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HomeMy WebLinkAboutBLDR-24-161 application ' ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department ...."r 1146 Route 28, South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508-398-0836 (NI 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: 131...b 2—Zy—'t L Date Applied: Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Pro erty Addres • 1.2 Assessors Map&Parcel Numberc fi RUss0 REGEIVD 1.1a Is this an accepted street?yes no Map Number Parcel Nurlbor �-- 1.3 Zoning Information: 1.4 Property Dimensions: MAR 2 6 2024 Zoning District Proposed Use Lot Area(sq ft) Fronta;e( _ _ _ BUILDING DL1ARTM NT 1.5 Building Setbacks(ft) By: _ -- 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® .' Zone: — Outside Flood Zone? Private❑ Check if yes❑ Municipal 0 On site disposal system SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Recorrd/• ,DAUB f11M.5 ! "s Lott/ '!N A. ©.2 Name(Print) City,State,ZfP 6 d ,C. 'c.J e. 13w IV Ave- 781- 761-7576 ,br1Ass c•Jig yMAI . c©1"I No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building Ir Owner-Occupied II(' Repairs(s) Cl Alteration(s) 0 Addition L!1" Demolition ❑ Accessory Bldg. 0 Number of Units Other 0 Specify: Brie Descriptio of Proposed Wor :_g C Hove 6( ! 7 i f C ozf ei / iO r C 1 a l Ne_� orero /3orcj/ irla moo r SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ oaa 1. Building Permit Fee: $ Indicate how fee is determined: �d 2.Electrical $ ❑ Standard City/Town Application Fee 0 Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ ``ll 4. Mechanical (HVAC) $ List: �76.(,1 V litp iv 5.Mechanical (Fire Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $AC? �o a 0 Paid in Full 0 Outstanding Balance Due: • V 1 .51 - SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) �� C .5 -do 1 S`�'.� o//71,v016 CA Pt s io, i .,p i. a Ar 11,e. 1 f License Number Exte Name of CSL Hider List CSL Type(see below) ti- G d 3 PO. yai~H00-'i-1 No.and Street Type Description / / J y� � ' U Unrestricted(Buildings up to 35,000 Cu. ft.) W. ) )14 �o 7 / R Restricted I&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering / /fl A WS Window and Siding SF Solid Fuel Burning Appliances SO -- J(�-3 la I.tiii1 I. C 0 plcI Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 1N N-e� �4• ark,f A.) HIC egistrat n Number xpiri Date HIC Company Nine or HIC Registrant Name No. and Street 5- �.1 � ' �" i ress 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 0 No 0 SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 11 O I,as Owner of the subject property,hereby authorize 1) -'e N 1v4! 13 U•t e A 5 to act on my behalf, in all matters relative to work authorized by this building permit application. 2)9L'e- M ,s ; 3/25 ./ lk 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 e and accurate to the best of my knowledge and understanding. CA 7'1at . i",> AR.e.)i 3 .z 3 ,2i4 Print Owner's or authorized Agent's Name(Electronic•Sigriature) / /ate 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.aov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dps 2. When substantial work is plaied,iiovide 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 a Number of bedrooms Number of bathrooms 0 Number of half/baths Type of heating system 0 Number of decks/porches / Type of cooling system CD Enclosed Open 1 3. "Total Project Square Footage"may be substituted for"Total Project Cost" )tc, © '6' The Commonwealth of Massachusetts ��_'=� _ /, Department of Industrial Accidents (E=0.15- 1,= 1 Congress Street, Suite 100 �•i_-' Boston, MA 02114-2017 M=,,s 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): /j'ti; e y /3 c,, k :i__., i-i-' Address: 6, 03 i' ' ( y/i1%`/ov/// /C -' . City/State/Zip: t'1) y,I, /y., 0-4C7-3 Phone #: •.. �ST-- 3 U t/- ,3/ i / Are you employer?Check the appropriate box: Type of project(required): 1. I am a employer with -3 employees(full and/or part-time).* 7. ,L�J/ construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. molition 3. I am a homeowner doing all work myself.[No workers'comp. insurance required.]t 10 5Building 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.❑Electrical repairs or additions proprietors with no employees. - 12.E Plumbing repairs or additions 5.❑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.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[/Other Ale5;ci r ni ( 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. rr J/ Insurance Company Name: ! re./7" /i• 1R67)5 ` /lz-A'z'y �/a,5- 9 ©0 Li Policy#or Self-ins.Lic. #: �; .z Z. i�0-, �'%�.� ,;j 7'f'77�-C� 'vt 3 Expiration Date: !! Job Site Address: // v S SO 4 City/State/Zip: �,> /1A ,� �� ���Vic;� f t7 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 pe allies of perjury that the information provided above is true and correct. Signature: /-&- / Date: ',0 V Phone#: ,�� ._ 3 6 - '3 0 i 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#: p - 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 // /43 Lyef50 ILL` Work Address Is to be disposed of at the following location: /4/4 c:Y71 Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. Signature of Applicant ate Permit No. The Commonwealth of Massachusetts • _ __ IDepartment of Industrial Accidents _ 1 Congress Street, Suite 100 _?:14 Boston, MA 02114-2017 -,,_5,,�'` 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): /)' e Address: 03 ( y/i1/L10 • City/State/Zip: i'U,y,lh /,, O- 73 Phone #: . Sf- 3 U 'I- Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 3.❑I am a homeowner doing all work myself. [No workers'comp.insurance required.]t 9. ❑ Demolition 10 ❑ Building addition 4.0 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.❑ 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.El Roof repairs These sub-contractors have employees and have workers'comp. insurance.: I 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.ff Other /(,it H 3 Si"c l r i✓ ( 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: R r'l'` �� jR�J�ll `- 1-- Policy#or Self-ins.Lic.#: L u f3 / ;31'f'77-6 -✓t 3 Expiration Date: c-01,/a`�1 001 L-1 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$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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and pe allies of perjury that the information provided above is true and correct. Signature: e it, ' ---��-'� Date: Phone#: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Commonwealth of Massachusetts Division of Occupational Licensure • Board of Building Re ulations and Standards Cons on rvisor CS-001895 i `,pires: 01/13/2026 CHRISTOPHR T KENNEY 603 WEST YA RMOUTH RD WEST YARMb UTH MA 02673 L b Commissioner Construction Supervisor Unrestricted - Buildings of any use group which contain less than 35,000 cubic feet (991 cubic meters) of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Call (617) 727-3200 or visit www.mass.gov/dpl / \ o Id , I II ; a Lu CP § - ° «� N : m / q o K{\ ' -n. }k■= 3 ® Rt£. : I—V- i - = a Q 2@ - 7 s i �._, i k » k n � � 1 1 ! /\. / Ta 7 �. / 2 . » {§$� w 1:1- ■ e - � o 1 C '. . k31 O © £< -,-- Z§ &q : `:2J # »' \ \ .$£ . k{/a$ /— cog / ;oe� �:._`Al /.$ . � � . - k n � _ \ •M ' o7 E C \ U E »- w 0 0 @ PMƒe§ \ / m� / 22 }k � 2~ xa 0 .z.r . . d 2eaE$ . . O�Z coMOM OMB §Z.\a k R E� %/I §k�� .\ &=4 }§/ o' t. jj\ 3 © o o \ =mac mu 22= « YSk . 5 ƒ>-= /0 § 2§# § a�§ @ 323 Ate O ® DATE(MM/DD/YYYY) RO CERTIFICATE OF LIABILITY INSURANCE 02/09/2024 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATEDOES 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 Alan Burstein NAME: _ Peter M.Bakker Agency,Inc. PHONE (860)378-2700 FAX (A/C,No,Ext): (A/C,No): 302 West Main St E-MAIL alan.burstein@king-insurance.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Avon CT 06001 INSURER A: Main Street America Assurance Company 29939 INSURED INSURERS: American Zurich Insurance Company 40142 KENNEY BUILDERS,INC INSURERC: 603 W YARMOUTH RD INSURER D: INSURER E: WEST YARMOUTH MA 02673-1459 INSURER F: COVERAGES CERTIFICATE NUMBER: CL242946936 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 SUtlH POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DDIYYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,DAMAGE T 000 CLAIMS-MADE X OCCUR PREMISESO(EaENTED occu occurrence) $ 500,000 MED EXP(Any one person) $ 10,000 A MPJ7842M 04/06/2023 04/06/2024 PERSONAL BADVINJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO-JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 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 LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ , $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY X STATUTE OTH- ER Y/N 500000 B ANY PROPRIETOR/PARTNER/EXECUTIVE N IA 6ZZUB-8H337477-6-23 09/25/2023 09/25/2024 E.L.EACH ACCIDENT $ , OFFICER/MEMBER EXCLUDED? 500,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I 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. Town of Yarmouth 1146 Route 28 AUTHORIZED REPRESENTATIVE MA 02664 k £' South Yarmouth �� ^..* I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD - • • ,, „ • , . ' •, .. • . ...--, - - , . - ,' " ._.311",- 4 • , ".•;. . - --":_o-.r,4,4101110 •• P''' '•.. •''tif• ' ' ; 1 '1101P ...•.• - ' , = ...?'y• f 4 - .4. ' , .. / / • ., , ;... 4,,... it • ; 0' r ....zs. ., . _". ..j-.... - .;.• ' "11 ,,w ,‘,. g 4. TlitA, # '4•r r 1 ,______ I •.. . , _ ../".0• • 1 .. . itli:.: c: •• ..- • , "e6" •0111 ""•• .— t,........4 444 -4.• -le ,.._ "444 4.f ••44 s .1 • • .• . , . 4 ,- • . . • , . ,I. i.1 k• •. ' f .I '' 4 . , . . • .. ,, . . ' ' -r. ' 4 '44,,,,k fi_.,..._,,,,•••• Sh '. .4,•;, frt.. 0111 4111, •'' OE ' • .0,-.4eff.t., ..._ ..... , ° - . .......... 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J w. , 4 A y i / .Q S �y<��,� _oi j O 1, A.1a i,1,--.-1 1�k_ - / IS ' .,.,,-, ._,,. 2,, 9V , n,, ,1.4 From: Chris kenneybuilders@gmail.com Subject: Fwd:Massicott-11 Russo Road Date: March 18, 2024 at 9:11 AM • To: Larry and Fran Kenney kenbuild@comcast.net Can you apply this plan to permit Sent from my iPhone Begin forwarded message: From: Donald Meyer <donaldmeyer42@gmail.com> Date: March 15, 2024 at 3:38:03 PM EDT To: Chris <kenneybuilders@gmail.com> Subject: Massicott ( l FtF1