§1(4),and we have no employees.[No workers'comp,insurance required.]
*Any applicant that checks box#1 must also ill 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
1Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state w
employees. If the sub-contractors have employees,they must provide their workers comp. new affidavit indicating such
P Nether°r not those entities have
I am an employer that is providing P policy number.
information. b workers compensation insurance for my employees Below is the policy and job site
Insurance Company Name:
Policy Y or Self-ins.Lic.#:
Job Site Address: Ci /Expiration Date:
Attach a copy of the workers' compensation policy declaration page(s3�ovvtngtthetato cip:
Failure to secure coverage as required under MGI:,c. 152>§25A is a criminal violation punishable by a fine up to$I,SOO.pp
p y umber and expiration date)
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER
day against the violator. A co
coverage verification. py of this statement may be forwarded to the Office of Investigations of the DIA for insuranc
e a
e
I do hereby certify render the pains and penalties of perjuty that their information p rovid ed above is true and correct.
Phone n: Date:
Official use only. .Do not write in this area,to be completed byci or town
� official.
City or Town:
Issuing Authorie Permit/License#
one):
I.Board of Health(2r Building .
I. Other Department 3. City/Town Clerk4.Electrical Inspector 5. plumbing Inspector
Contact Person:
�-- Phone#:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CCIlY_)-3
8(0
"Thu)01&U Bo.i 1L_) License Number
Expiration Date
Name of CSL Holder
Spa D chi.no aeU A I List CSL Type(see below) U
No.and Street Type Description
kJ'l a no -) AA O2 - . U Unrestricted(Buildings up to 35,000 cu.ft.)
City/T own,State,ZIP R Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
•
WS Window and Siding
5 o-C1 37-Sglj9-- -f bq I L ISF 9�J I
SF Solid Fuel Burning Appliances
J Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 51 G
HIC Com Name HIC Registration Number Expiration Date
p HIC Registrants
s f,..r c. tbaliCy \of @ qand E
Na.and Street- mail address
tin a..x�1.) n 'MG UZ13 SOg g525t-i.
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(1'I.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 Issua a of the buildnng permit.
Signed Affidavit Attached? Yes No E3
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
— r^
I,as Owner of the subject property,hereby authorize ' C CIO ( i
to ac n my behalf,in all matters relative to work authorized by this building permit apation.
V 13/23
er's Name(Flee attic Signatu Date
•
SECTION 7b: OWNER1 OR ACTH ED 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.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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.gov/oca Information on the Construction Supervisor License can be found at www.mass.gav/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"