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HomeMy WebLinkAboutBLDC-23-14 (2) ' , -1to GW6C/../(1-elki- ile-(--- ./lie- :of YaR BUILDING PERMIT APPLICATION •; �'�� APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE, OCCUPANCY OF, 0 _C OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING. y. Town of Yarmouth Building Department M4TTChl7 4• b�F'..-•.1••*GO'• 1 146 Route 28 • Yarmouth, MA 02664-1492 Tel: 508-398-2231 ext. 1261 Fax 508-398-0836 - /3/ �� Off Dnfy Planning Board Information Assessors Department Information: Permit No, I C1! Date Plan Type Map Lot Permit Fee ,�U Endorsement Date -/$ �� Recording Date New Deposit Rec'd. $, Date• Plan Na. 1.4 Property Dimensions: Net Due $ ft. other Lot Area(sf) Frontage(Planning Lot Coverage Building Permit Number: This Section for Office Use Only Date Issued: c; Certificate of Occupancy. Signature: ✓���,z 6 - j P cy. Building Official Date is Is not° • _i =i { Section 1 - Site Information j; - /1.1 Property Address: l.2 Zoning Information:_ `MAY `�5 ZUZ3 O o ie 4 inr ait1 54c-ej- E3uILDINiG r 'ME, . Zoning District , ''Y _...Proposed Use . . 1.3 Building Setbacks(ft) • � s. Front Yard Side Yards Rear Yard Required Provided Required ( Provided Required Provided 1.4 Water Supply(IA.Q.L c.40.S 54) 1.5 Flood Zone Information: Comments Public Private Zone: BFE Section 2 - Property Ownership/Authorized Agent 2.1 Owner of Record: d eCc ik.)ebk. Snce, 5 Og co (\ J n Name(print) Mailing Address: Signature Telephone Telephone / Email Address: 2.2 Authorized Agent: ,/' 5n. P ‘'\ C`n` -c I Lea.I nikert \S' Name (print) Mailing Address: ketst°t-\_ 14 ,346 —0S-1L13- 636° Signature Telephone Fax Email Address i Section 3 - Construction Services , 3.1 LI •need Construction Supervisor: Not Applicable D / . ckse,'' rY\J40 Li J'GL ee%l License Number i(ram t C)"� � 00, o�[ - Address ✓J.5��7 !� �• C -I n cl oa it_ Wvly ,� 6 - / /S--d3(ap j/ Expirationra Date Signature Telephone Email Address: SECTION 10b OWNER/AUTHORIZED AGENT DECLARATION , as Owner/Authorized Agent hereby declare that the statements and information on the forgoing application are true and acurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. • Print Name Signature of Owner/Agent Date Section 11 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be completed by permit applicant 1.Building 2.Electrical 3.Plumbing/Gas 4.Mechanical(HVAC) 5.Fire Protection / 5.Total=(1+2+3+4+5) " 7.Total Square Ft.(tornew seM1Ufes&add bore) 14S", o-0 Check Below ❑ Conservation-Commission Filing (if applicable) ❑ Old Kings Highway&Historical Commission approval (if applicable) • SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-109029 10/22/24 Jasen Muto License Number Expiration Date Name of CSL Holder 1621 Orleans Road List CSL Type(see below) U No.and Street Type Description Harwich MA 02645 U Unrestricted(Buildings up to 35,000 cu.ft.) City/Town,State,ZIP R Restricted 1&2 Family Dwelling Iv1 Masonry RC Roofing Covering • WS Window and Siding 508-945-0300 Jasenmutoconstruction@gmail.com SF Solid Fuel Burning Appliances Insulation Telephone Email address D Demolition , 5.2 Registered Home Improvement Contractor CHIC) Jasen Muto 183111 08/27/2023 HIC Company Nu or HIC Registrant Name HIC Registration Number Expiration Date 1621 Oprleans toad Jasenmutoconstruction@gmail.com No.and Street Harwich MA 02645 508-945-0300 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 9✓ 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 to act on my behalf,in all matters relative to work authorized by this building permit application. 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 applic to is true and accurate to the best of ray latowledge and understanding. 05/25/23 Print Owner's or Authori 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 nor 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 Tnformation on the Construction Supervisor License can be found at www.mass.gov/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" CLIENT Authorized Signature WO/ Jeffery Watson 6bc57212-671e-4cf6-a950-b5c... 04/24/2023 Name Jeffery Watson CONTRACTOR Representative Authorized Signature License Number: MA HIC# 183111 CSL Number: CS-109029 ia Digitally signed with JobNimbus. Document ID:7C1EB1A1-6302-470E-9A99-C8D11515E275 Page 4 of 5 Office of Consumer Affirs& HOME IMPROVEMENT CONTRACTOR TYPE:Corporation Registratiq, Expiration 183111 08/27/2023 4" MUTO INC. JASEN MUTO 1621 ORLEANS RD. • HARWICH.MA 02645 Undersecretary ' oft mr Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Regulations and Standards Constolt461 SIe,rvisor 4 CS-109029 etyires: 10/22/2024 JASEN MUTC; 1621 ORLEAiiS ROAD HARWICH MA 02645 •' , - i'ommissioner f, `,.. The Commonwealth of Massachusetts Department of Industrial Accidents T4,.7' Office of Investigations (7., :- Lafayette City Center � r 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): Muto, Inc Address: 1621 Orleans Road City/State/Zip: Harwich, MA 02645 Phone #: 508-945-0300 Are you an employer? Check the appropriate box: Type of project(required): 1.❑■ I am a employer with 10 4. ❑ I am a general contractor and I 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. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.* required.] 5. ❑ We are a corporation and its 10.n Electrical repairs or additions 3.n I am a homeowner doing all work officers have exercised their 11.❑ 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' 13.❑ Other 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. 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: Associated Employers Insurance Agency Policy# or Self-ins. Lic. #:WCC50050071002023A Expiration Date: 04/25/2024 Job Site Address: 308 Old Main Street City/State/Zip: S. Yarmouth MA 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 certify under pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 05/25/23 Phone#: 508-945-030 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): I—I 10Board of Health 20 Building Department 3L.�City/Town Clerk 4.0 Electrical Inspector 5Ellumbing Inspector 6.❑Other Contact Person: Phone#: ® DATE(MM/DD/YYYY) A R o CERTIFICATE OF LIABILITY INSURANCE 4/24/2023 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 NAME: RogersGray, Inc.-Kingston Branch PHONE FAX 63 Smith Lane (A/c,No,Ext): 508-746-3311 (A/C,No):877-816-2156 Kingston MA 02364 E-MAIL ADDRESS: g g y ADDRESS: mail r0 t3rS ra COm INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Arbella Protection 41360 INSURED MUTOINC-01 INSURER B:Associated Employers Insurance 11104 Muto Inc. and Jasen G. Muto 1621 Orleans Rd INSURER c:Selective Insurance Co of the 39926 Harwich MA 02645 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1058166753 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 i POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDD/YYYY) (MM/DD/YYYY) LIMITS C X COMMERCIAL GENERAL LIABILITY Y Y S 2207035 4/25/2023 4/25/2024 EACH OCCURRENCE $1,000,000 DAMAGE RENTED X PREM SESO CLAIMS-MADE OCCUR (Ea occurrence) $500,000 MED EXP(Any one person) $15,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $3,000,000 OTHER: A AUTOMOBILE LIABILITY N N 1020067250 9/22/2022 9/22/2023 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED y X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ C I X UMBRELLA LIAB X OCCUR Y N S 2207035 4/25/2023 4/25/2024 EACH OCCURRENCE $1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $1,000,000 DED RETENTION$ $ STATUTE g WORKERS COMPENSATION N WCC50050071002023A 4/25/2023 4/25/2024 X OTH- ER AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE N N/A E.L.EACH ACCIDENT $500,000 OFFICER/MEMBEREXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) When Required by Written Contract the Following Applies: General Liability—Additional Insured Ongoing(CG 7300 01/19)and Completed Operation(CG 7921 01/19) Primary and Non-Contributory Basis(CG 7300 01/19),Waiver of Subrogation(CG 7300 01/19) Excess/Umbrella—Additional insured follows form over underlying General Liability and Automobile Liability 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. For Insurance Purposes Only AU .•: ED REPRESENTATIVE 't" „ , 1 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-22311 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 308 Old Main St. South Yarmouth MA conducted at Work Address Is to be disposed of oat the following location: S+J Exco 200 Great Western Rd Dennis MA Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. 05/25/23 Signatur of Application Date Permit No. ij it N JI - - -_ J it IStaunri a ¢¢ : i anis t, t� �-- FRA '\ !+ .f < s:^, om i��,. ar 1 • 4 1::14i/11,1: '1:1:1' i. L r 44 `,,- �g i • Section 6 - Description of Proposed Work(check all applicable) ' New Construction ❑ (for multiple family only) No.of Bedrooms (for multiple family only) No.of Bathrooms Existing Bldg. ❑ f Repair(s) ❑ I Alterations ❑ Addition ❑ f Accessory Bldg. ❑ Type I Demolition I l Other Specify: P fy: Brief Description of Proposed Work: f1 .� lil(14 CZiP ,A-c2.+ C`BS( LA.) ;4-hor1 � ��Gt t'1►'2 CC��1r1'a00 b(��S J Section 7- Use Group and Construction Type I Building Use Group (Check as applicapable) Construction Type A ASSEMBLY ❑ A-1 ❑ A-2 ❑ A-3 ❑ IA ❑ A-4 ❑ A-5 ❑ 1 B ❑ B BUSINESS ❑ 2A ❑ E EDUCATIONAL ❑ ❑ F FACTORY ❑ F-1 ❑ F-2 ❑ 2C ❑ I-I HIGH HAZARD ❑ 3A ❑ I INSTITUTIONAL ❑ I-1 ❑ 1-2 ❑ I.3 ❑ 38 ❑ M MERCHANTILE ❑ 4 ❑ R RESIDENTIAL ❑ R-1 ❑ R-2 D R-3 ❑ SA l3 S STORAGE ❑ S-1 ❑ 3-2 ❑ 58 ❑ U UTILITY ❑ SPECIFY: • M MIXED USE ❑ SPECIFY: S SPECIAL USE ❑ _ SPECIFY: Complete this.section if existing building undergoing renovations;additions and/or change id use. Existing Use Group: Proposed Use Group: Existing Hazard Index 780 DMA 34 Proposed Hazard Index 7E10 CMR 34 Section 8 Building Height and Area Building Area Existing(if applicable) Proposed Number of floors or stories include basement levels Floor Area per Floor(sf) Total Area All Floors (sf) Total Height (ft) Section 9 - STRUCTURAL PEER REVIEW (780CMR 110 11) Independent Structural Engineering Structural Peer Review Required Yes No SECTION 10a 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. S ee a c 1 Signature of Owner Date 3.2 Registered Home Improvement Contractor. ' ' Company Name Not Applicable ❑ . Address Regi 3 I is�tion`Lmbgr (� C� �lJ ‘ U( lQ cix 3 QC4 Expiration D.te Signature 45P tAt) Telephone S( 11f S-63 0 0 (Ala-) a3 Section 4-Workers' Compensation Insurance Affidavit(M.G.L c. 152 S 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 Section 5- Professional Design and Construction Services-for Buildings and Structures Subject to Construction Control Pursuant to 780 CMR 116(containing more than 35,000 c.f. of enclosed space) Section 5.1 Registered Architect: Not Applicable ❑ Name (Registrant): Registration Number Address Expiration Date Signature Telephone Section 5.2 Registered Professional Engineer(s) Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name • Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Section 5.3 General Contractor Not Applicable ❑ Company Name Person Responsible for Construction Address Signature Telephone