HomeMy WebLinkAboutBLD-23-001660 E 7. ' ; VED_
SEP 2 8 20121E & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department
...,,;� DEPARTMENT 1146 Route 28, South Yarmouth,MA 02664-4492
508-398-2231 ext. 1261 Fax 508-398-0836 itilhv '
Massachusetts State Building Code,780 CMR. `
Building Permit Application To Construct, Repair, Renovate Or Demolish
a One-or Two-Family Dwelling
1 This Section For Official Use Only
Building Permit Number: 6(rI)a 3-( (1)(o() Date Applied:
/,
Building Official(Print Name) Signature Date
SECTION I:SITE INFORMATION •
1.1 Property Address: J 1.2 Assessors Map&Parcel Numbers
I1r i grey1-lc,
n-l`,I�na Ct1 10' A(14Ulifki Nk-kp U' 0 ,-E t
1.1 a Is this an accepted street?yes ; .- no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property imensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required I Provided Required Provided Required Provided
1.6 Water Supply: (Ivt.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private g Zone: _ Outside Flood Zone? Municipal 0 On site disposal system;>�__
Check if yes❑ .-
SECTION 2: PROPERTY OWNERSHIP'
p.1 Owner'of R rd;
0("11 4 HJu V ie bon 2 (,k 5-}er Ns' o j "3 0
Name(Print) City,State,ZIP
HA( i k.iyopJN P_d. ci4r)2. 3 7? Curl-,VJ Arcn2-0c p0, (•c5pi
No.and Street Telephone Email Addfss
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction 0 Existing Building❑ Owner-Occupied 0 1 Repairs(s) 0 Alteration(s) ❑ Addition ❑
Demolition 0 Accessory Bldg. ❑ Number of Units Other p',Specify:Kw C C__
Briefpescription o Pro os Work2: C1 c S-tru c� 2i� L 0, r k_lb (C f ktC'p -{- ' r t RR r
,l)0 i < C 6i W\Ct 11� !,a .A _ , L> R E C I
V
SECTION 4: ESTIMATED CONSTRUCTION COSTS. SEP 3 0 2022
Estimated Costs: Official Use Onl \�
Item (Labor and Materials) BUILpINC ejgtrM NT \
e,
I.Building $ &U( e 6, 4, "- 1. Building Permit Fee: '. =t Indicat A- \
0 Standard City/Town Application Fee •
2.Electrical $ 0 Total Project Costa(IIt�e, )x multiplier x ( '\./
3.Plumbing $ 2. Other Fees: $ ..----,,D a,S (-
4.Mechanical (HVAC) $ List:_
5.Mechanical (Fire $ — • .
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ d 1(0 0 0 ✓ 0 Paid in Full 0 Outstanding Balance Due: )1—0'
i
/z�/?1L
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) r•
l�GNiC1S ue License Number Expiration Date
Name of CSL Holder
1(2-[l�i 4112, -fZ) QY r N CI List CSL Type(see below)
No.and Street --Types Description
U I Unrestricted(Buildings up to 35,000 Cu.ft.)
��� �l �� Restricted I&..2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D ! Demolition
5.2 Registered Home Improvement Contractor(HIC)
icr MOS � C� 1 U r 3-262 2-
HIC Registration Number Expiration Date
gip Company Name or HIC Re 'str t Nam
No. d StreetEmail address
OS1r�1 RP\ c2-655 -YA'' bvl
Ci /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 F61---- No .0
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize • � v:z,v,_ CcnSiroctue— C-}
to act on my behalf,in all matters relative to work authorized by this building permit application.
ln(4 ks (Y-Vi(' rCAYl 4/1—so
Print Owner's Name(Electronic Signatutie) Date
• SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering m 'e below,I hereby attest under the pains and penalties of perjury that all of the information
containe thi lication is true and accurate to the best of my knowledge and understanding.
L%27l(52_Z
tnt Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. 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 nor 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.aov/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"
The Commonwealth of Massachusetts
Department of Industrial Accidents
_all= 1 Congress Street, Suite 100
Boston, MA 02114-2017
Nov•`' www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriciansfplumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/0rganization/Individual): T. . I e_\ ' \, l n S-i(i-)C'1(" C-6
Address: I i(2 Pict) -..)1DO 176
City/State/Zip: 0-2-6S`,) Phone#: S4 q 7E4 i
Are you an employer?Check the appropriate box:
Type of project(required):
I421 am a employer with ; employees(full and/or part-time).* 7. ❑New construction
2.0lam a sole proprietor or partnership and have no employees working for me in 8. El 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. 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 11.0 Electrical repairs or additions
proprietors with no employees.
12.E Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp. insurance.t 13.❑Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. I 4 Other
152,§I(4),and we have no employees.(No workers'comp.insurance required.]
*Any applicant that checks box#i 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 is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: h - i AA( l Ara f 6)
Policy#or Self-ins.Lic.#:WCC ' c[)Q O 2_ 13 7 - 76 Z)A Expiration Date: J) /2 !2 G 2
Job Site Address: I (�O tc �� Ct�.a� l<-t3!� I(, it ; A
� � � CitylState/Zip:���Q�� 1-� l�r. � t
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.
1 do hereby certify 1 e the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date: �` 2-7 zd.,
Phone#: tl/2 (
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#:
§TOWN OF YARMOUTH
1146 Route 28, South Yarmouth, MA 02664
508-398-2231 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 /'7( �6-/ S��4 I /A g:171Xi/7*A ) ° �' G.��3
ork Address
'n location: �/�/� 1 L `��'`7/
Is to be disposed of oat the following
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. 111, §150A.
1-2' ? 22 --
Si /tune of Application Date .
Permit No.
I
A' ® DATE(/31/20YVYY)
`...� CERTIFICATE OF LIABILITY INSURANCE o6i31r2ozz
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.
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 Maureen Roderick
NAME:
Horgan Insurance Agency PHONE (508)775-5830 FAX (508)775-6688
M No,Etdk (A/C,No):
44 Barnstable Rd EA LESS: meureenr)horganinsurance.com
PO.Box 250 INSURERS)AFFORDING COVERAGE RAC N
Hyannis MA 02601 INSURER A, Evanston Ins.Co.
INSURED INSURER B: Safety Insurance Co.
TA Nelson Construction Co.Inc INSURER C: A I.M Mutual Ins Co.
PO Box 749 INSURER D:
INSURER E:
Osterville MA 02655 INSURER F:
COVERAGES CERTIFICATE NUMBER: 21-22 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.
INSR ADOLSUUZR POUCYEFF POLICY EXP
LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMYDDIYYYY) (MMIDOIYYYY) LIMITS
X COMMERCIAL GENERAL UABILITY EACH OCCURRENCE $ 1,000,000.
DAMAGE TO bD
CLAIMS-MADE O OCCUR PREMISES(EaEMoccurrence) S 100,000.
MED EXP(Any one person) S EXC)
A — Y MKLVIPBC002058 10/12/2021 10/12/2022 PERSONAL&ADVINJURY $ 1,000,000.
GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S 2,000,000.
XI POLICY PRO- 2,000.000.
JECT 7LOC PRODUCTS-COMP/OP AGG S
OTHER'
AUTOMOBILE LIABILITY COMBINED SINGLE UNIT S 1.000,000.
iEa acutlent)
ANY AUTO BODILY INJURY(Per person) S
B OWNED >/ AUTOS SCHEDULED Y 5922218 09/29/2021 09/29/2022 BODILY INJURY(Peracodenn S
AUTOS ONLY X AUTOS
HIRED NON-0WNED PROPERTY DAMAGE S INCL
X AUTOS ONLY X AUTOS ONLY (Per accident)
UMBRELLA LIAB OCCUR EACH OCCURRENCE S
EXCESS LIAB —, CLAIMS-MADE AGGREGATE $
DEO RETENTION$ $
WORKERS COMPENSATION X)STATUTE E H R
AND EMPLOYERS'UABIUTY YIN 1,000 000.
C OFFICE ANY PROPREETORIPARTNERIEX I ,-
ECUTIVE N I A V C-500-5026132-2021A 1129/2021 11/29/2022 E L EACH ACCIDENT $
(Mandatory
In n NH)
N EXCLUDEDH) E L DISEASE-EA EMPLOYEE $ 1.000,000,
If yes.describe under 1,000.000.
DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101.Additional Remarks Schedule,may be attached I more space is required)
RE'Certificate Holder is named an Additional Insured on a primary non-contributory basis,per contract,for GL&Auto Waiver of Subrogation is in place for
additional insured
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Curtis and Ann Viebranz ACCORDANCE WITH THE POLICY PROVISIONS.
1170 Great Island Rd.
AUTHORIZED REPRESENTATIVE ��West Yarmouth MA 02673 `�� /V 4,f,(,aL/J .�/Ar j7�ar kiJI
11988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
Commonwealth of Massachusetts
Division of Occupational Licensure
Board of Building R ulations and Standards
onst :l r vlsu
CS-009889 40, l ires:0512812024
THOMAS A*LSO*
P 0 BOX 7481
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01-Yq1'`fir
�� Town of Yarmouth
armoutil Conservation Office
o
H 'ti Conservation Commissionk rantCawarmouth ma us
Yl;,��A➢pR tfO
Building Permit Sign-off Application
TO BE FILLED OUT BY BUILDING PERMIT APPLICANT:
Building Site Location: / 7 ✓Q t
Map# 0
Lot(s) #_
Property Owner: (.,(✓r-b s AN,�� �r ✓1 L.
Date filed:
*Applicant: / 4• P�iA %ns ir✓c7tic
Applicant Address: 2. i �. � /2 'PO iSex :?(/ 6
Email: L t,� ;tee ISG;,�,�
Please note:by submitting this applicat n,t pp cant grants permission to the Conservation io ,Office to enter the location to conduct a site visit(if needed).
Proposed Project Description:
J 6 el c "iQ '71 S72/i>
L.SG Cello wz- deck .
'l v , •7. z
Site Plan Title/Date: n
TO BE FILLED OUT BY CONSERVATION ADMINISTRATOR:
Does the proposed project require a permit? JO 0
Refer to: SE83- or DOA permit
Comments from Conservation Commission: Approved Conditionally Y Approved Rejected
Conservation Commission Sign-off Signature: r
Date: ei _ 2 -
*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
Conservation Administrator. At the time of site visit, the MassDEP Fier Numbersigng mite visit with the
along with the erosion control/work-limit line. A copy of the Order of Conditions must remain oust be nset
during construction. Please refer to the Order of Conditions for further details. e
ot•''"'�k TOWN OF YARMOUTH
" : ° HEALTH DEPARTMENT
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
• To he completed by Applicant:
Building Site Location: /7 0 9i1 ?"S/ii 'ed. i� '-f .
Proposed Improvement: 6r)Sfrlrc f hq k..) 9(zra. . , e i f c:e /is1- --/' S-IC A(' 7116r
Applica 7 I. t/e/�,.,,-‘ 0( ftcw ( Lkk- Tel. Na.:
A ess: - V'96 Cox -1Y GAS ( 4, 62-6S7 Date Filed:
*"`/f u would like e-mail notification ofsign off please provide e-mail address: e 4.ne (Sen. cJ T. ne 1SC ,C( r1
Owner Name: ((J(lL/S w ANN i4e 4/4nz
Owner Address: 6 S Flat:Ken he fry /?d°. ciAs{*i, ,N Owner Tel. No.: 96'8• g 72. 3477
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;
t{ f"!' ' (2.) Floor plan labeling ALL rooms within building
(all existing and proposed) —
HEALTH DEpT.
Note: Floor plans not required for decks, sheds, windows, roofing;
(3.) If necessary, Title 5 application signed by licensed installer
ith fee.
•
REVIEWED BY:
DATE: �^
LEASE NOTE
COMMENTS/CONDITIONS: