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HomeMy WebLinkAboutBLDR-23-12930- ONE & TWO FAMILY ONLY-BUILDING PERMIT Town of Yarmouth Building Department 1146 Route 28,South Yarmouth,MA 02664-4492 �._ Y 508-398-2231 ext. 126I Fax 508-398-0836 11N Massachusetts State Building Code,780 CMR • Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-FamilyDwelling This Section For Official Use Only G Building Permit Number: NIA_2 3 -1 Zr � Date A ed: C D BuildingOfficial I C 1 2 Y013 (Print Name) Signature L Date SECTION 1:SITE INFORMATIONI t BUILDING UCI'ARTMENT 1.1 Property Address: SS 09 1.2 Assessors Map&Parcel Numbers 1a3 ito I 11.1 a Is this an accepted street?yes k no Map Number Parcel Number 1.3 Zoning Information: ./ famiki 1.4 Prop tDimensions: r 0 Zoning District Prop Use Lot ArtaIt v '� (sq ) Frontage(ft) i 1.5 Building Setbacks(ft) Front Yard ! Side Yards Rear Yard Required I Provided Required 1 1 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 Lfl Private 0 Check if yes Municipal 0 On site disposal system Q!f SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'ofpRecord: 1/ v n� //!!Csri Ar, ')c�r•,r,c1 1 I Car 1 rr-t6 Jf-& �,r'� t-t/4 Name(Print) �' i S City,State,ZIP l No.and Street (1-16)1) l Icricho_ pee c"r� Ci Mta;I. (�a,+,. Telephone Email Address J SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction❑ I Existing Building 0 1 Owner-Occupied ❑ 1 Repairs(s) 0 I AIteration(s) ❑ I Addition Il Demolition 0 ( Accessory Bldg.0 ( Number of Units Other la Specify: Brief Description of Proposed Work"': .a 4 -ix ' a a d i E/c t c k E ; j i(.(,� E c re 28 r c rc. e <x (t' /7 t' > cw. d SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and Materials) Official Use Only 1.Building $ a 56t 6 67). 1. Building Permit Fee:SC, C. Indicate how fee is determined: 0Standard CitylTowrt Application Fee 2.Electrical $ 36 3 plumbing $ ' 0 Total Project Cost3(Item 6)x multiplier x C G — 2. Other Fees: $ p 60 4.Mechanical (HVAC) $ 5I) er?rJ — List: 5.Mechanical (Fire I Suppression) $ Total All Fees:$ 6.Total Project Cost: S �Ll G� . _ Check No. Check Amount: Cash Amount: / 0 Paid in Full 0 Outstanding Balance Due: 1--7 P Bii/oi 2./ e 6 O! i I, el) In SECTIONS: CONSTRUCTION SERVICES 5.1/Construction Supervisor License(CSL) CS Name of CSL Holder /� License Number Expiration Date d r'c< h/;2 di C,�a,�.•' List CSL Type(see below) Noo.and Sire t Type .�/ Description [i/ `a r 2�("'I, ) 6 E!r U Unrestricted :uildin__ u. to 35,000 cu.City/Town, ft.State,ZIP Restricted I&2 pamil Dwain_ Maw' • Nam= Roofino Coverin WS Window and Sidin Cj 3 `/-! kc r t s le Maya "40 a s Elimin Solid Fuel Burning Appliances Telephone—' F.htail address elation 5.2 Registered Home Improvement Contractor D Demolition 7�bn� s K / ��) /85Y56 ti ar , HIC Co pa p�I�IC�Rlscr�n.N a HIC Registration Number Expiration Date N rL d s C, / 7�'an greet ae .lent- yd(_� et,kedst re{' , rk 0. .L' AV a 6 s t F s'U%-//9/ Email address Ci /Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.IS?§ 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? y es No p SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,as Owner of the subject property,hereby authorize A 6 Atej S A `Je J to act on my behalf, all matters rela've to work a orized by this building permit a lication./ rim Owner's Name(Electronic Signature �( o, Date • SECTION 7b: OWNER/OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of contain ' this application is true and accurate to the best of my knowledge and underury that all of standing. information CAfkom,, g . 6,,H4s,, Print Owner's or Authorized A is �� J Name(Electronic Signature) Date 1• An Owner who obtains a building NOTES: 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 w'w'w.mass•sov/oca Information on the Construction Supervisor License can be found at ww_w.mass.00y/dns 2. When substantial work i� ed,provide the information below: Total floor area(sq.ft.) Q (including Gross living area(sq.ft) —--- garage,finished basement/attics,decks or porch) 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" N The Commonwealth -' mon wealth of 11 r ��J, Massachusetts .�;;$j; Department of fndustrialAccidents ::r^.� 1 Congress Street, Smite 100 - f' Boston,MA 02114-2017 r„- www.tnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant Information Name(Business/Organization/Individual): !lc xt4 e Please Print Le ibt 1�erJ Address: 75 ,N,r,K¢/ k:`�n/-5 (,)ti r City/State/Zip:11• 1 rk,''f-�t(e MiC Q'2 6 6 Phone : (5 z S " %`� i 1 Are you an employer?Check the appropriate box. Type of project(required): LEI!am a employer with 7 -------employees(foil and/or pan-time).. 2_O 1 am a sole proprietor or partnership and have no employees working for me in 7. New Jelin construction any capacity.No workers'comp. insurance required.] 3.0 I am a homeowner doing all work myself.[No 8. ❑Remodeling . workers'comp. insurance required)r 9. ❑ Demolition 4 1 am a homeowner and will be hiring contractors to conduct all work on my property. I will ,/ ensure that all contractors either have 10 El/Building Building addition proprietors with no employees. workers'compensation insurance or are sole °yam- 11.[�Electrical repairs or additions 5-D 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.0 Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.t 13.0 Roof repairs 6.Q We are a corporation and its officers have exercised their right of exemption per,�IGL c. 152,§1(4),and we have no employees.(No workers'comp.insurance required.) 1 Other *Any applicant that checks box 114 I must also fill out the section below showing their workers'core t Homeow who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating tConcractors that check this box must a compensation policy information. attached an additional sheer showing the w game of the sub-contractors number. and state whether or not those entities have employees. !ELM sub-contractors have employees,they mast provide their workers'comp.policy number, such I am an employer that is providing workers'compensation izzsrtranceor information. �}' •f my employees. Below is the policy and job site Insurance Company Name: 5 s e C 7-?F� �T C�k fit" t�� ,t5-,;,-a (cc o, f� Policy or Self-ins. Lie.#: 14 c C 5-t17) 5-6)/6,3'// d d?3 11 Expiration Date: i' °I) a Job Site Address: 3 0 9 i<E_ c A Attach a copy of the workers' compensation policy declaration page(showing theta City/State/Zip: 4 r$4 67)( � t rf 4114 f-) Failure to secure coverage as required under MGL c. 152 2�A is a criminal violation punishable by a fine up to$1,500.00 p Y number and expiration date) and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine day against the violator.A copy coverage verification. of this statement may be forwarded to the Office of investigations of the D1A for insuranflce a 1 do • `j ,J i,taer Ike pains and penalties of perjury that Me information provided above is true and correct Signature: Phone T: S ( `f _. c/ Date: 14)s a 3 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License ig Issuing Authorit y(circle one): 1. Board of Health 2. Building 6. Other 5 Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector Contact Person: Phone#: TOWN OF WN/1(4'"Fli 1146 Route 28 South Yarmouth MA 02664 508398-2231 ext 1261 Fax 508-398-0836 Office of the Building Com missioner 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 36 / ñ . , ros-1-(111/4 PY Work Address <'- rPL-Orta4 Is to be disposed of at the following location: Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. Signature of Appli nt Date Permit No. 9/24/23,7:25 PM IMG_0890.jpg b w���'e, &,,Wr�I _�,- ` "' r am :ig-,..., --4-,,i,w'r • ;kt ,,,:.v,:..,-...-op-k''' 40:19-, � �• ., x� 7f . 7 k� ya '9 � ,4t 7 f 3j y'°� � " � lk w ' " y se � � , f "' :k� ^{ r- f � +ks 's '' . � ,m, --,.- � �s _ �i � *.,,,,,,ld,. <. :.. u , � • d - $�� ' eAkt,ta fit• IL*'''PAL-A;445*tt, g‘ : ,“' V-"hri 0 C 4,0, LI oi ?.. trio4. *-4,.1*z:4m } - M. -el Imo - P'j k�i3+ rn � � �,sr + NI O 3 of w , C ,:;:s V,41.-0:4,,,,is ":::::-ss: s:: ,,ss-_:,--,:so-sc„;_ssOss? .s :; 7....) x g Uf,FY i b r 4 kY .qa '� Y'm 4 • �6 +' F i I , ? +� - 4 O hops://mail.google.com/mail/u/0/?tab=rm&ogbl&zx=frj2xm890xoe#inbox/QgrcJHrnmFXHwvhSfMcbVQbCjmrvxKhBXL?projector=1&messagePartld=0.2 1/1 9/24/23,7:25 PM IMG_0889.jpg m.,Ew` 'NJ r..l 3 Sl '3=`ei.'f''r" .-- "2 ro�'Alf-ti �4 Ctt 0 0 '; , �-1 "`i C te -,' `.` z �ry f/j >. ice ' -% • •,,: 441gt?'7:,.:1 -...-,0 ,..4.,.,... 0 co,' 40, , 2 S '� i° !. Q'. C r, ry r, - _ vu^" 1 N '▪���'C-*mot f `4 a^ �Iayyi� ram,.' FCry^' #♦ 3'��'',,fy{yµ i�uf�y{`+c ' A. °f n}`� yin'� ` €1 f " 440. C a&`, .,^mot+ 4, - r▪ '' � a` ,:k_ • `_ - tiMit §, • f �� -"�-0 r a.s "r Y 3'tigo ,fir 1 3' _y'' 0*�, : , ar : ,, + ' y', z !'i f https://mail.google.com/mail/u/0/?tab=rm&ogbl&zx=frj2xm890xoe#inbox/QgrcJHrnmFXHwvhSfMcbVQbCjmrvxKhBXL?projector=l&messagePartld=0.1 1/1 a1/40...t�RD® CERTIFICATE OF LIABILITY INSURANCEDATE(MMIDDJYYY1� THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.TH S 13/2023 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 Agency Accounts Cross Insurance-Wakefield NAME: PHONE (781)914-1000 FAX 401 Edgewater Place Suite 100 �°/ ENO: I(ac,No): (781)224-5777 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Wakefield MA 01880 INSURED INSURER A: Green Mountain Ins Co 20680 Thomas Demayo INSURER B: Associated Employers Insurance Company 95 N Winds Ln INSURER C INSURER D: INSURER E: West Barnstable MA 02668-1352 INSURER F: COVERAGES CERTIFICATE NUMBER: Updated 22/23 Master THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED A OE EIFORrTHE 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 ADUL LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF POLICY EXP X COMMERCIAL GENERAL LIABILITY DDiYYYY) (A�Vppryyyy) LIMITS IEACH OCCURRENCE $ 1,000,QO0 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ A MED EXP(Any one person) $ 5,000 20039842 12/31/2022 12/31/2023 GEN'LAGGREGATELIMITAPPLIESPER: PERSONAL&ADVINJURY $ I PRO- GENERAL AGGREGATE $ 2,000,0 POLICY 00 I 12s- I I LOC OTHER: PRODUCTS-COMP/OP AGG $ 2,000,000 AUTOMOBILE LIABILITY Umbrella(C) $ 1,000,000 COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) OWNED SCHEDULED BODILY INJURY(Per person) $ AUTOS ONLY ,_, AUTOS _ HIRED NON-OWNED '• - $ DAMAGE AUTOS ONLY AUTOS ONLY PROPERTY Per accident $ UMBRELLA LIAB $ ill OCCUR A EXCESS LIAB 20039842EACH OCCURRENCE $ CLAIMS-MADE 12/31/2022 12/31/2023 DED I I RETENTION$ AGGREGATE $ WORKERS COMPENSATION $ OTH- AND EMPLOYERS'LIABILITY r ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N XI STATUTE 1 ,ER B OFFICER/MEMBER EXCLUDED? I I N/A WCC5005016341-2023A E-L.EACH ACCIDENT 500,000 (Mandatory in NH) 08/22/2023 08/22/2024 $ (yes,describe under E.L.DISEASE-EA EMPLOYEE $ 500,000 — DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if 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 Town of Yarmouth,Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 �/� ;-y ACORD 25(2016/03) The ACORD name and logo are registered marks©1988- 015 ACORD CORPORATION. All rights reserved.