HomeMy WebLinkAboutBLDR-25-452 •
R l a
�� ONE & TWO FAMILY ONLY- BUILDING PERMIT
° r " Town of Yarmouth Building Department O4r Y`°l '`
1146 Route 28, South Yarmouth,MA 02664-4492 fi t
"
OCT 0 3 2025 1 508-398-2231 ext. 1261 Fax 508-398-0836 �J
i Massachusetts State BuildingCode, 780 CMR C `.� y
rr�cwccsc ,/
Building Permit Application To Construct, Repair, Renovate Or Demolish .tiro �b'`y
BuiLLi APOFl1Tf�,
By __ _i a One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: ( U)1 ' 5 J - Date Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1'ro Property Address: 1.2 Assessors Map& Parcel Numbers
1s-t Scotveilvtov‹ UnirA
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:Zone: Outside Flood Zone9 i,
Public 11 Private 0Municipal 0 On site disposal system a"
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Art prick Ccitoil jo4s -Cita /17/4 0 0 Yt
Name(Print) City,State,ZIP
BUD ilia,' Si 74/-76e- 3`// tyro I C 700 ® /4 0/,coo,
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 11 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Descriptionn of Proposed Work'-: ',trip//4c6/ )7/3—iatua//i /' 3ey in(r,//,,, 1 J�slmf/ A./C✓
S`/I'ro T rOGrt" 1ed7 o ii eeic k,reirn ('AAiAel .T f 7o//A/EA/Ski,/F✓ ,1 vIgmoy
.2 ,%D// n#F;/ /nsv/.aTrffreletejornT�,Gd.;1dotv.! A 1 4 tle"4/1i'i/ //�oer/4l.,
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Aryly.,,,A0
1.Building $ (2 6 U p 1. Building Permit Fee:$ 5S Indicate how fee is determined:
2.Electrical $ /D CJ G 0 Standard City/Town Application Fee
J 0 Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 0 0 0 2. Other Fees: $
4. Mechanical (HVAC) $ QQ List:
5. Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ` 0 0 0 CI Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 C str ction Supervisor License(CSL) a/�2 G L/
/%d ',7 6 k .("� License Number V5120424
ne
Name of SL Holder
9o , ,
11 . 7_ r-r List CSL Type(see belowt//f1/ J J
No.and Street—' T e Description
" 74' U Unrestricted(Buildings up to 35,000 Cu.ft.)
!N �Sv�"I ��`/ Restricted 1&2 Family Dwelling
City/T n,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 ssttee ed Home Improvement Contractor(HIC) ii 7/ c� e
" Ar--T`"' "`J oY t/ HIC Registration Number pi ion Date
HIC Company Name or HS Regtstran�t vame 7 /
9 a Mih S/t T X A/1 �/�r, —NE%c�'or��?/, iv,C
No.an Street/ / o, Email address
"1 f9f uv 7�`j 0/9 od,
Crty/T ,State,ZIP l 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 ill No 0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BBUILDING PERMIT
I,as Owner of the subject property,hereby authorize '2 7 /r/l" �Y�� 6/7-et--
to act on my behalf,in all matters relative to work authorized by this building permit application.
iF,'Jl GM/a h /U/3/9,4
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.
r-i-r11/vn �� /U �3a4
Print Owner's or Authorizedrt's Name(Electronic Signature) 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.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.) `j SYO (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) 3 rd Habitable room count f
Number of fireplaces Number of bedrooms A.
Number of bathrooms I Number of half/baths 02
Type of heating system OAS Number of decks/porches O
Type of cooling system J I '1'/i'G Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
'`' The Commonwealth of Massachusetts
Department of Industrial Accidents
-;, Office of Investigations
I y
.4 Lafayette City Center
tk, �%� 2 Avenue de Lafayette, Boston, MA 02111-1750
�� www mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): AA'S,/ i,//SA- -
Address: 9 /61 s--ii-r
City/State/Zip: Aype,r 4i/,#a Ca/F9 _ Phone #: 7f-/ 9/ 2 -‘6)0
Are u an employer. Check the appropriate box:
1. I am a employer with oZ 4. ❑ I am a general contractor and I Type of project (required):
employees (full and/or part-time).* have hired the sub-contractors 6 ❑ New construction
listed on the attached sheet. 7. I I Remodeling
2.❑ I am a sole proprietor or partner-
ship and have no employees These sub-contractors have 8. n 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 10.7 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.n 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' 13.0 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 arc 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: //AYP r'/L
Policy#or Self-ins. Lic. #: Expiration Date: ,�y�
Job Site Address: /S7 tiCr',4tic-,41,/ / /it--c" /
City/State/Zip: y,E9//!/64 `✓/l /
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 nder the ains and penalties of perjury that the information provided above is true and correct.
Si ature: �/ Date: /V i
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):
11:1Board of Health 21:Building Department 3❑City/Town Clerk 4.0 Electrical Inspector 5.EIF'lumbing
Inspector 6.0Other
Contact Person: Phone#:
i
TOWN OF YARMOUTH
, --v YA,:.;, Office of the Building Commissioner
,,, . - , 0, 1146 Route 28, South Yarmouth, MA 02664
.� y' 508-398-2231 ext. 1260 Fax 508-398-0836
R0GH4TEJ!/
HOMEOWNER LICENSE EXEMPTION
DATE:
JOB LOCATION:
N STREET ADDRESS SECTION OF TOWN
HOMEOWNER
NAME HOME PHONE WORK PHONE
PRESENT MAILING ADDRESS
CITY OR TOWN STATE ZIP CODE
Definition of Homeowner:
Person(s)who owns aparcel of land 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/orfarm 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 j
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
.og Yq'�, TOWN OF YARMOUTH
�/. 1.oa'; Office of the Building Commissioner
��,,,, rj 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 resulting from the proposed work/demolition to be
conducted at. /51 S't"re!V I`P k/ 4 V
Work Address
Is to bedisposed of at the following location: /VOrriA/V/t/ AMyS,Pt/
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter ,§150A.
/C/� �f
ignature of A scant Date
Permit No.
IIIMI/D
AC.:C:OR D DATE INYYYY)CERTIFICATE OF LIABILITY INSURANCE 09/26/2025
%iihm......-- .
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
It 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 ripts to the certificate holder in lieu of such endorsement(s).
CON TACT
PROOUC ER simaki Robert‘N Parker
Charles G. Jordan Insurance Agency _
PH°44E 781-337-0427 FAX 7 i 3 -76847
17 Front Street . tovc,NcLesti., , . - --;
E MAU ,
Weymouth, MA 02188 ADORL$$: rparker@ogjordaninsurance,com
INSURERISIAPPORDING COVERAGE NAIC I/
, INSURER A. Travelers Porperty Casualty Company of America TRA
....... ,....,.,..,, . ......._,
INSURED Robert Wagner INSURER 8:
90 High Street INSURER C:
Weymouth, MA 02189
„INSURER 0;
RE INSUR E
INSURER T
,.....,_
COVERAGES CERTIFICATE NUMBER. REVISION NUMBER:
I HIS IS TO CERTIFY THWIHE 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
..... __„,._ ___
iNsiR l lAdOtisuiSN POLICir Ef r7T Obit iEXP
LIR ! TYPE OF INSURANCE &LSD ,YVD, POLICY NUMBER ,0,00IPONYrr I;onaloyy,r(11, LIMITS
I COMMERCIAL GENERAL LIABILITY T l
, I
EACH OCCURRENCE: 1 i
..,...,;,.,..
DAMAGE'TO RENTED
AIMS MADE OCCUR : PREMISES JE:a iXtteret)c§) I $ ------g
fo4E:0 EXP(My one pefson) $
PERSONAL&ADV INJURY $
-- r
1.iENL AGGREGATE LSAT APPLIES PER: : GENERAL AGGREGATE $
POLICY , JECT LOC PRODUCTS-COMPIOP AGG $
OTHER. $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT g
f Ea accident)
ANY AUTO BODILY INJURY Wet parson) S
(WYNED ; ,; SCHEDULED $
AilTOS ONLY .: Autos BODILY INJURY(Per acculent)
, ..„
I IIRED ' NON-OWNED PROPERTY DAMAGE 1 t
AUTOS GM,V . .!:AUTOS OW Y (Pef accider_41
$
• UMBREL ..LA LIAR '
. OCCUR EACH OCC:URRENCE $
EXCESS LAB CLARA S-MAi/E AGGREGATE S
....____ — ,
DEO RETENTION$ $
. ,
A 1WORKERS COMPENSATION 1, 3 .f:,..7 K .i 18:202 1 PER• - OTI4-
ARO EMPLOYERS'LIABILITY ST
. .AIUTE ., _ ER_
Y IN
., AN YPROPRIE TORMARTNER/XECUTIVE " y N/A El EACH ACCIDENT $ 100,000
. of fiCERMEmBER EXCLUDED?
(Menditory.in NNI .
EA DISEASE-EA EMPLOYEE. $ 100,000
If yes,describe ulde;
' WE SC RIPT ION OF OPERATIONS Niko/ El DISEASE-POLICY LIMIT $ 500000-
. . . . . . . -.
2 I •
1 '
. ,
, - .... ,........ ,
' ,
DE SCRP I ION Of OPERATIONS LOCATIONS I VEHICLES (ACORD let Additional Rernadts Schedule.may be attached it tiore space Is reclolied I
The Worli,erfi Crripensation policy does not provide coverage for Robed Wagnei
. .
CERTIFICATE HOLDER CANCELLATION . .. .
, - •,- Si ' I ' - , . ,
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
TowrI Of Yarmouth ACCORDANCE;WITH THE POLICY PROVISIONS.
Building Dpt
151 Seaview Ave AOINORiZED REPRESENTATIVE
Yarmouth, MA 02664
--........,
. _ • . . ... .. .., ..,.....,..,.......____ _ _2
'') 19/18-2015 ACORD CORPORATION, Ali rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
•
+4,
Jaticsissmutuo0
* OUZO Vi Hi flOWA3M
1.331:US HDIN 06
.f,
tigNOVM N.th380b
SZOVE MO:sand3 P9/Z90-SD
i'mt)yks.uceuwiY4suo:j
H.,rx
swim-um pue suouembab Butpuneo pJeog
ainsuawi jettolledn3a0 JO uoisiAtO
suasntpPsspp jo queamuouJusop
krelanasJapiin
/91Z0 VPI'N.LnOINA3M
iS HON 08
ef3NOVAA'N INMON
i3N9VM
9Z0Z/90160 Z6ttlt,
uotwiek§ uto.#401E-41/
leaP/NPui:3thla
)4017011NO3 IN31,43A02idifi4 31410H
uogeineati seaulene s_ueiry Jeturtsuo3 Jo snug)
Si 1 4S1144qt/VQWV41 4r,U --tt,r,to —••
� , '0=
'— �E` e , - to0 _ _ -1
_
- ., .
V I i I
c.../. \ ......
ea -CP
o
O o.
In
C.
3 o I ()).
J 0 0 dippl ...
o
sr-
1.
It
0 0 5
S 4..
•-• Q T
9
it
aO Q " y
_
I 1\
Ay
3 • T *�
I)
( -
J 1 v= ado
C
3