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HomeMy WebLinkAboutBLDR-24-106 closed 5/7/24 i \/ 3 C604) , ONE & TWO FAMILY ONLY- BUILDING PERMIT // Town of Yarmouth Building Department ""'. _ 1146 Route 28, South Yarmouth,MA 02664-4492 �'f!�i 508-398-2231 ext. 1261 Fax 508-398-0836 ;M' ■ 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: d -Zy--1 O b Date Applied: Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 PropArty Address: 1.2 Assessors Map&Parcel Numbers C- e- /S/. - ./ iv' 1.1 a Is this an accepted street?yes no Map Number Parce Rb F,i v e D 1.3 Zoning Information: 1.4 Property Dimensions: 6 Zoning District Proposed Use Lot Area(sq ft) Fron,;ge ft) FEB 2 9 2024 1.5 Building Setbacks(ft) BUILDING Front Yard Side Yards ,__� T 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: J Public❑ Private CIZone: — Outside Flood Zone'? Check if yes❑ Municipal 0 On site disposal system 0 SECTION 2: PROPERTY OWNERSHIP` 2.1 Owner'of Record: y� r� Mir') W,. /eC "-�ii ->S X�Jc., 2 h7.+�1. O/G/) Name(Print) City, State,ZIP 6 6(//.sue/)_2)/2 . s7. ‘,/? ?C ) 9i ? 6 nzi265e-Aeq S - Gam No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 1 Existing Building 0 Owner-Occupied 0 1 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work'': /ZF/r)10c e 2 jA/T i C / 4 (7/a?/Or?S' /<!G/.U4),/1L 1TA9T.4/.ems /-1'�!Q "/-TI;,UFic✓ �%� 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: /DD. L)Q 0_eat) �\ 5.Mechanical (Fire Suppression) $ Total All Fees:$ Project Cost: $ ` f� . Check No. Check Amount: Cash Amount: � i'� ❑Paid in Full ❑Outstanding Balance Due: , \/ -, . SECTION 5: CONSTRUCTION SERVICES 5.1 Constructionf Supervisor License(CSL) z l/4? 'oL),026 e/ License Number Expiration Date Name of CSL Holder 4/7 j,ls..ke/6 ,coList CSL Type(see below) No.and Street �-i• J Type Description Q UT� � Q3 U Unrestricted(Buildings up to 35,000 Cu.ft.) t/ omity�Itwn,State,ZIP �/, R Restricted I&2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2�}Registered Home Improvement/�� �Contractor(HIC) / / '%� / ��UQ[Ti� .r.� /e /3� lac 'eg/e6 HI/C'Company Name or HIC Re i trant N e HIC Registration Number pirati n Date N and ee>���2 `1 � 1 R?�l2udQl5 �'T �sj J.¢/G ' CO* �J�l , , 7?4 —3/3 --7Nel Email address Ctty/Tor,state,ZIP Telephone i e Jiy /131 1 a,ha (dWL._ SECTION 6: WORKERS' COMPENSATION INSURANCE AFflDAVIT(M.G.L. c. 152.§ 25C(6)) �r Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide v 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. -� z �8�29 Print Owner's N+ _ __ Toni ignature) / ( 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.sov/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.) (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" 1 • 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 Work Address Is to be disposed of at the following location: eff5. �/,y,/�j + j ////- Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111,Section 150A. Signature of Applicant Date Permit No. The Common wealth of Massachusetts ;"�1(ts Department me ofIndustrialt1cci Accidents manta"wriemse . 111011MAIllo Mr Congress Street, Suite I0� ►sus arir r rat .... Boston, MA 02114-2017 www.mass.bov/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): Pr G140 ,, tee,_ Address: jt tv=Tate r�: v ) ' t" ', ya\ci, 'h►one #"E': 9 /3 .77 I Are you an employer? Check the appropriate box: Type of project (required): I c am a employer with employees(full and/or part-time).* 7. tew construction ..RI l am a sole proprietor or partnership and have no employees working for me in $. f Remodeling any capacity. [No workers' comp. insurance required] ' 3. I am a homeowner dondoinia all work myself. [No workers' comp: insurance required I t 9. //Demolition 10 D Building addition 4. I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all corm-actors either have workers' compensation rrsurance or are sole l LE E Electrical repairs or additions proprietors with no employees. 12.D Plumbing repairs or additions 5.7 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 : 13. Roof repairs • 14. flOther , = 6.1 ��e are a corporation and its officers have exercised their right of exemption per I MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] *Any applicant that checks box#1 must also Ell 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 contactors 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-cont..ctors 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 # or Self-ins. Lie. #: 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 SI.00,00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S25 .00 a day against the violator. A. copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coveraze verification. I do hereby cer ' under L.:e paiy and penalties of perjury that the information provided above is true and correct. . Signature v Date: t 2 1 ,-.9- Phone #: 72/ - 3/ 3 ` 7 9 ' Official use only. Do not write in th is.l" area, to be completed by city or town official. 1 City or Town: Permit/License 4 Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. Cittv.Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone : ... Scope of work In the kitchen and the bathrooms is to replace existing finishes. No change in locations of existing drains and plumbing. . . \ ..,.., 0 .. / ti 1 . . ...................._.......megli -, = i z„,...n.,..,...E---------••i-•--..-_ __ ....rammxii .11111— 1111 11\ ,•., -RI f -474R ' .4,441.. .. __ RMODL IEMODELED EEED I -.: -NO DINING ) LIVING 1 4, ..... 1 - 1 Iilk ‘) ....--• —-:.--_.. ...'''''' --. M MST. BEA TO REMAIN ,...:__„_ .„,...- -- A , -- — i p z I - / - 1 li / -- .1 . I ; -• II EW. '...__, .. GAS ' 5T. ____ INSERT/ /63 Ea-- AD:7, - :45 ______ 0 0_0 I I RAN E .,.., VIG:if - -....k._ 1 L , 113 I -.)N1 E---4I -. --...... — —WASH DRY `----------- ;' 111 REITMCP1EDN.vjrY IIIIIIII - LAVOUTCWA/50(NT WNER)1 ,.„ 2 6310 -., ... . INI .. • 11111 u x 6'8 $ - EXIST. UP — • 2IG°x GO" HALL E_X ED PAND 1 . _ Kli it3 I / 5--. , e)(S , 131-:PPLCI 2Q2'0" D<I5T- i-sk 7 , x610"- ___ _ya_ I I 2" C,--ToP - 5.L EX1 , bT. . • \ 5.L. ...... ........m.5 mo...../z. _ . Mr. \.:54 -— -7:*-4-'1-Ner- pr".• - i---'-;"'!:,:.---' 71."'',,-. 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II'ion midi EX�I�r C� _8n �-. >:_ L�. %sr. 111111111111111111111 Ex►ST. ...Milli LANDING _�� x6'8 „ 711, . 6/'� - 2 xG 57 1 Lasiri REM pp. r ` �' BATH , iron? ! s ' " NEW G_(y 1-, ,'��I LINEN - k1 1 ligliJill Ei'7 zi,, f ABOVE EVE 44(47 ,. - A9 1 4'-7 2'-5" 2'-4" 2'-4" • 4'-7" 2' IO�� $0wEi ) 2'-gm 22'-4"± 12'-O° ASTING) (NEW GABLE DOc II) Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Regulations and Standards Const,ctitkiogftwvisor CS-072808 6pfres:08/03/2024 .e• MARC A ElOiRGA 47 HASKELL f ARD : PLYMOUTH Ni', 4440000,E Corn mnsslorx r: ct,t-, 444/67' ion Q n p HOM MPROVEMENT CO CTOR N Efe-- TYPE:Indiv I fawiration V—PCI Ok-k C 169. 8 05118/2023 MARC A BOO MARC B RGAULT 47 H ELL ROAD 2;,(4,„' ..01„e"/41,400,4' P OOTH.MA 02360 Undersecretary fr-1 THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Individual Registration: 169138 MARC A, BOURGAULT Expiration: 01/28/2026 47 HASKELL ROAD PLYMOUTH, MA 02360 Update Address and Return 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:indlvicluai Office of Consumer Affairs and Business Regulation gingsmaon Exeirstign 1000 Washington Street -Suite 710 169138 01/28/2026 Boston,MA 02118 viARO A BOURGAULT 7/ ARC BOURGAULT a() 17 HASKELL ROAD 'LYMOU'TH.MA 02360 Undersecretary without signifkre ACo CERTIFICATE OF LIABILITY INSURANCE DATE(". YYY) i.r.� 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 endarsement(s). PRODUCER CONTACT NAME: BIBERK PHONE 844-472-0967 FAX 203-654-3613 P.O. Box 113247 WIG.No.EA): (PIC,roJ;_. E-MAIL customerservice-I biBERK,com Stamford, CT 06911 ADDRESS INSURRt15)AFFORDING COVERAGE NAIL 0 INSURER A: Berkshire Hathaway Direct Insurance Company 10391 INSURED Marc Bourgault INSURERS: INSURER C: 47 Haskell Road INSURER 0: Plymouth, MA 02360 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. NMR _ 'ADM'SUBR ___.. POLICY EFF POLICY EXP , LTR? TYPE OF INSURANCE LSD}WVD. POLICY numeral IMMIDOIVYYYI tMMR3Df(YYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 t s -L.Aims,MADE X OCCUR AGEfi©RENTE(� % 50,0�0 A ' N9BP537573 01/24/2024 01/24/2025 ` DPRExpiAES Eaoneperson MED EXP tArry one person) $ 5,000 i E ' 1 ,PERSONAL d ADV INJURY S Included GEML AGGREGATE UNIT APPLIES PER GENERAL AGGREGATE b 2,000,000 r POLKA' JECT PRO LOC i i PRODUCTS COMP/OP AGG I$ 2,000,000 X 1 OTHER: AUTOMOBILE LMBIUTY COMBINED SINGLE LIMIT (Ea occident) s ANY AUTO i BOULY INJURY(Per person) $ OWNED SCHEDULED ........._._. AUTOS ONLY AUTOS i i BODILY: INJURY(Per aCrde f . _._ .. ..._ HIRED ....� NON-OWNED ` i PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY i tFe, $ I t I UMBRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS LIAB ` CLAIMS1rtADE i AGGREGATE $ DEC , RETENTIONS $ ,WORKERS AND EMPLOYERLIABILITY LIN i STATIPE ._.._..ER ANYFROPRIETORmARTNER/EXECUTIVE Y 1 N -E ......_.... OFFICERAIEMBEREXCLUDED" -NIA; E L EACH ACCIDENT $ fMa_nd ry. DESCRIPTION�'in N E L.DISEASE Eh EMPLOYEE S n be OF OPERATIONS below - F t DISEASE•POLICY LIMIT ...$ ..... Professional Liability (Errors& Per Occurrence/ Omissions): Claims-Made Aggregate DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule.may be attached if more spacers required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Marc Bourgault THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 47 Haskell Road ACCORDANCE WITH THE POLICY PROVISIONS, Plymouth, MA 02360- AUTHORIZED REPRESENTATIVE , ' 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD /" ® DATE( YYI D AccoR CERTIFICATE OF PROPERTY INSURANCE # ,,,. 01t23J2024 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. PRODUCER NAME NAME: PHONE (844) 472-0967 x— (203) 654-3613 IA1G,No (A/C,Not . t3IBERK E-MAADDR`LEss, saIessupportObiberk.cam P.O. Box 113247 PRODUCER Stamford, CT 06911 CUSTOMER ID .. _ _.. _..INSURERIStAFFORDINO COVERAGE NAIL II INSURED INSURER A:Berkshire Hathaway Direct Insurance Comps! 238130 INSURER B Marc Bourgault 47 Haskell Road iNStFRER c Plymouth, MA 02360 INSURER a INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: LOCATION OF PREMISES/DESCRIPTION OF PROPERTY(Attach ACOR0101.Addrbormi Remarks Schecluie,#I more€p ce is required Location: 47 Haskell RoadPlymouth, MA 02360 Bldg #001: Carpentry - 7422101 THIS IS TO CERTIFY THATTHE POUCIES 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 1S SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR +,DATE POLICY EFMMRJIXYYYE POLICY EXPIRATION COVERED PROPERTY LI1INTS TYPE Of INSURANCE POLICY NUMBER COVERED=DATE BolAUDD/YYYY) X PROPERTY BUILDING S 0 ...... , CAUSES OF LOSS :DEDUCTIBLES ....... .. 0 _ PERSONAL PROPERTY SLALOMS ' N98P537573 01/24/2024 01/24/2025 NESS,NCo `S __*.. BROAD i. CONTENTSEXTRAEXPEN ............ j X . CIA&. RENTAL VALUE g EARTHQUAKE '': BLANKET BUILDING, ..._......__.. n/a 'WIND - BLANKET PERS PROP 5 nia t FLOOD BLANKET BLDG$PP $ a/a S <. 5 INLAND MARNE I TYPE OF POLICY : ' p # 1 CAUSE'S OF LOSS. I , ...._ ,.. , NAMED PERILS I POLICY NUMBER i i a TYPE OF POLICY ,.... ..., $ BOILER I MACHINERY I EOVIPNENTBREAKDOWN i $ i r---} 1 1$ SPECIAL CONDITIONS I OTHER COVERAGES IACORD 101,Additional Remarks Schedule,may be attached it more space Is required) * AL_S up to 12 months. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Marc Bourgault ACCORDANCE WITH THE POLICY PROVISIONS. 47 Haskell Road Plymouth MA 02360- AUTHORIZED REPRESENTATIVE If.01 44,41 ' 6+1:>-- - Ga 1995-2015 ACORD CORPORATION. All rights reserved. ACORD 24(2016/03) The ACORD name and logo are registered marks of ACORD