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HomeMy WebLinkAboutBLD-23-001854 i ONE & TWO FAMILY ONLY- BUILDING PERMIT RECEIVED Town of Yarmouth Building Department ;:" .... - --- 1146 Route 28, South Yarmouth,MA 02664-4492 AUG508-398-2231 ext. 1261 Fax 508-398-0836 G 1 7 2022 Massachusetts State Building Code, 780 CMR _ Build ng Permit Application To Construct, Repair, Renovate Or Demolish BUILDING DEPARTMENT a One-or Two-Family Dwelling By. This Section F r Official Use Only Building Permit Number: BLb—cRD— 1 R Date Applied: Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 ProperZ Address: 1.2 Assessors Map&Parcel Numbers ✓ �� ewtt'1t k , .-/ 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 0 Private 0 Zone: Outside Flood Zone? — Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of a ord: ti&G'Rea t^yT € V%L 3 -1 ' E\iD f," 0. �' l \� NA Oab Name(Print) City,State,Z ' 4J-a 4- CuIAZ&s . eV/ No.and Street V Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 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 k2: - 7 LEA i id_ r'n 1 C(nor - /2-e r tc 0 --e qD re dz- SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official U se Only (Labor and Materials) 1. Building $ 1. Building Permit Fee:$ LiS Indicate how fee is determined: 2.Electrical $ 0 Standard City/Town Application Fee 0 Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 0 Paid in Full ❑ Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) hr CAn_tz r\ ,\\e tA License Number Expiration Date Name of CSL Holder S_1 4�� 9 i \ y� (\ List CSL Type(see below) No,and treet `hv %s4 ^y trt \ l� Type Description Cev „O�v \\ \e t ti co3 U t Unrestricted(Buildings up to 35,000 Cu.ft.) City/Town,State,ZIP J - R Restricted Ick2 Family Dwelling M Masonry RC Roofing Covering • WS Window and Siding SF Solid Fuel Burning Appliances -CO g-XI"-L S" iw\. A. 0:1331PyctLIoO I Insulation Telephone Email address ' • I c;t'lN D Demolition 5.2 Registered Home Improvement Contractor(HIC) / 9 A19 /cli a);,/.2._ HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name \ —3 a,„ -gf7 i--V 1 M g.. .1. 4 v, C 3 i o.andStreet co-3 l ��•Cc Email address/ 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 ❑ No ,❑ 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 rii C LI a A ' `e t,, ,toot on my behalf,in all tters r lative to work authorized by this building permit application. ' WI7!Int Owner's Name 1 nic Si at(E Signature) D 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: 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.sov/oca Information on the Construction Supervisor License can be found at www.mass.aov/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 - l—=•;:ri w=_r Department of Industrial Accidents ="mill. 1 Congress Street, Suite 100 ;� < Boston, MA 02114-2017 OM wx w.mass.aov/dia \orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information ���`` Please Print Legibly Name (Business/Organization/Individual): Ft i'CINc-. \ 0- ) \ Address: \>Lt f. �---1-1—. L CYy 1 .1 \ \ A City/State/Zip: 'A e ,rv�� 10 l.1 1A Co.631_ Phone ;#: C) R-r- tic Are you an employer?Check the appropriate box: - Type of project(required): 1. l a`m iirtployer with • ( employees(full and/or pan-time).* 2.0 7. ❑New construction I am•a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp. insurance required.] 8. Rerilodeling ,3.E I alwa.lomeowner doing all work myself [No workers'comp. insurance required.]t 9. ❑ Detholition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 E 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._ I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 1 2'❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance.: 1 •n Roof repairs 6. We are a corporation and its officers have exercised their right of exemption per MIGL c. 14. Other 152,§1(4),and we have no employees. [No workers'comp.insurance required.] *Any applicant that checks box 4'1 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 hot 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 inforiMtion. 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 S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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 fperjury that the information provided above is true and correct. Signature: .fir!-#/•�� //5 �--y Date: Phone Y: ) L� - Z l `-1'7--. Z 7 Official use only. Do not write in this area, to be completed by city or town official. City or Town: . Permit/License r • 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 C� 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 , , Work Address Is to be disposed of at the following location: / q C vYty' Tectn5S-k-1-.(011 Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. CT) Cfr7/ 7 /09—T1-- Signature o plicant Date Permit No. 1 L as U c L w LL N S N R p O O 73 CO N N R C co d L o O O d C— Q — w L. (13 ID i U1 C a) c c as Cp d C 0) O Q_ O O Cl. m -O mO C) CD }, D Co � o 1- 1c2 aomti N !( ti00 - aw 'tea = ccocn , 0 O ,- O1 w > ai L , w ,• 3 L c Q L c M= u) O z.p m0co \ �d.. N to s- X C C O 0 +-' O O U t Q Z Cn U O i � c cam (z U y � a) o Ec� Co o 2 = -- n a oom C.) E ,_ o O oA 2. a)2 a) V N C N - C.---- M U N o O N y413 Ce � M cv I- •- cp •c Z- WZw °,) z -JO _1 ` wcc N a -IR r > Q w w w, d) co ww � >d co co O>- ,NL 00 NO Qfj ci.o ~ 'N °' >- wZ � < <Uo cE a) Z J � 2 _ w IX w U U w J Q p J o2 Q mu) ' 0x w ww12 w o = 2wF- U_ 0oW MJALL-1 OP ID: EB ACORO" CERTIFICATE OF LIABILITY INSURANCE 08/0DATE(M5/2022 2Y) 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 508-771-3300 COO cT Martha J Findlay Olde Cape Cod Insurance PHONE 508-771-3300 I FAX 508-775-3821 Martha Findlay (A/C,No,Ext): (A/C,No): 300 Winter Street E-MAIL marthaf@occia.com Hyannis,MA 02601 ADDRESS: Erica J.Barrett INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:James River Insurance Company I u�tEA INSURER B:LIBERTY MUTUAL 11�T Allen Builder LLC 34Strawberry Hill Road INSURER C Centerville,MA 02632 INSURER D: 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. ILTR ADDL SUBR POLICY NUMBER /MM/DD/YYYYI M/DD/YYm EXP LIMITS TYPE OF INSURANCE INSD WVD 1,000,000 A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE X OCCUR 00116769-1 05/10/2022 05/10/2023 DAAMAGET(EaEoNTurrence) $ 100,000 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JET LOC PRODUCTS-COMP/OP AGG $ 1,000,000 OTHER: $ AUTOMOBILE LIABILITY (Ea acccident)SINGLEINED LIMIT ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY _ AUTOS yy BODILY INJURY(Per accident) $ AUTOS ONLY AUOTOS ONL� PPor�RidentDAMAGE UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER ERH AND EMPLOYERS'LIABILITY N WC233SB20P8V021 08/05/2022 08/05/2023 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE YN N/A E.L.EACH ACCIDENT FandatoM $ O In BE EXCLUDED? 500,000 If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Carpentry-Remodeling CERTIFICATE HOLDER CANCELLATION TOWN-15 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town Of Yarmouth Building Dept 1146 Main Street AUTHORIZED REPRESENTATIVE Yarmouth, MA 02664 ,06/5,10x J ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Itt k.., 'fit:.;' V :� , s CV cam.;=:.',.;•..:' :. g ,-.A:::,::-`.4A,,0.,,,,0s,,,i,„f,,:.:„,:.m,:.,4::.14:....,.-,,1,-F,-.-4/-g:"",,:..',.,1,„:.1N.,...,,,' v emu >' ; '. 4 ,;> ,•,'' n ;fix'. ?- - . ' rye;;' ?,• .:. ;',,, .mow,.:•: • ss . t::),ii.'',.t,kig:ieg ,,!!""41: t: t „ .'t-.''. 1'''''';;:ilik(AgittiltA",• 40 ' ;' '' fit*' fir '. z ;. ft ft Ortrk!Il ;' , x. ' K ., '�:. '". '.,: r „ "s Vie: s iliofp „A.-.14i;-..,,,,,,„...-.44.: E .,,,,,,,,,,„.:„..,,,,,,,....„.""": , - ' 4W glimosot,,.4.,..:.„.t c .. . a) 0 ,,,..- . 00,4w __..,..--.:";,,v,,:.:.-,40,.‘„ , , .: - -",..,,. :44,,i0A:-„, 4* )0 ,.. % ,..--1141.i$. i:.) ' ' ' ;.. 0 N a - -‘,...,/ 0,,,,,,i, ,r, .41 t «» ' tin 44 E . ,,,,, tit al tri ' g - Alt g- . Cr �' ....