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HomeMy WebLinkAboutBLDR-24-88 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 yBuilding Permit Application To Construct, Repair, Renovate Or Demolish W a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: 3 4)V-Z� $ V Date Applied: • E1VF 4-- Building Official(Print me 7°°°#Signa re [ iài202: SECTION 1: ITE INFORMATION a NG DEPART ;ENT 1.1 Property Address: 1.2 Assessors Map&Parcel Numb a 18 Kearsarge Road g' — 1.1 a Is this an accepted street?yes X no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: RES 12,900 89.28 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:A-12 Outside Flood Zone? X PublicX3 Private❑ Check if yes❑ Municipal 0 On site disposal system 0 SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Matthew J. Ryalls Trust Kingston, Ma_—_ 02364 Name(Print) City,State,ZIP 23 Bay Farm Road 508-509-4700 rhburpeeco@comcast.net No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 I Existing Building Ili Owner-Occupied g Repairs(s) L Alteration(s) IN Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: 1. Replace existing rear deck. 2. Construct Front Brief Description of Proposed Work2: porch with roof. 3. Install gas fireplace within existing footprint. SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 38,000.00 1. Building Permit Fee:$ Indicate how fee is determined: 0 Standard City/Town Application Fee 2.Electrical $ 2,200.00 0 Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 1,800.00 2. Other Fees: $ 4.Mechanical (HVAC) $ List: U0.60 a 89 5.Mechanical (Fire $ • Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 42,000.00 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License (CSL) i 002099 4/20/24 Robert H . Burpee License Number Expiration Date Name of CSL Holder List CSL Type (see below) 5 Aldrin Road No. and Street Type Description Plymouth , Ma . 02360 U Unrestricted (Buildings up to 3 5,000 cu. ft.) R Restricted I&2 Family Dwelling City/Town, State, ZIP N1 Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 508-509-4700 rhburpeeco@comcast . net I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor (HIC) 180709 12 / 17 / 24 Robert H . Burpee HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name g p 5 Aldrin Road - rhburpeeco@comcast . net No. and Street Email address Plymouths Ma . 02360 508-509-4700 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 ❑ 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 authorizeRobert H . Burpee to act on my behalf, in all matters relative to work authorized by this building permit application. / # 1 2 / 13 /24 Print Own-r's Name (Electroni .. • • are) 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 i ...t re iU ca ci to the best of my knowledge and understanding. ' 2 / 14/ 24 Print Owner's or A ri s ame ec nic 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.Qov/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 �' � i Department oflndustrialAccidents_ r _ :;� l'r_ 1 Congress Street, Suite 100 *•• Boston, MA 02114-2017 zr www.mass.gav/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). R. H. Burpee Co. Address: 5 Aldrin Road City/State/Zip: Plymouth, Ma. 02360 Phone #: 508-509-4700 Are you an employer?Check the appropriate box: Type of project(required): I.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in ca aci 8. Remodeling an y p ty.[No workers'comp. insurance required.] 3.0 I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. ❑ Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ® Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions proprietors with no employees. 5.®I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12'❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.: 13•❑Roof repairs 6.0 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. 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 r 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 • p z perjury that the information provided above is true and correct. Signature: Date: 2/14/24 Phone#: 508-509-4700 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 4: 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 18 Kearsarge Road Work Address Is to be disposed of at the following location: Crocker Container Facility. 278 Service Rd. Sandwich Ma. Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. 2/14/24 Signature of pplicant Date Permit No. ACOREP CERTIFICATE OF LIABILITY INSURANCE DATE IMMRWNYYY) ��- 01232024 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(les)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 C..... Elizabeth Downie NAME Encharter-MA PHONE (g0p)67 I rAX,Noy (800)754-1602 Ertk IA/C Encharter Insurance LLC a Ess. edoonieOencharternom 25 University Dore INSURER'S)AFFORDING COVERAGE MACS Amherst MA 01002 INsuRERA: Merchants Mutual Ins.Co 23329 INSURED INSURER B: Govoni Construction LLC INSURER C: 2 Cromwell Drive INSURER D: INSURER E: Yannouthport MA 02360 INSURER F: COVERAGES CERTIFICATE NUMBER: Master Exp 102024 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, OCCLUSIONS AND CONDITIONS OF SUCH POLICIES.OMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR A00LYIIER POUCY EFF POLICY EdeUNITSLTR TYPE OF INSURANCE Wgp yryp POLICY NUMBER (MFNDDNYYYI (MIVDDNYYY) X COMMERCIAL GENERAL LMWUTV EACH OCCURRENCE f t•000'000 DAMAGE RENT. 00CUR® PREMISES/l Ea oavrence) f '°C° ICED EXP(Any one person) f 15,000 A BOPI092627 10202023 10202024 PERSONALSAW w.IunY f Included GEN-'LAGGREGATE La1ITAPPLIES PER: GENERAL AGGREGATE S 2'6W'� T]POLICY IR 2aT IR LOC PRODUCTS-COMPIOPAGG $2,1:DO'OW OTHER: Cyber Coverage S 100,000 AUTOMOBILELIABIUTV ICONODEEDSWGLE LIMIT S ANY AUTO BODILY INJURY(Per preen) S —OWNED SCHEDULED BODILY INJURY(PrecudeN) f _AUTOS ONLY —ALTOS HIRED AUTO NON-OWNED PROPERTY DAMAGE f AUTOS ONLY _AUTOS ONLY erel UMBRELLA UAB O CAR EACH OCCURRENCE f EXCESS UAB MAIMS-MADE AGGREGATE S DED I I RETENTION S f WORKERS COMPENSATION IMTUTE I IFOR AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑N EL.EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? /A (Mridetery in NH) EL DISEASE-EA EMPLOYEE $ yes describe F O EL.DISEASE-POLICY UNITf der DESCRIPTION O OF OPERATIONS hobo DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 10y MWirrl Remarks Schedule,may be attached If more space le meRmedl CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN R.H.Barpee ACCORDANCE WITH THE POLICY PROVISIONS. 5 Ak1dn Road AUTHORIZED REPRESENTATIVE Plym0utrl MA C2630 ®1N85-2015ACORD CORPORATION.All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD ® DATE(MM/DD/YYYY) ACORO CERTIFICATE OF LIABILITY INSURANCE `..---- 01/23/2024 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 Isaac Eutsler NAME: ENCHARTER INSURANCE LLC PHONE (413) 658-3404 FAX (A/C,No,Ext): (A/C,No): ADDRESS: ieutsler©encharter.com 25 UNIVERSITY DRIVE INSURER(S)AFFORDING COVERAGE NAIC# AMHERST MA 01002 INSURERA: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: GOVONI CONSTRUCTION LLC INSURER C: INSURER D: � 2 CROMWELL DRIVE INSURER E: YARMOUTHPORT MA 02675 INSURER F: , COVERAGES CERTIFICATE NUMBER: 970728 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' ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) ,(MM/DD/YYYY) UMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ - I ! DAMAGE TO RENTED CLAIMS-MADE L - j OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 1 PO- POLICY I ;. JE 0 [ LOC PRODUCTS-COMP/OP AGG $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED I NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY I AUTOS ONLY (Per accident) $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ — EXCESS UAB CLAIMS-MADE N/A AGGREGATE $ ___ DED , RETENTION$ _ �/ PERSTATUTE $ WORKERS COMPENSATION E OTH AND EMPLOYERS'UABIUTY ANYPROPRIETOR/PARTNERIEXECUTIVE YIN j E.L.EACH ACCIDENT $ 100,000 A OFFICERIMEMBEREXCLUDED? N/A N/A I N/A ; 6S62UB5N13320523 09/09/2023 09/09/2024 100,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes. describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE-POLICY LIMIT $ 500,000 N/A . I i I DESCRIPTION OF OPERATIONS/LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage - Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensation/investigations/. 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. R.H. Burpee 5 Aldrin Road AUTHORIZED REPRESENTATIVE Plymouth MA 02630 Daniel M. Crowley, CPCU, Vice President— Residual Market—WCRIBMA © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD �� Commonwealth of Massachusetts \ Division of Occupational Licensure Board of Building R uT lions and Standards Cons tonAlepisor CS-002099 x ... pires:04/20/2024 ROBERT H tDP: j I . 5 5 ALORIN ROADo 6.•01-.1.Vd'1JJ Commissioner da t/.F&„,iura THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE Corporation RealstratioR ' Rooiratlon 180709 _ 12/17/2024 R H B DEVELOPMENT,INC,_ - ROBERT H.BURPEE 5 ALORIN RD - �„",.ra.i Grok- PLYMOUTH,MA 02360 Undersecretary