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HomeMy WebLinkAboutBLD-23-000068 ,-) rin / 7/- itj, A(trzrk., ;) ., O. „,Office Use Only C 41 e j� r e�J1 r /u Permit4 C ga S _. iy Amount ! ©•UV �4+.��0%: ::``Permit fires 180 days Y from /� issue date 60 /a rf EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH 1, RECEIVED Yarmouth Building Department 1146 Route 28 JUL 05 2022 South Yarmouth, MA 02664 i (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT By: CONSTRUCTION ADDRESS: t. y ASSESSOR'S INFORMATION: /t p Map: v Parcel: Lc S^ OWNER: lG.SLt %•r•tom,t','.c/P// /r 34f4�/ S fi3O 1 L Avi-eAy., 1;12 1/9 2 Op-- ,.,2/7.�/3? NPRESENT ADDRESS TEL. # CONTRACTOR: y (!....'r-e,.s'shtlz /6z.5tr.a/1V6vsc A/1/� dR/rs„s pn.s, 026r/ 5afr-,2 5'2-4/7a, NAME MAILING ADDRESS TEL.# Wrifesidential 0 Commercial Est.Cost of Construction$ q-?-06,apt) Home Improvement Contractor Lie.#. _ ' .,.16 Construction Supervisor Lic.# CS'•d$'t:IS-7 Workman's Compensation Insurance: (check one) I am the homeowner ':I. I am the sole proprietor 2 I have Worker's Compensation Insurance Insurance Company Name: .fit<'eni A)G►t I U LnSu,p 4,,c '( Worker's Comp.Policy#/2,4- '25/3.712_ WORK TO BE PERFORMED /7<,,,,, m hoer- f 1- T (Fire Retardant Certificate attached?) Wood Stove 0f f Tent Duration x Siding: #of Squares Replacement windows:# A 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 atx__1�,4.,7 a I,.6,v .e,.../4 P's' Location 4FAcili i I declare under penalties of perjury that the statements herein 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 and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature:! Date: 4/3c 2-47,:2,- Owners Signature(or attachment) Date: 6 30 2-7-- Approved By:__ `'� Building O' al(o signee EMAI DRESS: Date: _ J — 2'1.— r>— o„e_s_a /f/ _@ c?O/ zt:G — Zoning District Historical District Yes No Flood Plain"Lone: Yes :F No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No C OoK 0K ANC) an m cr.: >I o o cnAr- nrm- 2, S O �� DO mn DW< mm _a O-'�K oDm rC7) o EN \ XI N 07n \w0 P vmm . > HP U m= m g G) � -i, om1-m m a0o \ D-Cn m ui{xI : Nn0Z D `�. -Ia w=mm r- rN � mv; Zcn7 Q c 0 o - > \ 0Cn a � O w � �� Dm z ` C) y =. O CD n .. n = Z O CD: i O ,'Cmj CD _ ti A D CD o 0 C) 3 0 Q C/) O .0 Cl) c z o ° C O CD - �• �o n � C .-► O f4 N-a < Cn (D �, i _o c •d Cy O CD 0- Q 1 q'''`-'11' 75.O 0 N t * E o =a� " CDC Cn 7\ m _ S \ y -. CD _' g y z CO � ° CD CD - X ca, C CO -.NI 0 7S m o _ fn j CO c o E O 71 . om Q-0 c CD �..< - CD '�_. rt3 m o'o- 00 CQ `' N• =. fD z y o S9j o> m N Z1 co N. N N a . . O 7 Q O N ID -",,, 9. qt. 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Cl : �` 0 Sr tu, lt, i to ,U CO to I. in ..I Cl/ Ifs ill a,. .3 N p.., :: :,:� . . -r n) tv 7/6/22,i 8:50 AM Details Licensee Details Demographic Information Full Name: MICHAEL WOESSNER Owner Name: License Address Information City: Orleans State: MA Zipcode: 02653 Country: United States License Information License No: CS-080957 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 4/26/2022 Issue Date: 3/4/2010 Expiration Date: 3/4/2024 License Status: Active Today's Date: 7/6/2022 Secondary License Type: Doing Business As: Status Change Reason: License Renewal Prerequisite Information No Prerequisite Information Complaint Number: 2008-235 Complaint Status: agencylprofOcomplaint_status100 Date Complaint Received: 2/21/2008 12:00:00 AM Date Complaint Entered: 5/7/2010 12:00:00 AM Violation Code: Violation Type: agencyl profOviolation_type2 Violation Description: Reprimand Sanction: Reprimand Sanction Start: 5/4/2010 12:00:00 AM Sanction End: No Available Documents https://madpl.mylicense.com/Verification/Details.aspx?result=eb19c5de-852a-4195-8a4a-cc6e80c49f6b 1/1 The Commonwealth of Massachusetts • Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 • W w.mass aov/dia Workers'.- '6 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Inform n atio Please Print Legibly . , „ Name (B usiness/Org anizationlIndiv'dual): deat,r..1:5,n e/2. Address: • - - City/State/Zip: 04/4, i./frin Phone 7-Lk .5 Are you an employer?Check the appropriate box: Type of project (required): 1.0 am a employer with employees(full and/or part-time).* 7. D New construction Iream a sole proprietor or partnership and have no employees working for me in 8. [pIeinodeling any capacity.[No workers comp.insurance required.] 9. D Demolition 3.0 1 am a homeowner doing all work mysel E [No workers'comp.insurance required.]t 10 Building addition 4 71 I am a homeowner and will be hiring contractors to conduct all work on my properoy, I wilt ensure that all contractors either have workers'compensation insurance or are sole I LE Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.L1I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp. insurance.1 6.0 We are a corporation and its officers have exercised their right of exemption per NIGL c. 14. Other 152,§!(4),and we have no employees [No workers'comp,insurance required.] *Any applicant that checks box#I must also till out the section below showing their 1.1.'0i-frets'compensation policy infor:nation. 1.Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit z 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 ain an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Al•tsit•An 7.f113 ,r‘vps,7 c e Cc) Policy#or Self-ins.Lie.#:APpie2i./.3 22 • Expiration Date: 42 Job Site Address: ; City/State/Zip: (-,2 `' Attach a copy of the workers' co pensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c, 152, §25,A.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. /do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: s/./.2.6.,..w 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/Tovvn Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Phone ACG►RL CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYY) 10/08/21 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 I C.ONIAt,r NAME: Todd E Sullivan EF SULLIVAN INSURANCE AGENCY PHONE 781.3265836 FAx (A/C.No,Ext): (A C.No): 781-320-0908 507 High Street E-MAIL Dedham,MA 02026 ADDRESS: todd@efsullivaninsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Western World Insurance Co INSURED { INSURER B: Michael Woesner INSURER C: 170 New Boston Rd j INSURER D Dennis,MA 02638 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 ADULSUbR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR wvD POLICY NUMBER I(MM/DDIYYYY},(MM/DOlYYYY} LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 500,01 DAMAGETO RENTEL) CLAIMS-MADE OCCUR PREMISES(Ea occurrence) S 50,01 MED EXP(Any one person) S 5,01 A NPP8243722 09/19/21 09/19/22 PERSONAL&ADV INJURY S 500,01 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 1,000,01 PRO- POLICY JECT LOC PRODUCTS-COMP/OPAGG S 500,0( OTHER: I S AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) S HIRED NON-OWNED PROPERTY DAMAGE _ AUTOS ONLY ^ AUTOS ONLY I (Per accident) _ S UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE S DED RETENTION S j S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y f N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A j E.L.EACH ACCIDENT 5 (Mandatory in NH) EL.DISEASE-EA EMPLOYEE S If yes describe under DESCRiPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS!LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Todd E Sullivan ©1988-2015 ACORD CORPORATION. All rights reserve ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Bk 35180 Pg192 #30046 • 06-10-2022 @ 01 : 53p NOT NOT AN AN OFFICIAL• OFFICIAL COPY COPY NOT NOT AN QUITCLAIM DEED A N OFFICIAL OFFICIAL I,SANDRA L. ERIIF\1C5,being unmarried,of i6 baFib4 Street,South Yarmouth, MA 02664, in full consideration paid of FOUR HUNDRED TWENTY-FIVE THOUSAND DOLLARS AND NO/100 Dollars ($425,000.00), grant to JOSHUA R. GREENFIELD, Individually,now of 16 Danbury Street,South Yarmouth,Massachusetts. y i WITH QUITCLAIM COVENANTS • 5 0 The land in Yarmouth (South), Barnstable County,Massachusetts with any buildings 0 thereon,being shown as LOT No.113 on a plan entitled"Property of George W. & 45 >4 Marion P. Wood,Plan of Land in South Yarmouth,Mass., as surveyed for L.Melva 0 Jones-Scale 1" equals 80' dated 1941-Whitney &Bassett, Architects and Engineers, cR In eers, Hyannis,Massachusetts,which said plan is duly recorded in Barnstable County y Registry of Deeds in Plan Book 72,Page 51 containing 5,000 square feet of land,more or less. Subject to and with the benefit of all rights,restrictions,reservations,rights of way, reservations,easements and encumbrances of record insofar as the same are in force 2 and applicable. Grantor hereby release any and all homestead rights to the within premises, whether created by declaration or operation of law,and further state under the pains and penalties of perjury that there are no other individuals entitled to homestead rights to the property being conveyed herein. For Grantor's title see deed recorded with the Barnstable County Registry of Deeds in Book 23244, Page 185. Property:16 Danbury Street, South Yarmouth,MA 02664 MASSACHUSETTS STATE EXCISE TAX BARNSTABLE COUNTY EXCISE TAX BARNSTABLE COUNTY REGISTRY OF DEEDS BARNSTABLE COUNTY REGISTRY OF DEEDS Date: 06-10-2022 @ 01:53pm • Ctl#: 463 Date: 06-10-2022 ? 01:53pm Doc#: 30046 Ct1#: 463 Fee: $1,453.50 Cons: $425,000.00 Do : ,0006 $4 Fee: $1,300.50 Cons: $425,000.00 Bk 35180 Pg193 #30046 N O T N O T AN p N WITNESS riiy Udlarc'tl sIeadi this// da}Aot' p‘ A L ,2022 Copy C O P(Y N O T A N • OF F I C I AL L COPY SANDPAEL. F vl4l0 STATE OF r!ofe Dirt County of R9L-K On this f 1 rhday of 2022, before me, the undersigned notar public, personall a eared SA DRA L. FEMINO y cr- personally known tom ,40 1 ❑ oved to me through satisfactory evidence of identification,which was o driver's license o (other) to be the person whose name is signed on the preceding or attached document,and who swore or affirmed to me that the contents of the document are truthful and accurate to the best of her knowledge and belief, and acknowledged the foregoing to be her free act and deed and signed it voluntarily for its stated purpose. •r••' DAVID C.MULLER • WARY MCC.ST/DE OF FLORIDA Notary Pu is '"►«�;:° COMMISSION#NH 178344 MYCamasslonExpires My Commission Expires:ip 6� .,g pal fj [SEAL] .0111 111 i• , . 1 • 1 d i1 :) 1 i ,.• //1IIII11 ‘ JOHN F. MEADE, REGISTER BARNSTABLE COUNTY REGISTRY OF DEEDS RECEIVED & RECORDED ELECTRONICALLY