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HomeMy WebLinkAboutBLD-23-000364 RE , r 1 ply & TWO FAMILY ONLY- BUILDING PERMIT - Town of Yarmouth Building Department L 2 2 2�22 1146 Route 28, South Yarmouth,MA 02664-4492 r (1°F 4N\ 508-398-2231 ext. 1261 Fax 508-398-083 6 Massachusetts State Building Code, 780 CMR BUILD' G c E PA 1.r3 zlr no Permit Application To Construct, Repair, Renovate Or Demolish By: -- a One-or Two-Family Dwelling ����Trh�is?Sectio For Official Use Only Building Permit Number: 23"CW367 l Date Applied: ),1-6-2- <5 �' 5 --.c-A, l Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Pr erty Ad ess: 1.2 Assessors Map&Parcel Numbers 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 9 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? Check if yes❑ Municipal 0 On site disposal system 0 SECTION 2: PROPERTY OWNERSHIP' Owner'taktik eD`5j-Le/ Milt- /' /Nam (Print) c City,State,ZIP X !arum jj MSS 014M ictft cr. �,i-. No.and Street Telephone l p Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 I Existing Building,{ Owner-Occupied 0 Repairs(s) 0 AIteration(s)A I Addition 0 Demolition ❑ Accessory Bldg. 0 Number of Units /� Other ❑ Specify: Brief Description of P op sed Work2: 010 01( SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and Materials) Official Use Only 1. Building $ a )an 1. Building Permit Fee:Stijl_ Indicate how fee is determined: 2.Electrical lil Standard City/Town Application Fee 3.Plumbing $ 0 Total Project Costa(Item multiplier x 4.Mechanical (HVAC) 2. Other Fees: $—'-' List: Ct44 S5 1 3 5.Mechanical (Fire Sue eression) Total All Fees:$ - 6. Total Project Cost: $ alb ...-- Check No. Check Amount: 0 Paid in Full Cash '"'ount• 'Outstanding Balance D e: \ \j17/IP SECTION 5: CONSTRUCTION SERVICES S.1 Construction Supervisor License CSL) inc Name of CSL Holder License Number Expiration Date PO0( /17 List CSL Type(see below) No.and Street tM I Type Description W inij" /Y/!� o i�tl10 U Unrestricted(Buildings up to 35,000 cu.ft.) City/Town,State,ZIPR Restricted 1&2 Family Dwelling IvI Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances Telephone I Insulation Email address D Demolition 5.2 Registe ed Hom Improvement Contractor(HIC) e HIC Registration Number Expiration Date HIC Company Name o C Registrant No.and Street !r # of ��� - e� Email address City/Town, State,ZIP Telephone SECTION 6: WORKERS' COMPENSATION i ISURANCE 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 authoriz `Q�����Q'Ml to act on my behalf, in all matters relative to work authorized b ��� r _('ithlii_. on.y this building permit application. u & g. jj 7/Iqf ac Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION I I 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. icooL. e, 641 Print Owner's or Authorized Agent's Name(Electronic Signature) f,i/jtc 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.Qov/oca Information on the Construction Supervisor License can be found at www.mass.e.ov/d s 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 bathrooms Number of bedrooms Type of heating system Number of half/baths Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" I ,► The Commonwealth of Massachusetts � Department of Industrial Accidents "sa°., 1 Congress Street, Suite 100 _`— Boston, MA 02114-2017 imp' ,� www.mass.a a o v/dca Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A.slicant Information Name (Business/Organization/Individual Please Print Lefibl ) f' _44 II cot, inni /1 Address: d ( eyn � � City/State/Zip: " Phone #: "`7& Are you an employer?Check the appropriate box: l Ll I am a employer with _employees(full and/or part-time).* Type of project(required): 7. Li New construction 2. I am a sole proprietor or partnership and have no employees working for me in Remodeling any capacity.[No workers'comp. insurance required.] 8. �] 3.0 I 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 ensure that all contractors either have workers'compensation insurance or are sole 10 ❑ Building addition proprietors with no employees. 11.❑ Electrical repairs or additions 5.0 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 13.❑Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. ❑ 152,§1(4),and we have no employees. [No workers'comp. insurance required.] 1 4' Other *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 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'com such. p.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: arch' Policy#or Self-ins.Lic. #:_� V� agN O'7 Expiration Date: al Q Job Site Address: n-d. City/ Attach a copy of the workers' compensation policy declaration page(showing the a ip,u 4. ©veS Failure to secure coverage as required under MGL c. 152, policy tuber and e. piration date). cr and/or one-year imprisonment, as well as civil penalties in the form of STOP WOnal IRK ORDER and a fine ofon punishable by a fine up o o$25 0.00 day against the violator. A copy to$250.00 a of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverageaa verification. 1 do hereby certify un he ns nd penalties of perjury that the infornzation provided above is true and Signature: `�-/ correct. Phone T: Date: � Official use only. Do not write in this area, to be completed by city or town official. City or Town: Issuing Authority(circle one): Permit/License# 1. Board of Health 2. Building Ins.Department 3. City/Town Clerk 4 ElectricalInspector 6. Otherp r 5. Plumbing Inspector Contact Person: Phone#: TOWN OF YARMOUTH 0 -P-; BUILDING DEPARTMENT 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261 HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DATE: JOB LOCATION: NAME STREET ADDRESS SECTION OF TOWN "HOMEOWNER" NAME HOME PHONE WORK PHONE PRESENT MAILING ADDRESS CITY OR TOWN STA l'h ZIP CODE The current exemption for `Homeowner' was extended to include owner—occupied dwellings of one or two units and to allow such homeowners to engage an individual for hire who does not possess a license,provided that such homeowner shall act as supervisor. (State Building Code Section 110 R5.1.3.1) Definition of Homeowner: Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is or is intended to be, a one or two family attached or detached structure assessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner; such"homeowner"shall submit to the building official, on a form acceptable to the building official,that he/she shall be responsible for all such workperformed under the building permit. (Section 110 R5.1.3.1) The undersigned `homeowner' assumes responsibility for compliance with the State Building Code and other applicable codes, by-laws, rules and regulations. The undersigned 'homeowner' certifies that he / she understands the Town of Yarmouth Building Department minimum inspection procedures and requirements and that 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, which meets the requirements of MGL Ch.142. Yes No If you have checked ves, please indicate the type coverage by checking the appropriate box. A liability insurance policy Other type of indemnity Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not the insurance coverage Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Checkone: g 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 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 til� tkTR' 1�G�1 ))1L1144Thi Y' Y tTh9 L r(M f ���7T Work Address Is to be disposed of at the following location: � e) 3 htnnb, /19/' Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. n Signature of Applicant Date Permit No. ....„;r wt .unsumerfurarrs s Rusiness Regulation HOME IMPROVEMENT CONTRACTOR TYPE;Individual Registration valid for individual use only �g[stratia9 ExoiratFon before the expiration date. if found return to: 128017 02/10/2023 Office of Consumer Affairs and Business Reg MATTHEW BOROWSK! 1000 washIngton Street Suite 710 Boston,MA 02118 MATTMEVv M.BOROWSKI j flite126 PLUM ST YESThf+iSTAaLE,MA 42668rL` _ � Undersecretary Not valid without signature Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Cons 'ril{ pery sc+r 'i€ CS-474669 , tic Tres:02/©7/2023 MATTHEW MOOR 74 SOUTH DEN MAPO Box 1173_1' '�. Commissioner offLeG K, atmtheL. 4 • A Ro® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 06/29/2022 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: COMPLETE BENEFIT SOLUTIONS PHONE -- I FAX ONE CARANDO DRIVE to EM) — (AtC,wo): E-MAIL SUITE 1 ADDRESS: Springfield, MA 01104 1NSURER(S)AFFORDING COVERAGE NAICS INSURERA: NorGUARD Insurance Company 31470 INSURED Crecon Inc INSURERS: Creative Construction INsuRERC: PO Box 1173 INSURER D: South Dennis, MA 02660-1173 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, ADDL SUBR INSR POLICY EFF POLICY EXP TYY LTR, TYPE INSD WVD POLICY NUMBER (MMiDDIYYYr) (MMIDDIYYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 0 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ 0 MED EXP(Any one person) $ 0 PERSONAL&ADV INJURY $ 0 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 0 P R ( - POLICY O- PRO- I 1 LOC PRODUCTS-COMP/OP AGG $ 0 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) _ ANY AUTO 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 UAB I OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY YIN k, PER x STATUTE ERH A OFFICER/MEMBERAN PEXCLUDED?ECUTIVE NIA E.L.EACH ACCIDENT $100,000 (Mandatory In NH) N CRWC359457 4)5/21f2p22 05/21/2023 If yes,describe under E.L.DISEASE-EA EMPLOYEE $100,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Employees: Full Time: 3; Part Time: 2 Governing Class Description: CARPENTRY-CONSTRUCTION OF RESIDENTI CERTIFICATE HOLDER CANCELLATION - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Crecon Inc DBA Creative Construction THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Po Box 1173 ACCORDANCE WITH THE POLICY PROVISIONS. South Dennis, MA 02660 AUTHORIZED REPRESENTATIVE: 4,1..<7;1:0---,.....a...7 01988-2015 ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD CORPORATION. All rights reserved. Sears, Timm From: Sears, Tim Sent: Tuesday, July Zfi2O221:18PM To: 'matt cemnsLmm' Cc: Slack, Christine Subject SO Alms House Rd Matt, I have reviewed your application and you are going to need to get Health Department sign off. Thank you Timothy Sears CBO Deputy Building Commissioner Town 0fYarmouth 5O8-39X-ZZ31Ext. 1259 noai|to:tsean(@yarmouth.noa.us TOWN OF YARMOUTH HEALTH DEPARTMENT � PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET To he completed by Applicant: Building Site Location: O iLl✓v1-S Proposed Improvement: � ,r►I c .�tr4' 1®Q �bc�etAD Ay pc I-h pe 1 �a�pe tom' Applicant: 4.v44L2Az jc 2 c$ Lt' S Tel. No.: 08 3b�- q(.39 Address: 1Z F7(�.v�° 1.A PL,} a1 ULU°S Date Filed: 2I 0122_ **Ifyou would like e-mail notification ofsign off,please provide e-mail address: 0141-C C-2,6 Copt sr; C..DrA. Owner Name: L,q A SOD Owner Address: Owner Tel. No.: 23'l Y307 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. r Please submit three (3) copies of plans, to include: (1.) Site Plan showing existing buildings, water line location, and septic system location; HEALTH DEPT (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. 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