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HomeMy WebLinkAboutBLDR-23-13048 1 RECEIVED --------- - E & TWO FAMILY ONLY- BUILDING PERMIT DECO 4 2023 Town of Yarmouth Building Department /oF r 1146 Route 28, South Yarmouth,MA 02664-4492 / 508-398-2231 ext. 1261 Fax 508-398-0836 �i,;;: BUILDING DEPARTMENT Massachusetts State Building Code, 780 CMR ar. Building Permit Application To Construct, Repair, Renovate Or Demolish' a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: nj(DR-.23'13 �' Date Applied: Building72a1)-- Official nt Name Date (P ) Mature ON :SITE INFORMATION /1/1 ProLpeerrtyy Address: q7 7-no 1.2 Assessors Map&Parcel Numbers 1/ 1.1 a Is tt is an accepted street?ee yes 7/ no Map Number Parcel Number 0 1.3 Zoning Information: 1.4 Property Dimensions: \(:):>.1 Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 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' 2.1nOwnr' Re rd: 4 de �e4� pi, ,. i /he � ! ne/ e(Print)c City,Statee,:ZIP ( t& eL C.� e 0 �--,- DfS iio -e3',)- R c. Q4t 0 b es 71 No.and Street Telephone Email Address G met i•k„.4 SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: �y Brief Description of P�ropos-��ork2: ,,,,A* t 0 I 6�5 feats . ? Z' evA, i _ 4 4_ CL-at�C( _ _ V .1 ,. .J P,INFR ZA e ' - ,"'lr0. �� ' SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined: 0 Standard City/Town Application Fee ��/ 2.Electrical $ a 0 Total Project Cost (Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 35- C - 1 IS-6-3-- 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: fit.5 6.Total Project Cost: 0 a Ui DOD 0 Paid in Full ❑ Outstanding Balance Due: 50 .-264--/ / . .( . S(7&24097IS-1e, V2_,wA) IX. cvm , SECTION 5: CONSTRUCTION SERVICES 1 a 5.1 Construction Supervisor License(CSL) Ca) 2 r-r-i 1 4a47 4c /a,'i License Number Expiration Date i/ me L Holder • 'J ` . 9 R 1 List CSL Type(see below) No.and Street A Type Description C-e,otceit p A ;4 e U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted I&2 Family Dwelling City/Town,State,ZIP M Masonry S J ers1—#4 /�/` Ct�� RC Roofing Covering i�'�J WS Window and Siding � �� �y1 /e.,(C n SF Solid Fuel Burning Appliances 66 I Insulation Telephone Email address D Demolition 5.2Registered Home Improvement Contractor(HIC)/ Ct 6,01dilko HIC R g I Jistration Number Ex it � tion Data / HIC om N gr any e or HIC t N p Nq,.and Street Aert at, 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 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 to act on my behalf, in all matters relative to work authorized by this building permit application. . _ l e,-l-I-' - '- 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. 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.eov/oca Information 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" ^-- The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 LIP Boston, MA 021I4-2017 ,;,,�•`'� 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): /t/6 is f e4 V/ Address: 4, Celce City/State/Zip: Sjaviet-st yYta. Phone #: SOS` 0Z6 9' 7 / Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).*t 7. ❑New construction 2 I am a sole proprietor or partnership and have no employees working for me in 8. Remodelin • any capacity.[No workers'comp. insurance required.] g � 3. I am a homeowner doing all work myself [No workers'comp. insurance required.]t 9 E Demolition 4. I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 n Building addition ensure that all contractors either have workers'compensation insurance or are sole 11. Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.0 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. 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. r 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: rrn /' 1. (Jn`T d C�/ 02© Policy#or Self-ins.Lic.#: C SO �Q( 6 Q '5'Expiration Date: // a2d, p2 Job Site Address: /`5 / l ioV/ r 4CJ' City/State/Zip: &!t V-® Attach a copy of the worker' 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 certjfy under the pains and penalties of perjury that the information provided above is true and correct. / Signature: Date: CAI -� 3 Date: / Phone T: 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 V 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 prop sed work/demolition to be conducted at p-'s 4 r/4(he 9 W rk Address Is to be disposed of at the following location: N E,f D4 90. Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. ii , 44 / 4 Q t- Sig re of Applicant Date Permit No. 1 Fallon, Rosa From: Rachel Rhodes <rcrhodes71@gmail.com> Sent: Monday, December 4, 2023 12:15 PM To: Fallon, Rosa Subject: 15 Lyndale Road, South Yarmouth, MA 02664 Attention!:This email originates outside of the organization. Do not open attachments or click links unless you are sure this email is from a known sender and you know the content is safe. Call the sender to verify if unsure. Otherwise delete this email. Hi Rosa, This is a follow up to the conversation that we just had on the phone that related to Henry Narsasian's visit to your office this morning. Henry is the builder who is going to be doing renovations at the home I own in South Yarmouth. By virtue of this email, I hereby give Henry Narsasian permission to pull a permit on my behalf for the renovations at 15 Lyndale Road in South Yarmouth. Thank you very much for your assistance and have a great day. Sincerely Rachel Rhodes AC'a CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/27/2023 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 polioy(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). CONTACT Lori Kenyon PRODUCER NAME: Morse Insurance Agency,Inc. PHONE Ext): (508)238-0056 FA/c,No): (508)230-8367 (A/285 Washington Street ADDRILSS: lorikenyon@morseins.com INSURER(S)AFFORDING COVERAGE NAIC# North Easton MA 02356 INSURER A: Associated Employers Ins.Company INSURED INSURER B: Narsasian Construction Co,Inc. INSURER C: 6 Cedar Drive INSURER O: INSURER E: — South Easton MA 02375 INSURER F: . COVERAGES CERTIFICATE NUMBER: 23-24 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. NSR ADDL SUBR POLICY EFF POLICY EXP ILTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DDIYYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ _ MED EXP(Any one person) $ ._.1 PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER'. GENERAL AGGREGATE $ PRO- POLICY JECT LOC PRODUCTS-COMP/OPAGG $ OTHER. AUTOMOBILE LIABILITY 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 LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- X STATUTE ER AND EMPLOYERS'LIABILITY Y/N 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE Y NIA WCC5006604012023A 11/22/2023 11/22/2024 E.L.EACH $ ,__ A OFFICER/MEMBER EXCLUDED? SOO,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes.describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) RE:Rachel Croutz 15 Lindale Road,Yarmouth J 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. Town of Yarmouth 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 atJ.. 41f{,LJ{f}(» t .a ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Ili Commonwealth of Massachusetts ' Division of Occupational Licensure d Boaol of Building Re ullations and Standards Cons Svlsor CS-035727 I * pires:0412512024 HENRY PNA S ' w 6 CEDAR DRA i I, S EASTON 14 0 0 • • 1b`�'pI Ldi1 �+ 3--N3 Commissioner dia11 K. blEoi i`°`" 1 ,r ■ as �a:: �; i ' y, j 3 6.66, r y HIC Registration Complaints Registration # 112152 Registrant NARSASIAN CONSTRUCTION CO., INC. Name HENRY NARSASIAN Address 6 CEDAR DR City, State Zip S. EASTON, MA 02375 Expiration Date 04/20/2025 Complaints Details No complaints found for this registrant. You can also view arbitration and Guaranty Fund history. Back To Search Site Policies Contact Us CO 2018 Commonwealth of Massachusetts. 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