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HomeMy WebLinkAboutBLDR-23-8790- i i ' 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 508-398-0836iie 1. Massachusetts State Building Code, 780 CMR e Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling Thisr Section For Official Use Only Building Permit Number: ethi2 --k-Pb Date Applied: Building Official(Print Name) Signature Date SECTION 1:SITE INFORIMATION 1.1 Property Address:ivt 1.2 Assessors Map&Parcel Numbers 1.1 a Is this an accepted street?yes 4 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 ORecord: iJ 0.1497441 L 01 19r44r Iyiiel- V Name(Print) City,State,ZIP &s �� <�e-,� /- 3 s-5197z }Qck��l e ,07,,./e a.-� No.and Street Telephone Ema- Address (/ SECTION 3:DESCRIPTION OF PROPOSED WORK'-(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work': A,, -© �)et,i,,r//4'' A i" 0,...,.*. SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and Materials) Official Use Only 1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑ Standard City/Town Application Fee ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Suppression) $ Total All Fees:$ - Check No. Check Amount: Cash Amoun : 6.Total Project Cost: $ 0 Paid in Full ❑Outstanding Balance Due: gf it-C t-U 01G/ Pf-i'%7) - .6(r —csi--OG'yc pet c C. . SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS_l05-1 ,, i6 ��,, l 7.4 i✓i License Number Expiration Date Name of CSLolder �� /ray/ List CSL Type(see below) No.and Street T Description Oy/Town, r A 67 d O/ ( U� Unrestricted(Buildings up to 35,000 cu.ft.) ,/ State,ZIP '' Restricted I&2 Family Dwelling Y M Masonry RC Roofing Covering WS Window and Siding &/?31 SCW? / � ,, SF InsSoluldation Fuel Burning Appliances c�9e7��r�CJ'!. ,S I nsulation Telephone Email address -Lei✓''? D Demolition i5.2 Registered Ho a Improvement Contractor(HIC) 53� / nate HI��'" �� "��* HIC Registration Number . ICmpan�j.Name or HIC Registrant Name J -s' r�-.Y/!r,- 3,44 �'i� -7 III./ 0.7. ,.. .$Ke4.e2/ Od Cc..i, No.and Street Email address 6/01-.3` i 6 /7 z,i ->?-r-7- 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 ❑ 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�doi`y �j , �r / to act on my behalf, in all matters relative to work auth rzed by this building permit application. Print Owner's Name(Electronic Signature) Date • SECTION 7b: OWNER1 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. a/�7/�y er's or Authorize gent'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.aov/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 ____ . •••111 Iiii • ' 1•••••• ,,,vir m ., 11 Department of Industrial Accidents 1 Congress Street, Suite MO '''.• --4::r=4,.,7' Boston, MA 02114-2017 —1,1= 'k.,...— — WWw.mass.gov/dia "•,-.4,„:11:x* Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE PILED WITH THE PERMITTING AUTEICIRITY. Apolickrit Information Please Print Le!ibly Name (Business/Organization/individual): ./.. ..,,(,--;:,'O/,,k Address: (5:„C i -- ( b„rgy i - e)t City/State/Zip: 1 /4.5.kAr? In•I/I4c, l Phone#: (‘)/7 7/9---'7577- Are you an employer?Check the appropriate has: . Type o: prole:et 0.-i.:quirec-1.). 1.0 I am a employer with employees(full and/or part-time).* 7. E New contraction 2.ri i am a sole proprietor or partnership and have no employees working for me in 8. r Remodeling . any capacity,[No workers'comp.insurance requred.] 9. 7 Demolition .3.11 I am a homeowner doing all work myrelf .:1•Ici workers"comp.iasurac:t„: i 0 El Building addition 4.0I 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 insurance or are sole i 1.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.17 I am a general contractor ant'I have hired the f.iii-.....•intraczcts listed(.14:t.4:41..j1C.iiCU"jbi:Zr. ' 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.l 14.El Other 6,111 We are a corporation and its officers have exercised their right of exemption per/i4GL c. 152,§I(4),and we have no employees.[No workers'comp,insurance required.] .. "Any applicant Clot checks leyic al mutt ILso fill out tlic.7w.:;oil belo:s i,lio‘viog thcir wockers'compensation policy information. 1 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 enwloyir. Rdow is thE piciacy and jub;,ii6,- 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 MM.,c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 nrVor one-year impi-isonnieut,as wcil 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 te the Office of Investiga.tions of the DIA for insurance coverage verification. 1 do hereby certify under the ains and penalties of perjury that the information provided above is true and correct. Sionat re: ' Date: 00/12 ( / Phone • 77 `-579 — '7'-e.- • ifificiat 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): I.Board at'Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: _ I. ACCPREP CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 01/03/2024 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 Elise Fiano NAME: Roger Keith&Sons Insurance Agency PHONE (508)583-1106 FAX (A/C,No,Ext): (A/C,No): (508)583-8478 1575 Main Street E-MAIL efiano@rogerkeith.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Brockton MA 02301 INSURERA: Preferred Mutual Insurance Company 15024 INSURED INSURER B: Ippolito Damiani INSURER c: 55 Pearl Way INSURER D: INSURER E: Brockton MA 02301 INSURER F COVERAGES CERTIFICATE NUMBER: 2023-2024 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 ADLSLSUIiR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDDIYYYY) (MMIDD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY 1,000,000 �/ EACH OCCURRENCE $ CLAIMS-MADE X OCCUR DAMAGE TO RENTED 100,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 A BOP 0100717263 04/25/2023 04/25/2024 1,000,000 PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 POLICY PRO- JECT LOC 2 000,000 PRODUCTS-COMP/OPAGG $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ 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- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ (Mandatory in NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 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) POLICY LIMITS IN EFFECT AT POLICY INCEPTION. 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 ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 I ©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 508-398-2231 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 �/ (��,�f/.,� ,j� Work Address 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 Applicant Date 3L a►i'-&3 -g ?9 J Permit No. I- 0 Q C 0 p ce Qi - N Cea a) N 0 B Ncv. w2 m ? 41?0 m t L ":3 c _•-o a to a iv_(U ta o© 1` i D N CD a) Q_0 O Q w( r. 4 'rri U to r b-r. w to Q O G Q ' ,.. `.`. Q Q 63 (} m R—0 to 11J Q 2 E a' m ' ° 0 = s ° ° mom° R ,S. aS U ' L v uj p0 - 0 ~ e © cv amp a Din Z V.N f) O gal ()i5 x 45 Z N p°o } >WO a 0za QQ < g 2 O 0- Z 3Etr*- 2 cc � r 5a t- Qn �w Z Nc w ZC o.4Q0 Um <0 ¢ dO , p fa-C3ttooCC o ° s 2z Q<- p J b am O. O 0-f1 CL;nm t in ,,,r- ve, ) 'lie ()-eci-Je2c-) ...i."' 5 4--1 if / 1 k il i 1,,,,, ‘ -.. .. fyi L,_ 0/17,),...c-e--- ( I k illkliIre""1113 \ ( C-( 11*Lke i Iiii fir 6 A }f)/ Dif, I Commonwealth of Massachusetts litDivision of Occupational LUcensure Board of Building Regulations and Standards Const iott$ ry sor CS-105223 z^ * 6ipires: 12/19/2023 9‘,/y IPPOLITO M 3AMi1 66 PEARL lAtAY BROCKTON MA to v) 1F(VA, Commissioner ,, f. cr.. .. Licensee Details Demographic Information Full Name: IPPOLITO M DAMIANI wner Name: License Address Information ity: BROCKTON State: MA Zipcode: 02301 • Count : United States License.Information License No: CS-105223 e License Type: i Yp Construction Supervisor Profession: Building Licenses Date of Last Renewal: 12/1/2023 Issue Date: 2/15/2011 Expiration Date: 12/19/2025 License Status: Active Today's Date: 2/27/2024 Secondary License Type: Doing Business As: Status Change Reason: License Renewal Prerequisite Information No Prerequisite Information ... 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