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Home My WebLink AboutBLDR-24-456 application ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department p4� YA14 1146 Route 28, South Yarmouth,MA 02664-4492 Z p 508-398-2231 ext. 1261 Fax 508-398-0836 Massachusetts State Building Code, 780 CMR j xy Building Permit Application To Construct, Repair, Renovate Or Demolish COMnTT�eH s;b�q RPO RAT EO a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: 1j (0, i y- Date Applied: Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 34 Hasting Ave South Yarmouth 76/243/// 57/J050/// 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: 10,890 Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) N/A Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided N/A N/A N/A N/A N/A N/A 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 ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Meghan Sullivan South Yarmouth,MA 02664 Name(Print) City,State,ZIP 34 Hastings Ave 781-351-2344 megsull14@gmail.com No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building B Owner-Occupied ® Repairs(s) 0 Alteratio$s} 0 Addition ❑ D Demolition 0 Accessory Bldg. ❑ Number of Units Other 0 Specify: Brief Description of Proposed Work2:Installation of new kitchen cabinets.Installation of 12 Harvey classic windows 21211 L, / BU Ltl � DE- 'AR-t NT SECTION 4:ESTIMATED CONSTRUCTION COSTS BY Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 11000 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ 0 Standard City/Town Application Fee 00 O 0 Total Project Costa(,Item 6)x multiplier x 3.Plumbing $ b 000 2. Other Fees: $ 4.Mechanical (HVAC) $ 5 toe)0 List: 5.Mechanical (Fire $ Total All Fees: $ Suppression) U Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 1 Opc ❑Paid in Full 0 Outstanding Balance Due: • SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS060478 8/19/2026 License Number Expiration Date Name of CSL Holder List CSL Type(see below) u Alexander H Campbell No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) 1102 Hanover St Unit C Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry Hanover,MA 02339 RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 781-389-7024 hugh@ahcampbellandson.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 184009 12/03/2025 A H Campbell and Son Inc. HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 1102 Hanover St Unit C hugh@ahcampbellandson.com No.and Street Email address Hanover,MA 02339 781-389-7024 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 B 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 Alexander Campbell to act on my/ behalf,in all matters relative to work authorized by this building permit application. e ,0 6,1 1` V\«t' 9/3/2024 Print Oqnr1Ger'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. fL}1 Q kC- C BIZ Ct 9/3/2024 Print Owner's or Authorized Age is 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" zoo Ago TOWN OF YARMOUTH 4. Office of the Building Commissioner / 1146 Route 28, South Yarmouth, MA 02664 '�~c�RPOPAI EOJb c=� ° -- 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.34 Hastings Ave Work Address Is to be disposed of at the following location: Trojan recycling Brockton, MA Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, §150A. A64. 14/1Zi ?"-- 3 74/ Signat�Gre ofpli nt Date Permit No. The Commonwealth of Massachusetts a 1_ ll, Department of Industrial Accidents _ �V ? 1= 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/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):A H Campbell and Son Inc. Address: 1102 Hanover St Unit C City/State/Zip:Hanover, MA 02339 Phone#:781-878-8106 Are you an employer?Check the appropriate box: Type of project(required): 1.I I am a employer with 3 employees(full and/or part-time).* 7. ❑New construction 2.1=I I am a sole proprietor or partnership and have no employees working for me in 8. ✓❑Remodeling any capacity.[No workers'comp.insurance required] 9. ❑Demolition 3i:I am a homeowner doing all work myself.[No workers'comp.insurance required.] 10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.❑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:Merchant Mutual Insurance Policy#or Self-ins.Lic.#:WCA9102956 Expiration Date:08/04/2025 Job Site Address:34 Hastings Ave City/State/Zip:West Yarmouth, MA 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 the pains and penalties of perjury that the information provided above is true and correct. A Hugh Campbell Jr 9/03/2024 Date: Phone#:781-878-8106 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#: Commonwealth of Massachusetts Construction Supervisor V`4 Division of Occupational Licensure Unrestricted - Buildings of any use group which contain less than - ; Board of Building Regulations and Standards 35,000 cubic feet(991 cubic meters)of enclosed space. Constlionl ?' rvisor -1s' ,r• CS-060478 spires: 08/19/2026 ALEXANDERji CAMPBEL , ,. s 1102 HANOVER ST 6 UNIT C HANOVER M/(i02339 k` rP . r O `�(�f LVd .ate Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Commissioner ,1-.e.W *t.._-_- Contact OPSI: (617) 727-3200 or visit www.mass.gov/dpl/opsi Ali o® CERTIFICATE OF LIABILITY INSURANCE DATE(MM1DD/Y`/Y") 09/03/2024 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 Anna Seymour NAME: Estabrook&Chamberlain Insurance (A/C.No,Ext1, (508)697-6963. AX,No): (508)697-5809 45 Main Street E-MAIL anna@candsins.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC C Bridgewater MA 02324 INSURERA: Merchants Preferred Insurance 12901 INSURED INSURER B: Merchants Mutual Insurance Company 23329 A H Campbell&Son Inc INSURER C: 1102 Hanover Street INSURER D: Suite#c INSURER E Hanover MA 02339-2043 INSURER F: _ COVERAGES CERTIFICATE NUMBER: 24-25 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 ADDLSUBR 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 SDAMAGE TO RENTED 1,000,000 CLAIMS-MADE X OCCUR PREMISES Ea occurrence) S 500,000 MED EXP(Any one person) S 5,000 A CTRI001784 08/04/2024 08/04/2025 PERSONAL aADVINJURY S 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 JET LOC PRODUCTS-COMP/OPAGG S 2,000,000 X POLICY OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) S A OWNED X SCHEDULED MCAI003100 06/27/2024 06/27/2025 BODILY INJURY(Per accident) S AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE _ AUTOS ONLY _ AUTOS ONLY (Per accident) X UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 1,000,000 B EXCESS LIAB CLAIMS MADE CUP9151178 08/04/2023 08/04/2024 AGGREGATE $ 1,000000 DED RETENTION$ S _ WORKERS COMPENSATION X MUTE LIABILITY Y/N STATUTE ER _ 1 000 000 B ANY PROPRIETOR/PARTNER/EXECUTIVE N N/A WCA9102956 08/04/2024 08/04/2025 E.L.EACH ACCIDENT $ _ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ , 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 Evidence of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. 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