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HomeMy WebLinkAboutBLD-21-005631 ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department �of 1146 Route 28, South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508-398-0836 4TM Massachusetts State Building Code, 780 CMR Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: j&(.j)-21--C S 3/_ Date A : r �{ Jib, Al Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers I/ t r QM) Seam 5ta dut 17 138.t C,IV- 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 I 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 0 Check if yes© Municipal 0 On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: �st1et t 9a4k QtiSMotr+ too. °At. 134 165 03 Name{Print) City,State,ZIP No.and Street Telephone Email Ad ress SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply) New Construction 0 Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Tlif Addition 0 Demolition Itif Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2: t.O% mL , Floarleas t'tQlaurntn$, L f&r til to %Naug►t ?moat(coolvt) WiOwco, window cf4gAtiw.t.nrr M OPcntng rly,a,rfr On tolode SECTION 4: ESTIMATED CONSTRUCTION COSTS • Estimated Costs: Item k ,) Official Use Only (Labor and Materials) 1.Building $ 24,111'pv 1. Building Permit Fee:S--Qtr? Indicate how fee is determined: 18 Standard City/Town Application Fee 2.Electrical $ 0 Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ h Check No. Check.Amount: Cash Amount: 6.Total Project Cost: $ 0E017 moo 0 Paid in Full 'al Outstanding Balance e: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS -togo-Lq -Tab tYl MVb License Number Expiration Date Name of CSL Holder List CSL Type(see below) Li Writ Oc tt s React No.and Street Type Description VkaruqC,1^, 1 OatiNt U I Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP lvt Masonry RC I Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 5og•qK5-o c :Iogtigneu carisfructton Qdvnny.( I Insulation Telephone Email address U D I Demolition 5.2 Registered Home Improvement Contractor CHIC) go* tAc. �83 tti HIC Company Name or HIC Registrant Name HIC Registration Number Expiration Date lie ZA ltans Road �05f?nmulater�4ruuHen arw�� cacti Na.and Street Email address KtuuSt_�A IAk O14 W City/Town, State,ZIP Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(.1.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 Issuanc f the building permit. Signed Affidavit Attached? Yes [/ 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 to act on my behalf,in all matters relative to work authorized by this building permit application. a Waunt tl NceNt. C.0 nivo cr 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. "Sasso Mtn 2-dW-zd Print Owner's or Authorized Agent s Name(Electronic Signature) Date NOTES: I. 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 I3IC Program can be found at www.mass.eov/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" §TOWN OF YARMOUTH 1146 t mute 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. 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 aUo Sou t 5ca Autnu4 Work Address Is to be disposed of oat the following location: 5k T exc.), QOO &oat- west-to Avc Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. 2 -arc-Zi Signature of Application Date Permit No. Division of Professional Licensure Board of Building Regulations and Standards rk!VCIwar 3 y • CS-109029 Expires: 10/22/2022 JASEN MUTO 1621 ORLEARS ROAD ' HARWICH MA62645 .'" Commissioner VEenata.., Office of Consumer Affairs&Emsiness Regulation HOME IMPROVEMENT CONTRACTOR TYPE;COl-aCrat —gca=tti-Cln E3__cpjLa_tic_jn 153111 CI3 27 202' MUTO INC JASEN MUTO 1621 ORLEANS RD HARWICH.MA 02645 Undersecretary t'-N The Commonwealth of Massachusetts Department of Industrial Accidents fl 0 Office of Investigations -lr, .(. .._ ii Lafayette City Center %% 2 Avenue de Lafayette, Boston, MA 02111-1750t91 /. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Muto, Inc Address: 1621 Orleans Road City/State/Zip: Harwich, MA 02645 Phone #:508-945-0300 Are you an employer? Check the appropriate box: Type of project(required): 1.0 I am a employer with 10 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction listed on the attached sheet. 7. ❑ Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' p y f 9. ❑ Building addition [No workers' comp. insurance comp. insurance.* required.] 5. ❑ We are a corporation and its 10.n Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. ■❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.11I Other 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: Associated Employers Insurance Company Policy# or Self-ins. Lic. #: WCC50050071002020A Expiration Date:4/25/21 Job Site Address: 300 5eu Sda hvt City/State/Zip: ithmeu}y. NA 63413 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. Signature: Date: 8-e1'I•a1 Phone#: 508-945-0300 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): 10Board of Health 20 Building Department 3.1:City/Town Clerk 4.0 Electrical Inspector 59Plumbing Inspector 6.❑Other Contact Person: Phone#: __i....4 MUTOINC-01 DEATON ACORE) DATE(MM/DD/YYYY) kili CERTIFICATE OF LIABILITY INSURANCE 5/4/2020 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). CONTACT PRODUCER NAME: _. RogersGray,Inc. 434 Rte 134 j Hc00,"r o,E>d>:(800)553-1801 (NC,No):(877)816-2156 South Dennis, MA 02660 aaoREss:mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:Selective Insurance Company of the Southeast 39926 INSURED INSURER B:Selective Insurance Company of South Carolina 19259 Muto Inc. INSURER C:Associated Employers Insurance Company 11104 Jasen G.Muto 1621 Orleans Rd INSURERD: Harwich,MA 02645 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 NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD /MMIDD/YYYYI (MM/DDIYYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X. OCCUR IS 2207035 4/25/2020 4/25/2021 DAMAGE TO RENTED 500,000 PREMISES(Ea occurrence) $ 1 ' MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY JEST LOC PRODUCTS-COMP/OP AGG $ 3,000,000 OTHER: $ B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ ANY AUTO A 9100597 4/25/2020 4/25/2021 BODILY INJURY(Per person) $ OWNED ' SCHEDULED 1 AUTEO�S ONLY AUTOSNN BODILY INJURY(Per accident) $ X AUTOS ONLY X AUUTOS ONEYY PROPERTY accident DAMAGE $ $ A UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE S 2207035 4/25/2020 4/25/2021 AGGREGATE $ 1,000,000 , DED RETENTION$ $ C WORKERS COMPENSATION X STATUTE �ORTH- AND EMPLOYERS'LIABILITY WCC50050071002020A 4/25/2020 4/25/2021 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE YN" N/A E.L.EACH ACCIDENT $ FFICER/MEMBER EXCLUDED? 500,000 Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below ' E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Certificate holder is included as Additional Insured for General Liability as required by a signed written contract or agreement with the Named Insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THEREOF, Muto Inc ACCORDANCE WITH TTHE ATE POLICY P OVIS ONSCE WILL BE DELIVERED IN 1621 Orleans Road Harwich,MA 02645 AUTHORIZED REPRESENTATIVE '' --)-- µ� L ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD COST-PLUS-PERCENTAGE-FEE AGREEMENT Muto, Inc. 1621 Orleans Rd Harwich Ma 02645 MAO constt Muto Construction, Inc. License Number: MA HIC# 183111 CSL Number: CS-109029 DATE: January 21 , 2021 Maria and Paul Reisman 200 South Sea Ave W. Yarmouth, MA I. PARTIES This contract (hereinafter referred to as "Agreement") is made and entered into on this 21st day of January 2020, by and between Maria and Paul Reisman (hereinafter referred to as "Owner"), and Jasen Muto Construction, (hereinafter referred to as "Contractor"). In consideration of the mutual promises contained herein, Contractor agrees to perform the following work: II. GENERAL SCOPE OF WORK DESCRIPTION Work to be performed in accordance with Reisman Cost Estimate dated 1-21-21 , attached. III. GENERAL CONDITIONS FOR THE AGREEMENT ABOVE A. CONTRACTOR'S DUTIES Contractor acknowledges and accepts the relationship of trust implicit in this Construction Agreement. Contractor agrees to use good efforts, judgment, and skills to complete the work according to the Contract Documents referred to in this Agreement. Contractor agrees to furnish competent construction management and administration and to adequately supervise the work in progress. Contractor agrees to complete the work in a timely and workmanlike manner. Page 1 of 9 Initial Here 2/24/2021 IMG_7804.jpeg S. ADDITIONAL LEGAL NOTICES REQUIRED BY STATE OR FEDERAL LAW • See page(s) attached: none I have read and understood, and I agree to, all the terms and conditions contained in the Agreement above. 1/21/21 Date Jasen Muto, Contractor J/2/2J Date Maria Reisman, Owner //9//( C(P/`(A-46761-t(1.4'6f.A Date Paul Reisman, Owner : e tea;: • • https://mail.google.com/mail/u/0/#search/south+sea?projector=1 1/1 c" raP � G� r C7 �' p rt o '3 i -rscl. Z C 0 = O aP • r-s rp U; CS' CL, 0 O n -' rD .f -� ��° 0 ro O 0 "� �* � � � 4 -,., . , PJ Cr �. O o U � y rD �-S P) 0- rr O ri r r N rD `t� :ID 0 rt O fl. ro O �, D rD p' O O 0'4 `0 -. Cr rr rD O : 0 �r, O T' s Q. rD r O r'D rt �. n -Os U rlD 00 0.. CIG rp CD CD] U r7 O h G rD C O C X 0 7/ 0 rC n OC z IvO N O CC X < .-r .CrP ro rP rD aa n Cr -iCID CP rD N rt if, �--' '�' Ci rD rr X 04 C o O x- 4 0 O OP n o r 0 Cr © Cr 10 0 O- 0 CrJ rt . rt A. 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