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HomeMy WebLinkAboutBLDR-24-551 application ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department pg 1r4"4` 1146 Route 28, South Yarmouth,MA 02664-4492 _- p 508-398-2231 ext. 1261 Fax 508-398-0836 Massachusetts State Building Code, 780 CMR O 3 y Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling ORp RATfO ' �{ This S.ectt n For Official Use Only Building Permit Number: 13J4 �7/ "C.� Date Applied: Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Addrtss, 1.2 Assessors Map&Parcel Numbers 1.1 a Is this an accepted strbet?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 0 ERSHIP' 2.1 O er'of Record: l G .4- Pc- 1T ( 7028` Pt q- IP S4 N.-e(Print) City,State,ZIP No.and Str9et Telephone Email Addref SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building 0 Owner-Occupied ❑ Repairs(s)Kl Alteration(s) 0 Addition 0 Demolition ❑ Accessory Bldg. 0 Number of Units Other 0 Specify: D - - Brje, Descri Lion o Propos d Work': Vv t tot." t • _. �1 OCT 25 2024 07) SECTION 4:ESTIMATED CONSTRUCTION COSTS F A RTM E N T Item Estimated Costs: Official Use Only By. -- (Labor and Materials) 1.Building $ f c- O7) 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ 0—DO 0 Standard City/Town Application Fee 0 Total Project Co 3(It m 6),x multiplier x 3.Plumbing $ p 0 V 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Suppression) $ Total All Fees:$ (� Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Constryction Supe visor Lice se(CSL)j L ( lit t c,k P% 0-e4A- License Number Expiration Date Name of Cy H Ider ( List CSL Type(see below) 7,Z " ` .,^ I' �� / Type Description No. Street p t, ' U Unrestricted(Buildings up to 35,000 Cu.ft.) R Restricted 1&2 Family Dwelling 7A- City/Town Stat ZIP M Masonry n RC Roofing Covering (G WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Re isteredsome Improvement Contr ctor(HI n,i c 4-._-\ P-r `- -Pt� HIC egistration Nu ��?"2Da er Expiration Date HIC Corn n Nam otHIC Registrant Name IM�+�1.• c® 4 No.andt `?S �`ice, WO u I No.and eet ,.__ Emai address _�b�7763766 City/Toi, 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 --4-- No 0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLI S FOR"WILDING PERMIT i I,as Owner of the subject property,hereby authorize !4t 1 •'�-ciz� k ‘A. ,-)4(..t..._ , to act/oon my behalf,in all atters relative to(work authorized by this building permit application. t 4.4-e A e A- LA( . -4 .. Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest a pains and penalties of perjury that all of the information contain in this pplicatio i true a d accur the best of my knowledge and understanding. • t Owner's or Authorize Ag nt's N e(Electronic Signatur Date N ES: 1. An Owner who obtains a building permit to do ' er own work,or an owner who hires an unregistered contractor (not registered in the Home Improve ontractor(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" 7. The Commonwealth of Massachusetts Department of Industrial Accidents 6.pOffice of Investigations v�J1�1� 41 8; _ 0,3 Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 ww».mass.gov/dia Workers' Compensation Insurance Affidavit: Build rs/Contractors/Electricians/Plumbers Applicant Information Pleas Print Legibly Name (Business/Organizatio ,nd' idual): t �/ `'C/ Address: 72 . 'l/ 441V( ' — .. - City/State/Zip: ✓ ,. D 61> it- Phone #: -'v 7 76 3- 7t 6 Are you an employer? Check the appropriate box: Type of project(required): I I.n I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part- ime).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' P h'. $ 9. [' Building addition [No workers' comp. insurance comp. insurance. 5. We are a corporation and its 10 Electrical repairs or additions required.] ❑ 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 12I ] Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.El Other comp. insurance required.] *My 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: Policy#or Self-ins. Lic. #: Expiration Date: 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 cover v rification. I do hereby certi un r the ains d pe !ti of perjury that the information provided above is true and correct. Signature: Date: /7 ka 2 Phone : 7?t 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): 11:1Board of Health 20 Building Department 3❑City/Town Clerk 4.❑Electrical Inspector 5I'lumbing Inspector 6.0Other Contact Person: Phone #: • TOWN OF YARMOUTH . YA Office of the Building Commissioner moo\ 1146 Route 28, South Yarmouth, MA 02664 c0 508-398-2231 ext. 1260 Fax 508-398-0836 :�"fAPOR4T E0 E�T/ HOMEOWNER LICENSE EXEMPTION DATE: JOB LOCATION: f4�.y (A/ C-r.Aj E THE ECTION OF TO HOMEOWNER c-De•'72e52‘:( NAME HOME PHONE% WORK PHONE PRESENT MAILING ADDA'RE�SS• � CITY R TOWNS'"'''--UU 77/J STATE ZIP CODE Definition of Homeowner: Person(s)who owns a parcel ofland on which he or she resides or intends to reside,on which there is or is intended to be, a one or two family attached or detached structure accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of780 CMR 110.R5,provided that if a homeowner engages a person(s)for hire to do such work, then such homeowner shall act as supervisor. This exception shall not apply to the field erection of manufactured buildings constructed pursuant to 780 CMR 110.R3 The undersigned 'homeowner' assumes responsibility for compliance with the State Building Code and other applicable codes,by-laws,rules and regulations,and certifies that he or she understands the Town of Yarmouth Building Department minimum inspection procedures and requirements and that he or she will comply with said procedures and requirements. HOMEOWNER"S SIGNATURE I _- t • '`W `'- TOWN OF YARMOUTH og TrA�'` 4 ' a'\i Office of the Building Commissioner \, —. .,, 4' 1146 Route 28, South Yarmouth, MA 02664 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 resultin fro the proposed work/demolition to be conducted at. 4' Work Address Is to be disposed of at the following location: 7 f 1)2 "u''^-✓r t Said disposal site shall be a lic used solid waste facility as defined by M.G.L. Chapter 111, §150A. /702i g 0 1-71 Signature of Applicant Date Permit No. DATE(MM/DD/YYYY) ACORO® CERTIFICATE OF LIABILITY INSURANCE 10/25/2024 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 Marshall K.Lovelette Marshall K Lovelette Insurance Agency Inc PHONE FAX 396 Main St (A/C.No.Ext): (508)775-4559 (A/C,No): E marsha West Yamouth, MA 02673 ADDRESS: G INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: Nautilus Insurance Co 17370J INSURED Healy Brothers Construction,Inc. INSURER B: 72 Old Main Street INSURER C South Yarmouth,MA 02664 INSURER D: 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. ILTR TYPE OF INSURANCE NSD SWVD POLICY NUMBER UBR POLICY EFF POLICY EXP LIMITS (MMIDD/YYYY) (MM/DD/YYYY) A COMMERCIAL GENERAL LIABILITY NN1637497 01/09/2024 01/09/2025 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE I OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- LOC PRODUCTS-COMP/OP AGG $ 1,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per acddent) $ 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 PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ; 'i ER ANYPROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED9 -- - --- (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 Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Rt 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD A ® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 10/25/2024 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 KimberlyFitzgerald NAME: 9 MARSHALL K LOVELETTE INSURANCE AGENCY INC WC.No.Eat): (508)775-4559 (A/C,No): E-MAIL kim loveletteins.com ADDRESS: ` 396 MAIN ST INSURER(S)AFFt7RDINOCOVERAGE NAIC# WEST YARMOUTH MA 02673 INSURER A: HARTFORD UNDERWRITERS INS CO 30104 INSURED INSURER B: HEALY BROTHERS CONSTRUCTION INC INSURER C: INSURER D: 72 OLD MAIN ST INSURER E: SOUTH YARMOUTH MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: 1058645 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. ITR ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF POLICY EXP L TYPE OF INSURANCE (MMIDD/YYYY1 (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO RENTED $ CLAIMS-MADE OCCUR PREMISES Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JET LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED N/A BODILY INJURY(Per sodden() $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE ER PER H AND EMPLOYERS'LIABILITY A OF CER/MEMB REXCLUDED E.L.EACH ACCIDENT $ 100,000 E?ECUTIVE N/A N/A N/A 6S60UB0W65672424 08/19/2024 08/19/2025 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage- Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 RT 28 AUTHORIZED REPRESENTATIVE S Yarmouth I MA 026E-4 Daniel M.Cro y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD • •` !' Division of Odc..Upational Licensure .T M easurrOVE 6,✓CONTWACTORion • Board of BuildingR ulations and Standards ;< • HOME IMPROVEMENT CONTRACTOR• TYPE:Individual• Cons ignr$ visor Registration Expiration 173878 04/22/2023 �tic , ;_ F C5-080855� �� � fires 11/2342024 MICHAEL HEALY MICHAEL A VEAL ; ; • 72 OLD MAIN'ST . SOUTH YARIpUTH 64= _ MICHAEL A.HEALY � 72 OLD MAIN ST 'I4s.k r, SOUTH YARRMOUTH,MA 02664 /f� Undersecretary, • • • • • • • • _ _ T � (/ r, cut I