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HomeMy WebLinkAboutBLDR-24-559 applicaiton ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department , o ' , 1146 Route 28, South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508-398-0836 R Massachusetts State Building Code, 780 CMR C '` Building Permit Application To Construct, Repair, Renovate Or Demolish =may `e . a One-or Two-Family Dwelling RPORATEo This Section For Official Use Only Building Permit Number: 0t Dk- a 551 Date Applied: Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property.Address: 1.2 Assessors Map&Parcel Numbers Atu d4L4 Nit 1.1 a Is this an accepted street?yes 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? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: jai kAct --1.4-;c e o t 4-Or\I M Y� Name(Print) City,State,ZIP No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work': it S i- L r Cut toi -e c 4-W06 to 1 C' .I � C p(ac e U-)� 4a I, %Ici i ch.ct:��rcer— SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 007 1. Building Permit Fee:$ Indicate how fee is determined: OO� 0 Standard City/Town Application Fee 2.Electrical $ I 0 Total Project Costa(Item 6)x multiplier x 3.Plumbing $5f)00 2. Other Fees: $_ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ t ry l r�'� 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 5 i i 1 4741 JJ0.1 IXA Sam kO tjj_.. D' L p, License Number ExpirationDate Name of CSL Holder 04 List CSL Type(see below) grid —Q No.and Street Type Description /�/�,� CIA U Unrestricted(Buildings up to 35,000 cu.ft.) �-Q.C�ANr� O/ R Restricted l&2 Family Dwelling City/Town,State,ZIP M Masonry W l0 h O, I , ��n �„ + U 14 5ir I� , LR % Roofing Covering ' ` M- �'C�-C �V 1� iS Window and Siding SF Solid Fuel Burning Appliances Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) Lit 04' a HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name No.and Street W I Y ID I '6 Email address 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 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 LL)OJ. ( L./e_Y re-- to act on my behalf,in all matters relative to work authorized by this building permit application. Tr Otit150 VCC, U c D1 11 y Print Owner's Name(Electronic Signature) 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.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.) 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" l The Commonwealth of Massachusetts Department of Industrial Accidents 9. . �——3 Office of Investigations Lafayette City Center J 2 Avenue de Lafayette, Boston, MA 02111-1750 -'(., . �M =� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Printn Legibly Name (Business/Organization/Individual): Q > ( ci �-� 1-- Address: 96 ',i -iciti k' - - au-� City/State/Zip: GjiUIV ff S Anil Q,1 I Phone #: Are you an employer? Check the appropriate box: Type of project(required): 1.�.a'l am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. III Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.+ required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 11.❑ Plumbing repairs or additions 3.❑ I am a homeowner doing all work myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other 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: G ue,(Ard :TN) U ('j/k C -e- Policy#or Self-ins. Lic. #: W Lusi C L 1 ' L( Expiration Date: L//6 /,ll-- 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 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 the pains and penalties of perjury that the information provided above is true and correct. Signature: 0 W_0, rr-C/V C Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License # Issuing Authority(check one): 1❑Board of Health 20 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 5.0Plumhing Inspector 6.DOther Contact Person: Phone#: �Y. TOWN OF YARMOUTH 40 Office of the Building Commissioner 1146 Route 28, South Yarmouth, MA 02664 !,`4 00gOgAi 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. j.!c 1.i 4J Work Address Is to bedisposed of at the following location: 1*--�l -t- er- - Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, §150A. Signature of Applicant Date Permit No. 3'S2 .1 5G - Messages CertificateOflnsurance 3017474 AutoFill can assist with filling out �� this form. AutoFill Form ACCJIRIY CERTIFICATE OF LIABILITY INSURANCE 0111.1.00V 1T' �� 12:I823 12 05PM 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(SI.AUTHORIZED REPRESENTATIVE OR PRODUCER.AND THE CERTIFICATE HOLDER. IMPORTANT:H Itw certIICato bolder b an ADDITIONAL INSURED.the puacy(lesl mum A.endorsed.N SUBROGATION IS WAIVED.suo)ect le the Mims and conditions W the policy,certain police.,may require an etISOIS WN.A statement on this CartiI.al.does not conic,rights to Me cerhIICAte holden in aee el such endorfeIMnl(s). e.agl[t, w.t.ctI CRst Peer 9ei vl Ce Da part went Ctvamp Insurance Semces.LLC �Nyr is (BOO)920-e12S ��c (r.11.c-a_: Y I dour Cariilr $.=IS _ AMMO.) _ 2244 Faraday Avenue a125 Carlsbad.CA 92008 mod tu/AnoeMM.)GOCcenpany I -10713 .BAV"I•A rowan 11110,11,111 Hon DetlMOn Flooring Inc eA.en,c 329 West Man Sheol Apt 11, • era a I' - _ Hyaitrtn,MA 02601 Pews.,' COVERAGES CERTIFICATE NURSER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POUCES OF•Sl1RANCE LISTED BELOW NAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD MIICATED NOTWITHSINCNG ANY REOIMIEMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO VIIACH THIS CERTIFICATE MAY SE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICES DESCRIBED HEREa+IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONOITGI4 OF SUCH PCT.ICES I.ARTS SHOWN MAY HAVE BEEN REDUCEDF � BY PAID.CCLAMS etfal Nice arleencs 111011.0..L IolI.00',mil iI E..m. fa/M --_. yl4 MAT ErmA X reAL OMIT LMDT GLSHST0006A332S3 12n B7023 12n5gp2a tAcncr.clmsti $1,000,000 A• . .A 1wAM .a .t..11 X IX<.N III .W.'.MStk�!rkNracmcL.. ua ,q>el..,o.. ,S5.000 rtssoN,t a.w elAar. $1,000.000 AVM Q_An MIst anrkS CcA EnM nw.anH $2.000.000 X 'Rs LJ LJ Ia 'i 4 MOaclsw.o.-r. $1,000.000 —004A • AYISUBSBI MRRY LIIreaosNIe�I two aiD/ ANrA ITO SCOT,*Len ia...10-. s OARED ^]bl:lato SCOW/NARY iN rr4.- IAUTOS AUTO; .— err daunt le AUtOS `AUTOS ..w 0 eD1_Cl. r Lug '...-I ocasl a El. wo( .. CYO hi1011XWI I t wWASCOTINNMTrA NOlsesons.,Uaa1W A11XL. I. .oir Wnawrrlg ronlnpRM Ir EI VW ACCOIHI trenartMen. tt DtI V fAl.r:OIII o.HNtvara. - II One Ay1 ,xL5 liter $ mummer/or 0e04.11CN1 I.CATon vlletllt IAtO,e.1Pr Aeenn..n rN.v..t<•wNe.yr M masc..•.we...to new... Verification of Coverage •Subject to all policy tern, •tclu.lone and cond L t Lon.• CERTIFICATE HOLDER CANCELLATION SIIOIILD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Verification of Covrag• THE ESPWAT1ON DATE THEREOF. NOTICE WILL BE DELIVERED 11 ACCORDANCE WITH THE POUCH MOY6101.8. A.moff o Aselflf slt a b,t Bru. Carllle �(•��` O INB1014 AOORO CORPORATION.AV o5tH.reserved. ACORD 23(201401) The ACORD name and logo are registered nwl$BI ACORO INSO05 9 Gt,l,Crd 11)S arance to L Luc 3 L�j i 74./ yh9lzs ACCPRO CERTIFICATE OF LIABILITY INSURANCE 4;�6�2o2;YY) 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 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 CONr/CCL Cheryl L. Hollis NAME: C.L. HOLLIS INSURANCE (P(aH�ONNEe Eztl. y(508)295-9500 I rin No) (5as1295-9ses 140 Marion Rd ADDS Cheryllee@insurehollis.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC d Wareham MA 02571 INsuRERA:Main Street America Group INSURED INSURERB:Safety Commercial Insurance WLO HOME IMPROVEMENT INC INSURER c:Guard Insurance 19682 26 BRISTOL AVE INSURER D: INSURER E: HYANNIS MA 02601-2606 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1511402052 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. INTSRR TYPE OF INSURANCE ADDL INSR MD POLICY NUMBER R POLICY EFF POLICY EXP LIMITS (MOLIC/YEFF {POUCY GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 X COMMERCIAL GENERAL LIABILITY 12/17/2021 12/17/2022 DAMAGE TO REN I ED 500,000 PREMISES(Ea occurrence) $ A CLAIMS-MADE n OCCUR 11PT7224Q 12/17/2022 12/17/2023 MED EXP(Any one person) $ 10,000 12/17/2023 12/17/2024 PERSONAL&ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 4,000,000 i]POLICY n j T ri LOC $ AUTOMOBILE LIABILITY 03/04/2022 03/04/2023 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 B ANY AUTO 03/04/2023 03/04/2024 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED 5924077 03/04/2024 03/04/2025 BODILY INJURY(Per accident) $ AUTOS AUOTOS X X NN-OWNED PROPERTY DAMAGE $ HIRED AUTOS _AUTOS (Per accident) PIP-Basic $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ — EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ C WORKERS COMPENSATION 04/19/2022 04/19/2023 X I OH/lIMU- I IOTH- AND EMPLOYERS'LIABILITY TORY I IMITS FR Y04/19/2023 04/19/2024 ANY PROPRIETOR/PARTNER/EXECUTIVE /N E.L.EACH ACCIDENT $ 1,000,000 (Mandatory OFFICER/MEMBER EXCLUDED? I N I N/A WLWC326174 04/19/2024 04/19/2025 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 • DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more apace 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. Fr Delfi 1 Webs r/r: Ya mit AUTHORIZED REPRESENTATIVE ,,/o' Richard B Hollis/RBH G( �`""-- I ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(201005).01 The ACORD name and logo are registered marks of ACORD • Commonwealth of Massachusetts Construction Supervisor s ` Division of Occupational Licensure Unrestricted-Buildings of any use group which contain less than Board of Building RRAegqIIulations and Standards 35,000 cubic feet(991 cubic meters)of enclosed space. Constt ktio ti f z5 ' isor CS-119445 �. M -. spires:04/17/2027 WALBER SAAPAt x1,R tiE'• M. OLIVEIRA zc 26 BRISTOL YSVE HYANNIS MA126Q1 Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Contact OPSI:(617)727-3200 or visit www.mass.gov/dpl(opsi Commissioner THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washingtp ,Street-Suite 710 Bostonr Massat usetts 02118 Home Improvement ntractor::Registration Type. Corporation fte gists l i o n: 210018 WLO HOME IMPROVEMENTS,INC. Expiration: 10/16/2025 26 BRISTOL AVE HYANNIS,MA 02601 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 r 'Expiration 1000 Washington Street-Suite 710 210018° Ll,1611$f2025 Boston,MA 02118 WLO HOME IMPROVEMENTS,•INC, WALBER S.OLIVEIRA. 26 BRISTOL AVE HYANNIS,MA 02601 Undersecretary Not valid without signature ..,1 - _ 1 L., I I 111'\ I • 1 .. 1 tow ry- tu _ • c -*-14V 4 ..... tit/21/72g , , 1111•111111111111111, 4. .p , "......,...._ t r r• IA) 41.1 Vim ,... ...."... -•••• . 3 2 521 , (-)c t—s *4- I • 0 ,,, r • ' I SEA —..rc /7 ♦ • /1Vm pay.,/ OrittriZij e. 1 v � 1 1,13 gmemmo 1 f "