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HomeMy WebLinkAboutBLDR-23-11033 ONE & TWO FAMILY ONLY- BUILDING PERMIT w Town of Yarmouth Building Department -_ RECEIVED 1146 Route 28, South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508- `398-0836 •„ Massachusetts State Building Code, 780 CMR "� MPV'l 2Idi g Permit Application To Construct, Repair, Renovate Or Demolish '`° it r__ _ 154 a One-or Two-Family Dwelling -" '`` BUILDING DEPARTMENT BY' ---- This Section For Official Use Only Building Permit Number: s LDR- a 3 -//d 33)ate Applied: C-1 3 Building Official(Print Name) i ature Date SECTION 1:SITE INFORMATION 1.1 Prop rty Addre�S 1.2 Assessors Map&Parcel Numbers 1.1a Is this an accepted street?yes V no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: ZoningiCS- District Proposed Use of Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required q 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 OWNERSHIP1 2. Ownerp'ofRecord: (�,� /� (� �int AV� AP , W City,State,ZIP `}- QJ`pi Is hn l' i dr-4010 8ckr-hrbulCapt.cA el,qc t. COO No.and Street Telephone Vmail Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 [ Addition 0 Demolition 0 Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work2: S l Oh/ Q- (W."3G)(.1 ie e( A4.4Il V1431 Lilt& inflovh.(t SECTION 4: ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: (Labor and Materials) Official Use Only 1. Building $ 1. Building Permit Fee:$ gra Indic how fee is determined: 2.Electrical $ ❑ Standard City/Town Asp cation Fee(-' 3.Plumbing $ El Total Project Costa(Item 6)x multiplier x 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire • Suppression) $ Total All Fees:$ - - /6-Total Project Cost: $ iicpt Check No. Check Amount: Cash Amount: 1. ❑Paid in Full 0 Outstanding Balance Due: i• SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) Name of CSL Holder License Number Expiration Date List CSL Type(see below) No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) City/Town,State,ZIP R I Restricted I&2 Family Dwelling Iv1 Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances Telephone I Insulation Email address D 1 Demolition 5.2 R istered Home Im rovement Contractor(HIC) 1-4 �1,, I mpanN e or HIC Registr Name HIC Registration Number Expiration Date 1�� C 1���lrrSt rI and Street �R V/ p41�`S �� �4-�eJ( ki ����(� 2 Email address j Town, State,ZIP Telephone J SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152.§ 25C(6)) 'a_ 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 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. c lk4ems . Print Owner's Name(Electronic Signature) Date • SECTION 7b: OWNER5 OR AUTHORIZED AGENT DECLARATION C.Jr By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information .P contained in this application is true and accurate to the best of my knowledge and understanding. C 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.2ov/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.) 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 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 Work Address 16 Is to be disposed of at the following location: fhrb�SC' d I 7 (s 40 ft C4 Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. C• 1 ture of Applicant Date Permit No. ADDITIONAL TERMS AND CONDITIONS 1. Swimming Pool and Spa Design also known as the contractor and all its sub contractors,warranties its work to be free of defects in material and workmanship for a period of one year from completion;Signatures Packages for a period of five years from completion.(Warranties are not in effect if payment schedules are not paid nor against neglect,abuse,improper operation,chemical imbalance,freeze damage,natural disasters,theft,low power,improper modifications by owner,other contractors,these acts void warranties. 2. The guarantees and warranties are effective only if Owner has complied with all of the terms and conditions,payments and other provisions of this Contract, and only if the Owner notifies the Contractor of the alleged defect in writing within the one year or other applicable labor warranty period of five years on Signature Package.Owner shall indemnify,defend and hold Swimming Pool and Spa Design Harmless for any and all claims arising,in whole or impart,out of a breach of theses warranties and representations. 3. This Contract constitutes the entire Contract,and the parties are not bound by any oral expression or representation by any agent of either party purporting to act for or on behalf of either party or by any commitment or arrangement not specified in the Contract.If any provision(or portion thereof)of this Contract shall be deemed invalid,it is agreed that such invalidity shall effect only such provision(or portion thereof)and that the remainder of this Contract shall remain in force and effect.Contractor may elect to substitute product(s)of equal or superior quality in the event the product(s)contemplated to be purchased in this contract becomes unavailable. 4. Contractor agrees to do all work provided in this Contract in a good and workmanship manner,but shall not be responsible for delay or failure to perform work when such delay or failure is due to Acts of God,Natural Disasters,Weather,war,riots or other civil disturbances,strikes,government prohibitions; non-issuance of all required permits affecting pool construction,or reasons beyond its control.Contractor is not responsible for damage to such items as,but not limited to,curbs,sidewalks,driveways,patios,lawns,shrubs,sprinkler systems and appurtenances.Contractor shall not be responsible for any damage to the pool after construction which is occasioned by the Owner's draining of the pool,a change in the water-table or ground conditions,or from natural causes. Not to Exclude any damages cause to owners or abutters property from pool draining out to a defect due to a defect or malicious damage 5. A.Contractor has been induced to enter into this Contract based upon the Owner's representation in this paragraph that: (i) The pool site is not fill ground(meaning soil which is not compacted to 95%or which doesn't have a load bearing capacity of 1,000 lbs.per sq.ft.) that may cause the pool to settle becoming unleveled once the pool walls are cemented in; (ii) The pool site contains no rock formation, boulders,cesspool, septic tank, gasoline, water pipe, drainage pipe, irrigation pipe,or underground electrical conduit,or other obstructions or other unknown ground conditions,such as poor soil condition that may require Contractor to replace the soil; (iii) The pool soil has adequate bearing capacity before and after excavation for the pool,land,improvements of Owner and land and improvements of adjacent land owners and"surcharge"("surcharge"meaning additional load condition that may be imposed on pool structure by existing or proposed adjacent structures which will require extra engineering or any damage that may be caused by water leakage from the pool; (iv) No underground or surface water conditions will interfere with the work or operation of the completed structure or installation; (v) No blasting or jackhammer work is required; (vi) There are reasonable means of access for Contractor's equipment, (vii) Contractor is not responsible for liner or packaging wrinkles and creases,not to exclude the waterline appearance due to liner patterns. B. It is understood and agreed that if any of the foregoing representations are incorrect,and if any additional work or material shall be required thereby to complete the Contract,Contractor's is hereby authorized to make such corrections,and the cost shall be added on to the Contract Price,plus 20%,Owner agrees to pay such additional charges upon presentation of a written estimate and prior to the rendition of additional work.(If the owners are not available at time of additional work is needed the contractor may elect to do the work to avoid delay if the work does not exceed$2,000 and owner will be responsible for payment). 6. Owner is required at Owner's expense to do all construction and other acts necessary,and to meet all conditions to allow necessary to allow Contractor to complete the work as provided in this Contract.Owner represents that the proposed pool location is within Owner's property lines and is in conformance with local zoning and building laws and regulations,Including set backs.Owner shall direct the location of the pool and other improvements,and where such locations used.there shall be no liability on the nail of Contractor for incorrect location of the non].other imnmvements and enninment or for violation of [1VQ X :Ctj NOI.LV'I IVISNIo NOI.LvATIdo NOI.LVDO'Io lOOdo Qd.Ld1DJV `QOAHDH)I VIdN/410-03 • 2IdNMO o;aea oa aLeifeap/Ir. :unapt samba sates /jl' g.Lv � '� le Pauli S laea;uoj I Idd� d?IdHM NI :Mo a Sped Qd I IId��d Ld IdY�IOO?8 21HT1lS IHI MI QdNOIS dOd2IHH I q alp peas pUtt spueq aqI ssau;IM lump 2urpeai AcIOD LDVXd Nd dO LdIdOd2I SdJQd IMON?I�t�2IdNM0 mom u8ts lou oQ joataq lied ate apts asaanat alp uo suoilipuoa atly .� ..,. ',C;ajes il xHNIMO xaAng MIL of aDI10N .toj saua[u`azidba3 t?�aur pue lt:i� �l�eof�- - ,fq auop st uouoadsui pug!pun pasn aq lou,into food uttuut1Ms dq1,:a;o E �('"ac •anoge palms se,Cpaexa paMorloj 1ou st afnpagas luautiied ,i nt aultnt / �� )r.IOM doll of lqu aglsauasat uSisa j edS'loot'uuuuttMS aqZ l2Id.7Idd0) ('rood jo uopaldtuoa jo amp uo aauautttloa of aauefeq pied un uo tpuotu.tad %! I a2.u:ga aatn taS'lae.nuoa.tad se pallelsui 2 patiddns wag aneq pasega -.tnd swan•asiut rood lie gown atutl ut lmod legl se paugap uopaiduuoD) u�ISaQ edS Iood�ulunrnMS `paldaooe�igalaq st loealuoo siq L $ aanoo Japan a iopq 28 uodn onQ.0 i nno�c $ �utoua3 uodn anQ fr '.Iaoujo ue,Cg.&urli.IM ul `uV!saig edrood \ The Commonwealth of Massachusetts • Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 =°.' www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant Information - / Please Print LeQibl (. Name (Business/Organization/Individual):S o)I m rn In I GnJ Address: n n v City/State/Zip: r)(lr� ��. V�VI Phone #: 5 e- c Are you an employer?Check the appropriate box: l. t am a employer with _ Type of project(required): employees(full and/or part-time).* 2.0 I am a sole proprietor or partnership and have no employees working for me in 7. New constdelinrUCtiOn any capacity.[No workers'comp. insurance required.] 8. n Remodeling 3. I am a homeowner doing all work myself. [No workers'comp. insurance required.]1. 9. Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 E Building addition j ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 11. Electrical repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 17'❑Roof rPlumb rig repairs or additions These sub-contractors have employees and have workers'comp. insurance.t 13.0Roof epai 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other l 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. 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. lithe 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: 141.4.4 rel. CcsG� t-t- LX3olicy rg,-' or Self-ins.Lic.#: ' r E ► C �( G/ / Expiration Date: U !� Job Site Address: I 1 Vi A :J rd City/State/Zip: �. tA__ , 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. yI hereby c. tify 1 er the pains and p:n ..s of perjury that the information provided above is true and corre ct. ature: Date: �` l!7 ' . Phone T; V Official use only. Do not write in this area, to be completed by city or town official. City or Town: Issuing Authority(circle one): Permit/License 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: ACCORD$ CERTIFICATE OF LIABILITY INSURANCE DATE{MMADfYYYYt kir' 03/27/23 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 PAUL SCHLEGEL Schlegel&Schlegel Ins Broker PHONe 508-771-8381 FAX (A ,No): 508-771-0683 34 Main Street ADCDR ADDRESS: Ezt (Am,schlegelinsurance@gmail.com West Yarmouth,MA 02673 INSURER(S)AFFORDING COVERAGE NAIC 0 INSURER A: NAUTILUS INSURANCE INSURED INSURER a: PROGRESSIVE STEVEN SENNA INSURER C: DBA SWIMMING POOL-SPA DESIGN 87 ENTERPRISE RD INSURER D HYANNIS,MA 02601 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. W INSRL TYPE OF INSURANCE fNso ���UULSUIIR POLICY EFF POLICY EXP ' VQ POLICY NUMBER {MM/DDfYYYY} (MM!OOIYYYY) LIMBS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR DAMAGE'r0 REN:tD PREMISES(Ea occurrencel $ 500,000 MED EXP(Any one person) $ 10,000 A CPS7515150 01/31/23 01/31124 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY PROF - JECT I LOC PRODUCTS-COMP/OP AGO $ 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ 50,000 B ovvNED ^^ AUTOS ONLY X AUTOSULED 02205243 06/05/22 06/05(23 BODILY INJURY(Per accident) $ 100,000 X HIRED X NOOWNED PROPERTY DAMAGE AUTOS ONLY AUTN-OS ONLY (Per accidentl $ 100,000 $ UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE AGGREGATE DEO 1 RETENTIONS $ WORKERS COMPENSATION r PAND EMPLOYERS'LIABILITY STATI.LTE ER RH Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) , If yes,describe under E.L.DISEASE-EA EMPLOYEE S DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS)LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached i1 more space Is required) INSURANCE COVERAGE IS LIMITED TO THE TERMS,CONDITIONS,EXCLUSIONS AND OTHER LIMITATIONS AND ENDORSEMENTS OF THE POLICY 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 REP SENTATIVE I ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ACORD CORPORATION. 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Conservation Commission 7Fpa>if Building Permit Sign-off Application TO BE FILLED OUT BY BUILDING PERMIT APPLICANT: Building Site Location: 2T7- gAc .clp ,_read Map # Lot(s) # 7 7 Property Owner: vusi'y + Elain-e t 0\7I Date filed: / Z /26 Z3 *Applicant: Gi r'1 avid l a/"L( tV-o Y Applicant Address: 'Z 64 2 /,w l leoa' Email: Telephone: Please note:by submitting this application,the applicant grants permission to the Conservation Office to enter the location to conduct a site visit(if needed). Proposed Project Description: Yb 7O e -3 YV 140( ev( r.ANT in -1,t leer &0 re a u in/6 ytd kik biz n'►�1 veG,e. i wc-\-tkr a t&& r-esJ uUO-/i,r t)vtei Site Plan Title/Date: V.OVOSPd PC904 BrO)tcf P!a pK (A-ea CDC 237- 13,tCl- .1-81014-d (124-)616 du 1-ed I Z 2 zrn2_ I I TO BE FILLED OUT BY CONSERVATION ADMINISTRATOR: Does the proposed project require a permit? \e$ Refer to: SE83- 238"/ or DOA permit Comments from Conservation Commission: Approved CCOnditionally Approved-) Rejected Conservation Commission Sign-off Signature: N Date: s/i !zt 13 *TO APPLICANT: All work-related debris shall be taken offsite or disposed in a legal upland location. At the end of each day, the area shall be clean and no debris shall be in the Resource Area. If work is permitted under an Order of Conditions, please arrange a pre-construction site visit with the Conservation Administrator. At the time of site visit, the MassDEP File Number sign must be installed, along with the erosion control/work-limit line. A copy of the Order of Conditions must remain on-site during construction. Please refer to the Order of Conditions for further details. 3ccn * N r - C m > m .A = ` ---- =---7:: i I AP O W Z N i y > ? =,. 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