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HomeMy WebLinkAboutBLDR-24-23 ONE&TWO FAMILY ONLY-BUILDING PERMIT Town of Yarmouth Building Department -o►--'r• 1146 Route 28,South Yarmouth,MA 02664-4492 508-398-2231 ext.1261 Fax 508-398-0836 4! t''■ I: Massachusetts State Building Code,780 CMR Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number:�u3 u"LL Z,3 Date Applied: Building O c cal • ,Vi re Date SECTION 1:S INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 76 Pine Street,Yarmouth Port MA 02675 1.1 a Is this an accepted street?yes V no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(It) 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 Private Cl Zone:_ Outside Flood gone? Municipal Cl On site disposal system Check if yesg SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Tim&Erica Layman Yarmouth Port MA 02675 Name(Print) City,State,ZIP 76 Pine Street 925-683-9732 Laymant@gmail.com No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building Cl Owner-Occupied Cl I Repairs(s) ❑ Alteration(s) il Addition O Demolition ❑ Accessory Bldg.❑ Number of Units_ Other Cl Specify: Brief Description of Proposed Work':Half bath and wine/media room in basement. SECTION 4:ESTIMATED CONSTRUCTION COSTS. • Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $30,000 1.Building Permit Fee:$ Indicate how fee is determined: Cl Standard City/Town Application Fee 2.Electrical $3000 0 Total Project Cost'(Item 6)x multiplier x 3.Plumbing $5000 2.Other Fees: $ 4.Mechanical(HVAC) $ List: 5.Mechanical(Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $38,000.00 ❑Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-097544 12/11/2024 Ken Moniz License Number Expiration Date Name of CSL Holder 50 Main Street Ext. List CSL Type(see below) U No.and Street Type Description Harwich MA 02645 U Unrestricted(Buildings up to 35,000 cu.ft.)_ City/Town,State,ZIP R Restricted 1&2 Family Dwelling M Masonry RC I Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 774-237-0317 Ken@kenmoniz.com I insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) Ken Moniz 179261 07-09-2024 HIC Company Name or HIC Registrant Name HIC Registration Number Expiration Date 50 Main Street Ext. Ken@kenmoniz.com No.and Street Email address Harwich MA 02645 774-237-0317 City/Town, State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(I(I.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 l/ No a 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 Ken Moniz, Moniz Home Improvement, Inc. to act on my behalf,in all matters relative to work authorized by this building permit application. Tim Layman 01-07-2024 Print Owner's Name(Electronic Signatu e) 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. Ken Moniz 01-07-2024 Print Owner's or Authorized Agent's Name ctronic 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.eov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) 500 (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 1 Type of heating system Electric 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 1 Congress Street, Suite 100 Boston,MA 02114-2017 ��• www,tnass.gov/clia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print LeoibIy Name (Business/Organization/Individual): Ken Moniz, Moniz Home Improvement, Inc. Address: 50 Main Street Ext. City/State/Zip: Harwich MA 02645 Phone#: 774-237-0317 Are you an employer?Check the appropriate box: Type of project(required): l.N(l am a employer with 4 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 anca aci8. Remodeling y p ry.[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 ail 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.t 13.Et Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MIGL c. 14. Other 152,§I(4),and we have no employees.(No workers'comp.insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Associated Employers Insurance Policy#or Self-ins.Lic.#: WCC-500-5018757-2023A Expiration Date:06-20-2024 Job Site Address: 76 Pine Street City/State/Zip:Yarmouth Port MA 02675 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. 1 do hereby certify rti er the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 01-07-2024 Phone T:774-237-0317 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License r • 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#: t,: I §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-223!1 ext.-1261 Fax 508-398-0836 Office of the Building Commissioner BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G.L. Ch. 40, §54 and 780 CMR- Section 105.3.1. #4. I hereby certify that the debris resulting from the proposed work/demolition to be conducted at 76 Pine Street,Yarmouth Port MA 02675 Work Address Is to be disposed of oat the following location: Harwich Disposal Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. 01-07-2024 Signature of Ap ication Date Permit No. ., .Rt • i AC�® DATE(MWDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 6/18/2023 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 NAME CT RogersGray-SBC RogersGray A Baldwin Risk Partner PHONE FAX 410 University Ave _(A/c.No.Ext): 781-208-8400 (AfC.NO: Westwood MA 02090 ADDRIESS: RGSBCrerogersgray.com INSURER(S)AFFORDING COVERAGE _ ...-- NAIC Licens0:PC-514062 INSURER A:Main Street America Assurance 29939 INSURED KENNMON-01 INSURER B:Associated Empkryers Insurance 11104 Moniz Home Improvement Inc. «_ 50 Main Street Extension INSURER C: Harwich MA 02645 INSURERD: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER:2013356878 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. WSR IADDL'SUBR POLICY EFF POLICY EXP" - LT* TYPE OF INSURANCE i INSD WVD POUCY NUMBER (MMIDD/VYYY)i(MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY MPT8148W S/3/2023 ' 5/3/2024 EACH OOCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED — PREMISES(Ea occurrence) _ S 50Q000 r-- -- MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GEM.AGGREGATE LIMIT APPLES PER GENERAL AGGREGATE $2,000.000 X I POLICY X jira X LOC PRODUCTS-COMP/OPAGG $2,000,000 OTHER: S AUTOMOBILE LIABILITY I I COMBINED SINGLE LIMIT S (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED ' SCHEDULED BODILY INJURY(Per eoddent) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY , Per accident) S UMBRELLA UAB — OCCUR EACH OCCURRENCE $ IL EXCESS!JAB CLAIMS-MADE i I AGGREGATE $ DE) y RETENTIONS r $ B WORKERS COMPENSATION WCC-500-5018757-2023A S/20/2023 6/201/2024 X SETA UTE ER AND EMPLOYERS'UABIUTY Y ANYPROPRtETORiPARTNER/EXECUTIVE, N/A EL EACH ACCIDENT $100,000 OFFICER/MEMBEREXCLUDED7 (Mandatory In NH) EL DISEASE-EA EMPLOYEE $100,000 If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $500,000 ' I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 1131,Additional Remarks Schedule,may be attached if more space Is required) WORK Class Code 5645-Carpentry-detached One Or Two Family Dwellings CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Evidence of Insurance AUED REPRESENTATIVE 7746(14+ ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD • • • • • • O ' • • • • • L• Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Regulations and Standards Constplii6 rvisor _ s CS-097544 ires:12/112024 KENNETH M$NIZ,` 50 MAIN STREET HARWICH MA 0 J� Commjsslc ier a • • • • • • s ti S . I e i THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington.SJrept-Suite 710 Boston,Massachusetts.:0Y 118 Home Im rolnteof Registration t"i Type: Corporation Aa MONIZ HOME IMPROVEMENT.INC. ?"� -_ twn 179261 50 MAIN ST EXT -- 71 -1"lion: 07l09/2024 HARWICH,MA 02645 _ ~' {" /47 ... Update Address and Ratan Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for Individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date.If found return to: TYPE:Corporation Office of Consumer Affairs and Business Regulation Reglafr.Uen EEpiration 1000 Washington Street -Suite 710 179261' 07/09/2024 Boston,MA 02118 MONIZ HOME IMPR a n-f=I e KENNETH MONIZ f I1fr41 50 MAIN STREET EXT v /., u�.,,.N_r MAIN STREET 026456 �( ,-1._ Undersecretary Not valid with signature HARWICH,MA �L_.r" • • • i • a • ' e ' • , I f • A `