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HomeMy WebLinkAboutBLD-23-001613 , (OVA 01/z-7J"2 Office Use Only ':, .4 �R40 IRECEIVED Pemrit# e.,(J 1 I Amount -7 v "4"'"--s :a- LsEp 26 2022 permit expires 180 days from u�9 `J issue date N_' B1.11L �' —A 3 60'/6, /3 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 1 I HAZEL M 00 Q Ro 5o U t h yazrnco+h nH O z 6'6 4 ASSESSOR'S INFORMATION: (� Map: 01 $ 11 Parcel: C.i Cl 32 OWNER:41ACk -Cn OO Q-ERITy ((OUP at Cki'12ELliOo(l Rd . S .y4i mookh 6 11 - 2,9I- 8 l s-'6 NAME �v PRESENT ADDRESS TEL. # CONTRACTOR: W al aCa 1 IQC�4do Iq3 Cam 5t AO' -5 11J. \lay moo* 0$- 366 - S t t O t/ NAME MAILING ADDRESS TEL.#Residential ❑Commercial Est.Cost of Construction$ t 6 '�� 06 Home Improvement Contractor Lic.# Zb ID IS Construction Supervisor Lic.# C S- I lb 6 4 b Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor d.I have Worker's Compensation Insurance ` Insurance Company Name: 0 I b E R 1\IL Worker's Comp.Policy# �\W C;\ 1 Z el l WORK TO BE PERFORMED Tent E Duration (Fire Retardant Certificate attached?) Wood Stove El Siding: #of Squares - Replacement windows:# Replacement doors: # Roofing: #of Squares 2.8 (N)Remove existing*(max.2 layers) Insulation I I I I Old Kings Highway/Historic Dist. 0)Replacing like for like Pool fencing I I *The debris will be disposed of at: 1 QM0' * ' D ?O5 ft I." 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. 1 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: 6..L9q r .pq,�,. 0-, ���„r, Date: C�9 I c,[.5/d a 0. Owners Signature(or attachment) y (s ✓' -5 .1 b L Date: c i/ 2c..> _ Approved By: c Date: --2' �2 Building Officia r desi e) EMAIL A?1TT S: Zoning District: Historical District: Yes No Flood Plain Zone: Yes -_ No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No ® A Rom CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 09/25/2022 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: BIBERK PHONE g44-472-0967 FAX 203-654-3613 P.O. Box 113247 AA/C No Ext) (A/C Noj E-MAIL - - Stamford, CT 06911 ADDREss: customerservice@biBERK.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:National Liability&Fire Insurance Company 20052 INSURED Walaci Machado INSURER B: INSURER C: 193 camp st apt j5 INSURER D: West Yarmouth, MA 02673 INSURERS: 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 ADDL SUBR LTR TYPE OF INSURANCE POLICY EFF POLICY EXP INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 0 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ 0 MED EXP(Any one person) I$ 0 PERSONAL&ADV INJURY j$ 0 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 0 POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 0 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) BODILY INJURY(Per person) .$ OWNED —'SCHEDULED -- - -- �- AUTOS ONLY AUTOS BODILY INJURY(Per accident)'$ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE :$ DED I RETENTION$ $ WORKERS COMPENSATION 1 AND EMPLOYERS LIABILITY Y/N X PER STATUTE ERH ANYPROPRI ETOR/PARTN ER/EXECUTIVE A OFFICER/MEMBEREXCLUDED? N N/A N9WC772492 09/09/2022 09/09/2023 EL EACH ACCIDENT $100,000 I EL.DISEASE-EA EMPLOYEE$100,000 yes,describe (Mandatory in NH)If yes,d under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$500,000 Professional Liability (Errors& Per Occurrence/Omissions): Claims-Made Aggregate DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION ANY OFBlack Rock Realty Group THEULD EXPIRATIIONHE DATABOVE E VTHEREOF, NOTICE POLICIES WILL CBECDELIE DELIVERED BEFORE IN 21 Hazelmoor Rd ACCORDANCE WITH THE POLICY PROVISIONS. Bass River, MA 02664 AUTHORIZED REPRESENTATIVE (1 I ad,I Gi..6.0--- 6+U- ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD • The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 ..Sv www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): 13d,I0,U 1�y I0C ho.do Address: r c13 CoroP S+ R p c City/State/Zip: U.)e5\ yQ1(mv}h M A Phone #: SO 8 r 3.60 - 01 () Are you an employer?Check the appropriate box: Type of project(required): 1.171 am a employer with _�. employees(full and/or part-time).* 7. 0 New construction 2.0I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] 8. El Remodeling 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t g El Demolition 4.0I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sol 11.QElectrical repairs or additions proprietors with no employees. 5.0I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.El Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.$ 1 Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§I(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: 61 6 a 12 1- Policy#or Self-ins.Lic.#: N J W C 11 24 q 2. Expiration Date: Qq I a:5" i Z 3 Job Site Address:?I HH ZE I moo a., Rd 5 . `Ia 1 mo c +h City/State/Zip: n A Oz.66 LI Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: 6c.9c-4- Ppn,._. 1 ��� Date:cpci ,c1), cij a Phone#: 5c cn G G 5 Li C 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#: Commonwealth of Massachusetts v./ Division of Occupational Licensure Board of Building R�eg, ulations and Standards Consr. - Gin�S rvisor CS-116646 spires: 12/29/2025 WALACI P MLCHADO 193 CAMP ST, APT J5 WEST YARMOZJTH MA 02673 a' iE 1 Commissioner ✓�-; J Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration 201015 02/22/2023 WALACI PEREIRA MACHADO WALACI MACHADO 193 CAMP ST APT J-5 WEST YARMOUTH,MA 02673' Undersecretary Registration valid for individual use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 1000 Washington Street -Suite 710 Boston,MA 02118 Not valid without signature Bk 35386 Pg308 #47693 09-23-2022 @ 02 : 47p NOT NOT AN AN OFFICIAL OFFICIAL MASSACHUSETTS STATECEXaSETA ECRNOTAPLEYCOUNTY EXCISE TAX BARNSTABLE COUNTY REGISTRY OF DEEDS BARNSTABLE COUNTY REGISTRY OF DEEDS Date: 09-23-2022 @ 0211 oo47 m j' Datj� V59-.23 0-2022 02:47pm Ct1#: 663 Doc#: 47693 Ct1 : 6631 47693 Fee: $1,265.40 Cons: ��tT ��`` 17�7� Doc#: ,000. 7B 000.D0 Fee:•$1`,'132.20 Cons: $370,000.00 OFFICIAL OFFICIAL COPY COPY (Space above this line reserved for Registry of Deeds use) FIDIUCIARY DEED I,STUART W. RAPP,CONSERVATOR OF GLORIA F. BANKOWSKI,surviving tenant by the entirety, having an address of 749 Main Street, Osterville,MA,holder of a Decree of the Barnstable Probate and Family Court dated September 16,2022,Docket No.BA21 P 1929PM,by power conferred in said Decree, for and in consideration paid in the amount of THREE HUNDRED SEVENTY THOUSAND AND NO/100's DOLLARS($370,000.00),do hereby grant and convey to BLACKROCK REALTY GROUP LLC,a Massachusetts limited liability company having a mailing address of 0 1193 Furnace brook Parkway Suite 15,Quincy MA 02169,the following described property: cWith FIDUCIARY COVENANTS The land in Yarmouth (South),Barnstable County,Massachusetts,bounded and described as follows: BEGINNING at a point on Hazelmoor Road,so-called,as shown on a plan of land hereinafter referred to: E Thence,North 79°57' 50"East along said Hazelmoor Road a distance of Seventy-Eight and 23/100(78.23)feet; Thence,in an arc,radius 25.00 feet,a distance of Thirty-Nine and 27/100(39.27) feet to a point; Thence,South 10°2' 10"East a distance of Ninety-Three and 84/100(93.84)feet,to land now or formerly of Myra Todd; Thence,South 79°38' 10"West along said land now or formerly of Myra Todd,a distance of One Hundred Three and 23/100(103.23)feet to Lot 4 as shown on said plan; Bk 35386 Pg309 #47693 Thence,North 10°2' th'wst(indicated as North 10°i'l'40'TEast on said plan in error) along said Lot,a distant aOne Hundred Nineteen and` 300 (119.43)feet to the point of beginning. O F F I C I A L OFFICIAL COPY COPY Containing 12,169 square feet,more or less. NOT NOT Meaning to convey Lotl shown on a plan of land enti1le1"Hazelmoor Section Plan of Subdivision ofLa idk f EldredgePF.r&Elva Shag ih Irturno hkS&uth)Scale 1 inch=80 feet October 30, 195;Nevkll43. Snow,Eng'r Buzzards Dad Mass."; which said plan is duly recorded with Barnstable County Registry of Deeds in Plan Book 113,Page 117. Said premises are conveyed subject to and with the benefit of all rights,rights of way, easements,appurtenances,reservations and restrictions of record insofar as the same are in full force and effect. For title,see Deeds recorded at the Barnstable County Registry of Deeds in Book 8426, Page 098, and Book 14977,Page 163, Grantor hereby releases all rights of homestead in said premises,and further represents that no person is entitled to claim the benefit of an existing homestead in the property being conveyed herewith. [Signature Page to Follow] Bk 35386 Pg310 #47693 NOT NOT AN AN OFFICIAL OFFICIAL Signed under the pails 2ncrp alties of perjury this 26Ih iia?ofYSeptember,2022. NOT OT AN N OFFICIAL F F I C I A L COPY STUARIW RAPP, C onservator of Gloria F. Bankowski COMMONWEALTH OF MASSACHUSETTS Barnstable, ss. On this 20th day of September, 2022, before me, the undersigned notary public, personally appeared STUART W. RAPP, Conservator, as aforesaid, proved to me through satisfactory evidence of identification, which were being personally know to me, to be the person whose name is signed on the preceding document, and acknowledged to me that he signed it voluntarily for its stated purpose and who swore or affirmed that the contents of this document are truthful and accurate to the best of his knowledge and belief. (SEAL) �•���,�+0 A iArr���i���'' JG>e�•$s10ti. /��'.,� Lucinda A. Civetti -Notary blic �,. o'4-02-2Qi'9�;..�a'S My commission expires: 06/02/2028 Bk 35386 Pg311 #47693 COMMO WEALTH OF MAS§4tI JSETTS BARNSTABLE, S� FFICIAL O F F I C I A L PROBATE COURT COPY C P Y $A21 P 1929PM At a Probate Court helot batnstable, in and for said Cotnt9 oFBarnstable, on the 16th day of September in the year of 6ui1tord two thousand twenty-tA.N OFFICIAL OFFICIAL ON the petition of C o S$aaR W.Rapp, COPY Conservator(s)of the property of Gloria F.Bankowski in said County of Barnstable,praying for license to sell certain real estate of his-her-thok protected person described in said petition, -atp -at private sale, in accordance with the offer named in said petition,or upon such terms as may be adjudged best, era,if he-she-they think best so to do,ail persons interested having-assented or been duly notified-and a GAL having been appointed-and no objections having been made; and it appearing that-said offer is an advantageous one, and that the interest of all parties concerned will be best promoted by the acceptance of said offer-and that it is necessary that said protected person's interest shall be sold for l ig-her-maintenance IT IS DECREED that the petitioner(/)be licensed to sell and convey stivebiiftemstioe -at private sale in accordance with said offer for the sum of$370,000.00 or for larger sum , or at public auction, if he-she--iihay shall think best so to do, the real estate of said ward described in said petition,for the purposes aforesaid, 4 :�' S . .Jude of Probate Court a4g ,64 JOHN F. MEADE, REGISTER BARNSTABLE COUNTY REGISTRY OF DEEDS RECEIVED & RECORDED ELECTRONICALLY