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HomeMy WebLinkAboutBLDR-23-12806 ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department of r 44. 1146 Route 28,South Yarmouth,MA 02664 1492 508-398-2231 ext. 1261 Fax 508-398-0836 ucku; .. Massachusetts State Building Code,780 CMR ` ", — ' V EC D Building Permit Application To Construct, Repair; Renovate Or Demolish z a One-or Two-Family Dwelling h . JUL11 N This Section For Official Use Only Building Permit Number: 13 L -I2 to Applied: BUILDING DEPARTMENT o,r -- Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Pro e,r�yY_Address: �- (� 1.2 Assessors Map&Parcel Numbers 3/ ,54,v/57 e(-Zt/�✓U /197Mlye . - /.a 2__ 1.1a Is this an accepted street?yes V no I Map Number Parcel Number 1.3 7gning2.formation: jeV4 � 1.4 Pro ert. 6 s;ons;, %�� f Zoning gjDistrict S Proposed Use Lot Area(sq . / �/ 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,I54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Private 0 Zone: _ Outside Flood re? Municipal 0 On site disposal system 0 Check if yes SECTION 2: PROPERTY OWNERSHIP1 2.1 Ow ert of��cor� �,�j/ ���r- �� U 7� �� Nam Print) 'e dX / G•CitOill)' 4,4 ZIP 7Vi¼' v 7 Lv • s0-34 V27j /e<N ur-S.se eCC4A-► and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(cheek all that apply) New Construction 0 I. Existing Building are' Owner-Occupied 0 1 Repairs(s) 0 Alteration(s) lid Addition ❑ Demolition 0 I Accessory Bldg.0 Number of Units I Other 0 Specify: Brief Description of Proposed Work?: fj,y y,e A.,-ti- .2/3 - t ./,;,G,,;,-r geA,t� .4/71'U 47.r - /2 4)4 u Se..ZPVVI.,/c r-ven, / - 10d r ha-i been q'O12e. 1 J/*1 pjjii SECTION 4:ESTIMATED CONSTRUCTION COSTS- Item Estimated Costs: (Labor and Materials) Official Use Only 1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ 0 Standard City/Town Application Fee 0 Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ ' � � 4.Mechanical (HVAC) $ List: gS.OO r% OZ/et3 5.Mechanical (Fire $ Suppression) Total All Fees:$ 1 j�a� CI No. Check Amount: Cash Amount: I 6.Total Project Cost: $ 3 ❑Paid in Full Outstanding Balance Due: ? ,cam ) \. cAL,I. / 4. .../ ,..3 t�lgl5tgn venrlea -tULbouu -unoe-4uoa- eLD-a' I'rnoe r r cap SECTION 5: CONSTRUCTION SERVICES 5.1 Construction S peiacisor License(CSL) o C i , M ( A _ License Number Expiration Date Name of CSL FR.older List CSL Type(see below) No.and Street Type Description (� S� � U Unrestricted(Buildings up to 35,000 cu. ft.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry 7 G' RC Roofing Covering WS Window and Siding r SF Solid Fuel Burning Appliances sod-3 6 7-„{z / �,au'°c. „ c'ivt a e Insulation Telephone Email address > € Demolition 5.2.2 Reregistered Home Improvement Contractor(HIC) 7 4 8��; I ' �'orvi '1-) 1 HIC Registration Number Expiration Date HIC Company Name r HIC Registrant Name ` I �3 i c>„.J A Ate.G r d F. M e A O. No. and St eat Email address m Ge.i„ty„ 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 0 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 ,'l ) P4.0141 to act on may�beehalf, in all matters relative to ork authorized bythis building permit application. /�EI1/'T.etk o�PA49w /jnivd1. Yount — 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 accura st of my knowledge and understanding. ��ar � -� =, 7 A) /a-3 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.gov/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: j Total floor area(sq. ft.) _ (including garage,finished basement/attics,decks or porch) Gross living area(sq. ft.) _ V 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" ''.� l • The Commonwealth of Massachusetts ��,;_ Department of Industrial _ Accidents ....114.4.' "' 1 congress street Stele 100 '"� <` Boston, MA 02114-2017 -ii.,' W W w.mass.go v/dia \I�orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant Information Name (Business/Organization/Individual): PO1 Please Print Le ibl c►� M U,�J Address: 1-13 .t5A, 5 1..---- 1.4_., ..5 -7- • City/State/Zip: �d Phone #: � 7 ? —BPS 1 Are you an employer?Check the appropriate box: I am a employer with Type of project(required): employees(full and/or part-time).* I----�� 2.❑I am a sole proprietor or partnership and have no employees working for me in 7. LJ New construction • 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. Li 4.1:1 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.D I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12. Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance.: 13•❑RO epairs 6.E We are a corporation and its officers have exercised their right of exemption per MGL c. 14• Other 152,§1(4),and we have no employees. [No workers'comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I 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: 14, .j, G s Policy#or Self ins.Lic. #: C.e-)G.- Expiration Date: Si—2)1 43 Job Site Address: 4 r 6,94 isioz Z f, Yieli 1 l2A City/State/Zip: 6.24(, 4( 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 ' under ins and penalties of perjury that the information provided above i tru .and correct. Signature: --=- . - ---- Date: 7 lAO 0--- 1 Phone#: S"�t' -367 PJ�1 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#: j)cwjci, dcc/mt,ui 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 3`7 1.) S T� �— Work Address Is to be disposed of at the following location: ,5 ,` Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. - 74L3 Signature of Applicant Date Permit No. ��...N DADM-12 OP ID: KV ,4cvmv CERTIFICATE OF LIABILITY INSURANCE DATE(MM/ Y) �� 07/11/20232023 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). 508-398-6060 CONTACT Bryden&Sullivan Insurance PRODUCER NAME: Bryden&Sullivan Ins Agency PHONE 508-398-6060 FAX 508-394-2267 of Dennis Inc. (NC,No,Ext): (NC,No): 485 Route 134,PO Box 1497 E-MAILDSS• So. Dennis, MA 02660 Bryden&Sullivan Insurance INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Associated Employers Insurance DNSL)RED INSURER B: avid Dadmun 43 Pond Street Unit 7 INSURER C: West Dennis,MA 02670 INI 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. INSR TYPE OF INSURANCE INSD SUBRvvjPOLICY NUMBER (MM/DD/Y YYY) (MM/DD!EXP LIMITS LTR COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Anyone person) $ PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO-JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident) $ANY AUTO BODILY INJURY(Per person) $ AOWNED UTOS ONLY AUTOS SCHEDULED BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED 1 i RETENTION$ $ PER OTH- A WORKERS COMPENSATION STATUTE ER AND EMPLOYERS'LIABILITY Y/N WCC50050112732022A 08/21/2022 08/21/2023 100,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A 100,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 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 Bryden&Sullivan Insurance ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ��...., DADM-12 OP ID: KV R�R® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 07/11/2023 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 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 508-398-6060 CONTACT NAME: Bryden&Sullivan Insurance Bryden&Sullivan Ins Agency PHONE 508-398-6060 FAX 508-394-2267 of Dennis Inc. (ac,No,Ext): (A/C,No): 485 Route 134,PO Box 1497 L ADDRESS: So. Dennis, MA 02660 Bryden&Sullivan Insurance INSURER(Si AFFORDING COVERAGE NAIC# INSURER A:Associated Employers Insurance INSURED INSURER B: David Dadmun 43 Pond Street Unit 7 INSURER C: West Dennis,MA 02670 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. INSR ADDL SUBR POLICY NUMBER IMM/DDY EFF/YYYYI POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WVD l /YYVYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENII AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ _ AUNED ONLY AUTOS ULED BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ ' DED , RETENTION$ $ PER OT-1- A 'WORKERS COMPENSATION STATUTE ER AND EMPLOYERS'LIABILITY Y/N WCC50050112732022A 08/21/2022 08/21/2023 100,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A 100,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION TOWNOFY 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 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth,MA 02664 Bryden&Sullivan Insurance ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD . • ili ,. , . ' ....3 _ , _ 41•10` g , ... • ' .1 -- _ -- - ito -tz < "•4, o 0 . . . .... . ..... _ i„,,, • . . , ,„ . . . . • .. . - -- citit ...I iia C) ''F"'"'Dh.:4, 0 ...1 • :. Asir DTI C?� ► < • .PARR «. 4, , ll,." Q 4111)1' o ' 1 r =c)(147) 4v . 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