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HomeMy WebLinkAboutBLDR-24-66 ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department 1146 Route 28, South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508-398-0836 Massachusetts State Building Code,780 CMR e Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling is Section For Official Use Only Building Permit Number: `p Date Applied: . 29/Buil ' g Oi ial int Name) Signat<tte Date SECTION 1:SITE INFORMATION 1.1 Propert Address: 0 1.2 Assessors Map&Parcel Numbers 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) 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: 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 d cor a ct s �;l�frs�e GG-C Name Pint) City,State, rnrA-\ a t Sep , rho 77`' i iy Itiomf -osAdVicrtnic,i.Cc•v, No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK''(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied ❑ Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other ❑ Specify: Brief Description of Proposed Work2: RtiL,'Ickg cube RQ sae15 Bv•'(o�i`�'/ti IR-e p1cir_1r,ct (:.his- -,'rl 2 de cic$ J --/U f /L/2 SECTION 4: ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: (Labor and Materials) Official Use Only 1.Building $ c, 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ G 0 Standard City/Town Application Fee 0 Total Project Cost3(te 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire / Suppression) $ Total All Fees:$ L. Check No. Check Amount: Cash Amount: 6.Total Project Cost: t b0 b — 0 Paid in Full 0 Outstanding Balance Due: (Noizkb\a . w//& 7L fIcA, 0(4 C • SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) ( ® ( ia%), a 1 1 2 it© ....._ CL is4 C' P/ , Iv?, License umber Expiration Date Name of�SL Holder / r/ ����/��n� ,[ List CSL Type(see below) U No.and Street Type Description l C 1�/ '?� U Unrestricted(Buildings up to 35,000 Cu.ft.) City/Town,State c- (//J R Restricted 1&2 Family Dwelling M Masonry RC Roofing Covering _ Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) ( 6 '/3// l 4 Pi.S IG 6' r. �r, HIC Registration Number Expiration Date HIC Company Nair&or HIC Regis rant Nank 4 No.andSt eet C°pU'4- Fitt \ G g 6 35 774(ra3a lac, ff 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 Issu,4rce of the building permit. Signed Affidavit Attached? Yes till No ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR PLIES FOR BUILDING PERMIT I, as Owner of the subject property,hereby authorize to act on my behalf, in all matters relative to work authori ed by this building permit application. 1 � Rr Dni ti sin/4 Print Owner's Name(Electronic Signature) ate 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 ' r ation is true and accurate to the best of my knowledge and understanding. t. uthorized Agent's Name(Electronic Signature) O 7 9 00.1iDat 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.cov/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" *1d� The Commonwealth of Massachusetts 1= Department of lndccstrialAcciderzts �V. ' `; 1 Congress Street, Suite 100 Boston, MA 02114-2017 Nue s• www.mass.gov/dig Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant Information Name (Business/Organization/Individual): G er- C 77/r Please Print Le ibl rl Address: f 2 -cc .et t City/State/Zip: C'crk, f' plc, C , VIMMINmEmIL Phone #: y - -/G-(� Are you an employer?Check the appropriate box: I.[[ a employer with Type of project(required): employees(full and/or part-time).* Ei 2. am a sole proprietor or partnership and have no employees working for me in 7. New construction any capacity.{No workers'comp. insurance required.] 8. [ Remodeling 9. ❑Demolition 3.[I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 4.E I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurancew or are sole 10 [ Building addition 11.[ Electrical repairs or additions roprietors with no employees. S. I am a general contractor and I have hired the sub-contractors listed on the attached 12.[Plumbing repairs or additions These sub contractors have employees and have workers'comp. insurance.t `led sheet. 13.El Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees. [No workers'comp.insurance required.] 1�'©Other ��•j� *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 1Contractors 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. such. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: •'ur e j 1 Policy/.-' or Self-ins.Lic.#: PU l U Expiration Date: Job Site Address: Lit) Cv ¢G U vit92/4 l s-S_G„a3 33 Attach a copy of the workers' compensation policy declaration page(showing thetate/Zip:policy number City/St expiratio 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 ains.and penalties of perjury that the information provided abo e is true and correct. /Signature• ✓ Phone#: Date: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Issuing Authority(circle one): Permit/License# • 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing 6. Other b Inspector Contact Person: Phone#: :YAR _ TOWN OF YAR MOUTH BUILDING DEPARTMENT a�'` MATTACMECSE �Q4 1146 Route 28, South Yarmouth, MA 02664 S08-398-2231 ext. 1261 HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DA'1 E: JOB LOCATION: 114/0 &7 5 Y C/f4 got-- NAME STREET ADDRESS SECTION OF TOWN "HOMFO' R" NAME HOME PHONE WORK PHONE PRESENT MA' NG ADDRESS C OR TOWN STATE ZIP CODE The current exemption or `Homeowner' was extended to include owner—occupied dwellings of one or two units and to allow such homeo. ners to engage an individual for hire who does not possess a license,provided that such homeowner shall act as sup. visor. (State Building Code Section 110 R5.1.3.1) Definition of Homeowner: Person(s) who owns a parcel of lane on which he/she resides or intends to reside,on which there is or is intended to be, a one or two family attached or de -ched structure assessory to such use and/or farm structures. A person who constructs more than one home in a two- ear period shall not be considered a homeowner;such"homeowner"shall submit to the building official, on a form a. eptable to the building official,that he/she shall be responsible for all such work performed under the building pe It. (Section 110 R5.1.3.1) The undersigned `homeowner' assumes respon 'bility for compliance with the State Building Code and other applicable codes, by-laws, rules and regulations. The undersigned 'homeowner' certifies that he / she Iderstands the Town of Yarmouth Building Department minimum inspection procedures and requirements and hat he / she will comply with said procedures and requirements. HOMEOWNER"S SIGNATURE APPROVAL OF BUILDING OFFICIAL INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent, w'ich meets the requirements of MGL Ch.142. Yes No If you have checked ves, please indicate the type coverage by checking the app opriate box. A liability insurance policy Other type of indemnity B. d OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the • surance coverage required by Chapter 142 of the Mass. General Laws and that my signature on this permit applicat'on waives 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 at , s / 'to t,✓-e5f rai/mocitA P: Work Address Is to be disposed of at the following location: To Vf.$' Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. 9-4J Signature of Applicant Date Permit No. """"'N MASTBUI-01 KCALFEE '41`1Cr CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/28/2023 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: Davidson Calfee Arthur D.Calfee Insurance Agency, Inc. PHONE FAX 336 Gifford Street (A/C,No,Ext):(508)540-2601 I(A/C,No):(508)457-1715 Falmouth, MA 02640 E-MAIL ADDRESS:info@calfeeinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Chubb 10052 INSURED INSURER B: Master Builder Pro Inc INSURER C: 49 Long Plain Rd INSURER D: Mattapoisett, MA 02739 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD /MM/DD/YYYYI (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO PREMISES Ea occu RENTED $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ _ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED _ AUTOS ONLY AUTOS BODILY INJURY(Per accident)_ $ AUTOS ONLY NON-OWNEDO N (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE 6S62UB-7H71366-6-23 10/6/2023 10/6/2024 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N N/A (Mandatory in NH) 1,000,000 E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 1,000,000 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) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Polhemus DaSilva Architects Builders THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Savery ACCORDANCE WITH THE POLICY PROVISIONS. 167 Route 137 East Harwich,MA 02646 AUTHORIZED REPR DA0Td((igned by: HC b bdF ACORD 26(2016/03) ©1988-2 a Ot C)CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD A:1-3 • ,,,,, - 7,1:ri:,:I.] et-R':* 0 ti ''N It 1K.iff,0 6M180 il.ti 81 .a.3 pi m. c.pliK ',..., ,..4 0 .g ..5,0 r...,...a frim 0,.0 02 t:o:E • i.<feg. wy :.w a e,-.-'? 83 •• 0 ea. ,?: _ . PR ' ..:. 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Vir - • -- 4 • " ' 4 OA* 1"' ...A 4. it.ir A ' '-• 441", 1 f 'fr 6' ; .4 - - ''. s 4 ' _ e a - 41s,' :A 4,f(,I',,!ir,',')'1i1t', i,r.,,,,,t it•q.-..-A ,,t•[,j-1 . 0th1. 0411. , ';i-°•-- , , . it, I X �4zC tomAP "b:1 I • t , , o. 0 :4 irlee'l u �' {' ., tor—. yA pY y A � , oOl + i ' • x° 1` � `x ro eo i :i � � • 1 14'ti Aar1e it E i ,nuy� } +. T. ojj :1� ' 4 `• '' TIs 1 � • +S , ,l� � ' . � `' , t Fit' •!d` d F". ` t .�1C • C ;7: r t 1 , • • {till - .I tet , - • •Ii -'aytrGi jl. ill.pi.Sioi; " r.; tf i1,.F'1 i L'1' it y ��yy i S a��p1.; f ►+ i4 c. • THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affaft aanq Business Regulation 1000 Washingt„_ . r °t Suite 710 Bostory-tvlassachusettE92118 Home impra trtarlieglstration „ �r w Type: Individual ' . e nation: 185690 CHRISTOPHER TRIPP Expttation: 0113112026 12 GERALDINE RD COTUIT,MA 0263.5 Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer AffaiSx.8 Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT'CONTRACTOR expiration date. if found return to: TYPE:salt ivaduai; Office of Consumer Affairs and Business Regulation Re tstraGon *c 1000 Washington Street -Suite 710 1 1 01,+31 `26 Boston.MA 02118 f,HRIST'OPHER'IN P t tii i ..f C"'iV-t r CHRISTOPHER C.TRIO .T ' 12 GERALDINE RD '}4 r,t I `';'''" C:OTLI]T,MA 02635 y ' g = Undersecretary Not valid without signature • Commonwealth of Massachusetts n Division of Occupational • Board ofiv Building Licensure I l tions and Standards CongN ivisor CS-112862 Aires:12/22/2024 CHRISTOpHeftt . 12 GERALDIlit COTUIT MA '1. 0 watt Commissioner C/ � Y •