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HomeMy WebLinkAboutBLD-23-000994 RECEIVED ONE & TWO FAMILY ONLY- BUILDING PERM! Town of Yarmouth Building Department A rz2 1146 Route 28,South Yarmouth,MA 02664-4492 1' ' 508 398 2231 ext. 1261 Fax 508-398-0836 ' y-sy.kl Massachusetts State Building Code,780 CMR B'�I EN ir ;n; il'MT Building Permit Application To construct, Repair, Renovate Or Demolish f a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: S LI)_,,I.3 _0 QOga q Date Applie • 9- Building Official(Print Nsm ��) Signature Date SECTION 1:SITE INFORMATION L1 Property Address: 1.2 Assessors Map&Parcel Numbers 21 Irphnlise Rd Yarmouth MA 07664 1.1 a Is this an accepted street?yes V 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 I Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.49,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: _ Outside Flood Zone? Check if yes❑ Municipal IDOn site disposal system 0 SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Connie Swedlund Yarmouth MA 02664 Name(Print) City,State,ZIP 21 Icehouse Rd, 774-487-2997 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK"(check all that apply) New Construction 0 Existing Building 0 I Owner-Occupied 0 I Repairs(s) Eill Alteration(s) 0 I Addition 0 Demolition ❑ Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work: Scope of Work-entire home reroof, 20 Squares total SECTION 4:ESTIMATED CONSTRUCTION COSTS. I Item Estimated Costs: (Labor and Materials) Official Use Only 1.BuiIding $ 13813.00 , 1. Building Permit Fee:$�40 Indicate how fee is determined: 2.Electrical $ i 0 Standard City/Town Application Fee 0 Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: &L*of 63.5 5.Mechanical (Fire Suppression) $ Total All Fees:$ 6.Total Project Cost: $13813.00 Check No. Check Amount: Cash Amount: ❑Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) Sunrun Installation Services- Stephen A. Kell CS-040622 08/01/2023 p y License Number Expiration Datz Name of CSL Holder 695 Myles Standish Blvd, List CSL Type(see below) No.and Street Type Description Taunton, MA 02780 U I Unrestricted(Buildings up to 35,000 cu.ft.) City/Town,State,ZIP R I Restricted l&2 Family Dwelling A4 Masoruy RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 978-793-7881 eastmapermits@sunrun.com i Insulation Telephone Email address D I Demolition 5,2 Registered Home Improvement Contractor(HIC) Sunrun Installation Services- Stephen A. Kelly HIC 180120 10/13/2022 HIC Company Name or HIC Registrant Name HIC Registration Number Expiration Date 695 Myles Standish Blvd, eastma No.and Street permits@sunrun.com Taunton, MA 02780 978-793-7881 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 0 SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETE])WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERIVIIT I,as Owner of the subject property,hereby authorize Sunrun Installation Services to act on my behalf,in all matters relative to work authorized by this building permit application. *Connie Swedlund See Attached Contract 08/15/2022 Print Owner'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. a Print Owner's or A orized Agent's Name lectronic Signature) 08/15/20 2 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.Qov/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" Conurioniveatin of Massacnuserts Onosn of Professional Licens.ui e Board of Batwing Begidations and Standards Construction Supervisor io Unrestricted -Buildings of any Use group which contain less than 36,000 cubic feet 1931 cubic meters)of enclosed space. CS-040822 .arpires 08/01 2023 STUMM A likiLLY * if PARKWAtMo STONENAN griss Failure to possess a current edition of the Massachusetts i I State Building Code is cause for revocation of this license. COMMISM/Ofter For information about this license CH fill)117-31/88 or visit viienranass.govIdpi Office of Consumer Affairs and Business Regulation 1004)Washington Street-Suite 710 Boston,Massachusetts 021 t8 Home Improvement Contractor!Registration Type Supplement Card Registration f3022 SUNRUN INSTALLAT'ON SERVCES'NC Expeaborr !Or`3/2022 225 BUSH STREET SUITE'4,00 SAN FRANCISCO CA 44104 Update Address and Return Card 1-7n1C9 o Con,umar aTrain I 3,113N1662 segotamin HOME MP ROYENIENT C CR-RAC TOR Registration valid for individual use only TYPE Stiotee-e- before ate expiation date If found return to. artaltlialtatt ''rnirtuari Office of Consumer Pilaus and Business Regulation 100/20 2022 rOOD Wasteuigban Street-Suite 710 SUWON INSTALLATION 3ER'0CES NC Boston_RIA 2211S STEPHEN 225 BUSH riREET SUITE 1400 -Mgt id without sign e SAN FRANCISCO CA 24104 Undersecretary Stephen A Kelly 200 Research Dr Wilmington MA 01887 TEL: 978-793-7881 Email: northmapermits@sunrun.com �.MININ SUNRINC-02 WANG Ao�R CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD 9/10/2021 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 NAppMEACT Walter Tanner Alliant Insurance Services,Inc. PHONE FAX 575 Market St Ste 3600 (A/C,No,Ext): I(A/C,No): San Francisco,CA 94105 ADDRESS:Walter.Tanner@alliant.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Navigators Specialty Insurance Company 36056 INSURED INSURER B:James River Insurance Company 12203 Sunrun Installation Services,Inc INSURER c:American Zurich Insurance Company 40142 775 Fiero Lane,Suite 200 Ph#805-540-7643 INSURER D: San Luis Obispo,CA 93401 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR INSD WVO POLICY NUMBER IMM/DD/YYYYI (MMIDD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE X OCCUR LA21CGL2303211C 10/1/2021 10/1/2022 DAMAGETORENcuDncel $ 1,000,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY x JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 X OTHER:Retention:$100,000 Per Project Agg $ 10,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED RE� AUTOS ONLY AUTOSO BODILY INJURY(Per accident) $ HAUTOS ONLY AUUTOyyNS ONED PROPERTY DAMAGE (Per accident) $ $ B UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 4,000,000 X EXCESS UAB CLAIMS-MADE 001072261 10/1/2021 10/1/2022 AGGREGATE $ 4,000,000 DED RETENTION$ C WORKERS COMPENSATION _ $ AND EMPLOYERS'LIABILITY X STATUTE ERH ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N WC614287600 10/1/2021 10/1/2022 1,000,000 OFFICER/MEMBER EXCLUDED? N N/A E.L.EACH ACCIDENT $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation Policy WC614287600 Deductible:$1,000,000. Re:Permitting within jurisdiction. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1146 Route 28 ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 02664-4492 AUTHORIZED REPRESENTATIVE w./ CD__X 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 of Industrial Accidents Office of Investigations Lafayette City Center 2Avenue de Lafayette, Boston,MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Sunrun Installation Services / Stephen Kelly Address:225 Bush St STE 1400 City/State/Zip:San Francisco CA 94104 Phone#: 978-793-7881 Are you an employer?Check the appropriate box: Type of project(required): 1.® I am a employer with 50 4. ❑ I am a general contractor and I have hired the sub-contractors employees (full and/or part-time).* 6. ❑New construction 2.❑ I am a sole proprietor or partner listed on the attached sheet. 7. El Remodeling shipand have no employees These sub-contractors have p 8. 0 Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance., 9. El Building addition required.] 5. El We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 11.❑ Plumbing repairs or additions 3.❑ I am a homeowner doing all work myself. [No workers' comp. right of exemption per MGL 12.►�I Roof repairs insurance required.] t c. 152, l(4),and we have no 13 ❑ Other employees. [No workers' comp. insurance required.] *Any applicant that checks box#l 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: American Zurich Insurance Company Policy#or Self-ins. Lic.#:WC614287600 Expiration Date: 10/01/2022 Job Site Address: 21 Icehouse Rd, city.'State/Zip:_Yarmouth MA 02664 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that 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. Sienature: a Date: 08/15/2022 Phone#: 978-793- 881 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(check one): l❑Board of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector 5E'lumbing Inspector 6.0Other Contact Person: Phone#: §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-22311 ext. 1261 Fax 508-398-0836 Office of the Building Commissioner BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G.L. Ch. 40, §54 and 780 CMR- Section 105.3.1. #4. I hereby certify that the debris resulting from the proposed work/demolition to be conducted at 21 Icehouse Rd, Yarmouth MA 02664 Work Address Is to be disposed of oat the following location: Sunrun Dumpster-695 Myles Standish Blvd,Taunton MA 02780 Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. 08/15/2022 Signatur of Applicatio Date Permit No. ONE or TWO FAMILY— BULDING PERMIT APPLICATION REGULATORY APPROVALS NOTICE Address of Proposed Work: 21 Icehouse Rd, Yarmouth MA 02664 Scope of Proposed Work: Scope of Work-entire home reroof, 20 Squares total Date: 08/15/2022 Based on the scope of work described above, the applicant is required to obtain approval sign- offs from the following departments as checked-of below: Health Dept. —508-398-2231 ext. 1241 Conservation—508-398-2231 ext. 1288 Water Dept. —99 Buck Island Road, 508-771-7921 Old Kings HWY. Hist. Comm. —508-398-22631 ext. 1292 Engineering Dept.—508-398-2231 ext. 1250 Fire Dept.— Kevin Huck/Scott Smith, 96 Old Main Street, SY Note: Please call Fire Department for an appointment. 508-398-2212 Other Appropriate plans and/or application shall be provided to each departments checked-off above. Each of these regulatory authorities has their own requirements outside the jurisdiction of the Building Department. All applicable approvals shall be obtained prior to submitting a building permit application to the Building Dept. Thank you for your cooperation. Receipt Acknowledgement: 08/15/2022 Applica 's Signature Date Rev.Jan. 2019