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HomeMy WebLinkAboutBLD-23-000867 ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department "oF" 1146 Route 28,South Yarmouth,MA 02664-4492 p-, 508-398-2231 ext. 1261 Fax 508-398-0836 iCM.. Massachusetts State Building Code,780 Building Permit Application To Construct, Repair, Renovate Or Demolish .� a One-or Two-Family Dwelling '' This Section For Official Use Only Building Permit Number: BLb-`3-l�,.btJk-V7 Date Applied: i iT \ 2.-\( —ICA-4 Building Official(Print Name) Signa a Date SECTION 1:SITE INFORMATION . 1.1 Property Address: i 1.2 Assessors Map&Parcel Numbers 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: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: Outside Flood Zone? — Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of R cord: lo' 7/ -C.. y(, eo 'r' /2-G'7 i`tiamh(Print) City,State,ZIP 6 /,t'- j " l=q12�-7 sue/ f o%!&ter �e/- =; No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 1 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 I Addition 0 Demolition ❑ I Accessory Bldg. 0 Number of Units Other ❑ Specify: Brief Description of Proposed Work2:/k,z1k -/L/iJ Jam ' lam/- "✓ / a >1 .. yx V( 7?' L''✓ fkiiil,I—Pei I 41.4- r w1,--- /:i'j/E J jjL--f//? SECTION 4:ESTIMATED CONSTRUCTION COSTS. • Item Estimated Costs: Official Use Only (Labor and Materials) I.Building $ . eta-- 1. Building Permit Fee:$ 15-0 -Indicate how fee is determined: 2.Electrical $ O i i Standard City/Town Application Fee 0 Total Project Costa/(Item 6 x A' ti lier x 3.Plumbing $ 1 e5V 2. Other Fees: $ 4'(] "i#I 3oo i C 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ - Suppression) Total All Fees:$ • Check No. Check Amount: Cash.Amo . 6.Total Project Cost: $ S el re 0 Paid in Full '+Outstanding Balance Due: • 041 W \191).1)' SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) N• /,hf License Number Expiration Date ame of CSL Holder List CSL Type(see below) 12 No.and Street Type • Description +�� y�.✓>, 9 U Unrestricted(Buildings up to 35,000 cu.ft.) City/Town,State, R Restricted 1&2 Family Dwelling 1v1 lviasonrry 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) Gr— C Registration Number Expiration Date 7fr71 Company Name off HIC Registrant Name e /i /2aceii3Oly, vvo 1"--o7 , 2 .r-w No.and Street Email address City/Town, c-Of rty/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 ! - No ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as ON. r of the subject property,hereby authorize C7'• to act ehalf,in all matters relative to work authorized by this building permit a plication. IT4-6-er d— /1--l1 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 contained in this application is true and accurate to the best of my knowledge and understanding. w ` ('� �--/7-47 P n 's or Adthorized Agen _ ame(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.sov/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" §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-22* 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 / L( Ow'Al >1i 7� rz r�,�0 Work Address Is to be disposed of oat the following location: 07 s Mg-lid-- 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. ONE or TWO FAMILY— BULDING PERMIT APPLICATION REGULATORY APPROVALS NOTICE Address of Proposed Work: 61/g-Lf1,' yarfriedry-7-40- 21 725 Scope of Proposed Work: /U�ar'f z irak /P.-AV %: /^4dnn PI e-%147) ,75v/ 81�' i��f� /oafr,7vn .CZ-)/u/l / eiie'�inc.�i WI/ 6a Sizili/ic /7%044/11-* 7.J h '�--A g ijJ7'i9 Date: t"/7- 2/2- Based on the scope of work described above,the applicant is required to obtain approval sign- offs from the following departments as checked-of below: Health Dept. —508-398-2231 ext. 1241 Conservation —508-398-2231 ext. 1288 Water Dept. —99 Buck Island Road, 508-771-7921 / ���`''�"` �nke fish l� V Old Kings HWY. Hist. Comm. —508-398-22631 ext. 1292 frt Engineering Dept. —508-398-2231 ext. 1250 Fire Dept.— Kevin Huck/Scott Smith, 96 Old Main Street, SY Note: Please call Fire Department for an appointment. 508-398-2212 Other Appropriate plans and/or application shall be provided to each departments checked-off above. Each of these regulatory authorities has their own requirements outside the jurisdiction of the Building Department. All applicable approvals shall be obtained prior to submitting a building permit application to the Building Dept. Thank you for your cooperation. Receipt Acknowledgement: Applicant's Signature Date Rev. Jan. 2019 _ The Commonwealth of Massachusetts >t =""t— 1 1, Department of Industrial Accidents 1 Congress Street, Suite 100 •=„; `_ - Boston, MA 02114-2017 5." www.mass.gov/dia I. Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Annlicant Information / n / Please Print Legibly Name (Business/Organization/Individual): /Me!�y �,4i /Jei�'1�%_ l",-/-7.4-09, 7—( Address: Calt, ,jec 77 J' 040Y City/State/Zip: 4I11> !4# c Z1'' ' Phone#: S�� 4(77 3 3/c7' Are you an employer?Check the appropriate box: Type of project(required): 1.®I am a employer with employees(full and/or part-time).* 7. ❑New construction �❑I am a sole proprietor or partnership and have no employees working for me in 8. P2. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑Building addition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.QElectrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 1-' ❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 14.❑Other 6.0We are a corporation and its officers have exercised their right of exemption per MGL c. 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:/ "/� /ate,/y cv e1ig/J`y Policy#or Self-ins.Lic.#: 2-001 k'43410 Expiration Date: /0 '/S '2-2.-- Job Site Address: Cl 11'(211/ City/State/Zip: � �� C!ZC7' Attach a copy of the workers' compensation policy declaration page(showing the policy n mber and a piration 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 and penalties of perjury that the information provided above is true and correct. Signatu e: //l��;/4-1) 6-) y Date: . ;; `, Phone# _ / 77 3 36'i v 1._ r L 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.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: • office of consuMerAitaifs -nets Rego HOME IMPROVEME ONTRACTO- TYPE:C�9 oar-'on \ - •I tr.tlo •. ion 102634. + 1 1/2022 ; TIMOTHY GRAY BUILD &REMOb LING,INC. TIMOT GRA?:,' x= a 77 • 68 COLETTA W MASHPEE,MA 02t4B,,x1.5' Undersecretary • Commonwealth Qt Massachusetts Division e4Professional ticelna�tfte Board ofBuiIding..R tidns aridStanddkis ., ' Constructio • 1 2 Family` CSFA-046234 '# fpires: 11/30/2022 TIMOTHY GOY ,pt . .a 68K NICOLEYJA' . MASHPEE MAjO OIS—1,1 Commissioner 000.12k • § k ' k. mU) a) § ) k k } o '0 2` z c $\ \ : : . . « ; ©d . . ■m pco �®}�\/\2\ © 4. j\ o _ z k< .H �ck - ± ° § ; E Tr:- $$ !P1 -Jmow 0 0 1-- . � . • : . R 7%« . $ . N 'a N 0 74 ---.. N Cir. 7 m G., ....• '''X .... t) •• 'iS 1:. ..... cr. 4.. 0.• u.) 1 44-;,-" -7... — 24" 21" 30" 21" - I 36" 7;3 .j _a) 0 — a. 0 .0 60" 551." 20 ... I I 1 '41 AO' ;" cz 4:,344 ," -,-1 •.4". y c 42" 30" 21" I . ,LI 36" ' IX CZ 71 .EL to 0 as •—,.„1-,-0 tn fze,, 05 •••4• 4.) tj . (... " 1 ce c„ -67 ,,-, •,) Ri ul c o u zi - - --I 3 — = el 3 (1._ ••••• .... 1.1.'1,3 0 CI $.-. . • CL 4ft, i^ ZOSO T 0.) - Lt- PO V4 I-- .• UN vri z $44 41, r Asa AAA ... • p, < " eq C' CL 0 .•d• ). .--Ca CZ 1/41 SI (ra X co cx. 0 Z iLa () 0 Cr) >. '" 0 Cr) 0 C.0 p -....) 4;:t. - ...... .... . .... , • 146 C6, CA C16 '> '11" ..3 , 4 N ajA ail '""1. 0. ,,... c7t Ci CO a- Q.. .) 7, t') Z L c,.. xi , , ce. x e 4„ ais 0 *4 > fld a.. -"Ci 4. CA as E E, - ,-.. 7 7 „, N r•-,— I on •-• 0 CO '1 Z; ;' ''' CO 0 a... C La.1 th Ij •....a .s C •``..,7) Mi ..1 0 4 CC , .a ••••• = ••., , ,i) CL ..• ' 1,11 tal ...'i•-• , cA. c...1 U.1' a• 0 Ca) a eit sA 0, vs AAA 14,1 0 c, ,4 0, 0, .. a• c'. 0 ';',.. ..--- ".-- 441 A—.. S.- ..- > •., ..4 ',..7 --., -,-, u I ''''', oc, • i-- 9 tt 1. 9 P X. cc ,-.Fi Ail 0 ,.. k— X LA• AJ- X 0 CA- a trt 00 DATE(MM/DD/YYYY) ACORLF CERTIFICATE OF LIABILITY INSURANCE 08/17/2022 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. 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 NAME: Donna Ostrowski Mark Sylvia Insurance Agency, LLC PHONE .Extt: (508)957-2125 FAX Not: 508-957-2781 404 Main Street E-MAIL ADDRESS: marmar � Y k ks Iviainsurance.com Centerville, MA 02632 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Farm Family Casualty Insurance INSURED INSURER B: Timothy Gray Building and Remodeling Inc INSURER C: 68 K Nicoletta's Way INSURER D: Mashpee, MA 02649 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTRINSD WVD POLICY NUMBER (MM/DDIYYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE RENTED CLAIMS-MADE X OCCUR PREMISESD(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 A N N 2001X2535 2/26/2022 2/26/2023 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER A ANY OFFICER/MEMBER ER EXCLUDED?PROPRIETOR/PARTNER/EXECUTIVE YNN E.L.EACH ACCIDENT $ 1,000,000 N/A N 2001W6340 10/15/2021 10/15/2022 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Carpentry Timothy Gray is covered by the workers compensation policy. Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION 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 Rte 28 AUTHORIZED REPRESENTATIVE //jjs,'•e�_ South Yarmouth MA 02664 FaX:(508)398-0836 Email: ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD s . t, A Aili - 1- 5 yk F 4.40111111141. 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