HomeMy WebLinkAboutB-10-068 # 96 Building PermitsSECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL)
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License Number Expiration Date
List CSL Type (see below) (J
Name of CSL- Holder
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Type
Description
U
Unrestricted (up to 35,000 Cu. Ft.)
R
Restricted 1&2 Family Dwelling
Signature
M
Masonry Only
RC
Residential Roofing Covering
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WS
Residential Window and Siding
Telephone
SF
Residential Solid Fuel Burning Appliance Installation
D
Residential Demolition
5.2 Registered Home Inm1provement Contractor (HIC)
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Registration Number
WC Company Name or HIC Registrant Name
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Expiration Date
,
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ignature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. i 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 .......... ❑ No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, , as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of u )
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 Horne Improvement Contractor (HIC) Program)• will yol have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations 110.116 and 110.115, respectively.
2. When substantial work is planned, provide the information below:
Total floors 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"
°�YAR TOWN OF YARMOUTH
„...,,. s BUILDING DEPARTMENT
CONSTRUCTION SUPERVISOR FORM
PLEASE PRINT.
Job Location:
Number Street Village
Owner of Property:
Construction Supervisor:
Name License No. Phone No.
Address: & � A 6A) C4 ZGL K /144-5*04EZ] `VJA ' -QZG C/9
Licensed Designee:
(If other than Supervisor) Name
2.15 Responsibility of each license holder:
License No.
2.15.1 The license holder shall be fully and completely responsible for all work for which he is supervising.
He shall be responsible for seeing that all work is done pursuant to the state building code and the drawings
as approved by the building official.
2.15.2 The license holder shall be responsible to supervise the construction, reconstruction, alteration,
repair, removal or demolition involving the structural elements of building and structures only pursuant to
the state building code and all other applicable laws of the commonwealth, even though he, the license
holder, is not the permit holder but only a subcontractor or contractor to the permit holder.
2.15.3 The license holder shall immediately notify the building official in writing of the discovery of any
violations which are covered by the building permit.
2.15.4 Any licensee who shall willfully violate subsections 2.15.1, 2.15.2 or 2.15.3 or any other section of these
rules and regulations and any procedures, as amended, shall be subject to revocation or suspension of
license by the board.
2.16 All building permit applications shall contain the name, signature and license number of the
construction supervisor who is to supervise those persons engaged in construction, reconstruction,
alteration, repair, removal of demolition as regulated by section 109.1.1 of the code and these rules and
regulations. In the event that such licensee is no longer supervising said persons, the work shall immediately
cease until a successor license holder is substituted on the records of the building department.
2.17 The license holder shall be responsible for requesting all required inspections. Failure to do so may
be deemed a violation of the permit conditions.
I have read and understand my responsibilities under the rules and regulations for licensing construction
supervisors in accordance with section 109.1.1 of the state building code. I understand the construction
inspection procedures and the specific inspection as called for by the building official.
INSURANCE COVERAGE:
1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.152
Yes X No
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy BJ Other type of indemnity ❑ Bond
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 152 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent
Owner ❑ Agent
Signature: /kt-�u' Building Official Approval:
For Office Use Only
Permit No.
Date TOWN OF YARMOUTH
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MGL c. 142A requires that the `reconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition or construction of an addition to any pre-existing owner -occupied
building containing at least one but not more than four dwelling units or structures which are adjacent to
such residence or building' be done by registered contractors, with certain exceptions, along with other
requirements.
Type of Work:
Est. Cost
Address of Work / 2 / GAW tO � f6
Owner Name: /W • W. 101A
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job under S 1,000
Building not owner occupied
Owner pulling own permit
Other (specify)
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH
UNREGISTERED CONTRACTORS FOR APPLICABLE HOME
IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION
PROGRAM OR GUARANTY FUND UNDER MGL c. 142A.
Signed under penalties of perjury:
I hereby apply for a permit as the agent of the owner:
61wo �
Date
OR:
Contractor Name
Registration No.
Notwithstanding the above notice. I hereby apply for a permit as the owner of the above
property:
Date;
Owner Name
.. The Commonwealth of Massachusetts
• Department of Industrial Accidents
02 Of ce of Investigations
600 Washington Street
Boston, MA 02111
r� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business, Organization/lndividual): /'ti���� t✓�N��LL
Address: & rvWAIA) 642c - /
City,'State/Zip: j� P 1 /'�%li 004(9 Phone #: 5Z'9�5� 9 W11
Are you an employer? Check the appropriate box:
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
2. aI am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me is any capacity.
employees and have workers'
[No workers' comp. insurance
required.]
qu
comp. insurance.:
5. ❑ We are a corporation and itsre
3. ❑ I a homeowner doing all work
officers have exercised their
myself. [No workers' comp.
right of exemption per b1GL
insurance required.] t
c. 152, §1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
11.0 Plumbing repairs or additions
12.❑ Roof repairs
13. ❑ Other
*Any applicant that checks box # 1 trust 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 NIGL c. 152 can lead to the imposition of criminal penalties of a
tine 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 certt; fy under the pains
and penalties of perjury that the information provided above is true and correct:
-Signature:,%� Date: /�'✓/ 09 _
Phone
QJJicial use only. Do not write in this area, to be complete y city or town ofJleiaL
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 #:
TOWN OF YARMOUTH
1146 ROUTE 28 SOUTH YARNIOUTH MASSACHUSETTS026644451
Telephone (508) 398-2231, Ext. 261 — Fax (508) 398-2365
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
BUILDING
ELECTRICAL
GAS
PLUMBING
SIGNS
Pursuant to M.G.L. Chapter 40, Section 54 and 780 CNIR, Chapter 1, Section 111.5,
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at /Zl C Q fj"' J)NAT flO
Work Address
is to be disposed of at the following location: ��S' &)GGO 1 Ak--'
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
.�% Pala a,
Signature of Applicant
Permit No.
Date
ROSSETTI ASSOCIATES, INC.
CONSTRUCTION MANAGEMENT CONSULTANTS
23 Everett Sheet Franklin, MA 02038 Tale -phone: 508-528-5071 Fax: 508-528-1854 Email:
To: Town of Yarmouth Building Inspector
Date: June 31, 2009
Re: Villages at Camp Street
Mill Pond Village
Yarmouth, Massachusetts
Dear Sir/Madam,
A few months ago, Rossetti Associates, Inc. was engaged as the Owner's Representative
to assist the Massachusetts Housing Finance Agency [MHFA] with construction
consulting and administrative services in connection with completing outstanding issues
that included capping the existing concrete foundations located on lot #s 96 97 and 98 at
the Mill Pond Village residential project in Yarmouth, Massachusetts.
It's my understanding that Mr. Alan Perrault of Horizon Partners, LLC [Horizon] was the
former facilitator for MHFA, and that Horizon provided you with written correspondence
on February 10, 2009 authorizing you to issue the requisite permits to Matthew Dunhill
[dba Matthew Dunhill, Builders], 16 Swain Circle, Mashpee, MA 02649 to complete the
work that remains.
I am writing this letter to advise you of my involvement with MHFA and this project and
to authorize you to issue the requisite permits to Mr. Dunhill for capping the single-
family dwellings on lot #s 96 97 and 98. An as -built [foundation] plan for each lot was
obtained from Holmes & McGrath, Inc., Civil Engineers & Land Surveyors of Falmouth,
MA, and those documents should have been given to you by Mr. Dunhill for record
purposes.
Sincerely,
Richard W. Rossetti
President
Mr. Richard J. Herlihy
Development Officer
Massachusetts Housing Finance Agency
One Beacon Street, 29th Floor
Boston, MA 02108
TOWN OF YARMOUTH
Building Department
Town Hall
Yarmouth, MA 02664
(508) 398-2231 ext.261
BUILDING PERMIT
TRANSMITTAL
Temp Permit No.:
T-10-023
Applicant Name:
Matthew Dunhill
Applicant Phone:
5085399891
Building Location:
0121 CAMP ST # 96
Owner's Name:
M.H.F.A
Owner's Addres
1 Beacon Street
Boston Ma
Owner's Telephone:
(617) 854-0000
REVIEWED BY:
(OFFICE USE ONLY
Recorded By:
Ic
Permit Fee:
$35.00
Deposit Rec:
$0.00
Payment Type:
Check ChkNo.: 0
Net Owed:
$35.00
Application Date:
7/7/2009
Issue Date:
Expiration Date
Comments: Map/Lot: 044.21.1.0
permit transfer - refer to B-07-886 new
constructio: 3 bahts, 2 bedrooms, 1
familyroom/diningroom, 1 kitchen, 1 livingroom
as per plans dated 11/17/09.
1. WATER DEPARTMENT:
DATE:
N/A:
2. ENGINEERING DEPARTMENT:
DATE:
N/A:
3. CONSERVATION:
DATE:
N/A:
4. HEALTH DEPARTMENT:
DATE:
N/A:
5. BUILDING DEPARTMENT:
DATE:
N/A:
6. FIRE DEPARTMENT:
DATE:
N/A:
PLEASE NOTE
COMMENTS:
RECEIPT OF COPY:
SIGNATURE OF APPLICANT:
DATE:
Date Printed: 7/10/2009
- The Commnwealth of Massachusetts d
Board of Building Regulations and Standards
bl
Massachusetts State Building Code, 780 CMR, T° edition
Building Permit Application To Construct. Repair, Renovate Or Demolish a
One- or Two -Family Dwelling
is 5Etion For Official Use Onl
Building Permit Number:
Date Applied:
Signature: z/z_i/a r
Building Commissioner/ Inspector o uildings )—
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map & Parcel Numbe
12.( �P ST ur>>T 9G �l l
1.1 a Is this an accepted street? yes no Map Number I Parcel Number
1-3 Zo=rmation: 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. 40.154)
PublicJ9- Private ❑
1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Check if yesO I Municipal ❑ On site disposal system
SECTION
2: PROPERTY nwNFRcwtW
2.1 Owner' of Record:
Name (Print) Ad4ress fo Service:
G/7585V- I odo
Signature Te ephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check a0 that apply)
New Construction ❑ Existing Building ❑ Owner -Occupied ❑ Repairs(s) O Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief -D'eVscription of Proposed Work":
tl�►� of oparmir"
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: pej� Use Only
(Labor and Materials) y
1. Building S 1. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑ Standard City/Town Application Fee
❑ Total Project Costa ( Item 6) x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. 'Mechanical ( Fire
Suppression) �' Total All Fees: S
Check No. Check Amount: Cash Amount.
6. Total Project Cost: S ❑Paid in Full C�1(;?utst tttig � ue:
BUILDING DEPT