HomeMy WebLinkAboutBLDR-23-12996 ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department y
1146 Route 28,South Yarmouth,MA 02664-4492
508-398-2231 ext. 1261 Fax 508-398-0836 . .,r
Massachusetts State Building Code,780 CMR
Building Permit Application To Construct, Repair, Renovate Or Demolish
a One-or Two-FamilyDwelling
This Section For Official Use Only -
Building Permit Number: A3L JD/. 23 12-9yb Date Applied:
Building Ofcial(Print Name) Sign re Date
SECTION 1:SITE INFORMATION
1.1/Property Address: 1.2 Assessors Map&Parcel Numbers
3} C, 't:�l LL.1Ar le. !mil a}01
1.1 a Is this an accepted street?yes z 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:
Public® Private 0 Zone: _ Outside Flood Zone?
Check if yes❑ Municipal 0 On site disposal system Uill
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'oF Record:
Ise Pi/JCilei 60,it -a 4 c` Ok % ,t (4i/ fA4 cJ f6,23
e(Print City,State,ZIP
31 e-0 c..t/r 4/3 .-S3 MO
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction 0 I Existing Building 0 Owner-Occupied 0 I Repairs(s) 0 I Alteration(s) 21 I Addition 0
Demolition 0 I Accessory Bldg. 0 Number of Units € Other 0 Specify:
Brief Description of Proposed Work': /41 9 - 4 - 47
SECTION 4:ESTIMATED CONSTRUCTION COSTS,
Estimated Costs: N 0 202.
il
Item Official Use Onl ` U,
(Labor and Materials) u t t D N (
UFUn�TTN ENT I.Building $ l , sz� 1. Building Permit Fee:Si.q't) Indicat d p
?.Electrical $ < _ ❑Standard City/Town Application Fee j
/.Ste. e22 0 Total Project Costa Item x multiplier x
3.Plumbing $ ( s ?2 CJ 2. Other Fees: $ 5�
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) $ Total All Fees:$
6.Total Project Cost: $ Check No. Check Amount: Cash Amount.
/1 S h 0 Paid in Full &'Outstanding Balance Due:41 h
U
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
t�v�� License Number Expiration Date
Na f CSL Holder
t ,) _ ' i at C5 List CSL Type(see below)
s
No,and Street Type Description
fr/V//y.A/V/th S 1/� c 9)60 / U Unrestricted(Buildings up to 35,000 cu.ft.)
City/Town,State,ZIP R Restricted 1Ft2 Family Dwelling
M .I Masonry
RC I Roofing Covering
WS Window and Siding
�� SF Solid Fuel Burning Appliances
')OI3� ��e I Insulation
Telephone Email address D ( Demolition
5.2 Registered Home Improvement Contractor(HIC)
-2HIC Company Name or trant Name HIC Registration Number Expiration Data
22 Sitn.,1lf rtlp<- 67''�2CI
No.and Street S C!C l_C/��
Ir4!t/,/Vi S E/1/14 Q.. 6 0 A 9 360e/7y ? Email address
City/Town,State,ZIP Telephone d
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(N.I.G.L. c.in.§ 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 Cl
•
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 /iL a (/4 e-e / 4/
, 'Z �c'� 0 ,
to act on my behalf,in all matters relative to work authorized by this building permit application.
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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.
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.rnass.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/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.j.-----Number of fireplaces Habitable room count
Number of bathrooms Number of bedrooms
Type of heating system Number of half/baths
Type of cooling system Number of decks/porches
Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
The Commonwealth of Massachusetts
�'-- Department of Industrial Accidents
e =_" I 1 Congress Street,Suite 100
�a Boston,MA 02114-2017
_ www.mass.gov/din
\Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): j�f$ � N� //C40
Address: /' C'�'/e\ t jW
City/State/Zip: l_i42 , i'f ° ' hone#: 5O/ 36' 9
Are you an employer?Check the appropriate box:
Type of project(required):
iirZfi am a employer with --y employees(full and/or part-time).*
7. New construction
in I am a sole proprietor or partnership and have no employees working for me in
any capacity.[No workers'comp.insurance required.] 8. Remodeling
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. Demolition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will I O C Building addition
ensure that all contractors either have workers'compensation insurance or are sole
11.0 ElectricaI repairs or additions
proprietors with no employees.
in I am a general contractor and I have hired the sub-contractors listed on the attached sheet. i 2'❑Plumbing repairs or additions
These sub-contractors have employees and have workers'comp.insurance.' 13•�Roof repairs 1�
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.t r 7 Dyer ��Q /l J ,
152,§I(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box Al must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing ail 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 ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: = 5Q 4 C! 6=44 QL 1( S 11/St),et/ ; C
Policy#or Self-ins.Lic.II: WC,('_ pry 54)( 5' 5 6 2J.23 iq Expiration Date: -/p
Job Site Address: 3 &4 . ( City/State/Zip: V/ 2,,ta.s , j' O )3
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 certif r the s and penalties of perjury that the information provided above is true and correct.
Signature:
/ Date: /0- 3 2
Phone T: / 2rf 3 '90 3 7
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):
I.Board of Health 2. Building Department 3.City/Town CIerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
TOWN OF YARMOUTH
BUILDING DEPARTMENT
IC4TT:=� ,., 1146 Route 28, South Yarmouth,MA 02664 508-398-2231 ext. 1261
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE:
JOB LOCATION: 3./ 1 Uhr'21-5414/V40/ /Ni"
NAME STREET�AD RESS SECTION OF TOWN
"HOMFOWNER" x P/-/ (Jfc`5nif/c--STREETS)
v 413 3 7 6 '1
NAME HOME PHONE WORK PHONE
PRESENT MAILING ADDRESS 3 / - -r C%'.te4 G./
W -7% /42/-2 o /r7i i 44 7 3
CITY OR TOWN STATE 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 work performed 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 OH-ICIAL
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 have the insurance coverage required by
Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner Agent
h:homeownrlicexemp
§TOWN OF YARMOUTH
1146 Route 28, South Yarmouth, MA 02664
508-398-223** 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 3 �sC��c 2� wPkAi) 1,0 , V /2
Work Address
Is to be disposed of oat the following location: 1/2'Uc/17-/ s eb �
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. 111, §150A.
` =C 0 � � 3
Signa e of.Application Date
Permit No.
AGRL� CERTIFICATE OF LIABILITY INSURANCE DATE
C
10/11/2023
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 pollcy(les)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). I
PRODUCER NME CY Glen Davis
The Hilb Group New England,LLC PHONtlE (800)840-1820 FAX
dba Dowling&O'Neil avi hil rou cam (A/G No):
9d � b9 P�
973 lyannough Road
INSURERS}AFFORDING COVERAGE NAIG A
Hyannis MA 02601 INSURERA: Hartford Underwriters Insurance Co 30104
INSURED INSURER B: Associated Employers Insurance Co 11104
Fabulous Building and Remodeling INSURERC:
y
11 Sierra Way INSURER D: ti
INSURER E: �.
West Yarmouth MA 02673-2622 INS RER F:
COVERAGES CERTIFICATE NUMBER: CL2391113075 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED 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.
) EFF POLICY EXP
LTR R TYPE Of INSURANCE INSO INVD POUCY NUMBER (MMIDO YY) (MVdDOfYYYY) LThSTS
COMMERCIAL GENERAL LUiBIUIY EACH OCCURRENCE $ 1,000,000
r t DAMAGE TO RENTED I000000 -----"N`
CLAIMS-MADE i/ OCCUR
PREMISES(Ea owurrence) $ 1' '
MED EXP(Any one person) $ 10,000
A 08SBAAX7YTL i 05/16/2023 05/16/2024 PERSONAL a aDv INJURY a 1'000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE S 2,040^000
POLICY X JEC�T 7 LOC PRODUCTS-COMP/OP AGO $ 2,000,000
Base Premium s
OTHER:
AUTOMOBILE LIABILITY COMBINED SINGLE UNIT $
(Ea accident)
ANY AUTO BODILY INJURY(Perperson) $
— OWNED SCHEDULED BODILY INJURY(Per accident) S
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY — AUTOS ONLY (Per accident)
$
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
i` EXCESS LIAR CLAIMS-MADE AGGREGATE $
€€
DED RETENTION S S
WORKERS COMPENSATION Set PER OTH-
AND EMPLOYERS'LWBIUTY Y N /`N STATUTE ER
B ANY PROPRIETOR/PARTNER/EXECU7PROPRIETOR/PARTNER/EXECUTIVEN N/A WCCS0050150562023A 09/10/2023 09110/2024 EL EACH ACCIDENT S 500'�
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH) I E.L DISEASE-EA EMPLOYEE S (:),CM
If yes,describe under
DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 50(400
1
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(AGGRO 101,Addltonal Remarks Schedule,may be attached If more space Is required)
Insurance coverage is limited to the terms,conditions,exclusions,other limitations,and endorsements.Nothing contained in the Certificate of Insurance
shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions
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.
AUTHORIZED REPRESENTATIVE
l
0 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2018/03) The ACORD name and logo are registered marks of ACORD
ONE or TWO FAMILY— BULDING PERMIT
APPLICATION REGULATORY APPROVALS NOTICE
Address of Proposed Work: 57 i 1 C K.E/a L4jt C1 6-`7�/401 1,' P14De'
Scope of Proposed Work: ADD e.)o4q 127 Ot4('u
Date: it) o 2 3
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.
y 2
Receipt Acknowledgem
fir ! ,;;
Applicant's Signatu fi V w c�
Date
Rev.Jan. 2019
•
•
L.
Commonwealth of Massachusetts
Division of Occupational Licensure Construction Supervisor
• Board of Building Regulations and Standards Unrestricted -Buildings of any use group which contain
II is less than 35,000 cubic feet(991 cubic meters) of enclosed
Con�tion Srvisor space.
CS-109981 itpires:12/22/2023 ►
JOAO DEMOtJRA
22 SMITH STREET
HYANNIS MAT 02601
ti •
6iTvd.1a1
Failure to possess a current edition of the Massachusetts
Commissioners f �Gmr State Building Code is cause for revocation of this license.
!l For information about this license
Call (617)727-3200 or visit www.mass.gov/dp1
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
TYPE:Corporation
Registration Expiration
197431 12/10/2023
CREATE BUILD&REMODEL INC Registration valid for individual use only before the
expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
1000 Washington Street -Suite 710
JOAO DE MOURA /9 Boston,MA 02118
22 SMITH ST t;,$� •
HYANNIS, MA 02601
Undersecretary ;.
Not valid without signature
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