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HomeMy WebLinkAboutBLDR-23-12869 R F M V & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department - y.._ AL 1 2 23 1146 Route 28,South Yarmouth,MA 02664-4492 __ 508-398-2231 ext. 1261 Fax 508-398-0836 . . ; BUILDI VG DEPARTViEIyT Massachusetts State Building Code,780 CMR By: _ l�tuz7dmgPermitApplication To Construct, Repair, Renovate Or Demolish - a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: MIX -Z 3`/zie y Date Applie . ' r 1N--• :4( C - cAc-Ai Building Official(Print Name) gnature Date f W A SECTION 1:SITE INWRMATION i 11 yopertyrA ress: i af f `sessors Map&Parcel Numbers ki-C., 1.1 a Is this an accepted street?yes..---- no 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: (Ivf.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private El Zone: _ Outside Flood Zone? Check if yes❑ Municipal 0 On site disposal system 0 SECTION 2: PROPERTY OWNERSHIP` 2.1 Owner'of Recor �) ,State,Z1�PJ k deli ,oko 21.4.kC N d Street e S Ci© 4 1 0341,s- •ci'".4./'6.1 Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building- Owner-Occupied El' Repairs(s) Q Alteration(s) 0 I Addition 0 Demolition 0 I Accessory Bldg I Number of Units Other 0 Specify: W Brief.Description of Proposed rk2: as-tOJe_._ Ce Pict (_ cc( L l i.e K e_.e kL. L C� i��� t...J bO f S •`�C l" , q,cI 1 /44 r.tit-1c{o�j 3tfoor e,ito 'Z t k` q1. Jue 47-.es . �j�U -Pro `� , VSECTIOIN 4: F IMATED CONSTRUCTION OSTS. Ail ?tWn'1 ma,.., ' —, Estimated Costs: e Item Official Use Only 1.Building $ 1. Building Permit Fee:S ‹ Indicate how fee is determined: 2.Electrical $ 1Standard City/Town Application Fee 0 .Total Project Co/�ss Item 6 x multiplier x 3.Plumbing $ 2. Other Fees: $N r 11° sVI • 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire • . Suppression) $ Total All Fees:$ ' 6.Total Project Cost: $ Check No. Check Amount: Cash Amount: 0 Paid in Full Outstanding Balance Due: (),;� I SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) u / ' ( c L ti,c" A `✓MA_ License Number ''v e of CSL Holder Expiration Date 9-$c ' List CSL Type(see below) i�5 No,and Str et Type Description a✓l -k-A01C-c.-f Ho- C0 J R Unrestricted(Buildings up to 35,000 cu.ft.)- CityCl'own,State,ZIP Restricted 1&2 Family Dwelling M Masonry • RC f Roofing Covering WS Window and Siding . ,36&,-qt 5 4 e /' / 4 Lit d SF Solid Fuel Burning Appliances ��l Cod Insulation 11 elep 'ne Email a dress .-[cu , , pi D Demolition (k, ,.'giitered Home Improvement Contractor IC) HIC C mp y Name or,HIC 'egistrant Name HIC Registration Number E pira ion Date NACI 711�� S �K .f.-No and Street „ n- OctS _ $- O ..�Email address kicA4.14-4r Q, � City/Town,State,ZIP Telephone • SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c.152.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes ..,....::''t7 No ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WIIEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorizer f re_ or .4 54.i to actl on my behalf,in all matters relative to work authorized by this building permit application. I" ( K c� K 7�- c" / d$l/l 2023 Print Owner's Name(Electronic Signature) !/ Date SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contame in this application is true and ace ate tot 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 Constriction Supervisor License can be found at www.mass.eov/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" z? The Commonwealth of Massachusetts t 1 Department of IndustrialAceidents it c7 ` 1 Congress Street, Suite 100 111Nf f, Boston,MA 02114-2017 �• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A !leant Information Please Print L gib! Name (Business/Organiaatio Individual). De,_. '.)1V �— ems , / e` 0 tr'�t`�` Address:' City/State/Zip: i .A0 L( 3 r�i , Phone# t� 6S Qk 50 . c Are you an employer?Check the appropriate box: ` ���� l.Q I am a employer with employees(full and/or part-time).* Type of project(required): 2.Q I am a sole proprietor or partnership and have no employees working for me in y' 0 ReW Jelin construction any capacity.1No workers'comp. insurance required.] 8. []Remodeling 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 4am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 El Building ensure that all contractors either have workers'compensation insurance or are sole addition proprietors with no employees. 11.Q Electrical repairsion or additions 5.1D I am a general contractor and I have hired the sub-contractors listed on the attached sheet, 12'❑plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.t 13.Q Roof repa' MGL c. 6•0 We are a corporation and its officers have exercised their right of exemptionper14,.0 Other Q R t i'S 152,§1(4),and we have no employees.(No workers'comp.insurance required.] *Any applicant that checks box ml 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. ii am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:1F-D�� e�1 (-, �` �", ---1- =.-kr.q�,� CO, Policy=or Self ins.Lic.;i: k D t 10I �,� ] Expiration Date: Job Site Address: t b ` ( e-� �-�1Y�, 1 y�t q Attach a copy of the workers' compelsation policy declaration page(showing tthetpolicy numbe and expirationda�l �c��"� 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi• under the pains and penalties of perjury that the information provided above is true and correct. Signature: / •7 `�`l ( o ._._. 3 b e Date: — I ( — <v i1 Phone�: `-t _ l C Ste. Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-201 ext.-1261 Fax 508-398-0836 Office of the Building Commissioner BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G.L. Ch. 40, §54 and 780 CMR- Section 105.3.1. #4. I hereby certify that the debris resulting from the proposed work/demolition to be conducted at t q L tOeS1. q - oJ W rk Address Is to be disposed of oat the following locatior `G-Ve _,& Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. Signature of Application Date Permit No. Mark Kozma 146 Bayview Street West Yarmouth, MA 02673 August 1,2023 Town of Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 To Whom it May Concern: I, Mark Kozma,owner of the property located at 146 Bayview Street, West Yarmouth, MA 02673, provide Trevor A.Smith and Cape Cod Pro Builders permission to pull permit(s)on my behalf. This permission is valid for one year for the mutually agreed upon home repair and renovations to my property. Please allow them to obtain permits for my home. 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Via:"`< _ • "° �;,1 t...' # /"'4 .s"0;`ri.. `v�'S�?zr��s rs+, .„$"s i; Y et. ,> CT) /,cif' ���/i/��/ + kSy"?'',v,, "2' '"',�r�_S�Yy 'm �'"�r,.p-: s at` 3.J b v;7 s ,jTM :SY,'�:;ir,z ' " ; 0 °+F M �' ' �s, , ',,,,�,,,.>'a�s; ':sip ' ,> i • :' y ` 4"M• 1< S Fin". 4 ,'�, :< F. - ate•`'„ g - r n', ,; 'ram �,�.,, :.'�;„ <_� 1 v`h p {�s o�� a �Ra sf. 1riI v`- re \C\\". kic_INivc n% -->s" --'X/ 44 Ck 1( ez‘ y 1 I it . . - 0 0 0 20 r(-‘ , o5r. _ ao AAA_ Poltkvo O vii/A,____ 1 - ti'4: 1_ , _______ __________ 3,6,DDL, 4- ?cam 1_ gagrooph. , ; 1 1 G p PETER-5 OP ID: KV CCD,R� M/DD/YYYY) DATE(M +.._.- CERTIFICATE OF LIABILITY INSURANCE DAoE(Mono2s 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 508-775-6060 CONTACT Bryden&Sullivan Insurance Bryden&Sullivan Ins Agency PHONE 88 Falmouth Road (NC,No,Ext):508-775-6060 I FAX No):508-790-1414 Hyannis, MA 02601 E-MAIL Bryden&Sullivan Insurance _ADDRESS. INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: INURED Inman Peterkin INSURERS: 299 Route 28 INSURERC: W Yarmouth,MA 02673 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 ADOL SUBR POLICY EFF POLICY EXP ITR TYPE OF INSURANCE INsn wvn POLICY NUMBER IMM/DD/YYYY1 (MMIDf/YYYYI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL$ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO" GENERAL AGGREGATE $ JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO $ OWNED SCHEDULED BODILY INJURY(Per Denson) $ AUTOS ONLY AUTOS HIRED NON-OWNED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS ONLY (PROaE de DAMAGE r t) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I RETENTION$ WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY PER OTH- ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N STATUTE ER OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ (Mandatory in NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION TOWNOFY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE Bryden&Sullivan Insurance ACORD 25(2016/03) ©1988-2015 The ACORD name and logo are registered marks of ACORD CORPORATION. All rights reserved. ACORD