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BLD-23-000848
Office Use Only O�'YA C RECEIVED Permit# 17 202Amami lU56{fd [AuG2 Permit expires 180 days from issue date Bu lei, By _ EXPRESS BUILDING PERMIT APPLICATION $O-23- ,E9 TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 8 Burch Rd ASSESSOR'S INFORMATION: Map: 26 Parcel: 60 OWNER:Mark and Carol Kyer 2616 Crepe Myrtle Dr Flower Mound.TX 75028 (972)977-0914 NAME PRESENT ADDRESS TEL. # CONTRACTOR:Goff Brothers Construction Inc 1 Housewrights Way Orleans, MA 02653(774)353-6876 NAME MAILING ADDRESS TEL.# Residential 0 Commercial Est.Cost of Construction$ '�—ri7;,- k si, 000 Home Improvement Contractor Lic.# 133765 Construction Supervisor Lic.# CS-108899 Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor 'dI have Worker's Compensation Insurance Insurance Company Name: Dowling&O'Nail Insurance Agency Worker's Comp,Policy# WCC50050150112021A WORK TO BE PERFORMED Tent LI Duration (Fire Retardant Certificate attached?) Wood Stove I Siding: #of Squares 15 Replacement windows:# 14 Replacement doors: # 4 Roofing: #of Squares (❑)Remove existing*(max.2 layers) Insulationul , n nOld Kings Highway/Historic Dist. f3))Replacing like for like Pool fencing I ] *The debris will be disposed of at: onsite dumpster ABC Disposal Services 1245 Shawmut Ave New Bedford, MA 02746 Location of Facility 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 evocation of my license and for prosecution under M.G.L.Ch.268,Section 1, n ^ Applicant's Signature: Date: 5/J Owners Signature(or achment) /� Date: �( Approved By: Q Date: v IC a`e Building Official(or designee) EMAIL ADDRESS: contact@goffbrothersinc.com Zoning District: Historical District: Yes No Flood Plain ZoneN Yes No Water Resource Protection District: Within I00 ft.of Wetlands: Yes _ No Yes -. No LcxWO zee)(&..., The Commonwealth of Massachusetts F =7. _ 1, Department of Industrial Accidents t, T_= IA 1 Congress Street, Suite 100 __C1- Boston,MA 02114-2017 www.mass.gov/dia Arm Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organizatiorvindividual):Goff Brothers Construction Inc Address: 1 Housewrights Way City/State/Zip:Orleans, Ma 02653 Phone#:53:c*'5°3`8*711±-, —I-1 4-35-3-1.p8 (P Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 3 _employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. Eemodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 10 0 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 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. ROOf repairs These sub-contractors have employees and have workers'comp.insurance.t 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 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. I 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:Associated Employers Policy#or Self-ins.Lic.#:WCC5005015012021A Expiration Date:8/26/2022 Job Site Address:Ei BIXC(e, City/State/Zip:50 - "GYynock' r l 4 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).OR1P(04 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 cer ' unde t ains and penalties of perjury that the information provided above is true and correct. Signature: % ep Date: S/l C o� Phone#: 1 -1 Li—353- llia-RD 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#: ACCMCP CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 08/24/2021 THIS CLRTIFICATE 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 REPRESENTATIVEOR 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 Jane Logan NAME: Dowling&O'Neil Insurance Agency PHONE (800)640-1620 FAX (A/C,No,Ext): (A/C,No): 973 lyannough Road ADDRESS; jlogan@doins.com INSURER(S)AFFORDING COVERAGE NAIC# Hyannis MA 02601 INSURER A: Main Street America Assurance 29939 INSURED INSURER B: Citation Insurance Company 40274 Goff Brothers Construction,Inc. INSURER C; Associated Employers Ins Co 11104 One Housewrights Way INSURER D INSURER E: Orleans MA 02653 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2182480435 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 AUUL SUBH LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF POLICY EXP (MMJDD/YYYY) (MM{DD/YYYY} LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X`OCCUR DAMAGE TO RENTED 500,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 A MPT6053P 08/29/2021 08/29/2022 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMITAPPUES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO PRODUCTS-COMP/OP AGG $ PRO- JECT LOC 2,00 0,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ B OWAUTNEDOSONLY X AUTOS SCHEDULED BCRQ23 11/20/2020 11/20/2021 BODILY INJURY(Per accident) $ X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) Waive Collision Ded $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION _ AND EMPLOYERS'LIABILITY �,t N eNI STATUTE EERH C ANY PROPRIETORiPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N N t A WCC50050150112021A 08/26/2021 08/26/2022 (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,O0Q000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 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 Orleans ACCORDANCE WITH THE POLICY PROVISIONS. 19 School Street AUTHORIZED REPRESENTATIVE Orleans MA 02653 s 4 2*§ ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Conti h of Massachusetts I r S�fr+�iil�,l�i of rre//si�1/. rirf i,�rir iiirf/} Mini' n d Prafasakmal Licensure . * Botird P169ftegpikeons and Standards . z Office of Consumer Affairs a Business Regulation or HOME IMPROVEMENT CONTRACTOR TYPE:Individual g_f:Pisiratian i_ 23 CS' i iv - µ" * }Jei:0711 , 08/05/2023 .�SN0W 2JOHN F.GOFF 13376 5 MONSTER IS) "' r' {.r 1 �• JOHN F.GOFF _ fi ;' r ;� I HOUSEWR1GHTS WAY f/„-.nsf4.- ,sl�..so-z ORLEANS•MA 02653 Undersecretary Commissions t• � ! o Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constl�; f� ' rvisgr CS-108899 sf ASHLEY H«aC' spires:01/20'202.3 140 STURBRIDGE WAY , BREWSTER MA 02631 Commissioner •', i, A cl, - 1 • Substantial Improvement Worksheet for Floodplain Construction (for reconstruction,rehabilitation,addition,or other improvements, and repair of damage from any cause) Property Owner: 1'-'1(%y cdd CO ro1 VNJ Address: Permit No.: Location: 8 rrY, Kd Sa.*h \ICIYYYlet�-+-� Description of improvements: t4 vrA-v rienl r nni I�l ()i re_pla efite.41-, lS Se6x.tre .si+1tr1[tkz MadcetvArtiw ofe ONLx appl or acfitit*L assessed iralue - $ 3MS,000 �y f _..v.- .... .. ... ......__..+ : .:... .'-..-:: v +s lf�pso sis # Q� t€off ►�} 1 % If ratio is 50 percent or greater(Substantial Improvement),entire structure including the existing building must be elevated to the base flood elevation(BFE)and all other aspects brought into compliance. Important Notes: 1. Review cost estimates to ensure that all appropriate costs are included or excluded. 2. If a residential pre-FIRM building is determined to be substantially improved.it must be elevated to or above the BFE. If a non-residential pre-FIRM building is substantially improved,it must be elevated or dry floodproofed to the BFE. 3. Proposals to repair damage from any cause must be analyzed using the formula shown above. 4. Any proposed improvements or repairs to a post-FIRM building must be evaluated to ensure that the improvements or repairs comply with floodplain management regulations and to ensure that the improvements or repairs do not alter any aspect of the building that would make it non-compliant. 5. Alterations to and repairs of designated historic structures may be granted a variance or be exempt under the substantial improvement definition)provided the work will not preclude continued designation as a"historic structure: 6. Any costs associated with directly correcting health,sanitary,and safety code violations may be excluded from the cost of improvement. The violation must have been officially cited prior to submission of the permit application. Determination completed by: Date: • Costs for Substantial Improvements and Repair of Substantial Damage Included Costs Items that must be included in the costs of improvement or costs to repair are those that are directly associated with the building. The following list of costs that must be included is not in- tended to be exhaustive, but characterizes the types of costs that must be included: ■ Materials and labor,including the estimated ■ Structural elements and exterior finishes value of donated or discounted materials (cont.): and owner or volunteered labor ■ Windows and exterior doors ■ Site preparation related to the improvement or repair (foundation excavation,filling in ■ Roofing,gutters,and downspouts basements) ■ Hardware ■ Demolition and construction debris disposal ■ Attached decks and porches I Labor and other costs associated with ■ Interior finish elements,including:demolishing,moving,or altering building components to accommodate ■ Floor finishes (e.g.,hardwood,ce- improvements,additions,and making ramie,vinyl,linoleum,stone,and repairs wall-to-wall carpet over subflooring) ■ Costs associated with complying with any ■ Bathroom tiling and fixtures other regulation or code requirement that is triggered by the work,including costs ■ Wall finishes (e.g.,d y all,paint,stuc- to comply with the requirements of the co,plaster,paneling,and marble) Americans with Disabilities Act(ADA) ■ Built-in cabinets (e.g.,kitchen,utility, ■ Costs associated with elevating a structure to entertainment,storage,and bathroom) an elevation that is lower than the BFE I Interior doors ■ Construction rnanagement and supervision IIContractor's overhead and profit I Interior finish carpentry ■ Sales taxes on materials I Built-in bookcases and furniture ■ Structural elements and exterior finishes, I Hardware including: I Insulation ■ Foundations (e.g.,spread or continu- ous foundation footings,perimeter walls, ■ Utility and service equipment including: chainwalls,pilings,columns,posts,etc.) ■ HVAC equipment Monolithic or other types of concrete I Plumbing fixtures and piping slabs I Electrical wiring,outlets,and switches ■ Bearing walls,tie beams,trusses I Light fixtures and ceiling fans ■ Joists,beams,subflooring,framing, ceilings I Security systems I Interior non-bearing walls I Built-in appliances ■ Exteriorfinishes (e.g.,brick,stucco,sid- I Central vacuum systems ing, painting,and trim) ■ Water filtration,conditioning,and re- circulation systems 4 of 7 SAMPLE NOTICE FOR PROPERTY OWNERS, CONTRACTORS,AND DESIGN PROFESSIONALS s1 Excluded Costs Items that can be excluded are those that are not directly associated with the building.The fol- lowing list characterizes the types of costs that may be excluded: ■ Clean-up and trash removal t Outside improvements,including II Costs to temporarily stabilize a building so landscaping,irrigation sidewalks,driveways, that it is safe to enter to evaluate required fences,yard lights,swimming pools, repairs pool enclosures,and detached accessory structures (e.g.,garages,sheds.and gazebos) ■ Costs to obtain or prepare plans and specifications ■ Costs required for the minimum necessary 1� Land survey costs work to correct existing violations of health, safety,and sanitary codes ■ Permit fees and inspection fees ■ Plug-in appliances such as washing �'� $ Carpeting and recarpeting installed over machines,dryers,and stoves finished flooring such as wood or tiling SAMPLE NOTICE FOR PROPERTY OWNERS, CONTRACTORS, AND DESIGN PROFESSIONALS 5 of 7 TOWS Of- AR OL TH 1146 Route 2 o th MA 42664 508-398-223 a 24 a $08-398-0836 { Office of the uild — . missioner FINAL COST AFFIDVIT FOR WORK IN FEMA FLOOD ZONE To the Building Commissioner, In accordance with 780 CMR Section 109 of the Massachusetts State Building Code, the total estimated cost of construction, including all related costs* of the building at rah �‘ and constructed,reconstructed,altered,repaired,or extended under building permit no. amounts to $ I(p ci ,00t7 I, k\'11 ,being referred to as the owner/agent identified below,do solemnly swear that the statemeeade herein are strictly true, correct and made in good faith *Related construction costs include all work done with or concurrently with the work contemplated by the building permit including construction, reconstruction, repairs, demolition, HVAC work, etc. Furnishings and portable equipment are not part of the total construction costs. Sign a of owner/agent A i Ziii g doev7 otary li e ' M Cossion Expires Notary Seal: , &, Gailynn G Miller NUotary Public I COMMONWEALTH OP MASSACHUSETTS e My Commission Expires November 4,2027 ° ' TOWN OF YARMOUTH ra;tritt -i BUILDING DEPARTMENT y 4 ., ,s„ G 1146 Route 28, South Yarmouth, MA 02664 °tG Telephone 508-398-2231 ext. 1261 Fax 508-398-0836 Owner's Affidavit: Substantial Improvement or Repair of Substantial Damage Property Address: 13 V rc k- 12-,CQ SciA)11- ya(in 0() 61-eg,ea Parcel ID Number: ci„,„/0)1(p . 0 r,Owner's Name: 4 /�a� /�ye.,-(� Owner's Address/Phone: -/ IC �7- 9 t 7-O / Contractor: ;-o E'C B IO er,- GI/s IYwc—(aori C:__ Contractor's License Number: I D BY 9, Date of contractor's Estimate: 6t ' ji 5 f /1, 2V -2 I hereby attest that the description included in the permit application for work on the existing building all improvements, rehabilitation, remodeling, repairs, additions, and other forms of improvement. I further attest that I requested the above-identified contractor to prepare a cost estimate for all of the work, including the contractor's overhead and profit. I acknowledge that if, during the course of construction, I decided to add more work or to modify the work described, that the Town of Yarmouth will re-evaluate its comparison of the cost of work to the market value of the building to determine if the work is substantial improvement, Such re- evaluation may require revision of the permit and may subject the property to additional requirements. I also understand that I am subject to enforcement action and/or fines if inspection of the property reveals that I have or authorized repairs or improvements that were not included in the description of work, and the cost estimate for that work that were basis for issuance of a permit. Owner's Signature: 14/ e7 Date: //VaR0 9--;- Notarized: W�.� _ _ ` s.:�.cr { ( �>. ` LOUISA MORROW �, ,t Notary Public ' �I'';! Massachusetts \ > ;% My Commission Expires --- Dec 4, 2026 o o �Q1,.._ ,, TOWN OF YARMOUTH `'�'tr' of ,., ° BUILDING DEPARTMENT . P-34 ��" » ,;R 0,<' 1146 Route 28, South Yarmouth, MA 02664 %' Telephone 508-398-2231 ext. 1261 Fax 508-398-0836 Contractor's Affidavit: Substantial Improvement or Repair of Substantial Damage Property Address: 6 ,Boa i rvw +-tri, . V-t H Parcel ID Number: aLo/cDO Owner's Name: - Cj Y IC '- vi k Cad. I Cy Q, - Contractor: G -61(6 iix CO IS UC_ncr LC Contractor's License Number: I C(P CI..9 Date of Contractor's Estimate: 8/ I Eq.: I hereby attest that I have personally inspected the building located at the above-referenced address by the nature and extent of the work requested by the owner, including all improvements, rehabilitation, remodeling, repairs,additions, and any other form of improvement. At the request of the owner, I have prepared a cost estimate for all of the improvement work requested by the owner and the cost estimate includes, at a minimum,the cost elements identified by the Town of Yarmouth that are appropriate for the nature of the work. If the work is repair of damage, I have prepared a cost estimate to repair the building to its pre-damage condition. I acknowledge that if, during the course of construction, the owner requests more work or modification of the work described in the application,that a revised cost estimate must be provided to the Town of Yarmouth, which will re-evaluate its comparison of the cost of work to the market value of the building to determine if the work is substantial improvement. Such re- evaluation may require revision of the permit and may require revision of the permit and may subject the property to additional requirements. I also understand that I am subject to enforcement action and/or fines if inspection of the property reveals that I have made or authorized repairs or improvements that if inspection of the property reveals that I have made or authorized repairs or improvements that were not included in the description of work and the cost estimate for that work that were basis for issuance of a permit. Contractor's Signature (/)I /h1_j Date: 8/ I E)102a Notarized: " A ' / / .� ' nn G Miller Tel, otary Public COMMONWEALTH OF MASSACHUSETTS My Commission Expires r November 4,2027 CAPE COD APPRAISAL PARTNERS Linda Coneen,MRA SRA ccappraisalpartnersl gmail.com Julia A Lee,SRA,RA MA Cert Gen RE Appr Lic#214 www.capecodappraisalpartners.com MA Cert Res RE Appr lic#76040 95 Rayber Road,Orleans,MA 02653 A+.a•R•E A Telephone 508-255-4241 — FAX 508-255-6387 Mil It[ October 15,2021 John Goff for Mark S&Carol A Kyer Goff Brothers Construction Company,Inc 1 Housewrights Way Orleans,MA 02653 8 Burch Rd,South Yarmouth,MA 02664 (Improvements Only) Dear Mr.Goff, In accordance with your authorization, I have prepared an estimate of the Actual Cash Value (ACV)of the residence located at 8 Burch Rd,South Yarmouth,MA.Actual Cash Value is defined by the Federal Emergency Management Agency (FEMA) as "The cost to replace a building on the same parcel with a new building of like-kind and quality,minus depreciation due to age,use, and neglect." FEMA,Substantial Improvement/Substantial Damage Desk Reference,4.5.3. Site improvements and land value are not included in the analysis. The market value of the real estate has not been appraised under the definition of"market value" commonly used in the practice of real estate appraisal: "The most probable price, as of a specified date, in cash, or in terms equivalent to cash, or in other precisely revealed terms, for which the specified property rights should sell after reasonable exposure in a competitive market under all conditions requisite to a fair sale, with the buyer and seller each acting prudently, knowledgeably, and for self-interest, and assuming that neither is under undue duress."The Appraisal of Real Estate,14"'Edition,Appraisal Institute,2013,page 58. This definition includes the land,building,and all site improvements,as well as outbuildings and other man-made structures. The intended use of this report is to assist you, my client, with building code compliance by providing an opinion of the depreciated value of the improvements as of the date of value, and prior to any work completed on the date of inspection, as required by National Flood Insurance regulations ("50%Rule"). •Intended users of the report are you, the client; Mark S Kyer; Carol S Kyer; and the Yarmouth building Commissioner, for the stated purpose. The appraiser is not responsible to any other user for any other purpose. The National Flood Insurance Program(NFIP) regulations do not define "market value" but do note two specific requirements: • "Market value must always be based on the condition of the structure before the improvement (sic)is undertaken or before the damage(if any)occurred. • "Only the market value of the structure is pertinent.The value of the land and site improvements (landscaping, driveway, detached accessory structures, etc) and the value of the use and occupancy (business income) are not included. Any value associated with the location of the property should be attributed to the land,not the building." The date of value is September 1,2021,which is the date prior to any demolition of interior finish in preparation for renovations by John Goff of Goff Brothers Construction Company, Inc. The date the property was inspected by appraiser Julia A Lee, SRA, RA, was October 8, 2021. In the last weeks of September and early October 2021,the dwelling underwent preparation for renovations which involved interior demolition of finish, the removal of flooring and fixtures, the removal of baths and the kitchen. Photographs publicly available in Cape Cod & Islands MLS used to determine the condition of the improvements prior to the commencement of demolitions, have been included in this report. Photos of the interior at the time of inspection have also been included in this report. The cost analysis to follow is based on the quality and condition of the building on the date of value prior to any work completed, September 1,2021. The written cost analysis, attached, has been prepared in compliance with the requirements of Standards Rules 1 and 2 of the Uniform Standards of Professional Appraisal Practice (USPAP) for real property appraisal assignments, as promulgated by the Appraisal Standards Board of the Appraisal Foundation, 2020-2022 Edition, and applicable guidelines and regulations. The cost analysis reflects the building component(only)of market value as required by NPIF regulations. This report includes a summary cost analysis of the building improvements but not the underlying land value, furnishings, personal property, or the value of site improvements such as landscaping,parking areas,walkways,septic system, and utility hook-ups. The improvements consist of an above average to good quality, wood frame, 1860 square foot (SF), detached Cape style dwelling originally constructed in 1957. The dwelling has one finished floor above grade, and a finished attic, considered two finished floors above grade for the purposes of this 'report. There are three bedrooms, two full bathrooms, a kitchen, a living room, a large family/multi- purpose room, and a dining room, above grade. Items not included in base costs include adjustments made for:an attached deck,two brick fireplaces,and the recent increase in lumber costs due to increased demand and lumber shortages as reported by area builders. The cost analysis is based on the quality and depreciated condition of the improvements as of the date of value. My knowledge of the interior finish materials and condition of the subject is based on the photographs from a listed sale on Cape Cod &Islands MLS, and a recent property inspection. Overall, the improvements were judged to be above average to good quality construction in average condition with dated style of finish. The scope of work included a physical inspection of the interior and exterior of the home, examination of MLS and assessor record information, and development of an appropriate cost analysis. Cost data are based on the Marshall Valuation Service manual and local builder estimates. The sales comparison and income approaches are not applicable to the assignment and were not developed and do not apply to the appraisal problem. On the basis of the attached cost analysis, the "as is" depreciated cost of the subject improvements(Actual Cash Value),as of the date of value,September 1,2021: THREE HUNDRED FORTY FIVE THOUSAND DOLLARS ($345,000) rounded Thank you for allowing me to be of service in this matter. Please feel free to contact me should you require any additional assistance. Yours truly, 94144- Julia A Lee,SRA,RA MA Certified Residential Real Estate Appraiser License#76040 Cape Cod Appraisal Partners Federal Tax ID 83-4185920 COST APPROACH PROPERTY TYPE Single-Family Residences Residence Class & Type/Quality D Above Average to Good Exterior Wall Wood Shingle Number of Stories Two Stories GLA 1,860 SF Year Built & Age 1957/64 Years Condition& E:ff Age Average w/Dated Finish/25 Yrs Foundation Full Basement/Concrete Block Region Eastern Climate Moderate Single-Family Residences Sec 12, Pg 25-Class D BASE SQUARE FOOT COST $130.00 Height&Size Refinements Story Height - Multiplier 1.000 Shape Multiplier 1.000 Combined Height&Size Multiplier 1.000 Refined SF Cost $130.00 Builder 15% Architect 10% FINAL SF COST $162.50 GLA 1,860 SF SUB-TOTAL $302,250 Plus: Lump Sum Adjustments Brick Fireplace 2 @ $5,000 $10,000 Attached Wood Deck 50 SF @$27/SF $1,350 Lumber Overage $20,915 Lump Sum Total $32,265 SUB-TOTAL $334,515 Current&Local Cost Multipliers Current Cost Multiplier 1.080 Local Cost Multiplier 1.200 Resort Cos'[ Multiplier 1.020 TOTAL COST NEW OF IMPROVEMENTS $434,870 Depreciation Eff Age:"25 21% S91,323 DEPRECIATED VALUE OF THE IMPROVEMENTS $343,547 Rounded to $345,000 GENERAL COMMENTS The cost data are obtained from the Marshall Valuation Service Manual, supported by local builders' and contractors' costs. The cosh,used are for "Single Family Residences," Section 12, Page 25, Class D, of the Marshall Valuation Service Manual, and local builder estimates. Ratings and definitions are in the Marshall&Swift Valuation Service Manual. • COST ANALYSIS Cost data are based on the Marshall Valuation Service Manual, supported by local builders' costs. Base costs are for single family residences. Appropriate multipliers have been applied to the base cost for the number of stories and the shape of the footprint. Current cost, local cost, and resort cost multipliers have been applied to adjust for the higher cost of construction in the regional (eastern) and local (Cape Cod)markets.This is standard methodology when using the Marshall Valuation Service Manual. SKETCH(ASSESSOR/CONFIRMED INFIELD) SAS 13 5 WDK 10 PTO18 24 19 5 16 16 16 BAS 8 13 8 10 EAF 10 BAS USIA 26 16 24 10 2 16 30 SUBJECT PHOTOGRAPHS TAKEN OCTOBER 8,2021 j M ,,,, _. L 4 r, Syl" n i s` . ix..,. k .-. .t + 7 , ifi T F . . • ,� d s ' -- - _ -- _ Front Rear III ba I ,l �� #0 F., # §.` tl ` tom, `� -' f 1 $1' 1 , /r 1 ' 1� d..A i NA a�x l'' w "'o�.y Side Side _ . ...• ... . ..„. ...,... . i mi. - AI 1 r ,,... .. . . _ .. _ , . _ _ . , s . .., I N �� I .' I • r I Ft .� I r T - ` - , :'."awl OM- . Bedroom Living Room&Fireplace SUBJECT PHOTOGRAPHS Yz• .. t'N' ' ' kiiii, ,, x , n yr * µ'0ke z. Bedroom in Finished Attic Family Room&Fireplace :II , ' 1'1 ..,:'.. , _i al Bath Bedroom E t j y �.` Ai• Lt P1 . 1FK ,4 �- P AR SUBJECT MLS LISTING 1 Residential Closed MLS#:21902800 8 Burch Road South Yarmouth MA 02664 LP:$550,000 Sold Price:$500,000 ,ik, le g r Property Type: Residential Prop Subtype: Single Family Residence ++ County: Barnstable Village: South Yarmouth I�4 Yarmouth Beds: 3 '� � ,�µ ��" Town: ' , , Rooms: 7 Total Finished Space: 1,860 ' AlibilfrBaths F/H: 2/0 Lot Acres: 0.21 , Year Built/Desc: 1957/Actual DOM/CDOM: 417/417 Tax ID: 26-60 Annual Taxes/yr: $5,052/2020 Total Assessment: $505,200 Building Assessments: 251,100 ' Leased Land: No Land Assessments: 254,100 Other Assessments: 0 Property Includes Recording Devices: No WF/WV: No/No WB/WBV: WF/WV Type: Water Access: Salt Location Description: South of Route 28 Special Listing Cond: None Remarks:`Please note we have a video tour as a walk through experience while we all deal with this coronavirus issue.The estate of 8 Burch has reduced to $550,000 the price their independent appraisal came in at just before they listed in this$650K neighborhood where several homes on the market are priced over $650k.The estate realizes that updating needs to be done and the price now reflects it.This 3 bedroom with a master suite is just 2/10 of a mile&3 lots to Nantucket Sound beaches!?The 1st floor offers one floor living with a separate master suite,renovated Cherry kitchen w Corinan counters,guest bdrm,2 full baths,dining room,front-sitting&great room each with a fireplace!The 2nd fl.has the 3rd bedrm plus an extra room that has only been used as storage.The 2nd fl.would be a perfect candidate for a single/double dormer renovation with a full bath.Partially fenced natural backyard for a low maintenance plus an extra long storage/beach shed.Passing TitleV in hand. If you're looking for a true Cape Cod beach house where you can hear the surf from your backyard then this could be where your 2020 family memories can begin...as well as all those family beach walks! Agent Remarks:Call/text Jim at 508-776-3450 for quicker response for showings and/or questions.Easy to show.The second floor with 2 dated smaller rooms (1 storage room has a chimney in the middle of it!)has only been utilized as storage so renovation should be a consideration for buyers looking to utilize the 2nd floor to its fullest capabilities.Full dormers with a full bath has been discussed at showings. Directions:From Route 28 in Yarmouth take Old Main to South Street which curves to the right and turns into South Shore Dr.and then a right on Burch and#8 is the second house on the right.Yard sign Listing Agent: Jim&Reginz, 508-776-3450 jaugat@kinlingrover.com Listing T Exclusive Right To Buyer Agent Augat g Type: Sell Comm: 2.5% Listing Office: Kinlin Grover Real 508-775-5200 List Date: 04/20/2019 Concessions: Yes Estate Under Contract 06/10/2020 Concessions Date: Amount: $10,000 Buyer's Jim&Regina 508-776-3450 jaugat@kinlingrover.com Estimated Selling 07/14/2020 OwnerGlen P Name:Agent: Augat Date: Thierwechter Buyer's Agent Kinlin Grover Real 508-775-5200 Sold Date: 07/28/2020 Facilitator Comm: 2.5% Office: Estate DOM/CDOM: 417/417 Compensation Gross Original List Price: $629,000 Type: Sold Price: $500,000 Dual Var Comm: No SP/LP%: 90.91% Financing: Conventional Garage: No Zoning: Residential Sub-Area: Bass River Basement: Yes Lot Size SqFt: 9,148 Renovated: No Basement Description: Bulkhead Access;Full Lot Size Source: Field Card Year Renovated: Foundation Block #of Parking Spaces: 2 Additional SqFt Irregular: No Topography/Lot Desc: Fenced/Enclosed;Level Source: Year Round: Yes Siding: Shingle Additional SqFt Field Card Title Ref Book: D1107878 Roof: Asphalt,Pitched Source: Year Built: 1957 Total Finished 1,860 Space: School District: Dennis-Yarmouth Beach Ownership: Public Miles to Beach: .1 -.3 Beach/Lake/Pond: Nantucket Sound;Parkers River Beach Beach Description: Nantucket Sound;Ocean Flood Ins Yes Required: FEMA Flood Zone: AE Lead Base Paint: Unknown Elevation No Certificate: Exterior Features: Deck;Fenced Yard;Outbuilding;Outdoor Shower;Yard Street Description: Paved,Public Convenient To: Cape Cod Rail frail;Conservation Area;Golf Course;In Town Location;Marina;Public Tennis;Shopping Showing Requirements: Appointment Required;Call Listing Agent;Tenant;Yard Sign Stories: 1 Heating: Forced Hot Water Private Pool: No Style: Cape Cooling: Other Private Dock: No Floors: Carpet,Hardwood,Vinyl Hot Water: Tankless Fireplace: Yes-2 Hot Water Source: Electric Mass Use Code: 101 -Residential,single family Water: Town Water Sewer: Septic Tank:Title V Grade Level Fuel: Oil ROOM Room Level Length Width Features Room Name Room Level Length Width Features c itM8 Primary Beamed Ceilings;Cathedral Ceiling; Master Bedroom Ceiling Fan;Cable TV;Private Full Bath; Rnrlrnnm I c.f.i.Gircf Rnrocend I inhfinn•{Ato14_in f`Inent• Master ;rlMa eedroom L ae �"'_IOnr`PIN 4 y W F�'� _ # . + 4 a �{t`a` � r `-1 A - s F � r • r +fir` • s 't byD -Yp Wd N • "t • • s r 1� R {is }1. 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ADDENDUM STANDARD CERTIFICATION STATEMENT I certify that,to the best of my knowledge and belief: • The statements of fact included in this report are true and correct. • I have performed no other services regarding the subject property within 3 years prior to the date of report and date of value,as appraisers or in any other capacity. • The reported analyses,opinions,and conclusions are limited only by the reported assumptions and limiting conditions are my personal,impartial,and unbiased analyses,opinions,and conclusions. • I have no present or prospective interest in the property that is the subject of this report and no personal interest with respect to the parties involved. • I have no bias with respect to the property that is the subject of this report or to the parties involved with the assignment. • My engagement is this assignment was not contingent upon developing or reporting predetermined results. • My compensation for completing this assignment is not contingent upon the development or reporting of a predetermined value or direction in value that favors the cause of the Client, the amount of the value opinion,or the occurrence of a subsequent event directly related to the intended use of this appraisal. • The reported analysis, opinions and conclusion were developed, and this report has been prepared in compliance with the requirements of the Code of Professional Ethics and Standards of Professional Appraisal Practice of the Appraisal Institute. • Use of this report is subject to the requirements of the Appraisal Institute relating to review by its duly authorized representatives. Additional Certifications-Appraisal Institute Julia A Lee,SRA • As of the date of the report,I,Julia A Lee,SRA,have completed the requirements of the continuing education program for designated members of the Appraisal Institute. • a. lee- Date: October 15,2021 Julia A Lee,SRA,RA Certified Residential Real Estate Appraiser,MA Lic#76040 QUALIFICATIONS OF APPRAISER CAPE COD APPRAISAL PARTNERS Linda Coneen,MRA,SRA ccappraisalpartners(agmail.com Julia A Lee,SRA,RA MA Cert Gen RE Appr Lic#214 www.capecodappraisalpartners.com MA Cert Res RE Appr Lic#76040 95 Rayber Road,Orleans, MA 02653 +rIMFn Telephone 508-255-4241 — Cell 508-737-7684 Qualifications of Julia A Lee, SRA, RA FOUNDING PARTNER,OWNER AND PRINCIPAL,RESIDENTIAL APPRAISER Cape Cod Appraisal Partners 95 Rayber Road,Orleans, MA 02653 March,2019-Present RESIDENTIAL APPRAISER Office of Linda Coneen, MRA, SRA 95 Rayber Rd,Orleans, MA 02653 2016-2019 Cape Cod&Islands Appraisal Group, LLP Plymouth County Appraisal Group Main Production Office: 95 Rayber Road,Orleans, MA 02653 Mid-Cape Office:3311 Main Street, Barnstable, MA 02632 2012—2013 PROFESSIONAL DESIGNATIONS SRA Member,Appraisal Institute,designated April 9,2019 Continuing Education Completed through December 31, 2021 RA Member, Massachusetts Board of Real Estate Appraisers,designated May,2019 AFFILIATIONS Board of Assessors,Town of Orleans,member 2o2o-present LICENSE Massachusetts Certified Residential Real Estate Appraiser License#76040 Expires 10/14/2022 EDUCATION University of Maryland,College Park, MD, Bachelor of Arts Degree, Psychology/Archaeology,1995 Appraisal Institute: 2020 COVID 1g:Latest Developments and Collaborative Effects, Panel Discussion(Webinar) 2019 General Market Analysis&Highest&Best Use(with exam) 2019 General Appraiser Income Approach Part I 2018 Residential Case Studies&Highest&Best Use(with exam) 2018 Advanced Case Studies Part I(with exam) 2018 Advanced Report Writing w/Demonstration of Work(with exam) 2017 Online Business Practices&Ethics 2017 Residential Report Writing&Case Studies(with exam) 2017 Residential Site Valuation&Cost Approach(with exam) 2017 Real Estate Finance, Statistics, and Valuation Modeling(with exam) 2017 Residential Sales Comparison and Income Approaches(with exam) 2017 Basic Appraisal Procedures(with exam) 2016 Basic Appraisal Principles(with exam) 2016 Uniform Standards of Professional Appraisal Practice 7hr Update 2016-2017 2016 Supervisory Appraiser/Trainee Appraiser Course Massachusetts Board of Real Estate Appraisers: 2020 COVID 1g:Guidance for Appraisers(Webinar) 2020 COVID 1g:Implications of Real Estate(Webinar) 2019 Uniform Standards of Professional Appraisal Practice 7hr Update 2020-2021 2017 Uniform Standards of Professional Appraisal Practice 7hr Update 2018-2019 2013 Residential Market Analysis&Highest and Best Use(with exam) 2012 Basic Appraisal Procedures(with exam) 2012 Uniform Standards of Professional Appraisal Practice(with exam) 2012 Basic Appraisal Principles(with exam) The Appraisal Foundation: 2020 Modifying "Standard" Appraisal Forms: Distance Learning and Education Cycle Guidance (Webinar) PROFESSIONAL EXPERIENCE Residential Appraiser,2018-present Residential Appraiser Trainee,2012-2018 Network Systems Administrator, Help Desk Manager, Outer Cape Health Services, 2013-2016 Network Systems Administrator, Cape Cod Academy, Osterville, MA 2002- 2012 Quality Assurance and Software Development, Intramedia, Hyannis, MA 1999-2002 Exchange and Windows Server Administrator, Ciena Corporation, MD 1997—1999 Litigation Technical Support, Forensic Technologies,Annapolis, MD 1996-1997 Trainer - Help Desk Tech Support, GE Information Services, Rockville, MD 1995-1996 Real Estate Sales-Personal Assistant to Broker, Upper Marlboro, MD,1993-1995 PROFESSIONAL MEMBERSHIPS Appraisal Institute,since 2012 Massachusetts Board of Real Estate Appraisers,since 2012 TECHNICAL COURSES&CERTIFICATIONS Microsoft Certified Systems Administrator, MCSA#3360526, 2005 Microsoft Exchange Server 2010, Boston University CE Center,Wareham, MA Microsoft Windows Server 2008, Boston University CE Center,Wareham, MA Microsoft Exchange Server 2003, Boston University CE Center,Wareham, MA Microsoft Windows 7, Boston University CE Center,Wareham,MA Wireless Security&Administration,Boston University CE Center,Wareham, MA VMWare,Training Center, Lexington, MA Microsoft Access Database Development,Cape Cod Community College, Hyannis, MA Filemaker Pro Database Development, Intramedia, Hyannis, MA Advanced Crystal Reports Development, Boston, MA TechEd 2010, New Orleans, LA SOFTWARE DEVELOPMENT Real Estate Appraisal Business Management Software and Database Development Website Development PUBLISHED ARTICLES Featured HP ProCurve Case Study,Cape Cod Academy,mob EDUCATIONAL AFFILIATIONS&AWARDS Psi Chi Honor Society, University of Maryland,1993-1995 Golden Key Honor Society, University of Maryland 1993-1995 Dean's List,University of Maryland,College Park, MD,1993-1995 9 r DIVISION OF PROFESSIONAL LICENSURE BOARD OF REAL ESTATE APPRAISERS ISSUES THE FOLLOWING LICENSE CERT RES.REAL ESTATE APPRAISER JULIA A LEE 5. PO BOX 153 SOUTH ORLEANS,MA 02662 Y 76040 10/1412022 624327 LICENSE NUMBER E.XPIRATI• DATE- SERIAL NUMB i w _ ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department v E [� 1146 Route 28, South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508 398 0836 AUG �t AG 22 2022 Massachusetts State Building Code, 780 CMR E. Bui i Permit Application To Construct, Repair, Renovate Or Demolish BUILDING DEPARTMENT a One-or Two-Family Dwelling By: This Section For Official Use Only • Building Permit Number: J�3s Date Applied: r• Sea(5 •�-—"'"= - S=4._ Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 4•1 P �ty le) , 4/4 1.2 Assessors Map&Parcel Numbers ,/ (le) /�1 i 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 0 Zone: Outside Flood Zone? Check if yes❑ Municipal CIOn site disposal system 0 SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: /�� yrhr�Dd / t ' . 74.14 �4 Name(Print) City,State,ZIP V G. -j /i,.Uo 141 /L v frotsses eye(' 444 S i/,I Ae 14,1.6 4-..-, No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction❑ Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2: fZ Ci )c,tlY Zell pat) t.C.— tZ 4 violcd the /-?.4 th Cht_lz A./t---le/ .....czowei \-Di SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only and Materials) Y 1. Building $ 1. Building Permit Fee:$ Igo Indicate how fee is determined: v 2.Electrical $ ❑ Standard City/Town Application Pee ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ ac Gic. )14.24 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Suppression) $ Total All Fees:$ - Check No. Check Amount: Cash Amount 1 2 t/U� �- y6.Total Project Cost: $ L V"\v� 0Paid in Full 0Outstanding Balance Due: I� \ r SECTION 5: CONSTRUCTION SERVICES 5.1 Co r tion upervi or License(CSL) �I j� //�/2/ Q p j' u (/e /?C�, �����"/ `v 1L �! i(�f� License Number Expiratio ate Name of CSL Holder r9- ill , /J_- �/f/i i List CSL Type(see below) No. and Sit-eel /,/�L�"(— �C(S Type Description .-k,ee t Unrestricted(Buildings up to 35,000 cu.ft.) /�' ' �t Restricted I&2 Family Dwelling / City/Town,State,ZIP C�GI Masonry ✓ RC Roofing Covering • WS Window and Siding Slit ///B�—YJ� r�I /�� Q ��,/ SF Solid Fuel Burning Appliances ��/ GI ! ���� �! S,�� iG/rQ� I Insulation Telephone Email address QQccww-- D Demolition 5.2 Registered`Home IImprovv eat Contractor(HIC) / ?r2Or ` `�i��'r' HIIC Registration Number E rati Datz 2HIC(//4e pany Name or HIC Registrant Name No. an treet 4,,ed,./abosvc,ftie? ` d`"�, 2 ten/f( -2-kf-2,r/i/ Email address t City/Town, State,ZIPTelephone "b 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. j Signed Affidavit Attached? Yes ❑ 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 to act on my behalf, in all matters relative to work authorized by this building permit application. (, , 7T'oe 4 22 Printer'sfilame(Electronic Signature) Da • 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. Print 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 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.zov/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 _I ' l Department oflndustrialAccidents WiVI 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia `porkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le i�bty Name (Business/Organization/Individual): IG,� i c" Address: .2- ''4440,-,1 City/State/Zip: /. 75/�qic�-V! f Phone #: C37f " Are you an employer?Check the appropriate box: Type of project(required): l.O I a. mployer with employees(full and/or part-time).* 7. 0 New construction 2 am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers'comp. insurance required.] 8. 0 Remodeling 3. 1 am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. ❑ Demolition '4.]I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 5.0 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• Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Outer 152,§I(4),and we have no employees. [No workers'comp. insurance required.] *Any applicant that checks box 41 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. v Insurance Company Name: -Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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 ', •. orm of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. A copy of this statement •. be fo •rded to the Office of Investigations of the DIA for insurance coverage verification. ' I do hereby certify u gains and pen - . .erjury that the information provided above is t ue and corr t. lenature: f / t 22 2e Date: Phone#: 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 o �� , BUILDING DEPARTMENT " =E • a 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261 HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DA'i'b: JOB LOCATION: AME STREET ADDRESS SECTION OF TOWN "HOMEOWNER" N IE HOME PHONE WORK PHONE PRESENT MAILING ADD N. SS CITY OR TO STA 1i ZIP CODE The current exemption for `Romeo ner' was extended to include owner—occupied dwellings of one or two units and to allow such homeowners to en,;.ge an individual for hire who does not possess a license,provided that such homeowner shall act as supervisor. ( ,.te Building Code Section 110 R5.1.3.1) Definition of Homeowner: Person(s)who owns a parcel of land on whit he/she resides or intends to reside,on which there is or is intended to be, a one or two family attached or detached st cture assessory to such use and/or farm structures. A person who constructs more than one home in a two-year pe 'od shall not be considered a homeowner;such"homeowner"shall submit to the building official, on a form acceptas e to the building official,that he/she shall be responsible for all such work performed under the building permit. ( -ction 110 R5.1.3.1) The undersigned `homeowner' assumes responsibilit for compliance with the State Building Code and other applicable codes, by-laws, rules and regulations. The undersigned 'homeowner' certifies that he / she unde tands the Town of Yarmouth Building Department minimum inspection procedures and requirements and tha he / she will comply with said procedures and requirements. HOMEOWNER"S SIGNATURE APPROVAL OF BUILDING OFFICIAL �\ INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent, whi• meets the requirements of MGL Ch.142. Yes No If you have checked yes, please indicate the type coverage by checking the appro►riate box. A liability insurance policy Other type of indemnity Bons. OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the ins, ranee coverage required by Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent h:homeownrlicexemp • TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261 Fax 508-398-0836 Office of the Building Commissioner ,.7 BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G. L. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section 111/5 I hereby certify that the debris resulting from th propos d work/demolition to be conducted at �,t{ f l Work Address Is to be disposed of at the following location: ///1/4/7,70-70c41( Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. Signature of Applicant Date Permit No.