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HomeMy WebLinkAboutBLDR-24-381 ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department ., ijg Y`�j4 1146 Route 28, South Yarmouth, MA 02664-4492 ,� r' .,y 0 508-398-2231 ext. 1261 Fax 508-398-0836 4% Foal Massachusetts State Building Code, 780 CMR `�, Y , ;` Building Permit Application To Construct, Repair, Renovate Or Demolish +,,, ,�cwr�. bAa f. - ORPORATES/ a One-or Two-Family Dwelling -- This Section For Official Use Only Building Permit Number: Lbli-< Li "'-` Date Applied: Z„../•-;'. -./:::;2. /-47 ' Building Official(Print Name) Si ture nale SECTION 1: S TE INFORMATION RECEIVE D 1.1 Pro ert Address: 1.2 Assessors Map& Parcel Numb rs s .JO 47 4f � JUL 1621124 1.1 a Is this an accepted street?yes no Map Number Par:el umber 1.3 Zoning Information: 1.4 Property Dimensions: B UIIDING EPARTMENT /t, 4 -4 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 /I ti4 �1 �/4 A/4 1.6 Wat r Supply: (M.G.L c.40,§54) 1.7 Flood Zone Informati n: 1.8 Sewage Disposal System: Publig) Private 0 Zone: Outside Flood Zone?Check if yes Municip n site disposal system 0 SECTION 2: PROPERTY OWNERSHIP' 2.1 Owne ' f Record: 5 4 <' ,#.(3014a trk , 06 7_)'— Name( rint) City,State,ZIP 30 l76tr wa;).,1 ya 4/3 / 77 ( No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s)_ Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: B,�riefff escription`off Proposed Work2: 7 �1jk�e ej&c.- fv !.✓A •'A /✓ L4Pe Jrt- /&2 C .-24u /ac -'That/ SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ /Z/ Oo U I. Building Permit Fee: $ Indicate how fee is determined: 0 Standard City/Town Application Fee 0 2. Electrical $ 0 Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ .71/C9 2. Other Fees: $4.Mechanical (HVAC) $ 1„.4./ List: 3 ¶.OD ( 4' I )5 5. Mechanical (Fire $ L-. Suppression) �T Total All Fees: $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ /7 rvy 0 Paid in Full 0 Outstanding Balance Due: / SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisoree-�-��- License(CSL) Cs- 67z77Z q- 7— 37e—zo-- License Number Expiration Date me of older List CSL Type(see below) 41 p 4"' No.and Street Ty. Description Unrestricted(Buildings up to 35.000 cu. It.) 7273 Restricted 1&2 Family Dwelling /T - [yown,State, M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances $-leL , 1 T Insulation Te ephone Emai address / Demolition 5.2 Registered Home Improvement Contractor(HIC) r57C-n r HIC Registration Number Expi Lion Date C Comp y Name or HIC Registrant Nameevoiortriis • re- o.and Street Email address Lst 4 i s1_ a/VYJ City/Town, State, ZIP Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.C.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 Issua ce 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 authorize ' ' ✓fT—t'J2J /Ne Crs7L7:j �� 57-att--) to act on my behalf, in all matters relative to work authorized by this building permit application. Cjit r f14 7 1 r Zy Print Owner's Name(Electronic Signature) to 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 ' is application is true and accurate to the best of my knowledge and understanding. �S`ikr °7 'r Z Print Owner's or Authorized Agent's Name(Electronic Signature) 'bate 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.gov/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.) Habitab om count Number of fireplaces Nu er of bedrooms Number of bathrooms umber 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" J �F� bal-h bu1s4 , �y i he Commonwealth of Massacfz usetts Department of Industrial Accidents y _ Office of Investigations \-1-61=71-4/ = Lafayette City Center �'•�_ .. ;f ..t i 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Bath Busters Inc Address: 30 N Main St City/State/Zip: Leominster Ma 01923 Phone #: 978-828-4398 Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 12 4. EI I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. New construction 2. ElI am a sole proprietor or partner- listed on the attached sheet. 7. [] Remodeling p p ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' g• 1:1Building addition insurance.: [No workers' comp. insurance comp. suranc required.] 5. fl We are a corporation and its 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no Bathroom remodel employees. [No workers' 13. Other comp. insurance required.] *My applicant that checks box#I 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: Universal Insurance Agency Policy # or Self-ins. Lic. #: UB6N457719 Expiration Date: 51612;` — Job Site Address: 5�-3c 1-kCity/State/Zip: , 4/1,_ Z7)1'v Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that 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 th - i n ' ' I ties 'fi j at ' information provided above is true and correct. . 4Z Si• ature: .. ' _� Date: Phone #: 978 .-4398 Official use only. I o not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (check one): 10Board of Health 20 Building Department 3f City/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 61:Other Contact Person: Phone #: fro Y TOWN OF YARMOUTH "413\ Office of the Building Commissioner 1146 Route 28, South Yarmouth, MA 02664 ry?ORA0R A1E0+°: � 508-398-2231 ext. 1260 Fax 508-398-0836 DEMOLITION DEBRIS DISPOSAL APPLICATION Pursuant to M.G.L. c.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. .-23c) //16.1i7/Oi z-vc>ti / �rl Work Address Is to be disposed of at the following location: 30/v -) -Jr Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, §150A. 7/Vr Si atu of Applicant ate Permit No. coe 4:01mtAitalt5t4siaitd. IFtt-' , ; i , ; CUSTOM REMODELING A Product of Safety Tithe Company,tic AGREEMENT .802 west tetrier Perko/Sy CT HIC#0640355 Grano Prairie, Texas 75050 MA Reg.41/8962 Phone: 855-225 2183• Fax 257-295-8098 RI fley.#38169 www Liwattoneath,nore -0,- heir,el Cietral 4kinat 4,1i,tirtf, 41.11-)•€, 1 le CiLi-o r c - i - 44 _ 4 -3- o .4„ Ye,r I's,0.71-1. roe,t c) ,,,,.,„ n oe-,-I"t e,---rrott OM 4 tret00 NAtie,Er a 1 Atitm 90.1t. j cog ,A3C4 1)90 5-og. -q ' .c.,,., ill o ,,-.-*a.o.aw.......... rTVCfr013 0 01411,1*,4114i‘4"liTal1/ago, -i ,ple0 ,, , ii , fei,ii I 11;1 ' ,1 =0 ,I:f d SAIt'f',. I .,1,,,C:omp,im, j j f::"Cieltrdi.,,,e- in A., 4 41 LiiiV '1, ,1114“610,1 ,II,tif i Ilk ii, 11 1 i 13' , 1 I ,,,1 , 1 1111 ,1 t 1 I 'III r,l,iPtil , ,..<4,aiiynig;Tr, 14 Atli 0 clie,,t -. finw F. ,a) I i, I; ,,,ii f..i ,,Iy, ilk i 01. I till, Najernielit, ilall "1:1_ 6o0c1 , Method of Payment: tetrileck ,J Cash J Financed It\CO Est.Starting Date: Ptetmase Portm. VI% I 1 Name on Credit Card, 1 2 co 00 -to C *.. )4 (I( 41 im) It) Est, Cornplition Date: Credit Card#: 1 Lpi 00 11 (itP fc 4,-.once Ottani', iki 0 1 CW-ttar I Q - Credit Card Exp, Date: Security Code: ,,--f 1 _., .. acknowledges receipt of a copy of the pamphlet, "Renovate Right: Important Lead Hazard ln*cwmation for Families,Child Care Providers, and Schools". Buyer(s) rieceived this pamphlet on the date of this Arritstrment before commencement of work. (Buyer's initials: fiIA ) Bayer s agrees and understands that this Agreement constitutes the entire understanding between the par*Ies. and that there are no verbal understandings changing any of the terms of this Agreement. Buyer(s) ges that Buyer(s) (1)has read this Agreement,understands its terms,and has received a completed, signed, and dated copy of this Agreement, including the two attached Notices of Cancellation, on the date I written above and (2) was orally informed of Buyer's right to cancel this Agreement, DO NOT SIGN THIS FCGWTRACT rrinERE ARE ANY BLANK SPACES. (Muni,Island Sales Only): Notice to buyer: (1) Do not sign this Agreement if any of the spaces intended for die agreed terms to the extent of then available information are left blank, (2) You are entitled to a copy of at the time you sign it. (3) You may at any time pay off the full unpaid balance due under Agrttment and in so doing you may be entitled to receive a partial rebate of the finance and insurance arazges. (4). The seller has no right to unlawfully enter your premises or commit any breach of the peace to repossess goods purchased under this Agreement. (5)You may cancel this Agreement if it has not been signed as . main office or a branch office of the seller, provided you notify the seller at his or her main office or / office shown in the Agreement by registered or certified mail, which shall be posted not later than sniriaright of the third calendar day after the day on which the buyer signs the Agreement, excluding Sunday sod any holiday on which regular mail deliveries are not made. See the accompanying notice of cancellation an explanation of buyer's rights. (Rhode Island Sales Only): liu,!rtis, atknowledgcs receipt of required ContrattorS' Registration anti Licerisiih; B.),trd ,,i//4,44,1 ,., ,,44,0r. 'N,:I, ( rr's Istia ; SAFETY TUBS COMPANY,LLC 11 14 I- 0;' ; -- , _,,, ... - , . a , i rawing (-* ....) emilimiammon. Customer Name: Kqc,t-,0 le rif)ectoe" Date: C_ of Existing Bathrocrn (Sow tuo, van,t.:,.., tol'e'._ wIhdow and shower) (de/r4—1 ii,)- A fa ANtitc ) a , 0 k (4\s.e. ou i Kt S.' / 4,, if 4 1 i OW( c rk-s ---- V. I 0 . ,0 OM,. '3o ***, 1 r---„_____. -•- 3 --- D , 1 1 ' II 1 (---- 73 S--,/:)' ------) \ ll .G1 J./ i D , ) 3 \6 CO 4 1 Nir 1 ...., ,...,,, ti., i r 11 4 ).6 to " h.9 LI X. -30 -0-6 ri, 4 ora(5 c 11.it, II 0 n.g. CkG 41 I,a 7 11 0(: 7 b iliti 1"411 OL•-, P 41 il ; ' ) 0 (,)( 1 , R 1 Uclr 46 (Q lir $-11(0 Flu.s.e. k'fr, 5 } Commonwealth of Massachusetts ' � ;- Division of Occupational Licensure - Board of Building Re ulations and Standards r , oust o'libnS%e4 isor fi �, . ._ ires: 04107/2024 JEFF C STE E � . tort 24 SHERWO AV, ,. DANVERS mg'e, 0192 i 1 �k Y I 1, �� 4. C . missioner clai g. y�� ,„ _ „ ,, ,? r , 4 THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington ± reet - Suite 710 Boston, Massachusetts 02118 Home Im ro e ent Contractor Registration -' r•� ---,""* Type: Corporation Registration: 159805 BATH BUSTERS, INC. ; Expiration: 07/14/2024 30 NORTH MAIN ST -� � LEOMINSTER, MA 01453 t. r -, 'p \*"11."fit _ s'S 414 ,,, w_ 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:Corporation Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street -Suite 710 159805 07/14/2024 Boston, MA 02118 TH BUSTERS, INC. ENER ALMEIDA 4ORTH MAIN ST. [ ...ora.*4,04' MINSTER, MA 01453 Undersecretary Not valid ut signature 6/20/24;10:11 AM Details Licensee Details Demographic Information Full Name: Jeff C Steele Owner Name: License Address Information City: Danvers State: MA Zipcode: 01923 Country: United States License Information License No: CS-072772 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 3/6/2024 Issue Date: 6/3/2010 Expiration Date: 4/7/2026 License Status: Active Today's Date: 6/20/2024 Secondary License Type: Doing Business As: Status Change Reason: License Renewal Prerequisite Information No Prerequisite Information Complaint Number: 2005-006-C Complaint Status: agencyl profOcomplaint_status100 Date Complaint Received: 2/1/2005 12:00:00 AM Date Complaint Entered: 11/3/2006 12:00:00AM Violation Code: Violation Type: agencyl profoviolation_type2 Violation Description: Reprimand Sanction: Reprimand Sanction Start: 7/7/2006 12:00:00 AM Sanction End: Complaint Number: 2005-007-C Complaint Status: agency 1profOcom pla int_status100 Date Complaint Received: 2/1/2005 12:00:00 AM Date Complaint Entered: 10/25/2007 12:00:00 AM Violation Code: Violation Type: agencyl profoviolation_type2 Violation Description: Reprimand Sanction: Reprimand Sanction Start: 9/26/2006 12:00:00 AM Sanction End: No Available Documents hNnc•//m.einl mulirr,nce rnm AlnrifrnKnn/r1Mnilr nn....O...r..11-070..4 nA 0 t,...e AAA A QA Ar. _-n__ .n-.rrr •A�Q® DATE(MM/DDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 05/20/2024 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 Mosarene Scalzer NAME: Universal Insurance Agency,Inc. PHONE (508)752-9333 FAX (508)752-9303 (A/C,No,Ext): (A/C,No): 374 Belmont Street E-MAIL mscalzer@universalinsagency.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Worcester MA 01604 INSURERA: Hartford Underwriters Ins Co. 30104 INSURED INSURER B: Travelers Indemnity Co of CT 25682 Bath Busters,Inc INSURER C: 30 N Main St INSURER D: INSURER E: Leominster MA 01453-3784 INSURER F: COVERAGES CERTIFICATE NUMBER: 05 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) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 2,000,000 DAMAGE RENTED CLAIMS-MADE X OCCUR PREMISESO(Ea occurrence) $ 1,000,000 MED EXP(Any one person) 5 10,000 A 08SBABB4MHU 11/12/2023 11/12/2024 PERSONAL&ADVINJURY $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 4,000,000 XPRO 00,000POLICY ECT LOC PRODUCTS-COMP/OPAGG S , OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ _ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION X STATUTE ERH AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 B OFFICER/MEMBER EXCLUDED? N N/A UB6N457719 05/06/2024 05/06/2025 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1000000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 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 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD