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HomeMy WebLinkAboutBLDR-23-12831 pu de/4 ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department .,.....4"—.);- -__ -- 1146 Route 28, South Yarmouth,MA 02664-4492 R C E D 508-398-2231 ext. 1261 Fax 508-398-0836 (4' �'' . - .. Massachusetts State Building Code, 780 CMR ui ing Permit Application To Construct, Repair, Renovate Or Demolish s-i JUL Z 1 2023 a One-or Two Family Dwelling DEPAK I MLN I Bar-DING This Section For Official Use Only L.--2 _— """---` ing g Permit Number: j(J j 73—.12-3 I Date Applied: / Building Official(Print Name) Signa re Date SECTION 1:SITE INFORtMATION 1.1 Property Address: 1.2 Assessors Map &Parcel Numbers 2 S s.e-ru c�c>.T RD yacw� M RALI" 1.1 a Is this an accepted street?yes ( no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) (OD I 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,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: Outside Flood Zone? _ Public 0 Private 0 Check if yes❑ Municipal 0 On site disposal system 0 SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: x ?& Y,J/_EI.t.Pi ( K.I15 P %J�7 - 0 2_c- 9cT Name(Print) State,ZIP No.and Street ephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 1 Existing Building 0 Owner-Occupied V Repairs(s) 0 Alteration(s) 0 Addition ❑ Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work'`: (-( )Q *,ft-1-' (44 iL,ni'Oo rim SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 1. Building Permit Fee: $ 37Q Indicate how fee is determined: 0 Standard City/Town Application Fee 2.Electrical $ s 0 Total Project CostIte 6)x multi lien x 3.Plumbing $ 2. Other Fees: $ j IL 1 0\‘jr 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Total All Fees:$ Suppression) Q Check No. Check Amount: Cash Amount: 11 6.Total Project Cost: $ I 0 f C:G o .c C: 0 Paid in Full 0 Outstanding Balance Due: ,,5 a �o` SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) cs-1166�!6 do1�1.iaaas. (,J d La c T rn-3C License Number Expiration Date Name of CSL Holder List CSL Type(see below) (f 7t3 C-a p sT p 3 No.and Street ,• Type Description /j. a R r'IO UT 1—\ '.4. 03.693 �U) Unrestricted I 2 Family up tol 35,000 Cu.ft.) Restricted I&2 Family Dwelling City/Tobin,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances soR.3co al.j c a ci`M Ir -C.(6i-ktrr- ,L._ I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) aa1o15 Qal biz. HIC Registration Number Expiration Date ]IC Company Name or HIC Registrant Name No.and Street Email address (J ab.".0 . . 00 6cAL ,So 6e,51.10 City own, State,ZIP Telephone SECTION 6:WORKERS' COMPENSATION i NSURANCE 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 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 (i aL (j as)0 to act on my behalf, in all matters relative to work authorized by this building permit application. Print Owner's Nam (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. 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.Qov/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" The Commonwealth of Massachusetts sY L Department of Industrial Accidents —' 10 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. Applicant Information Please Print Legibly Name (Business/Organization/Individual): 1 C ✓ 5 le ,j /3 t� ! / . tr,t/ f ./10^ r 1 rArRaveAvtt;,r{, Address: q R N A a r) c i R C ( - C ,✓t r f2( l//l; v ? . Nt A City/State/Zip: p '1 3 'l Phone #: ie' j f/c q f/C Are you an employer?Check the appropriate box: Type of project(required): . I am a employer with employees(full and/or part-time)* 7. New construction 2.E I am a sole proprietor or partnership and have no employees working for me in 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 C. Demolition o 4. I am a homeowner and will be hiring contractors to conduct all work on my property. I will 1 C Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.C Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp. insurance.t 13. Roof repairs 6. We are a corporation and its officers have exercised their right of exemption per MGL c. 14•El 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. 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: Policy#or Self-ins.Lic. #: Expiration Date: Job Site Address: City/State/Zip: 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature:()06.1 P � Z.�_ Date: eAtt110,2©43 Phone#: sp e 3605110 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 of _y BUILDING DEPARTMENT nATTAG [ s[_� 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261 HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DALE,: JOB LOCA '.ON: NAME STREET ADDRESS SECTION OF TOWN "HOMROWNE " NAME HOME PHONE WORK PHONE PRESENT MAILLNik. ADDRESS CITY OR OWN STATE ZIP CODE The current exemption for ' •omeowner' was extended to include owner—occupied dwellings of one or two units and to allow such homeowner, to engage an individual for hire who does not possess a license,provided that such homeowner shall act as supervis,r. (State Building Code Section 110 R5.1.3.1) Definition of Homeowner: Person(s)who owns a parcel of land on , hich he/she resides or intends to reside,on which there is or is intended to be, a one or two family attached or detach:. structure assessory to such use and/or farm structures. A person who constructs more than one home in a two-yea •eriod shall not be considered a homeowner;such"homeowner"shall submit to the building official, on a form acce. .ble to the building official,that he/she shall be responsible for all such work perfoi wed under the building permit. Section 110 R5.1.3.1) The undersigned 'homeowner' assumes responsibil - for compliance with the State Building Code and other applicable codes, by-laws, rules and regulations. The undersigned 'homeowner' certifies that he / she unde tands the Town of Yarmouth Building Department minimum inspection procedures and requirements and that le / she will comply with said procedures and requirements. HOMEOWNER"S SIGNATURE ityltk . _ s, APPROVAL OF BUILDING OFFICIAL INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent, which neets the requirements of MGL Ch.142. Yes No If you have checked yes, please indicate the type coverage by checking the appropri.. e box. A liability insurance policy Other type of indemnity Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insur e coverage required by Chapter 142 of the Mass. General Laws and that my signature on this permit application way es this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent h:homeownrlicexemp 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 atcs1 .sUQ Ke7 RJ kakk.1.4,\CW-1-kPe ,RT Work Address Is to be disposed of at the following location: rkbv\Q;Ulvi..', JSSFt,S .L Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. Signature of Applicant Date Permit No. DATE(MM/DDNYYY) CERTIFICATE OF LIABILITY INSURANCE 07/20/23 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 CON1 ACT NAME: JIM HINDMAN PHE Schlegel &Schlegel Ins Brokers,Inc. (A/CON No,Ext): 508-771-8381 FAX No): 508-771-0663 34 Main Street E-MAIL West Yarmouth,MA 02673 ADDRESS: schlegelinsurance@gmail.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: NGM INSURANCE COMPANY 14788 INSURED INSURER B: HN CUSTOM BUILDING AND INSURER C: HOME IMPROVEMENT INC INSURER D: 39 OAK ST 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. ILICY EXP LT R I TYPE OF INSURANCE INSDADDL WVDR POLICY NUMBER MM/DD/YYYY) (MPOLICY EFF M/DDIYYYY) LIMITS LTR INSD WVD S X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 500,000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 A MPJ0249B 03/21/23 03/21/24 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER. A COMBINED SINGLE LIMIT AU LIABILITY $ (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 LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB �I CLAIMS-MADE AGGREGATE $ DED RETENTION$ 1 PR $ WORKERS COMPENSATION 1 STATUTE I I EERH AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE NIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ if yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 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 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 watlacimachado@hotmail.com ACCORDANCE WITH THE POLICY PROVISIONS. 29 SETUCKET ROAD YARMOUTHPORT MA 02675 AUTHORIZED REPRESENT E ©1 8 2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of/CORD ® Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Re ulations and Standards Cons inns s rvisor CS-116646 j pires: 12/29/2025 WALACI P MACHADO 193 CAMP STY APT J5 WEST YARMOUTH MA 02673 Commissioner ja THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE: Individual Registration Expiration 201015 02/22/2025 WALACI PEREIRA MACHADO WALACI MACHADO 193 CAMP ST APT J-5 WEST YARMOUTH,MA 02673 z/.10 Undersecretary Registration valid for individual use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 1000 Washington Street -Suite 710 Boston,MA 02118 7`" Not valid without signature