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HomeMy WebLinkAboutBLDR-23-12919 ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department 1146 Route 28, South Yarmouth,MA 02664-4492 1 4\1 508-398-2231 ext. 1261 Fax 508-398-0836 i 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: ( [ ) K_ .J 9 I(/ Date Applied: i \\V`r• 2\CS _________ , 9 4,)/43 Building Official(Print Name) signature RSCEIVFD SECTION 1:SITE INFORMATION r�t+1.1 Prope Address: 1.2 Assessor Ma &Parcel Numbers id tree �= -41 >2t6 Y-/b J/ SEP 1 2023 1.1a Is this an accepted street?yes no Map Number Parcel Numbe pU1LQINt;pA 1.3 ZoningInformation: By. RrMENT 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: (Ni.G.L c.40,§54) 1.7 Flood Zone Inforration: L8 Sewage Disposal System: •\/° Public 0 Private 0 Zone: _ Outside Flood Zone? Check if yes❑ Municipal 0 On site disposal system 0 SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: `S14.lfk'40 So//A) I RIlI/51 bliz. he V..LS Aft 0A67 01, Name(Print) City,State,ZIP to hoj< E 4'r.-d37-d '7/ asw '.0 9 '? k' ..�___ liNo.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building❑ I Owner-Occupied 0 I Repairs(s) if? 1 Alteration(s) ❑ I Addition 0 Demolition © I Accessory Bldg. ❑ I Number of Units 1 Other 0 Specify: Brief Description of Proposed Work2: fig 4,A 2cii ,O.4,A Z IN ��aa� . i-/rx�k' SilhifiT ��t/o, ,04/�1�Sod,i. /0.�4r'�1 -( . f�4A c c1' &f24ecrAi j 7fr!".. SECTION 4:ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: (Labor and Materials) Official Use Only 1.Building $ / Cb o 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ' lB Standard City/Town Application Fee 3 Plumbing $ - CI Total Project Cost3(Item 6)x multiplier x /0.criev 2. Other Fees: $ 4.Mechanical (HVAC) $ List: lii) /1 i 5.Mechanical (Fire �- ' 7 7��3 _Suppression) Total All Fees:$ 6.Total Project Cost: $ Check No. Check Amount: Cash Amount: 5 a ) 0 Paid in Full 1:1 Outstanding Balance Due: r'{G---- SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) Name of CSL Holder License Number Expiration Date /P4 a C IL, List CSL Type(see below) 0 No,and Street Type 1 Description /414ak, ,€, t a MA * 0Z 3Yb U ( Unrestricted(Buildings up to 35,000 cu.ft.) City/Town,State,ZIP R Restricted 1&2 Family Dwelling NI Masonry RC ! Roofing Covering �; _ WS Window and Siding U S 7 Ec / t SFBurning Appliances �,,y` _ Solid Fuel Telephone f/kig I Insulation Email address D I Demolition 5.2 Registered Home Improvement Contractor(HIC) O�9`1; /i0 //1" a SY 1 /b� / "J1.' .y� HIC Compan Name or HIC Registr t e HIC Registration Number ira on Date No.a d�treet, t✓/ ��'' ' J/ C®i� �'S if//r� C�CJ �y/ A � 414 0WO/ 57�'—e, 'Vs�.� 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. Signed Affidavit Attached? Yes 141 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 CC50 �` i 7/5 46L to act on my behalf,in all matters relative to work authorized by this building permit application. <.e,C��%,/,, S ti/ (_() '"c56 . /vl Wy ,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. s're-72-611 ,Y -5.s1/.6,2 7•13/ -1 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 unreq(not registered in the Home Improvement Contractor �i contractor (HIC)Program), will not access to the arbitration program or guaranty fund under M.G.L. c. 142A.Other important information on the IIIC Program can be found at www.mass.aov/oca Information on the Construction Supervisor License can be found at www.mass.eovldps 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.) 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" §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-223t1 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 0 b ',e: , ',- Work Address Is to be disposed of oat the followng location: LS*r ieu Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, 150A. 2//::VOt5 Signature of Application Date Permit No. #7 Marston ilrim Hyansos,Maas O2€ ?I Phone:. 77 t-3tl0or - 4=311 Fax;77447442 t t ASSIGNMENT AND AUTHORIZATION TO PAY The undersigned, herein called claimant, has aut io r. . i .F t .,I from Oceanside, Inc. , the materials and r services :r , , i =c. .zf,, attached scope. Undersigned hereby assigns to Oceanside, Inc . -thy Impend p f,r c o,ti. (hi or to become due, under the claimant 's pol , ''i With the inn ,:ino company to pay direct to Oceanside, inc. or to n,'' i U(1(" i t.;> Th'IM0 00 check or draft, for all requested work. In the event that. Oceanside's claim herein is not covered by, or Paid by, an insurance company, claimant agrees to pay Ocear4side, Inc. within sixty (60) days after work has been completed. :. Claimant understands that Oceanside, Inc. is working for them and not the insurance company or the adjuster. Payments remaining due and payable after the claimant has received F payment from the insurance company shall bear interest at one and one- hatf (1-1/2%) percent per month. In the event that there is a breach by either party, of any of the conditions of this agreement, either party shall be entitled to recover, as additional damages, attorneys ' fees, costs and any other collection expenses reasonable and attributable to said breach . if payment is not received within 60 days, collection action will commence without further notice to the claimant . LOSS/DAMAGE ADDRESS -t k e MAILING ADDRESS S (,Lie 1 1 t5 co- I i (BILLING} CITY STATE ZIP =nISt7ANGE ADJUSTER` r - - _ _: v NAME/�"t�, Ch r1. 5+ Pie SLO PRINT NAME - !D i Ny . a .. N� (9 LAIMfANT `S S I GNATS_..___ _ DATE .. _ a The Commonwealth of Massachusefts icilj_ Department of Industrial Accidents ( • Office of Investigations —:k Lafayette City Center '"" f� 2 Avenue de Lafayette, Boston,MA 02111-1750 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): 0 c e Yl s/d€ _Z / Address: ,Q/ 7 /'-)car-r7 r7 2)r t LIE' , City/State/Zip: e4/67/z'z/5/ Z- C. -' f Phone#: c - 77/-- '3 /. ` Are you an employer?Check the appropriate ro rate box: I.LI I am a employer with 4. 0 I am a general contractor and I t Type of project(required): employees(full and/or part-time).* have hired the sub-contractors 6 ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp. insurance.t j 9- El Building addition required.] 5. [] We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12 0 Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' I 13.0 Other comp.insurance required.] *My applicant that checks box#1 must also fill out the section below thawing 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: /l- G=/Gz7tE' 7 ((. h2 e_,_,5. D /127 5 f 2-76 yetia/..Z'i.5' Policy#or Self-ins. Lic. #: VWC/0061£0 4 ?8.0v7 i0c2 ,h Expiration Date: //,'/ 41 Job Site Address: /6 > 6 ./ City/State/Zip: -44 y���RA,� 0�2" 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 certi,trunder4rhe pains and penalties of perjury that the information provided above is true and correct f Siatnature: ,-"�.--- / Date: / ; ` /c.9 G?4,, Phone#: ,-© - '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(check one): lDBoard of Health 20 Building Department 3fCity/Town Clerk 4.0 Electrical Inspector 5.alumbing Inspector 6.[1Other Contact Person: Phone#: Act CERTIFICATE OF LIABILITY INSURANCE DATE(" D0''rrrTI �----- 01/04/2023 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(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). PRODUCER CONTACT NAME: Linda Sullivan DOWLING & O'NEIL INSURANCE AGENCY PHONE For (508)775-1620 T.FAX AGGRESS: IsuIlivan ins.com 973 IYANNOUGH RD RNSu REA(ES)AFFORDING COVERAGE IWC/ HYANNIS MA 02601 ersuRERA: AIM MUTUAL INS CO 33758 INSURED INSURER 8 t OCEANSIDE INC INSURER C: INSURER D 217 THORNTON DRIVE INSURERS: HYANNIS MA 02601 INSURER F: COVERAGES CERTIFICATE NUMBER: 849163 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 diSR i TYPE OF INSURANCE �ADOLISUBR , POLICY EFF ' POLICY EXP 1. LIR INSD I WVD' POLICY NUMBER 1(MMAWYYYY)I imialooprrr i! LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 3 C1AlIdS&1ADE ` OCCUR i I DAMAGETORENTED PREMISES(Ea Qcc y5,cel :$- I MED EXP(My one person! ! S N/A I j .PERSONAL.&ADVINJURY : S GEML AGGREGATE LIMIT APPLIES PER I GENERAL AGGREGATE 13 I : ' PRO- i I POLICY: JECT I I LOC t PRODUCTS-COMPIOP AGG ' $ I OTHER: I i I I i 1 3 -. ---_ _- AUTOMOBILE 1..IA841TY I i j I COMBINED SINGLE LIMIT ;$ ANY AUTO j i l(Ea auJoenU_ f SOOILY INJURY(Per person) 13 OWNED ; SCHEDULED AUTOS ONLY AUTOS ( N/A eCx31LY INJURY(Pe(swam-ill 3 HIRED ( I NON-OWNED i PROPERTY DAMAGE ' AUTOS ONLY I I AUTOS ONLY (Per eccleeMI 3 i j 3 UMBRELUILIAB j OCCUR 1 j EACH OCCURRENCE t S I I EXCESS LIAR I CLAIMS MADE N/A I AGGREGATE f 3 DED I RETENTIONS i S WORKERS COMPENSATION 1 I X I STATurE : ,OTH ANO EMPLOYERS LIABILITY YIN 1 I I ? ! ER i ANYPEEPRIETORIPARINENEXECUTIVE ; E.L EACH ACCIDENT 5 1,000 000 A .OFFICER/NE.1.3EREXCLUDED? NIA 1 wA ; NIA VWC10060198022023A ; 01/01/2023 01/01/2024(M i Mandatory NNl E.L.DISEASE•EA EMPLOYEE� $ 1,000 000 Ir yes,eescnbe uncle, I a --. -_._ _.__ --_. DESCRIPTION OF OPERATIONS L*DI E L DISEASE•POLICY LIMIT 1 3 1,000,000 I I N/A I DESORPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Add"Itlonal Remarks Schedule,may be attached If maw space Is,squired) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees In slates other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the Issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www,mass.govfwd/workers-compensationtinvestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Oceanside Inc ACCORDANCE WITH THE POLICY PROVISIONS. 217 Thornton Drive AUTHORIZED REPRESENTATIVE Hyannis MA 02601 .. j k� Darnel M.Crowley,CPCU,Vice President-Residual Market-WCRIBMA 1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Aco® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) �� 01/04/2023 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 Tina Reeves NAME: The Hilb Group New England,LLC PHONE (800)640-1620 FAX (A/C,No,Ext): (A/C,No): dba Dowling&O'Neil E-MAIL ADDRESS: treeves@hilbgroup.com 973 lyannough Road INSURER(S)AFFORDING COVERAGE NAIL# Hyannis MA 02601 INSURERA: Arbella Protection Insurance Co 41360 INSURED INSURER B: Colony Insurance Company 39993 Oceanside,Inc. INSURER C: 217 Thornton Drive INSURER D: INSURER E: Hyannis MA 02601 INSURER F: COVERAGES CERTIFICATE NUMBER: CL22122020988 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 S I:. POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY (MM/DD/YYYY)( ) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED 100,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 A 8500066712 01/01/2023 01/01/2024 PERSONAL&ADVINJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X 'ECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED 102006166607 AUTOS ONLY X AUTOS 01/01/2023 01/01/2024 BODILY INJURY(Per accident) $ X HIRED v NON-OWNED PROPERTY DAMAGE AUTOS ONLY /� AUTOS ONLY (Per accident) $ X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS-MADE 462008968604 01/01/2023 01/01/2024 AGGREGATE $ 5,000,000 DED X RETENTION$ 10,000 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER _ ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Pollution B CSP4223638 01/01/2023 01/01/2025 Aggregate $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional 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 Oceanside Inc ACCORDANCE WITH THE POLICY PROVISIONS. 217 Thornton Drive AUTHORIZED REPRESENTATIVE Hyannis MA 02601 _.fi ry}\�.rIv/s 4ii . - ,..,, ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD DVm O Ill z 2 m Z 0 ?C m m m _N NZF9 Pa n0 b oo om rn 2 3 ZSD O^ 17z A `� ZD m0 rn DH. cm "r m = rn0. pm3-i � _, m 0z D o . � o co C n m C) 1ZIC C) y �cm 2 00 m Fe ; y 3 n p � r OWoz ''� ' , ,, , , ,„ . :„ ,. . 0= i ,:f i i„u., , , .s-. › w. °x � i eq, 1.II. i a k...,,,...-+, -...-" ,i.' 1 tw..,a) r- 32'0o O [1 CIl4, q li,,1 ��., i i{ a) I C Nu° c P r+w �i r 'i 5 T �7 a i : 1'Q a e „ °cct ., O CS (. a _ a 0 � y oy°° @ 0 � � CC/3 = o `D 0 �p f-1{1 .,al m a a o -I _ �, .g a ooc C 0 co c o w N�� SD rt to O N d A 7 0 3 O ® 0 e 3 El n d a Commonwealth of Massachusetts 3ani Division of Occupational Licensure Board of Building Regulations and Standards Coast (on IS rvisor CS-055571 v E';1pires:09/17/2024 STEVEN M TESSIER 18 DEE BEE!~IR MIDDLEBOROMA 02346 x 4)#.1,"4'8.2/-)30 Commissioner daeG 8'F� N w � o C ro rn co O ¢O O N BCD N f�-W•al.Q.. 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