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HomeMy WebLinkAboutBLD-23-000503 , . ; Pill & )16/7jL CKI4 For boor- [ R E C E i VEND& TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department , JUL 2 9 2022 1146 Route 28, South Yarmouth, MA 02664-4492 , 508-398-2231 ext. 1261 Fax 508-398-0836 EN Massachusetts State Building Code, 780 CMR . 4Ntil o.m e BUILDWG DEPARIi[I[dtng Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: ekV 3-0 tbcbc) Date Applied: Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 51 Rory F.a¢,01 Qom) (J. artf} 1.1 a Is this an accepted street?yes 1/ 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: Zone: Outside Flood Zone? _ Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system 0 SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: t' PCh4 11 IChavt V'1 .010 01-poer MA 09,675- Name(Print) City,State,ZIP Si (2Ag tart Q04o (Nnan, 500-3SS-4313 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 Existing Building lie Owner-Occupied Li Repairs(s) V Alteration(s) 0 Addition ❑ Demolition ❑ Accessory Bldg. 0 Number of Units Other ❑ Specify: Brief Description of Proposed Work': PepalIL Fin tsk broertsanr to -C-loeIA otinr4 tnS .,_ �6,,, basaehen-1 en,m t 0.002 SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ .70,000— 1. Building Permit Fee: $%SO Indicate how fee is determined: 2.Electrical $ _ rl Standard City/Town Application Fee a 4 oo 0 Total Project Cost (Item 6)x multiplier x 3.Plumbing $ R 00 0 2. Other Fees: $ 3— Y‘lic_ h 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ el-Suppression) Total All Fees:$ Check No. Check Amount: Cash ount: 6.Total Project Cost: $ 2q, Ip0' 0 Paid in Full EJO Outstanding Balance D e: ki? SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 050 432.1 71. 13 i Z-LI SAn/ L3. 3/9G/CSot/ License Number Expiration Date Name of CSL Holder 271 i'na'4 S/_ee r List CSL Type(see below) U No..7)and Street �/l Type Description /`�/(.2.G(/ICW /0/¢- 004 N.S U Unrestricted(Buildings up to 35,000 Cu.ft.) City/Town,State,ZIP R Restricted 1&2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 5bg-dBo-6YA8 ,f/cKC�4,6 d y44dD.owl I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) i 5-7S71 /01 I5i 23 pa g' .'4.�ei/ HIC Registration Number Expiration Date HIC CompanyName or HIC Registrant Name 02?n 4./1 5/i e r IGLCK.Ge-(AO® 41100,torn No. and Street Email address ll¢.u4Cli AI gol r!s 5V8-ISO-68861 City/Town, State,ZIP Telephone SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c.152.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes ler 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 CC,r't j /�,,-�_ to act on my behalf in all matters re tive to work authorized by this building permit application. 146 C1y riniatet.A.4 q ,24 -2.:2-- Print Owher'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. Ten 13 L .7Ic.KSo41 71 Z8•22 Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/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 2� r Departmeni of.Industrial Accidents 41-10:6411: 1 Congress Street, Suite 100 Boston, MA 02114-2017 ;� 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 : > —,Ltto A, TAemc®mil Address: 0273 149arn Shoe r City/State/Zip: / .wtcty /17A. 12,74.4g— Phone #: . S -,2 - (a fig Are you an employer?Check the appropriate box: Type of project(required): l._ I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.V I am a sole proprietor or partnership and ha'e no employees working for me in any capacity.[No workers'comp. insurance required.] 8. [ Remodeling • 3.E I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9 C Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 C Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.C 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. These sub-contractors have employees and have workers'comp. insurance.! 13. Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 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. 1Contractors 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: 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 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: 9„.._. Date: 7 Z€. • 2-2-- Phone#: 5be -- Z4O- 61386 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License.# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261 Fax 508-398-0836 Office of the Building Commissioner 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 the proposed work/demolition to be conducted at 57 /3414-cf ra2art o2o4-9 albarif) Work Address Is to be disposed of at the following location: /2t /,& r C/i, u s Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. 7, Z ' Signature of Applicant Date Permit No. ..7, ift,PhroMI . n HOME IMPROVEMENT CONTRACTOR TYPE:Individual Re istr i n Expiration 157 ' 10/15/2023 IAN JACKSON - D/B/A JACKS( s4 W'.110' AON&ELECTRICAL CO. IAN B.JACKS 7° 273 MAIN ST . ',« 1,/,,,,,s( 1/7 ,4 N.HARWICH, Undersecretary Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Re ulations and Standards Cons ion fStivicegvisor CS-050829 .; P spires:•07/13/2024 $k ALA'IAN B JACK$ N wl ' " ` ' 273 MAIN STA 1 ' ►i N HARWICH`OA 02• ��" s ra s- ;.) � Commissioner as t°. wr,1l t ,, r ACC: tcLi CERTIFICATE OF LIABILITY INSURANCE I u1 1C/+8/ u'i 04/28/2022 i THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS i 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 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 Rogers and Gray Processing BALDWIN KRYSTYN SHERMAN PARTNERS LLC PHco."No.Ed): (508)398-7980 FAX No): ADDRESS: mail@rogersgray.com 4211 West Boy Scout Blvd Suite 800 INSURER(S)AFFORDING COVERAGE NAIC# Tampa FL 33607 INSURER A: TRAVELERS INDEMNITY CO OF AMERICA 25666 INSURED INSURER B: JACKSON IAN B INSURERC: DBA JACKSON CONSTRUCTION & ELECTRICAL CO INSURERD: 273 MAIN ST INSURER E: HARWICH MA 02645 INSURER F: COVERAGES CERTIFICATE NUMBER: 769013 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. ADDL SUBR POLICY EFF POLICY EXP INSR TYPE OF INSURANCE INSD N/VD POLICY NUMBER (MMIDD/YYYY) IMMIDDIYYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S DAMAGE TO RENTED $ CLAIMS-MADE OCCUR PREMISES(Ea occurrence) MED EXP(Any one person) S N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S POLICY JPERCT O LOC PRODUCTS-COMP/OP AGG S OTHER: $ AUTOMOBILE LIABILITY CO aBBINEDt)SINGLE LIMIT $ (EaI ANY AUTO I BODILY INJURY(Per person) S ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) S NON-OWNED PROPERTY DAMAGE S HIRED AUTOS AUTOS (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE S l DED RETENTIONS �/ H $ WORKERS COMPENSATION STATUTE ER AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNERJEXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBEREXCLUDED? N/A N/A N/A 6HUB0151N86122 02/16/2022 02/16/2023 E.L.DISEASE-EA EMPLOYEE S 1,000,000 (Mandatory in NH) If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 1,000,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Iwdiworkers-compensation/investigation si. Sole proprietor has not elected coverage. 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. Ian Jackson Construction & Electrical Co 273 Main Street AUTHORIZED REPRESENTATIVE Harwich MA 02645 Daniel M.Crowley,CPCU,Vice President—Residual Market—WCRIBMA I ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD ,te TO N OF Y RMOUTH 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451 ,Jui_ 2 8 zo Telephone(508)398-2231 Ext. 1292—Fax(508)398-0836 OLDKGSHIGHWPYD KING'S HIGHWAY HISTORIC DISTRICT COMMITTEE APPLICATION FOR CERTIFICATE OF EXEMPTION Application is hereby made for the issuance of a Certificate of Exemption under Sections 6 and 7 of Chapter 470 of Acts of 1973, as amended, for the proposed work as described below and on plans,drawings, or photographs accompanying this application. Type or print legibly: Address of proposed work. 51 F Map/Lot# Ovvner(s): /Li /77 /1/14-4(,...41 Phone#: All applications must be subMitted by owner or accompanied by letter from owner approving submittal of appli don. Mailing address. A-4-4-ri_e,/ Year built Email: Preferred notification method. / Phone Email Ai:tent/Contractor - 'TINC-44cf*4 Phone# it50 .2088 Mailing Address t.4.1 344.6er 4112.1,1tcH, frI 404 Email. 3C‘C-44.41.e_40,1te Preferred notification method Lit Phone Email Description of Pronosed Wort((Additional panes may be attached if necessary): (aeekace 501e- cti204.- 01\ 614 61.e ex4. eloirts 40 loaR1117: " ro tkk otoog, (fa I'\ iht.e. A,e2cee,f1 FWC • Signed(0Wher or agent): Date: ...nericontractoriagen,is aware that a permit may be required from the Building Department (Check other departments,also.) > This certificate is good for one year from approval date or upon date of expiration of Building Permit whichever date shall be later. For Committee use only: Date 11402 4?-2 Approved Denied Amount a'0,60 Reason for deniat Cash/CK# IOqi JUL 2 8 211. Revd by: LA 5, f Afik4M111- 01 D KING'S HIGHWAY Date Signed liA,(93" signed, 562 e,,iflz.et-pci eity) ?1 ) APPLICATION#: (1/) VS 2017 °-0•Y` -'= TOWN OF YARMOUTH 'S ''" ; ,4 HEALTH DEPARTMENT 1•t4 MATul. ' ` "'°A`°`ES c` '` PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET To be completed by Applicant: Building Site Location:,S 1 (3 `;srom Q8. (V i9Qr� Map No: Lot No.: Propced Improvem t: t vk /S�ec� \c�S2w�A� A► . F.,,CA- 13 c4 (4.-)4-1 k'c.4�1 j 4v :-i� 4 /f'O�� c d-!i r►, �n(1 /3'C ��' '�1 R(,."C/�'K_S' Applicant: kICL it Ma Ney-‘c..ovL Tel. No.:50g .2 a9 U Address: "73 .r Q.Oo &j lam. Y Yeux vvAQ01.,,QcriT My - Date Filed: **If you would like e-mail notification of sign off,please provide e-mail address: Owner Name:F�ST.4 c ct (or,c,s oNA- Owner Address:7 3 L& ncc 22 oc j - Y y( 13o,cr Owner Tel. No.:SoK-385=a aok A RESIDENTIAL AND/OR COMMERCIAL BUILDING HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e.,Requirements For Septage Disposal and other Public Health Activities. Please submit four(4) copies of plans, to include: (1.) Site Plan showing existing buildings, water line location, and septic system location; (2.) Floor plan labeling ALL rooms within building (all existing and proposed)— Note:Floor plans not required for decks, sheds, windows, roofing; (3.) If necessary, Title 5 application signed by licensed installer with fee. REVIEWED BY: DATE: Y / /7 PLEASE NOTE COM�NTS/CONDITIONS: �� roc"....". ji �.<< cKT /vcT1� tvse c CI 1-#0.4-e " r„et 3 3..e.C ✓t7. Gl./, -- } 0 v1 S,c.... lc /o-'' rn 0 r r y t i\ u (111., 4 0 il%. - �- ---*T �i - - 2 p o i Q1Cb 8 o rgs. r o C Z ri c .. , 5 3 m : i J � 9 t� w s n 8 T i-' 4 X -al r- a � • -� t/ — t 'N 2.Z. 4 ''''t r q a