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HomeMy WebLinkAboutBLDR-23-12803 V 'i i ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department 1146 Route 28, South Yarmouth,MA 02664-4492 , R F C 508-398-2231 ext. 1261 Fax 508-398-0836 �' Massachusetts State Building Code, 780 CMR �` JUL- 11 . uil in PermitApplication To Construct, Repair, Renovate Or Demolish �02 a One-or Two-Family Dwelling BUILD NC,DF-PARTIVICNT __ This Section For Official Use Only By �� Building Permit Number: 1�,�1(� 23—' 12 0,. )ate Appli J i—, rS , q Ilci /), Building Official(Print Name) ignature Date SECTION 1:SITE INFORMATION 1.1 /Property AcPO� l l / 1.2 Assessors ep Map&Parcel Num7 bers / 1.1 a Is this an accepted street?yes i' no Map Number Parcel Number 1.3 Toning Infor ation: 1.4 Property Dimensions: - o ?aS' 5.f' /Z 7 3 O Zoning District Proposed Use Lot Afea(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) S Front Yard Side Yards Rear Yard 2a Required Provided Required Provided Required Provided 3oi qa, Pf ./-.7 3d .5 o Ili A 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 OWNERSHIP1 2.1 Owner'9f cord: � (DAU! c S�.�i( 114x/ 1� N fl'd5o/1 . © &/o / Name int) `, City,State,ZIP S" /I, i Iy 0PivG 33 7 7017 ./7© No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK''(check all that apply) New Construction 0 Existing Building Er Owner-Occupied iA Repairs(s) lQ' Alteration(s) gi— Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other ❑ Specify: Brief escription of Proposed Work'-: ? M aaa, 1 y /5 /1'A 7 As.. ff e/J7 Re e A 00 SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ -7 0 v O , ,---,1. Building Permit Fee:$ Indicate how fee is determined: CIStandard City/Town Application Fee 2.Electrical $ a 1 c e Q• 0 Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ 7 �O (' , 'List: 5.Mechanical (Fire Suppression) $ Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $/O �Oi i r 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) J �'/� CS— d O I8' 5 C3 Q`/ 5'L;/7h a t" Ji a /2l11 C/ License Number Exp' atio ate Name of CSL Ijolder 6 \ List CSL Type(see below) U /i+i�yom l i/ No.and Street Type Description U Unrestricted(Buildings up to 35,000 Cu.ft.) wo,5/ Y/j.lr/YO'v 7-11 it c9 '6,73 R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry • RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 6-0 a 3 G.1., 3!/( I Insulation Telephone Email address D I Demolition 5.2 Registered Home Improvement Contractor(HIC) I P A., tun 0`,ald it / LI C HIC Registration Number Ex iration Date C Company Na e or C Registrant pi, /Name - No.and Street A /�]i�a�C'�/ �(>/ �h&c0 G���II' 1-6S,/tj Email address 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. i 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 �A)� • e ` ..,f•A5 f, ' _ I to act on my behalf, in all matters relative to work authorized by this building permit application. Z7 At, d 5 11 PIA 0 3 c, V a.7 Print Owner's Name(El tronic 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 app ication's true and accurate to the best of my knowledge and understanding. 41 Print Owner's uthorized Agent's Name(El onic Signature) 1 /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.aov/oca Information on the Construction Supervisor License can be found at www.mass.cov/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 Iiving 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" a The Commonwealth of Massachusetir 9 Department of lndustrialAccidents !"F�7:141 - �" Office of Investigations `° = E 600 Washington Street ':41 Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information /' Please Print Le& • Name(BusinesslOrganization/Individual): 1� 6' ,{1 A...) ,y 'IT'Il L1't'l 1 / C Address: 6,-.>.0 3 iiLl. y hi, 6 L 7 ./ City/State/Zip: t .l _-'p iL /M. d,7c 7_.3 Phone#: L_-', = ,;36 `l ' i / Are you an employer?Check the appropriate box: • Type of project(required): • I.Q I sm a employer with `J 4. 0 1 am a general contractor and I 6. 12rNew construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ffRemodeling ship and have no-employees These sub-contractors have 8. ❑Demolition working for mein any capacity, employees and have workers' 9. ❑Building addition [No workers'comp.insurance gyp•insurance.: required.] . 5. 0 We are a corporation and its 10.0 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 MOL 12.0 Roof' epairs insurance t c. 152,§1(4),and we have no > ] employees.[No workers' 13.0 Other _ comp.insurance required.] *Any applicant that chocks box#1 must also 511 out the section below showing their workers'compensation policy informatics 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 subcontractors and state whether or not those entities have employees. If 9,e 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: 1e , 4"..- '�,, ,' 1- / c' rv/v c-')%. t At C- Policy#or Self-ins,Lie.#: Cv /3 t-/ 3_ 7 'y T ' 4- ! Expiration Date: 0 / ,J fa,..1., 3 Job Site Address: /i 6- C_ r -t44 1/ l q r City/State Zip:. W y f'i,r-tG 7"// l Y C&67,1 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 S250.00 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 pen ofperJury that the information provided above is date and correct: S. start: 4I( te: 0 a �3 Phone#: 'Sc'-J — A //`x.. 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: • 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 /% C y, et (( /QQ Work Address Is to be disposed of at the following location: ) )4/ tie 1/// Pzi ,^1 Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. 7// efr7,23 Signature of Applicant Date Permit No. CC o ii.','' m0 ot.o Cr0 a)0a) IX 3a) t O #I o t•o c 3 s NNa)o) 3W (aa) f a) C I- O k Z C V N a) vs -o ° 3 V t a5 a) a) c 0 0 Z. y t a v -o x 0 co t A a as a, -0 a 0 o c E E a) ui f co 4-, as CZ _0 a) .C) us a r O or K W E 0, N C 0 o Ua 0 `a cc) 0 c 0 r'. o— 0 E 1- 0 a) m m o V m 5 N a) a) L 0 N v v ca I a) - as 0 (a CZ L C m O 3 C E > A y:. .c d c o Y Z �0 E U to E �' a) a w c °oo ` '= • a•0 cE ca 3 o cn- 0 a)i -c 0a cN _c N C g C C a.0 ''� n N L C a) Y c -- O 0 fb r ~• > M v)U r id i of o C/ III ,, s' I 1!I 0 1 I i V r J (.„ - I Y 0 r,„ c _ 3 C = ?� o O Y C a A E -cu0. c fa •a ocu � NOV O0) m `0' E o aa)) o cE EOoo z. d U N p o an 0 c> >. lf) __ >— O o) o as C a) O >m as v a a) .ccc f' c R3 f° a.) c 0) vro E ca).c EE c ro >o 0 N > (a CO3 O co Q. c = ro�•c a c ah t a a) 0 �' m U v o0 Y 2 yQ d(} d Y Ta a m ti o W N O » -co — 3 v a) ry L N 1- a) o N m o C E N r.> C • C� -D C 0 o . ._ O O c 0r 7ch _ V co _ •- a) RO a) = _ a)_ — C N N 0-p a)m E w �,.) N 0 0 0,v_) ° Y N as c T py V o .0 N N N 0 a N E. a) ca 0 c3 O w c > N 0. a)_ 0 Y of c mga as T in 0 co i;u m3 mf°v „a c.oc ° Lcanv U o o Oa f 3� ° ° ' 2 c Ca u -O C as o r . a m m 0 0 __ Y m ° > 0 > ,d. N - r C N�0. 11. o C a) o ca> m — 0 t: _ N ii W. _.. H- a 7 Y ..W. a r 7 W. G 7 e e o. " a ,,, a W H .. H ii ': a V1, m G v. X it. v 0_ • . N it el p C O N 3 m v D Q.ro ,th N < Q , fk< 0 0 Q 0 O w 1 n c . o i m =' a. d c w it , .. W I a d a g ` s F z x_ Y 4 i S : t AC RQ CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 03/06/2023 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 CONTACT Alan Burstein NAME: Peter M.Bakker Agency,Inc. PHONENFAX Ext): (860)378-2700 F No): 302 West Main St E-MAIL alan.burstein©optisure.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Avon CT 06001 INSURER A: American Zurich Insurance Comp 40142 INSURED INSURER B: Main Street America Assurance Company Kenney Builders Inc. INSURER C: 603 W YARMOUTH RD INSURER D: INSURER E: WEST YARMOUTH MA 02673-1459 INSURER F: COVERAGES CERTIFICATE NUMBER: CL233624254 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 EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 500,000 CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 B MPJ7842M 04/06/2022 04/06/2023 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO 2,000,000 JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT $ (Ea accident) • ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER OTH STATUTE AND EMPLOYERS'LIABILITY Y I N 500,000 A ANY PROPRIETOR/PARTNER/EXECUTIVE NIA UB-8H337476-22 09/25/2022 09/25/2023 E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 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 it 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 Tom Cardone ACCORDANCE WITH THE POLICY PROVISIONS. 21 Lakewood Rd AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 4 _ ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts cm- Division of Occupational Licensure Board of Building Re ulations and Standards Cons•••t �`",ton IrSke,±visor CS-001895 a Spires:01/1312024 CHRISTOPHER T KENNEY 603 WEST YARMOUTH RD WEST YARMOUTH MA 02673 v"Lit',{al Commissioner ct 2 fi. T/ ks�t -,22/22.owitiea-dio/dAze)-1,}ae/ dat,le/7,-) Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation Registration: 181256 KENNEY BUILDERS INC. Expiration: 03/16/2023 603 WEST YARMOUTH ROAD WEST YARMOUTH,MA 02673 Update Address and Return Card. SCA 1 Cr 20M-05117 r/. Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 181256 03/16/2023 1000 Washington Street -Suite 710 KENNEY BUILDERS INC. Boston,MA 02118 CHRISTOPHER KENNEY �fGG • 603 WEST YARMOUTH ROAD Not valid'witho signature WEST YARMOUTH,MA 02673 Undersecretary i Z -4 -4 - 0 :: ;/ _T to 0 RI ' '"z� GAO ''':1 Off I 1§ ▪ F$ > 0 p� g _ 0 £7 _ J ~ Q m -a-. 2 8 m00 - 3 2, c 2 4 0.7 }`ci 44#`. fit I.i ., :;-.2+ -w > � '6 w ih ! a a.= a 'T w -t r a) .� 2 0 Q a2 ? ill F 033 c 1 m `" t� <? rga 111 a; �at"t} z a c�. 2 0 a 2 0 3 0. to