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Home My WebLink AboutBLDR-24-503 application 1 R EC E I V F E & TWO FAMILY ONLY- BUILDING PERMIT OCT 0 Town of Yarmouth Building Department pF YA 1 2014 1146 Route 28, South Yarmouth,MA 02664-4492 ,� 508-398-2231 ext. 1261 Fax 508-398-0836 BUILDING DEPARTMENT Massachusetts State Building Code, 780 CMR By. -_d ng Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling ---.. This Section For Official Use Only Building Permit Number: 8 U,-2' - V 3 Date Applied: — Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 72, TO t Roc Sg 1341 1.1 a Is this an accepted street?yes j.' 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) ' ) I D 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: Zone: _ Outside Flood Zo ? �,/ Public Private❑ Check if yesl Municipal❑ On site disposal system !P SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: -7O4rz - L4u 12A Sc1mcJ se,th,Iciv' /H4 cif Name(Print) City,State,ZIP a 2-ilkm,A // DR. j n 4l1n 5a/37*-1 1* 12,/.C. 1 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 Existing Building EV Owner-Occupied ❑ Repairs(s) Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2:/4., p/4 4.2 417/Qe, .2,7 L�.:, A. .l o 1' .S,J1 L3,gf a/ het.." _�C4,vI 0 VI /[d/��1•�./ S r f/ Z�L -I/ /tom�c/lqr /�j� Acro rr.. "r.`// /i,e��4 t Y ti j� a/ v�ov no...� .5�>iC 4,4 4,, j a'c/14,M SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined: 0 Standard City/Town Application Fee 2.Electrical $ 0 Total Project Costa(Item 6)x multiplier x 3.Plumbing S 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ co Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ .J �'�5- ❑Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) ('f— Off CS YES` Zd2 fi 112/c.4 s.. /i J � ,-.'j e.q License Number E it ton Date Name of CSL Holder List CSL Type(see below) No.and Street T Description yU Unrestricted(Buildings up to 35,000 cu.ft.) C' J 4, ..1' /OM 0) G S3 R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances e.s,fiilr I Insulation Telephone,$Oa' 2-12 'Q3Email address®-Q'/, C44., D Demolition 5.2 Registered Home Improvement Contractor(HIC) n7/CA e/4i ri %,' C Coe-oet I C.,evylAii,94,‹ HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name /6'2 S71b/f,i j3«/ / p Wo'4S/YtiTtvQq-o! cc, No.and Street Email address CV(At.y s /n4 0.2G6-3 Sag'2 2 4/703 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 e 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 hi f•C h y t/ r� to act on my behalf,in all ma el ive to work authorized by this building permit application. �4hr) £o ,pa c/z3/zc �/ Print Owner's Name(Electronic S• Date SECTI N 7 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. lc ��, �•��t � f �r/6 - /2..3/2e y Print Owner's or uthorized 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" k "... • The Commonwealth of Massachusetts Department of Industrial Accidents 9 • . ,, Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 (. c,;M www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): /I°m,'4hC. n-' Address: /O.2 57(x1(. 1g,e 4.-1 RD City/State/Zip: a//„ ,,,f /h1,z ,,g 2,,s--j Phone #:S -2 .Z - -7 2 c''_ Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction listed on the attached sheet. 7. ❑ Remodeling 2. ►�I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. 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 3.❑ I am a homeowner doing all work officers have exercised their 11.0 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 employees. [No workers' 13.[rOther /9,y4„uli Gi,-t,., 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: z z..,- ,,g/j 1,/J2 2-"A r C-G Policy#or Self-ins. Lic. #: / PP /24/-3?-2.2 Expiration Date: VIV2O, .-s — M Job Site Address: 72 Xc. . j/a,,_'e /3jj City/State/Zip:, ,,,,,n„14 �,q 0244g 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. i Signature: i Date: /-�f-/.20:2 Phone#: Jod''-,. 92 -//743 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): 10Board of Health 20 Building Department 311City/Town Clerk 4.0 Electrical Inspector 5.0Plumbing Inspector 6.0Other Contact Person: Phone #: •.�• Jpg Ya�q , TOWN OF YARMOUTH Office of the Building Commissioner " 1146 Route 28, South Yarmouth, MA 02664 rya--=.•°;r 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. 72 .mac //vs r jec cf.,/ Work Address Is to be disposed of at the following location: { .0m* /> y/ 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. r.-.ti DATE(MM1D0lYYYY) A 'a)R1:, CERTIFICATE OF LIABILITY INSURANCE 10/24r23 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: Todd E Sullivan EF SULLIVAN INSURANCE AGENCY {q{ tC No,Extt: 781-326-5836 {,41c,No): 781-320-0908 507 High Street E-MAIL Dedham,MA 02026 ADDRESS: touvi efsuilivaninsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: Western World Insurance Co INSURED INSURER B: Michael Woesner INSURER C: 8 Longview Dr. INSURER D: Yarmouth Port,MA 02675 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. INRR TYPE OF INSURANCE INS()WVp POLICY NUMBER POLICY EFF POLICY EXP LIMITS (MM7DDlYYYY) {MM10DiYYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE T $ 500,000 RENTED CLAIMS-MADE OCCUR PREMISESO(Ea occurrence) $ 50,000 MED EXP(Any one person) $ 5,000 A NPP8243722 09/19/24 09/19/25 PERSONAL&ADV INJURY $ 500,000 GEN'L.AGGREGATE LIMIT APPLIES PER:. GENERAL AGGREGATE $ 1,000,000 POLICY PRO- JECTI ILOC PRODUCTS-COMP/OPAGG $ 500,000 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 $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y l N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E L.DISEASE-EA EMPLOYEE $ If yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I 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 Cheri Maher 0 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD MICHAEL WI ESSNER =_ 102 SKAKET:-BEACH RD -F ORLEANS MA 02653 THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washingt. _ re, t Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Individual MICHAEL VdOESSNER Registration: 169191 Expiration: 05/25/2025 D/B/A MICHAEL WOESSER, GENERAL CONTRACTOR 102 SKAKET BEACH ROAD ORLEANS. MA 02653 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:individual Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street -Suite 710 169191 05/25/2025 Boston,MA 02118 MICHAEL WOESSNER D/B/A MICHAEL Vi/OESSER.GENERAL CONTRACTOR MICHAEL K.'JVOESSNER 102 SKAKET BEACH ROAD ORLEANS,MA 02653 Undersecretary Not valid without signature ii••••••••ravrournoamommaiaola.w................................0 1? in 2:4,-T < ,,,i1:4* .tr'' I ., : I --I -‘1A —`.- w <i ta .....1 i _9� -.2. ''' )Iq 21Akirj4- --.7h7Sqti:1---- ; I . . L \ ., a1I w•� iI IA T- 1 4 -.CIllY E ht 0. 9'1" is a! ,xz / -r 1P4C770..S.: , A. i.... , S . MAY . t ' c100�:a L ,. • L , i.,:,,, ) , s,„. st„, 4, ,.t . ... . _________. .. -- --if 4...4,:d ''' "c* 7-. ; - ' ' ',.° 1.,'''. -, ' —ICLE CtJDILO, P.E. ' Caneufting Structural Engineer 123 fiaEtamreea3 ice. Calmn44. Youoohurlb 02632 _. 1?1_. `01>te+C-A-1—#, 4.5 . -- 'Drown Dy: MC Dab''''':1--- Off, .... File Mri jest --; I/a _._