HomeMy WebLinkAboutBuilding PermitsTHE COMMONWEALTH OF MASSACHUSETTS
I TOWN OF YARMOUTH No . ..... ...........
ry
�'/3 OCCUPANCY PERMIT 2*0*
"No building nor structure shall be erected, and no land, building or structure shall be used
for a now, differcrit, changed, or enlarged use without a Building Permit therefor first having
been obtained from the Building Inspector. No building shall be occupied certificate of
occupancy has been Jssued by the Building Inspector."
Issued t
I --
. .. ....... . ........ .........
Wiring Inspector ..... nspection Date../W.;,.�! 25x&
10�
Plumbing Inspector.. ............................. Inspection Date/. .........
. .........
2 rj
Fire Department ...... ... . ...... .... .................... Inspection Date.
Building Inspector.. . ...... on Date .... Z-� .. . .. ...................
Jnspecti ... .. . �P.6
Assessors............. ..................................................................... Inspection Date.........................................
THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED
BY THE BUILDING INSPECTOR UPON SATISFACTORY COMP�I TOWN REQUIREMENTS.
BOARD. OE HEALTH 7r-1-1.
................ Building Inspector. . . ....... .........
TOWN OF YARMOUTH Building Department
(508) 398-2231 ext.1261
PERMIT NO 6-�
ISSUE DATE 5/13/2011 . ;
rge APPLICANT _GeoDavis
AT(LOCATION) 10218SETUCK
SUBDIVISION MAP LOT BLOCK
LOT SIZE
strip and reroof,14 squares, paper and vent to code
REMARKS
BUILDING
PROPOSED USE
PERMIT
_ _ _ _ _ JOB WEATHER CARD
PERMIT TO Repal-r
ZONING DISTRICT R-40 Bldg. Type: Residential
BUILDING IS TO BE: CONST TYPE 5-B USE GROUP R-3
AREA (SQ FT) EST COST ($ $3,850.00 PERMIT FEE ($) $35.00
OWNER IBOUCHER, ROBERT K BUILDING DEPT BY
ADDRESS 10218 SETUCKET RD
Yarmouth Port MA 102675
INSPECTION RECORD
Date Note Progress - Corrections and Remarks
ov
PHONE
CONTRACTOR
LICENSE 058130
Davis, George
33 North Main Street
South Yarmouth MA 02664
5083940832
FIELD COPY
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BOARD OF FIRE PREVENTION REGULATIONS
Permit No.
Occupancy and Fee Checked
Rev. 1/071 leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
CEASE PRINT IN INK OR TYPE ALL INFORMATIOA9 Date: ( — I a— !
City or Town of: 1(f.111.� "n � To the Inspector of W res.
this application the undersigned Ives notice of his or her intention to To
the electrical work described below.
cation (Street & Number) e-;? / V/ C-e 6[ jZrj (ion--r
ruer or Tenant -7;�g, t r c 14 C'(L Telephone No. .
Address
Is this permit in conjunction with a building permit? Yes ❑ No � (Check Appropriate Box)
Purpose of Building P:AM bLY Utility Authorization No.,
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: W ttZL A l G el d r iP#'ZC-. fvi�
Comn!¢tion ofthe followinv table may M wnivod by the Inmartn' of W:we
No. of Recessed Luminaires
No. of Ceil.S(Paddle) Fans
r n °�
Tran
Tansformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
ove n-
Swimming Pool ibov ❑ rnd. ❑
o. o m-2ency Lighting
BatteryUnits
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
o. o etection an -
Initiating Devices
No. of Ranges
No. of Air Cond. Tons
No. of Alerting Devices
No. of Waste Disposers
eat Pump
Totals:
um rTons---
I
o 0 ontamed
Detection/Alertin Devices
I
I
No. of Dishwashers
Space/Ama Heating KW
local ❑ unictpri El other
Connection
No. of Dryers
Heating Appliances KW
SecuritySystems:*
No. of Devices or Equivalent
o. o Water KW
Heaters
o 0 o. of
Signs Ballasts
Data Wiring:
No. of Devices or E uivalent
No. Hydromassage Bathtubs
No. of Motors _ Total HP _ _
Telecommunications irm
No. of Devices or uivalent
OTHER:
Attach additional detail ifdesire4 or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: to 9 -- 1 y Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless.waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation^ coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to thepermit issu�ffice. / r
CHECK ONE: INSURANCE [BOND ❑ OTHER [I(Specify:) Celsily"&Z _711f
I certify, under the Pains and pens/lies of perjury, that the information on this application is true and completeq
FHtM NAME: d/4-VA �CEG�.�IG� • LIC. NO.A / 1 y7
Licensee ll 411 G✓ gsw•4' W Signature LIC. NO.•�Z/b
(Ijapplicable, enter ' ex 1 " in the lice a number line. Bus. Tel. No.4. Address: _c3 :ea_ !G/!/PJd D�3 Alt. TeL Nos5-y y7o7d
'Per M G L. c. 147, s. 57-61, security w rk requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability mi surance coverage normally
required by law. By my signature below, I hereby waive this requirement I am the (check one owner [I owner's a ent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $
Mice Use unty 6al$
OFF I!BUILE)
Pemrit&V_46
�
2011 'Fs
Permit expires 6 months from
wTTwGn aa4'_ a � issue date.
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS:
ASSESSOR'S INFORMATION:
OWNER:
CONTRACTOR: MAI 1Ei V J • Iv I a V —1"
N LING ADDRESS M_#
idential Commercial ESL Cost of Construction S * �J &5p r ` —
Home Improvement Contractor Lic. # uoo I Construction Supervisor Lic. #
Workman's Cm-pensation Insurance: (check one)
I am the homeowner 1 am the sole proprietor 1 have Worker's Compensation Insurance
Insurance Company Name: -Aep— Worker's Comp. Policy# eq IP I
WORK TO BF, PFRFORAIF,D
Tent (fireRetardant Certificate auactwd)
Duration Wood Stove Sited
Siding: # of Squ rm Replacement windows: #
Replacement doors: #
Re -root # of SquarejPpoi-
8
old shingls, () going over la)ers of existing roof K Old Kings ILghway/flistoric District
Roofing/Siding (like for like)
'Tlx: debris will be disposerd of at:
Location of Fa6r6ty
I declare under penah"' of perjury that the sW {ements herein contained are we and correct to the best of my knowktlge and belief. I understand that any false answer(s)
will be just cause for denial or revocatiot r icense and for proseLution undo M.G.L Ch. 268, Section I.
Applicant's Signature: C Date:
Owners signature (or suachm nt) Date: :5 9 f I
Approved By Da",
Building Official (err designee)
Zoning District: t�, 7, —
Historical District: No Flood Plain Zone: Yes
Water Resour otectio1n1District: Within 100 t. of Wetlands:
Ye No A No
Z�x The Commonwealth ofBiassachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
�+ Xoston, AM 02111
mac'' www.nwssgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name
Are you an employer? Check the appr
1. L'I am a employer with _;)_
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
Phone #:
4. ❑ I am a general contractor and I
have hired the sub -contractors
listed on the attached sheet.
These sub -contractors have
employees and have workers'
comp. insuranee,t
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.l
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
S. ❑ Demolition
9. ❑ Building addition
10. ❑ Electrical repairs or additions
11. ❑ Plumbing repairs or additions
IPETRoof repairs
13.❑ Other
*Any applicant that checks box # I 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 subcontractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below it the policy and job site
information.
Insurance Company
Policy # or Self -ins. Lic. #: C 4 (; N 1 4 i'oI, Expiration Date:
Job Site Address: ,,^^(� 1J Sciii L Gk t Ill., City/State/Zip: K
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expirat►on 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 cerkfy under the pains and pen aldes of perjury that the information provided above is true and correct
Phone#: 16A " JOY - M32 ►
Official use only. Do not write in !Iris 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 M
A f%non
CERTIFICATE OF LIABILITY INSURANCE
DATE(MMMDIYYYY)
03/04/2011
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(les) must be endorsed. If SUBROGATION IS WAIVED, subject to
the ters 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
Mason & Mason Insurance Agency, Inc.
CONTACT
NAME'
N"CD"N EM,781.447.5531 F� N,:781.447.7230
458 South Ave.
Whitman, MA 02382
E-.UUL
ADDRESS:
PRODUCER
CUSTOMER
INSURER(S) AFFORDING COVERAGE
NAIC 0
INSURED
INSURER A.- Travelers Ins. Company
00034
George Davis, Inc.
33 North Main St.
South Yarmouth, MA 02664
INSURERS: National Grange Mutual
014788
INSURERC: ACE Property & Casualty
INSURERD:
INSURERE:
INSURER F-
COVERAGES CERTIFICATE NUMBER: 10/11 BA 11/12 GL WC 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.
W R
OF INSURANCE
ADDL
INSR
SUBR
WVD
POLICYNUMBER
POLICY EFF
MM/DD
POUCYEXP
MM/DDNYYY
LIMITSTYPE
A
GENERAL 11ABILITY
X COMMERCIAL GENERAL LIABILITY
CLAIMSUADE O OCCUR
16807900MZ26INDII
01/1212011
01/1212012
EACH occuRRENcE
$ 10000,000
DAMAGE TO RENTED
PREMISES Me occurrence)
f 30-0OO
LED EXP (Any one person)
$ 50,000
PERSONAL & ADV INJURY
f 1,000,000
GENERAL AGGREGATE
$ 2,000,000
GENL AGGREGATE LIMIT APPLIES PER
POUCY JE° LOC
PRODUCTS - COMP/OP AGO
S 2,000,000
S
B
AUTOMOBILE
LIABILTTY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNED AUTOS
M9M28491
10/26/2010
10/26/2011
COMBINED SINGLE LIMIT
(Ea accident)
S 1,000,000
BODILY INJURY (Per person)
f
BODILY INJURY (Per accident)
f
X
PROPERTY DAMAGE
(Per accident)
f
X
X
S
S
UMBRELLA LIAR
EXCESS LIAB
OCCUR
CLAIµq.MADE
EACH OCCURRENCE
S
AGGREGATE
f
DEDUCTIBLE
RETENTION f
f
$
C
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETORIPARTNERIEXECLITIVE
OFFICERIME BER EXCLUDED?❑
(Mandatory in NH)
I es, describe under
DESCRIPTION OF OPERATIONS below
NIA
C46414561
03/05/2011
03/05/2012
1 1'VC STATU- OTH-
E.L. EACH ACCIDENT
$ SOO OO
E.L. DISEASE -FA EMPLOYEE
S 500 00
E.L. DISEASE -POLICY LIMIT
t 500,00
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101. Additional Remarks Schedule, R more space Is mquirad)
Dperations: residential remodeling
RE: OFFICE COPY
CERTIFICATE HOLDER
FAX: 508.394.5460
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
George Davis AUTHORRED REPRESENTATIVE
33 North Main Street
South Yarmouth, MA 02664 David H. Mason
®1988-2009 ACORD
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD
d
iilussachusetts - Department of Public Saret�
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 56130
GEORGE F DAVIS
33 N MAIN ST
S YARMOUTH, MA 02664
(ununiseiunrr
Expiration: 311l2013
Trii: 12051
? pp I
Office of Coummer Affairs & B sioess Repulxnou
'- HOME IMPROVEMENT CONTRACTOR
Registration: :160164 Type:
Expiration: 7DJ2012 Private Corporatio
G GE DAVIS 'INC X
GEORGE DAVIS
33 NORTH MAIN STREET.,.;
SOUTH YARMOUTNI,1A`02664 Undersecretary
ONE & TWO FAMILY ONLY - BUILDING PERMIT
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DE&IOLISII A ONE OR TWO FAMILY DWELLING
Town of Yarmouth Building Department
1146 Route 28 • South Yarmouth, MA 02664-4492
508-398-2231 ext.1261 Fax 508-398-0836
onto Use ONy Planning Baud Infomutlon Assam Deputmatl INormatioa:
Permit No. Da — Plan Type Map to
Permit Fee $/60 Endarsawt Due
Reconima Deposit Rec'd. $ lj Date plan Oate 1.4 Property DimensiQ New
Net Oue $ %�� Omer L ArArra (st) montage Inl L 1 Cwaage
Ulkli
t3ulltitrt Pe um . •
i ns section Tor 011tos use only
Q8 IssUOCL
Sigpat<r
:. .7=%%
CertfficaGlo►OcctipancY
E. I: nor
,
tsq**&
twra,oatttrr� DeY!_..
Section l - SHO Intotmattoo I Use Orou : R-4 Typo: 5SB
1.1 Pn ortr Adilt"m
1.2 Zoning Information;
Zoning District
Proposed Use
1.3 swtdlnv s.tlese"n Inl
Front Yard
Side Yards
Rear Yard
Required
Provided
RegWred
Provided
Required
Provided
1.4 wa1N SUPPt f JUALL c. 4e. s tTe)
Public Private
1.3 Flood Zod Wormmd= t:atrerler$
Zorlec tDFE
G' J
Yf'
.v_pw.l vw„v my anuujunzuu ►9e(nl 1111 JAN 2 5 2011
_-- ��.�.•.—•w�w.ww �t.1fIT
L�. _
� I It I I, ■ R /I
Address V . L - -
00�
Siguture Telephone
NotAppliaade i>
License Number
SGO
Expiration Date
--a1/1
Not Applicable Q
. tense Number
Expiration Date ,
1of2 OVER
Sectla . A - NC Cc lrisbriltiLtiAffiitwit W291
Workers Compensation Insurance affidavit must be completed and submltted with this application. Failure
to provide this affidavit will result In the dental of the Issuance of the building permit.
Signed Affidavit Attached Yes .......... No ..........
Secdon &- D ' of P Wbrk(checlt elf )
New Cautructlon (3 1 No. of Bedrooms Na of 110narts
E*&M etdq. ❑ I ReWs) 07 Amrm«a .® I Mddloe (3
Accessory Bldg. ❑Type
Demolition
Other Specitr
Brief Dawaiptlon of Proposed Wark
�O' 11 n�a
U b u
--�
Section 0- Estimated construction costs
Item Estimated Cast (Doders) to be Check Below
completed by hermit epppeanl
t. BuIkIkV uvV ❑ COM"ation-Cammlaalon Flung
2. OacbJeel a, -7L)0 (lf appoeable)
3. / Gas N, So u
4. Medwicnl (HVAC) ❑ Old Kings Highway • HI&I&* l
S. Fire Protection — Commission approval
B.Tota1.(t+1+3+4+b) (if OWN 1011
7. foist S¢tere FL (nee hears to a4llvy
A
. as owner of the sublect property
hereby authorize ' to act an
my behalf, In all matters relative to workia lhorized by this building permit application.
� �'� % -R. /7,2wo
Date
!A
, as Owner/Authorized Agent
hereby declare that the statements and information an the foregoing application are true and accurate,
to the beat of my knowledge and belief.
Signed under the pains and penalties of perjury.
Pf" name v
Sigma" al Owner/Agar! Oats
9 • IJ - 99 2 of 2
TOWN OF YARMOUTH
BUILDING DEPARTMENT
CONSTRUCTION SUPERVISOR FORM
PLEASE PRIM'
job Location:
Owner of Prol /�
Construction Supervisor: 6eo rL
A Na(n
Address: C31,l Nfryt. a 1-
Licensed Designee:
(If other than Supervisor) Name
No.
License No.
2.15 Responsibility of each license holder.
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 lie, 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 willfullyviolate 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 raider 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:
have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.152
Yes No ❑
If you have checked yg", please indicate the type coverage by checking the appropriate box.
A liability insurance policy W 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 thaMass. 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: Building Official Approval:
The Commonwealth ofblassaehusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
fi .Boston, MA 02111
rvtvrv.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lcuibly
Name
Address:
City/State/Zip:_(1, Y/l.Yhtn 1. tlti MR 0 Phone #:
Are you an employer? Check the appropriate box:
LIED am a employer with k— 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
listed on the attached sheet.
These sub -contractors have
employees and have workers'
comp. insurance.:
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, §1(4), and we have no
employees. [No workers'
coma. insurance reouired.l
Type of project (required):
6. ❑ New construction
7. Remodeling
S. ❑ Demolition
9. ❑ Building addition
10. ❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation polity 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 subcontractors and state whether or not those entities have
employees. If the subcontractors 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. �L
(l
Insurance Company Name: 1 i- r ThPa {r(, .n r ,:,
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address:�e l 1 P_t oo ke City/State/Zip:�Q►i n LLt r7(Ji t
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 thepains and penalties of perjury that the information provided above is true and correct.
aI//0
Phone #: VW - 3`I il" 6P(302.
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: PermitiLicense #
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 #:
For Office Use Only
Permit No.
Date TOWN OF YARMOUTH
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MOL c. 142A requires that the 'reconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition or construction of an addition to any pro -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: 1-, o Est. Cost -5
Address of Work
Owner Name: ldUGY t 3011skr ,
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job under $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:
6w
Date Cont�Ic
I tor Name Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above
property:
Date Owner Name
og''rgRTOWN OF YARMOUTH
�r C BUILDING DEPARTMENT
o y 1146 Route 28, South Yarmouth, NIA 02664
508-398-2231 ext. 1261 Fax 508-398-0836
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 II ? t 1 r.t/10 knk, ya.rnt13 t.thport
Work Address
Is to be disposed of at the following location: Jq-\ [ yin
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
,I��l�i
Signature of Application Date
Permit No.
Nh1.SN11ChU.St:tt.S - Department of Public 5gerl.
Board or Buildin.- Regulatims and Standards
Construction Supervisor License
License: CS 56130
Restricted to: 00
GEORGE F DAVIS
33 N MAIN ST
T
S YARMOUTH, MA 02664
Expiration: 3/1/2011
Tr#: 12220
!L\ Office of Consumer Affairs & B siuessReeulation
WHOME
IMPROVEMENT CONTRACTOR
Registration: -IIPO164 Type:
Expiration: 7=012 Private Corporatio
DAVIS,
GEORGE DAVIS
33 NORTH MAIN St EET
SOUTH YARMOUTH, MA-02664 Undersecretary
r
TOWN OF YARMOUTH
Building Department
Town Hall
Yarmouth. MA 02664
(508) 398.2231 ext.1261
BUILDING PERMIT
TRANSMITTAL
Temp Permit No.:
T-11-292
Applicant Name:
George Davis
Applicant Phone:
5083940832
Building Location:
0218 SETUCKET RD
Owner's Name:
BOUCHER, ROBERT K
Owner's Addres
0218 SETUCKET RD
Yarmouth Port ` MA 02675
Owner's Telephone:
(508) 394-0615
REVIEWED BY:
1. WATER DEPARTMENT:
2. ENGINEERING DEPARTMENT:
3. CONSERVATION:
4. HEALTH DEPARTMENT:
5. BUILDING DEPARTMENT:
6. FIRE DEPARTMENT:
1
RECEIPT OF COPY:
(OFFICE USE ONLY
Recorded By.
IC
Permit Fee:
$0.00
Deposit Rec:
$25.00
Payment Type:
Check ChkNo.: 7511
Net Owed:
($25.00)
Application Date:
1/25/2011
Issue Date:
Expiration Date
PLEASE NOTE
SIGNATURE OF APPLICANT:
t:omments: Mapn-ot: 1JO.J4
removate xlsting 1st floor bathroom, renovate
existing basement exercise room - lower slab
floor
DATE:
N/A:
DATE:
N/A. -
DATE:
N/A:
DATE:
WA:
DATE:
N/A:
DATE:
N/A:
DATE:
Date Printed: 1/25/2011
of A k,� TOWN OF YARMOUTH =
s c HEALTH DEPARTMENT
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEEAN Zy 2011
To be completed by Applicant:
• ��L���ir(1�r1:�t1ii7)ILI.A%I.�III.U� IA1I�1'L
Tel. No. - a 2
eglk y 11
Date Filed:
"/fyou would like e-mail notification ofsign off, please provide e-mail address:
Owner Name:
Owner Address: t P&yy , Owner Tel. No.:96 e' c3 q V - 6rd
RESIDENTIAL AND/OR COMMERCIAL BUILDING
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
Please submit three (3) copies of plans, to include:
(1.) Site Plan showing existing buildings, water line location,
and septic system location;
(2.) Floor plan labeling ALL rooms within building
(all existing and proposed) —
Note: Floor plans not required for decks, sheds, windows, roofing;
(3.) If necessary, Title 5 application signed by licensed installer
with fee.
REVIEWED BY:
IV PLEASE NOTE
COMMENTS/CONDITIONS:
TE: 1 1 �- iit l
w �R%
CERTIFICATE OF LIABILITY INSURANCE
DATE(MMIDWYYYY)
01/26/2011
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 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 endorsements).
PRODUCER
Mason &Mason Insurance Agency, Inc.
CONTACT
NAME:
PHONE E.t:781.447.5531 FivcNo:781,447.7230
458 South Ave.
Whitman, MA 02382
ADDRESS:
ADDRESS:
PRODUCER
CUSTOMER
INSURERS AFFORDING COVERAGE
NAIL a
INSURED
INSURER A: Travelers Ins. Company
00034
George Davis, Inc.
INSURERB: National Grange Mutual
014788
33 North Main St.
INSURERC: Star Insurance
000204
South Yarmouth, MA 02664
INSURERD:
W SURER E :
INSURER F
COVERAGES CERTIFICATE NUMBER: 11/12 GL 10/11 BA & WC 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.
WSR
LTR
TYPE OF INSURANCE
ADDL
W
SUER
Vivo
VD
POLICY NUMBER
PO Y FF
M/DD
PP
MMOM/DDNY
LIMITS
A
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
CLAIMS4AADE X❑ OCCUR
1690790OM226IND11
01112/2011
01112/2012
EAcHo=RRENGE
$ 1,000 00
I E—W—EU—
SES Me occurrence)
$ 300,000
MED EXP (Any one person)
$ 50,000
PERSONAL A ADV INJURY
s 1,000,000
GENERAL AGGREGATE
s 2,000,000
GENL AGGREGATE LIMIT APPLIES PER:
PRO -
POLICY ECT LOC
PRODUCTS - COMPIOP AGO
s 2,000,000
$
B
AUTOMOBILE
LIASUM
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNED AUTOS
M9M2849
10/26/2010
10/26/2011
COMBINED SINGLE LIMIT
(Ea acciderd)
.•
$
1; 000 00
BODILY INJURY (Par person)
$
BODILY INJURY (Par accident)
$
X
PROPERTY DAMAGE
(Per accident)
$
X
X
$
$
UMBRELLA LIAR
EXCESS LIAB
OCCUR
CLAIMS -MADE
EACH OCCURRENCE
$
AGGREGATE
$
DEDUCTIBLE
RETENTION $
_
s
s
C
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y I NDRY
ANY OFFICEWMEMMBEER EXCLUDED?
(Mandatory In NH)
H yes, describe under
DESCRIPTION OF OPERATIONS below
NIA
WC04SZ478
03/05/2010
03/05/2011
WC STATU- OTH•
E.L. EACH ACCIDENT
$ SOO OO
E.L. DISEASE -EA EMPLOYEE
s S000O
E.L. DISEASE -POLICY LIMB
S S0O 0O
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES JAtiach ACORD 101, Additional Remarks Schedule, ti more space Is required)
Aerations: residential remodeling
E: OFFICE COPY
CERTIFICATE HOLDER CANCELLATION
FAX: 509.394.5460
George Davis
33 North Main Street
South Yarmouth, MA 02664
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
ACORD 25 (2009/09)
01988.2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
Ni
1/2 wall
izio 5/8
Existing Exercise Room
i
i
Step down area
TE I
Basement Level Project:
FEB b 12011
Drop Ceiling - existing
.xisting Carrying Beam - ixsti Wall - Remain
Inaffected
Existing Full
Basement Area
Existing Wall - remove, replace
4 — — = Slab Removed
Brick Stem Wall
Remove existing floor in excersise room (slab)
New Slab Excavate approximately 12"
Place new slab
Brick exposed sides.
Construct steps into lower area
construct 1/2 wall
Re -construct removed wall, ceiling, as req'd
----� 00
0J 1st Floor Bath Renovation
OERenovate existing hall bath
Exist. No layout or configuration changes
Bath
No insulation exposed
_ — — — — — Orr
— No framing material cut
i
cu.L .. s 1 :iPT
January 21, 2011
1/411= V-0" unless noted
TOWN OF YARMOUTH
REVIEWED FOR BUILDING AND ZONING CODE COMPLI•
ANCE. ERRORS OR OMA9!SSIONS DO NOT RELIEVE THE
APPLICANT FROM THE RESPONSIBILITY OF 'AS BUILT'
COMPLIANCE.
DATE:
BUILDING OFFICIAL
Boucher Residence FILE
218 Setucket Road
Yarmouthport, MA 02675
C0 P DEUGN # BUBO o RENOVATE
33 North Main Street
South Yarmouth, MA
(508) 394-0832
494::
1/2 wall
I 12'10 5/8
Existing Exercise Room
F
I
Step down area
------
:xisting Carrying Beam -
Inaffected
Fvicfinn PInnr Anictc - 1 Innffarfind M
Drop Ceiling - existing
Eixsting Wall - Remain
Existing Wall - remove, replace
— Slab Removed
Brick Stem Wall
New Slab
_111008
I Oo 1st Floor Bath Renovation
i
° O �
Renovate existing hall bath
Exist. No layout or configuration changes
— — — — Bath No insulation exposed
No framing material cut
i
TOWN OF YARMOUTH
REVIEWED FOR BUILDING AND ZONING CODE COMP I
ANCE. ERRORS OR Oh1MISSIONS 00 NOT RELIEVE THE
APPLICANT FROM THE RESPONSIBILITY OF "AS BUIL
COMPLIANCE.
DATE:
9
Basement Level Proiect:
Remove existing floor i xcersise r m (slab)
Excavate approximately 12"
Place new slab
Brick exposed sides.
Construct steps into lower area
construct 1/2 wall
Re -construct removed wall, ceiling, as req'd
January 21, 2011
1/411= 1'-0" unless noted
R'2CLEOC7FD
JM 2 4 2011
HEALTH DEPT. FILE COPY
Boucher Residence
218 Setucket Road
Yarmouthport, MA 02675
DEnG r * svua o Rm;ovATs
33 North Main Street
South Yarmouth, MA
(508) 394-0832
V
-1
y.4 t
J }
0F'YgR,�
C
F
TOWN OF YARMOUTH
BUILDING DEPARTMENT
1146 Route 28, South Yarmouth, MA 02664
508-398-2231 ext. 1261 Fax 508-398-0836
Permit Number -1 - Z
Date Issued
Expiration Date
$50.00
TRENCH PERMIT
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended)
THIS PE LMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Naawo(Appikant��� R.�r�,^�` Phone CCU
Street Addreee p O C3oX' 3 7l 51o7?. - o g o
Ckyfrown %(A ZIP
Naar of Excavator (if different from applicant) Pbom
Street Address���
Cityfrown MA I ZIP
Qb +. c. r-C.'\ � c 'g r- r� CeU
Sired Address StT2- 3cvi 0 S'
Uucrlpitoav loeall" and purpose of proposed tnnelu
Plesu dexrUw the exact location of the proposed trench and its Purpose (tocluda a description of what is (or is intended) to
be laid In proposed trench (el; pipea/cable Ilnm etc-) Please use reverse „ids if addiilonal space Is needed.
E lFf
0
� insurance C"ertifkat. tc �--�a�
i `faaw and Conran Inrornuibn or Insurer. �Lat•�CfSa-,U
Policy Egirallon Due:
ves we /:
Q of o - 3 oc�.=i3gy
Naaw of ComPeient Person la defined by 520 C'. IR 7.112;:
1 of 2
Maamc uWU HaWnB Licetw 0
wt 67
Lktnot Gnide _ E:Dintioo Data
BY SIGNING THIS FORM. THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CP.RTWY
THAT THEY ARE FAMILIAR WIM OR, BEFORE COMMENCEMENT OF THE WORK, WILL BECOME FAMILIAR
W rH, ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED. INCLUDING OSHA REGULATIONS.
G.L. a 82A, SM `CMR 7.00 d wq., AND ANY APPLICABLE MUNICIPAL ORDINANCES, BYLAWS AND
REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR
SUCH WORK WELL COMPLY THEREWITH IN ALL RESPECTS AND WITH THE CONDITIONS SET FORTH
BELOW.
THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND THE
EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER, AND ALSO, FOR THE
DURATION OF CONMUCTION, AUTHORIZES PERSONS DULY APPOIM M BY THE MUNICIPALITY TO
ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WITH THE
CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS COVERING SUCH WORK.
THE UNDERSIGNED APPLICAM', OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE
MUNICIPALITY IN CONNECTION WITH THIS PERMITAND TUB WORK CONDUCTED THEREUNDER,
INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OI STATE LAW AND CONDITIONS OP
THIS PERMIT, INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH, AND MEASURES TAKEN BY THE
MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO
COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED
NECESSARY BY THE MUNICIPALITY,
THE UNDERSIGNED APPLICANT, OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,
INDEMNIFY, AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYEES FROM
ANY AND ALL LIABILITY, CAUSES OR ACTION, COSTS, AND EXPENSES RESULTING FROM OR ARISING OUT
OF ANY INJURY, DRAM LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK
CONDUCTED UNDER THIS PERMIT.
APPLICANT SIGNATURE
DATE O
EXCAVATOR SIGNATURE (IF DIFFERENT)
DATE
OW ,N RE (IF DIFFERENT)
_ DATE: 7W10
2 of 2
r r TOWN OF YARMOUTH Building Department BUILDING
PERMIT NO 6-09
.. _ 474 _ . _ . (508) 398-2231 ext.261
'- _ �•• ISSUE DATE ; _ 10122/2008_ : PROPOSED USE
_ _ _ _ _ _ _ PERMIT
APPLICANT ;Ton'yKoski"""."""" j`J""'""'"' JOB WEATHER CARD
.............................
PERMITTO Repair
AT (LOCATION) 0-218SETUCKET RD ZONING DISTRICT R"40 Bldg. Type: Residential
SUBDIVISION MAP LOT BLOCK 1136.34 BUILDING IS TO BE: CONST TYPE 5"B USE GROUP R-4
LOT SIZE
take shell of chimney down due to spaulding rebuilt with new brick
REMARKS
AREA (SQ FT) EST COST ($)i$7,000.00 PERMIT FEE $100.00
OWNER IBOUCHER, ROBERT K BUILDING DEPT BY
ADDRESS 0218 SETUCKET RD
Yarmouth Port I MA 102675
INSPECTION RECORD
Date „ Dote Progress -Corrections and Remarks
CONTRACTOR
LICENSE CS SL56572
Koski, Tony
P.O. Box 1172
East Dennis MA 02641
5083855506
PHONE 15083940615
FIELD COPY
Inspector
M
J, ✓
R r, E V ESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
OCT 2 2 2008 1146 Route 28
South Yarmouth, MA 02664
By: BUILDIN (508) 398-2231 Ext. 261 ,n.. A
�J V
CONSTRUCTION ADDRESS: Lf&f-VCKQT JQd yi¢i2n1UuTK, A—
ASSFCSOR'S INFORMATION:
nr,J"
Map: Parcel:
�ouc/v�a Z/8 cfeTvcicer 7"
Permit _Q I
Fee S I
Permit eVifes 6 nrnths Gum
Lime date.
Sa8-.i'9yd6If—
MUM v PRESENTADDRESS TEL #
�
CONTRACTOR: TD�i �O,r a jo //7Z etf -PI—JZ Uf , / 14. ��- 3d'SSs06
NAME MAILING ADDRESS TEL#
twcsidential ❑ Commercial Est. Cost of Construction f 14
I Lome Improvement Contractor Lic. # Construction Supervisor Lie. # CS JL .S6.S7Z
Workman's Compensation Insurance: (check one)
❑ I am the homeowner ❑ 1 am the sole proprietor 1311 have Worker's Compensation insurance
Insurance Company Name: Worker's Comp. Policy# u%C d?27 I r .6-3
WORK TO BE PERFORMED
❑ Tent (Fire Retardant Certificate attached)
Duration Wood Stove Shed
D Siding: p of Squares D Replacement windows: #
DReplaeement doors: M
U Re -roof: # of Squares—
() Stripping olddsshinglesO () going ova layers orexisting roof ❑ Old Kings Ilighwayi)listoric District
%�%)+K� .S/�8� pT nG�i �sr �AGtJ ✓ �ili'C /�' s��v��iwy Roofm&Siding(Like fur lAe)
• _ �6aicf _Ldl�'_`�! _.✓mow _6.gr_/. _----------------------
lAwation of Facility
1 declare under penalties of perjury that the statements herein curtained are true and correct to the best of my knowledge and belief. I understand that any false answa(s)
will be just cause for denial or revocation ormy license and For prost9djon under KU.L Ch. 268. Section 1.
Date:
.Date:
,%pproved By:
Building Officiall (car designee)
uue:
Zoning District: 1�--t' V
l listorical District: Yes I ) No Flood Plain 7.tme: 0 Yes ) No
Water urce Protection District: Within4(M) ft. of Wcdands:
P es 1) No I `K 11 No
APPROVED
OCT 22 2008
YARM UTFi
OLD KING'S HIGHWAY
301
�' . '•
The Commonwealth ojMassaehusetts
-. Department oflndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.masf gov/dla
Workers' Compensation Insurance Affidavit: Buildera/Contractors/ElecMCians/Plumbers
Aoallcant Information Please Print Legibly
Name(Business/OrganiratioNlndividual):
Address: 169b. /17 z, P il3 �/^✓G �,¢�» Ef 171 , �. !��'.r/,�is� sn�—.
OZ6 yi
City/StatdZip: 1 'D.CiX1, Eiji%Phone /l:
Are ygu as employer? Check the appropriate box:
1. I am a employer with % 4. ❑ I am a general contractor and I
employees (tWl and/or part-time)." have hired the subcontractors
2. ❑ 1 am a sale proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required]
3. ❑ I am a homeowner doing all work
myselL [No workers' comp.
insurance required] t
listed on the attached sheet
These sub -contra tars have
employees and have workers'
comp. insurance.$
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, ¢1(4), and we have no
employees. [No workers'
comp. insurance required]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
3.1&emoudon
9. ❑ Building addition
10.❑ Electrical repairs or additions
1 L[] Plumbing repairs or additions
12.❑ Roof repairs
MaOther
Any applicant dot checks box a t ewt also fir out the section below showing their wmken' ennVelWtlon policy iniuenadoTM
t Homeowners who submit dda anidavit indicating they an doing all work and then trim outside contractors resat submit a new affidavit indicating arch
tiZontracton "check this box rust attached an additional sheet slowing the name of the subcontractors and sum whether or not thaw entities have
cnployea. !f ds subcontractors have enVloyees, they n wt provide their workers' comp. policy numbs.
Ian an employer that Is providing worriers' compensation Litsursace for my employees, Below Is files poly and fob site
Informatlox6
Insurance Company Name.
Policy q or Self -ins. Lic. Expiration Date: S- 7'Dy
Job Site Address- .Z I� cfETdC/f e T,, CityiState/Zip: Y lLv1PVTN hi 14
Attach a copy of the workers' compensation polity declaration page (showing the policy n mber and expiration date).
Failure to secure coverage as required under Section 25A of MOL c. 152 can lead to the irrposition 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 S250.00 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 coveraite verification.
! do hereby cerrljyWs► r6e ea� Ie psnaldts of
erjure that the Informaden provided above is &w and coff"
use only. Do not write to iftu area, to
or town offlclaL
/G Z y-4
City or Town: Permit/License tt
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone tl:
.nu wwVaL.A aae - "/ J' as luKaaa us a Ya101 JV.Q: .
t ' Board of Buildin;- Regulations and Standards
Construction Supervisor Specialty License
a License: CS SL 56M
Restricted to: 1A
ANTHONY P KOSKI
143 KING JAMES DRIPOBX 117
E DENNIS, MA 02641
\ .'; •' .,,; '; j �-G- —� i�� Expiration: 6/26/2010
• •. ' , (lommni,4.waer Tr#: 26992 ,.
1
GEORGE DAVIS /�4
BUILDERS, INC.
9 New Venture Drive, Unit A
phone (508) 394-0832
July 22, 2003
Mr. James Brandolini
Building Commissioner fxl -
Town of Yarmouth, MA 02664 -r,A
Re: 218 Setucket Road, Yarmouthport
South Dennis, MA
fax (508) 394-5460
Greetings Jim,
I am writing to request a bit of latitude with regards to your foundation inspection
procedures. We applied for, and were issued a building permit for an addition at the
home at 218 Setucket Road in Yarmouthport. Due to budgetary constraints, the client
made a couple of changes to the project. Though these changes will mostly certainly be
approved, they do require review by Historic, understandably. As such, I am told, your
department will not perform the site inspection until said approval is issued.
This concerns me for two reasons.
1. Safety - the client has an active 14 yr. old child. I would like to get this foundation
capped & backfilled as quickly as possible. Though we can certainly erect temporary
fencing, I doubt it would discourage an inquisitive mind. Secondly, the over -dig is
adjacent to an active driveway.
2. Timing — Like most builders, we are very busy and we schedule our time carefully.
Though perhaps I should have anticipated this development, I didn't. I do however
have several employees that count on me to keep working. If we are allowed to, we
would pour the slab, cap the foundation, and backfill the site. We could then continue
working on other aspects of the permitted project, such as changing the existing
windows, siding and aluminum trim coverage on the existing home.
Therefore, my request is that you instruct your Inspector to inspect the foundation.
Pending his approval, we would be permitted to proceed "at our own risk" with this
project. If this means we can go no further than cap, slab & backfill, that's okay; that
would take care of my most pressing concern, which is safety.
Thank you for you consideration, and I look forward to hearing from you.
Regards,
George Davis
George Davis Builders
9 :*A- A laffl-t.
We Make Your Dream HOMES Come True!
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CERTIFIED PLOT MAN
LOCATION ZIESET! ......... .C�l!7vvi
SCALE.. DATE
PLAN REFERENCE
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i✓EsrjoA/LJiavTN 19hus.
REGISTERED LAND SGRVEYOR
J�
- - - - - - - - - - - - - - - - --
SAWS: 27
4wr
IV
TW
2446
44' 1n
-1 '1 13'11 112 D16'
7'5 x 3'
-- - - - - - - _
-------------- Tw2446: i
PS 6 Slider
f
TW 2432
TW 0
2446
4'
Master Bedroom Shower
Master
Flush to Ceiling - Beam ,..
NAN
/1 3 -13/4" x 91/2"
LVL's Closet
— — — — — — — — — — — — — — — — — — — — — — —
Post �J\ Posts
/ Former bath
Wall converted to
TW removed walk-in closet
2446 \
0
0
I
I
I
I
Water
Closet
I I I Exist.
'v, I Back Bedroom "Re -configured" to Bath
accomodate laundry
I
� I
Closet Removed
-co -- --
I "
Existing Closet to rennin 1
I
TW 2446
\ I
\\ I
1
\\ Family / Diningrookm
I
\ I TW 2446
\ I
\ I
\ I .
\\ Flush to Ceiling - Beam
\ N[111
--- D 2-13/4"x14" —
\ Lt.'s — — — — —33/41
I
\ \ DW
I
Kitchen \ \ \
Entry
06 LI
I
I I
I I
I I
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TW 2446
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44'
f I I f
\\� r--�-7 ----------------------------------------------i
Place p.t. 2 x 4's vertically at 16" o.c., flush to the top of
I foundation, with bottoms following approxinwte final grade.
Field Determine, confir w/ G.C. during foundation setup. .
f-- — —
FOUNDATION NOTES:
16" x 8" Continuous keyed
footings - 3,000 psi
8" x 7'9" Concrete Wall - 3,000
psi
P x B" anchor bolts - 6' o.c. 4
Win 12" of corners
3" concrete slab - 2,500 psi
Damproof Below Grade
i--
8
8
ty
N
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t
'
y d
W
Go
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+-c
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0
TOWN OF YARMOUTH Building Department BUILDING.
. _ _ _ _ _ . _ _ , (508) 398-2231 ext.261
► PERMIT NO 102 B-03-4. ' PERMIT
= - 102 .
N ISSUE DATE :. - 5/16/03 _ .: PROPOSED USE
APPLICANT 'ROBERTKBOUCHER : JOB WEATHER CARD
ADDRESS 00218 SETUCKET RD PERMIT TO Addition
------------'
AT (LOCATION) 100218SETUCKETRD ZONING DISTRICT R-40
SUBDIVISION MAP LOT BLOC 1136.34 BUILDING IS TO BE USE GROUP R-4
LOT SIZE CONST TYPE &B CONTR'S
LICENSE ON130
addition: diningroom, familyroom, expended bedroomthath/closet, entry w/covered porch, CONTR'S NAM
REMARK remodel kitchentlaundry. Windows & siding as per plans dated 02/24103.
.01� Davis, George
AREA (SO FT) EST COST ($ $1 1, PERMIT FEE
OWNE ROBERT K BOUCHER
ADDRESS 100218 SETUCKET RD BUILDING DEPT BY
INSPECTION RECORD
FIELD COPY
Date
77 Wbite2P'"r`oTress - Corrections and Remarks
Inspector
7 -
A; a
'- of -ate
�c••),w &7cz
• •• pF'Y'`1!i
-r' • MAITAIME f
�ID
ONE & TWO FAMILY ONLY - BUILDING PERMIT ,
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLINCy
Town of Yarmouth Building Department
1146 Route 28 - Yarmouth, NIA 02664-1492
Tel: (508) 398-2231 x261 - Fax: (508) 398-0836
Office Use Only
Permit NoLZ ate wt
� /-
Permit Fee $ 3G91-1
�
Deposit Rec d. $�� Date t�
Net Due $ 3%,
Planning Board Information
3n Type
Endorsement Date
Recording Date
Plan No
Oilier
Assessors Department Information:
Map Lot Map Lot
/ °� 2 2
Old New
1.4 Prope Dimensions:
/(r 134
Lol Area(sQ Frontage(ft) Lot Coverage
This Section for Office Use Only
Building Permit Number: j
Date Issued:
Signature: d`3
Building Official ate
Certifica ' Occupancy.
'
is is not required
Section 1 - Information
I Use Group: R-4 Type: 5-B
1.1 Property Address:
218 Setucket Road, Yarmouthport
1.2 Zoning Information:
R-40 Res.
Zoning District Proposed Use
1.3 Building Setbacks (it)
Front Yard
Side Yards
Rear Yard
Required
Provided
Required
I Provided
Required
I Provided
0 -,
20 '2a
21'
20 01
+50'
1.4 Water Supply (M.G.L. c. 40. S 54)
Public xxxx Private
1.5 Flood Zone Information: Comments:
Zone: BFE:
Section 2 - Property Ownership/Authorized Agent
2.1 Owner of Record:
Robert Boucher /. V� �218 Setucket Road; Yport
Name (print) ^ .. (� Mal ing Address
,4 0615
Signature V
2.2 Authorized Agent: ^I
George Davis Ib� 9 New Venture Dr., S.Dennis
Name (print) Mailing Address f,,
Signatur `--------Tele7ibne
- Lkj3
i L:� i
Section 3 - Construction Services
3.1 Licensed Construction Supervisor:
George Davis
Not pp�icab e ❑
9 New Venture Drive, South Dennis, MA 02660
License Number056130
Address
3$4— 0 8 3 2
Expiration Date
3 / 1 / 0 3
Signatu Telephone
3.2 Registered Home Improvement Contractor:
Company Name
George Davis Builders
Not Applicable ❑
License Number
Address
9 New Venture Drive, South Dennis, MA 394-0832
Signature Telephone
Expiration ae
71;511u5
9-15-99 / 1of2 OVER
r°,ARC TOWN OF YARMOUTH
BUILDING DEPARTMENT
CONSTRUCTION SUPERVISOR FORM
PLEASE PRINT:
�•
Job Location: 21y S,`.�.�,, 1� , � �—O•
Number Street Village
Owner of Property: �'� `'` N-- ��`" I "� .
Construction Supervisor: 4vJ1 e C- 'Ddn/i S D-5-6 i3Z) 3T1-0-23 2--
Name License No. Phone No.
Address: lc /t�t.,,r V t s n� D(2 . S. Q�� �i t'lu&v
Licensed Designee:
(If other than Supervisor) Name License No.
2.15 Responsibility of each license holder:
2.15.1 The license holder shall be fully and completely responsible for all wort: 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:
have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.152
Yes [�J, No ❑
If you have checked M, please indicate the type coverage by checking the appropriate box.
A liability insurance policy 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 oKOwners Agent Owner ❑ Agent /1Sl`
Signature: 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: o,r, Est. Cost 1S121 1 o uo
Address of Work 21 51c f�f ; Y•
Owner Name:
Date of Permit Application: ► \ k---)) k
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job under $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:
Date Contractor Narne Registration No.
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above
property:
Date
Owner Name
El
O
The Commonwealth of Massachusetts
Department of Industrial accidents
ONCO011"WOS / JONS
600 Washington Street
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
locatiocim.n
. Bonn- phone a
O 1 am a homeowner performing all work myself.
O 1 am a sole proprietor and ha%e no one working in any capacity
p�j am an employer pro%iding workers' compensation for my employees working on this job.
L `
rsml2anv name:
address:
GEJf CE DiX1,3'
:. en urn UrIV0,.: 73�u-t—u�32
fitly S Denn°^ MA 02660 (r•nq� `i f1, n1n1y phone a l�
Incur tnce co b ^ e �' e-� ` polity It � �L u 1 r—��� 02—
o 1 am a sole proprietor. general contractor. or homeowner (circle one) and have hired the contractors listed below who have
the following %wrkers• compensation polices:
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of cringing peaaldes of a fiat up to S1,5N.00 and/or
one years' Imprisonment as wdl as civil penalties in the form of a STOP WORK ORDER and a not of $100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Otlice of investigations of the DIA for coverage verification.
I do hereby certify under she pains and penalties of perjstry that the information provided above is taste and correct
Print name , be 9-- Phone 0 313 3Z
official use only do not write In this area to be completed by city or town official
city or town: YARMOUTH _ permittlicense 0 nBuilding Department
pucensing Board
p check if immediate response is required 263 ❑Selectmen's Office
pHealth Department
contact person: phonto;_ (508) 398-2231 est. riOthcr
1,n tied IM PIA1
0
BUILDING
TOWN OF Y A R M O U T H ELECTRICAL
1146ROUTE28 SOUTHYARMOUTH MASSACHUSETTS02664-4451 GAS
Telephone (508) 398-2231, Ext. 261 — Fax (508) 398-2365 PLUMBING
SIGNS
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 Z 1 B e7:te14-%)"Ic ��
Work Address
is to be disposed of at the following location: S <T Sc c.o ,
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
Signat re of Applicant
Permit No.
01'-)ly 2
Date
From: Joe Madera 508-832-6007 To: George Davis
Date: 4/1/2003 Time: 2:37:10 PM Page 1 of 2
■
WISE- BC CALCO 2002 DESIGN REPORT - US Tuesday, April 01,2C031436
File
' Double 1 3/4" X 14" VERSA -LAME) 3100 SP
Name - G Dads Boucher.BCC : RBC2
Job Name - Boucher
Description - Beam atlGtchen
Address -
Specifier -
City, Sate, Zip -
Designer - Joe Madera
Customer - George Davis
Company - SHEPLEY WOOD PRODUCTS
Code reports - ICBO 5512, BOCA 9B-52, SBCCI 9852
Misc -
General Data
Version:
Member Type:
Number of Spans
Left Cantiever
Right Cantilever
Slope
Tributary
Repetitive
Construction Type
Live Load
Dead Load
Part load
Duration
US Imperial
- Roof Beam
-1
- No
- No
0/12
ill-00-Do
n/a
n/a
25 PSF
15 PSF
0 PSF
115
Disclosure
The completeness and accuracy of
the Input must be verified by anyone
who woUd rely on the output as
evidence of sulabiCty for a particular
application. The output above Is
based upon building code -accepted
design properties and analysis
methods. Instalation of BOISE
engineered wood products must be
In accordance with the current
Instalation Guide and the applicable
building codes. To obtain an
Installation Guide or If you have any
questions. please call
(800)232-0788 before beginning
product installation.
BC CALCe, BC FRAMER®, BCID,
BC RIM EOARDTM, BC OSB RIM
BOARDm, BOISE GLULAM m,
VERSA -LAM®, VERSA-RIMD,
VERSA -RIM PLUSIA,
VERSA-STRANO* ,
VERSA-STUDO, ALLJOISTO and
AJSTM are reg!stered trademarks of
Boise Cascade Corporation.
Total Horizontal Lenyh-15-03.00
Load Summary
ID Description Load Type Ref. Start End Live Dead Trib. Dur.
S S'andard UnfArea Load left 00-00-00 15-06-00 25 PSF 15 PSF 12-00-00 115
1 ce,ling UnfArea Load Left 00-00-00 15-06-00 20 PSF 10 PSF C6-06.00 100
Controls Summary
Control Type
Value
%Allowable Duration
Loadcase
Span Location
Moment
20685 ft-Ibs
61.9% G 115%
3
1 - Internal
End Shear
4534 Ibs
41.6% Q 115%
3
1 - Left
Total Deflection
L/332 (0.559")
54.1%
3
1
Live Defection
U533(0.349")
45.0%
3
1
Max. Dell.
0.559' (Umit: 1")
55.9%
3
1
Span!Dep91
133
1
NOTES:
Design meets Code minimum (L/180) Total bad deflection criteria.
Design meets Code minirrum (L240) Uve load deflection criteria.
Design meets arbitrary (1 ") Ma)dmum load deflection criteria.
Minimun bearing length for 80 is 1-314".
Minimum bearing length for B 1 is 1-3/4".
Entered/Displayed Horizontal Span Lergth(s) = Clear Span +• 12 min. end bearing + 1re Intermediate bearing
Member Slope = 0, cons,der drainage.
Page 1 of 1
From Jce Madera 508.832.8007 To:. 3eorge Davis Date: 4!t/2003 Time:2:37.10 PM Page 2 of 2
v
RAISE- BC CALCO 2002 DESIGN REPORT - US Tuesday, April01, 2CO31436
File
Triple 1 3/4" x 9 112" VERSA -LAMS 3100 SP Name - G Darls_Bcucher.eCC : RSC1
Job Name - Boucher Desaiption -
Address - Specifier
City, Sate, Zp - Designer - Joe Madera
Customer - George Davis Company - SHEPLEY WOOC PRODUCTS
Code reports - ICBO 5512 BOCA 98.52, SBCCI 9852 Misc -
12
AL
BO
3657 bs LL
2095 Ibs DL
13.06-CO A
Bi
9153 bs LL
5510 bs DL
Tolai Horizontal Length- 22-03-00
09-001-00
B2
2457 W LL
843lbs DL
General Data
Load Summary
Version: US Imperial
10 Description Load Type Ref. Start
End Live Dead Trib.
Dur.
S Standard Unf.Area Load Left 00-OC-00
22-00-CO 25 PSF 15 PSF 14-00-00
f 15
Member Type: - Roof Eeam
1 attc Unf.Area Load Left 00-00-03
22-00.00 20 PSF 10 PSF C7•CO-00
100
Number of Spans -2
2 shed roof UWArea Load Left 00-00-00
22-CO-00 25PSF le PSF C6-G0-00
115
Left Cartl'ever - No
RightCenbleyer - No
Controls Summary
Control Type Value %Allowable Duration
Loadcase Span Location
Slope 0/12
Moment 17888 ft-Ibs 74.3% Q 1150%
3 1- R ght
Tritutary 14-00-00
End Shear 4942 is 44.6% Q 115%
4 1 - Left
Repetitive Na
Cont. Shear 7427 ibs 67.0% Q 116%
3 1- R'gnt
Constructon Type We
Uplift -210 Ibs
4 2 - R gM
Total Deflection Lr263 (0.615") 68.3%
4 1
Live Load 25 PSF
Uve Defection L/;99 (0.406") 60.1%
4 1
Dead Load 15 PSF
Total Neg. Deft -0.11" 14.6%
4 2
Part Load 0 PSF
Max. Del. 0.615" (Unit V) 61.5%
4 1
Dure9on 115
SpallDepth 17.1
1
Disclosure
CAUTIONS:
The completeness and accuracy of
Upliftof -210 Ibs found at spa12 - Right.
the irput must be verified by anyone
who would rely on the output as
evidence of su;tatility for a particular
NOTES:
application. The output afore is
Design meets Code mlniman (U180) Total load deflection criteria.
based upon budding code -accepted
Design meets Code minimum (U240) Lve load deflection criteria.
design properties and analysis
methods. Installation of BOISE
Design meets aroitrary (1") Maximan load deflection criteria.
wood products be
Minimum bearing length for BO Is 1-1/2".engineered
nt
in accordance with the current
Minhur beaing � len for B1 !s 3-1W.
Installation Guide and the applicable
Minimum bearing length for 62 Is 1-1R".
building codes. To obtain an
Entered0splayed Horizontal Span Length(s) = Clear Span + 1,2 min end bear.ng + 1R ante- sedate bearing
Installation Guide or If you have any
Member S ope = 0, consider drainage.
questions, please car,
(803)232-0788 before beginning
product Installation.
BC CALCO, BO FRAMERO. SCID,
BC RIM EOARDTM, BC OSB RIM
BOARD^' BOISEGLULAMTM.
VERSA-LAMOD, VERSA -RIM®,
VERSA -RIM FLUSID,
J
VERSA-STRANDTm
L
VERSA•STUDO.ALLJOISTOand
tj
AJSTM' are reg stared tademarks of
1D 2�p3
Boise Cascade Corporation.
3v
Page 1 of 11
■
BOISE'
BC CALCO 2002 DESIGN REPORT - US Friday, February28, 20M 1&56
Single 1 3/4" x 8112" VERSA -LAND 3100 SP Name - George Dav's 8ou:her.BCC : FBOl
Address acme - Deaeriptien _ Hipped porch root cantlever
Specirier
City, State, Zip - Designer - Joe Craight:ri
Customer Company - Shepley Wood Products
Code reports • ICSO 5512. BOCA 98-62, SSCCI 9652 Misc - Eng. Wood (506) C624=1
`Po1zc-'A `'Z o
�e�i'Ipfi �;, ¢': nia'ir �'• � �}� � M� � '..I I:b,",'��•,: ,:. 'f� d'��o. ,I,fil:.'r` ,$��I11I+���»'ii � 11 '4 t{.
12OD-0d
BO
-50 Ibs LL 2008lbs LL
-5 lbs DL 170lbs OL
Total Horizontal Length-16.00.00
General Data
Load Summary
Versbon: US Imperial
ID Descrfptlon Load Type Ref. Start End Live Dead Trib. Dur.
S Standard UnfAca Load Left OD-00-W 16-00-00 0 PSF 0 PSF 12-M,00 100
Member Type: - Fleor Beam
1 conservative Conr-Pt. Load Left 16-OM 16-D"o 1501tu go The rea 115
Number of Spans -2
Left Cantilever - No
Controls Summary
Right cantilever - Yes
Control Type Value % Allowable Duration Loadcase Span Location
Moment 997fMb6 11VA
Slope 0112
End shear - 9 Ibs 1.6% Ca 116% 3 1- Left
Tributary 12-MCO
CcnLShear 255lbs rig% 0115% 3 2-Left
Repetitive rva
Uplift .55lbs 3 1-Left
Construction Type n'a
Total Deflection 2xU598 (0.1377 25.3% 3 2
Live Deflection 2xU1065 (0.053j 33.21A 3 2
Live Load 0 PSF
Total Neg. Deft-0.055" 11.05A 3 1
Dead Load 0 PSF
Max Deg. 0.13r (Limit v) 13.7% 3 2
Part Load 0 PSF
Spon/Depth 182 1
Duration 100
CAUTIONS:
Disclosure
Uplift of -bS its found at span i - Left
The completeness and accuracy of
the Input must be verified by "one
who would rely on the output as
NOTES:
evidence of suitability for a
Design meets Code minimum (1.1180) Total load deflec tlon criteria for cart lever spans due to roof loads.
particular application. The output
above is based upon building
Design meets Code minimum (U180) Total toad deflection criteria for non-eanrilever spans.
code -accepted design properties
Design meets Code minimurr. (L/240) Live load deflection crl:aria for cantilever spans due to roof bads.
and analystsmethods, Installation
Design mass Code mt lmurr (L=0) live Wad deflactcn criteria for rrcncandever spans.
en
of BOISE engineered wood
Design meets arb lira 1- MaArnum load deflection criteria.
� ry ( )
products must be in accordance
Minimum bearing length kr BO is 142'.
with the current Installation Guide
Minimum bearing length fcr 81 is 3-.
and the applicable bui4rq coves,
Entered/Displayed Horizontal Span Length(&) ■ Clear Span + W min. end bearing 112 lnlemradv9a bearing
To obtain an Installation Guile of 9
Iou have a.1y questions, please call
(S00)232-0786 before beginning
product ins'illatiom
SC BC RIM BOARDv. OC 60 OSB I®,
IIh"
BOARD", BOISS GLLLAMTv,
t
VERSA-LAM4P, VERSA -RIM®,
VERSA -RIM PLUS®.
2003
L
Ly�
VERSA -STRAND^',
VERSASTUDO, ALLJOLST3 and
AJST" are registered trademarks of
Bolas Cascade Corporation.
Page 1 of 1
T'd 95S'CN S3-IHS A3_1d3HS Wdt,0:9 Ee02*82*83d
PROPERTY ADDRESS: 1 S S' -roct(f r I .
l3Lfay -
:ALCULATION F_O_ R PERMIT COST TYPE OF ROOM ETC
ADDITION
ALTERATIONS
(o 9 6 BATH,
3� BED ROOM
CERTIFICATE OF OCCUPANCY
Ri-T[.2, i�m s�� COMPUTER ROOM
3 I Z • DECK OPEN
tolt` a0A/ _ DECK WITH ROOF
S! D� N� �� � .DEMOLITION
17�P' DEN
___..... DINING ROOM
FAMILY ROOM
FIREPLACE
FOUNDATION ONLY
GARAGE NO. OF BAYS
GREAT ROOM
KITCHEN
(LAUNDRY ROOM
LAUNDRY ROOM
OFFICE
PORCH CLOSED
PORCH OPEN
REROOFING
SHED
STORAGE AREA
SUN ROOM HEATED
SUN ROOM UNHEATED
SWIMMING POOL ABOVE GRO
SWIMMING POOL INGROUND
WINDOW REPLACEMENT
03 TOWN OF YARMOUTH
BUILDING DEPARTMENT
BUILDING PERMIT APPLICATION DEPARTMENTAL SIGN OFF
TRANSMITTAL SHEET
Building Site Location �/8 „(C.�r %C�( v,f Map No: /3LLot No: 3�
"0
The Building Department will be responsible for assisting the appla�spatching your plans and or application to the following
applicable departments.
IDENTIAL AND/OR COMMERCIAL BUILD
WATER DEPARTMENT: Determines Compliance of Water Availability and or existing location.
ENGINEERING DEPARTMENT: Determines Compliance for Parking and Drainage.
CONSERVATION CONMUSSION: Detamines Compliance to Wetlands Acts; i.e., If Lot(s) Border any Type of
Wetlands, Streams, Ponds, Rivers, Oceans; Bogs, Bays, Marshland, Etc
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
FIRE DEPARTMENT: Determines Compliance to State and Town Requirements for Personal
Safety, Property Protection; i.e., Smoke Detectors, Sprinkler Systems, Etc.
REVIEWED BY:
1. WATER DEPARTMENT: DATE: N/A
2. ENGINEERING DEPARTMENT: DATE: N/A
3. CONSERVATION: / DATE 1 U—O Ac
4. HEALTH DEPARTMENT: DATE: N/A:
INDUSTRIAL AND/OR COMMERCIAL PERMITS
S. WIRING INSPECTOR: DATE: N/A:
6. PLUMBING INSPECTOR DATE: N/A
7. FIRE DEPARTMENT: DATE: N/A:
COMMENTS:
RECEIPT OF COPY:
PLEASE NOTE
SIGNATURE OF APPLICANT: DATE:
Whft co" -BaJdwgDepL- Pmtcopy -WatcrDept. - YeWwCopy - HcalM >W- - Pok Cow -E%gDTL . �-Fire Depicc�*a_b'm !
Building Site Location:
TOWN OF YARMOUTH
BUILDING DEPARTMENT
BUILDING PERMIT APPLICATION DEPARTMENTAL SIGN OFF
TRANSMITTAL SHEET
OV3 Map No: 43 Lot No: 3
The Building Department will be responsible for assisting the applfcditC 4ispatching your plans and or application to the following
applicable departments.
RESIDENTIAL AND/OR COMMERCIAL BUILDING
WATER DEPARTMENT: Determines Compliance of Water Availability and or existing location.
ENGINEERING DEPARTMENT: Determines Compliance for Parking and Drainage.
CONSERVATION COMMISSION: Determines Compliance to Wetlands Acts; i.e., If Lot(s) Border any Type of
Wetlands, Streams, Ponds, Rivers, Oceans, Bogs, Bays, Marshland, Etc
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
FIRE DEPARTMENT: Determines Compliance to State and Town Requirements for Personal
Safety, Property Protection; i.e., Smoke Detectors, Sprinkler Systems, Etc.
.....................................................................................................................................................
REVIEWED BY:
1. WATER DEPARTMENT: DATE: N/A:
2. ENGINEERING DEPARTMENT: DATE: N/A:
3. CONSERVATION: DATE: N/A:
4. HEALTH DEPARTMENT: DATE: N/A:
INDUSTRIAL AND/OR COMMERCIAL PERMITS
S. WIRING INSPECTOR DATE: N/A:
6. PLUMBING INSPECTOR: DATE: N/A:
7. FIRE DEPARTMENT: DATE: N/A:
PLEASE NOTE
COMMENTS:
RECEIPT OF COPY: SIGNATURE OF APPLICANT: DATE:
White copy - Building Dept - Pink copy - Water Dept - Yellow Copy - Health Dept - Pick Copy - Pig Deft • Goldwod - Fire MptlConsavatim
TOWN OF YARMOUTH BUILDING DEPARTMENT
PLAN REVIEW & BUILDING PERMIT APPLICATION REVIEW NOTES '
ADDRESS: 02 /� �ir� v G k 7—
Map / Lot: / 3 613 .
Date of Initial Review:.. / /31 /O 3 ... Other. Approval Date:
Inspector. ►f
NOTES:
l App 4I%i % /%�• , %tea c �( (JN D Gn l�i�w S�f)-�3
kU(N D otu 4-r-1'vG T-N .rjy f%gArt�ovs .coca r/o.v
y� 20V,
oiz- Po-rl; am L X /sT-I.w-r- f/�r�-r•.,r� ,��io�n /fr�G
e
Toning Denial (if applicable):
Section 1043.7„ pars Change, Extension or Alta ation (pttiAmdsting,
nonconforming)
..requires a�5pecial Permit from-the-Z,o�g Boardof Appeals. - .
Other
Building Code Denial (if applicable)
R". I1.01
w*' .".\YIGY ./Myyq. �IaM.l. �.r�..1Yy..J�1" n..r.++�..+.�..r�M��1in+M..w.i r:w/'►�++Y`/��i+I YA+.N�-M.y".'1'��"rM'MK/
.o� Y R p3• �'� TOWN OF YARMOUTH
oury �� BUILDING DEPARTMENT
�, �--w• BUILDING PERMIT APPLICATION DEPARTMENTAL SIGN OFF
T
TRANSMITTAL SHEET
Building Site Location:
Proposed Improvement:
arJr•W+! rwr+'�trf N
No /3L Lot No:
,:?9V oe-30-1�
Address: CI �U 12a, 4240 �_ �, �riiri Tel.No.: 3 ;Y 0k3.)- Date Filed: bY 0
The Building Department will be responsible for assisting the appl{fr�4ispatching your plans and or application to the following
applicable departments.
RESIDENTIAL AND/OR COMMERCIAL BUILDING
WATER DEPARTMENT: Determines Compliance of Water Availability and or existing location.
ENGINEERING DEPARTMENT: Determines Compliance for Parking and Drainage.
CONSERVATION COMMISSION: Determines Compliance to Wetlands Acts; i.e., If Lot(s) Border any Type of
Wetlands, Streams, Ponds, Rivers, Oceans, Bogs, Bays, Marshland, Etc
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
FIRE DEPARTMENT: Determines Compliance to State and Town Requirements for Personal
Safety, Property Protection; i.e., Smoke Detectors, Sprinkler Systems, Etc.
.....................................................................................................................................................
REVIEWED BY:
1. WATER DEPARTMENT: DATE: N/A:
2. ENGINEERING DEPARTMENT:
3. CONSERVATION:
4. HEALTH DEPARTMENT:
5. WIRING INSPECTOR
N/A:
6. PLUMBING INSPECTOR DATE: N/A:
7. FIRE DEPARTMENT: DATE: N/A:
PLEASE NOTE
COMMENTS:
RECEIPT OF COPY: SIGNATURE OF APPLICANT: DATE:
White copy - Building Dept - Pmk copy - Water Dept - Yellow Copy - Haft Dept - Pmk Copy - Fa1 =4 Brpt - Goldenrod - Fire Dq*Coawvatwn
• TOWN OF YARMOUTH
Building Department
Town Hall
Yarmouth, MA 02664
(508) 398.2231 ex1261
BBUILDING PERMIT
APPLICATION RECEIPT
Temp Permit No.: T-03-321
Applicant Name: George Davis
Location: 00218 SETUCKET RD
Owner's Name: ROBERT K BOUCHER
Owner's Addres 00218 SETUCKET RD
Yarmouthport I MA 02675
Owner's Telephone: (508) 394-6015
(OFFICE USE ONLY
Recorded By:
Ic
Permit Fee:
$0.00
Deposit Rec:
$25.00
Payment Type:
Check ChkNo.: 12474
Net Owed:
($25.00)
Application Date: 1/17/03
Issue Date:
Expiration Date
Comments: /
addition: diningroom, familyroom, expanded
bedroom/bath/closet, entry w/covered porch,
remodel kitcheMaundry. Windows & siding
ZONING APPROVED
7
This is NOT a building permit. Application subject to plan review. Contact Building Department for permit status. Official
Building Permit will be issued upon plan review completion, approval, and complete payment of Net Owed on Permit Fee.
Date Printed: 1/23/03
�1..1..a."�• i ✓.ox r,.2r .. �.1"'f, f. 1\. I. ...1'" ,,,Tli • _ s<u .. .. i.l.'. .. !a._i Ji.- `n. �`.,
3 O�.YgR�r
0 C '/
O H
Building Site Location:
Proposed Improvement:
Off• �'� TOWN OF YARMOV
BUILDING DEPARTMENT
C:P/
BUILDING PERMIT APPLICATION DEPARTMENT.
TRANSMITTAL SHEET
2 ! n'q
yarn'lou:h "dater Dept.
No: 136 Lot No: 3L
p v
Address: CI 'La) 7) 7, IL a —L st�yy+v_� - TelNo.: 3 !�/ 0 k3)- Date Filed:
The Building Department will be responsible for assisting the appllca rY6 ispatching your plans and or application to the following
applicable departments.
RESIDENTIAL AND/OR COMMERCIAL BUILDING
WATER DEPARTMENT:
Determines Compliance of Water Availability and or existing location.
ENGINEERING DEPARTMENT:
Determines Compliance for Parking and Drainage.
CONSERVATION COMMISSION:
Determines Compliance to Wetlands Acts; i.e., If Lot(s) Border any Type of
Wetlands, Streams, Ponds, Rivers, Oceans, Bogs, Bays, Marshland, Etc
HEALTH DEPARTMENT:
Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
FIRE DEPARTMENT:
Determines Compliance to State and Town Requirements for Personal
Safety, Property Protection; i.e., Smoke Detectors, Sprinkler Systems, Etc.
---•---------------- ••-------.-.-.....-......--.-....-...---..--...-..........-...............------------........................---........
REVIEWED BY:
1.
WATER DEPARTMENT:
DATE:
- 23 N/A:
2.
ENGINEERING DEPARTMENT:
DATE:
N/A:
3.
CONSERVATION:
DATE:
N/A:
4.
HEALTH DEPARTMENT:
DATE:
N/A:
INDUSTRIAL AND/OR
COMMERCIAL
PERMITS
5.
WIRING INSPECTOR:
DATE:
N/A:
6.
PLUMBING INSPECTOR
DATE:
MA:
7.
FIRE DEPARTMENT:
DATE:
N/A:
COMMENTS:
RECEIPT OF COPY:
1i-pn"hl�Y11�
SIGNATURE OF APPLICANT: DATE:
Whac cM -Budding Dcpt. - PmkcM -WakrDTL - YdlowCopy-H=MDTL - Pink Copy -EngiamingDcpt. - Goidrmod-FmDep Coawvadon
Y I -
JA.FI ? ' 2003
t 'r % �G � � 't
s
"AS BUILT" PLOT PLAN
TO THE BEST OF MY INFORMATION, yATZ.-+o iTN MASS.
i KNOWLEDGE, AND BELIEF THE Lo r 37, I_ 29
fb✓,•'V,? rno.,) <.SHOWN ON THIS
e PLAN HAS BEEW 'LOCAT'I ON THE °� OHEAf?N /lI/C.
SWAN RIVER PLAYA
GROUND AS INDICATED. 35 ROUTE 134, UNIT 2
SOUTH DENNIS, MASS. 02660
��
r •� ,-, _ -
TE �
zy
SCALE:
6`
�
B N0.
r,))
TJo -_- 3 t
CLIENT:
i DATE
REGISTERED-1 AND SURVEYOR
. BY
SHEET
OF _..'
1 � A
f�r� 1977
'.TO THE BEST OF MY INFORMATION,
KNOWLEDGE, AND BELIEF THE
Co✓.won rro.J ,SHOWN ON THIS
a PLAN HAS BEEN' 'LOCATO ON THE
GROUND AS INOICATED.
'I
DATE REGISTERED LAND SURVEYOR
Old King's Highway Regional ITistoric District Committee
in the Town of Yarmouth for a
CERTIFICATE OF APPROPRIATENESS
Application is hereby made in triplicate, for the issuance of a Certificate of Appropriateness under Section 6
of Chapter 470, Acts and Resolves of Massachusetts, 1973, for proposed work as described below and on
Plans, drawings or photographs accompanying this application for. ,_ ..
CHECK CATEGORIES THAT APPLY:
I. Exterior Building Construction: p New Building O Addition p Alteration so FF�-13 AM 9:25
Indimte type of building: CI House 0 Garage 13 Commercial 0 other
2. Exterior Painting: p _ . • `-_ . , .
3. Signs or Billboards: p New Sign 17 Existing Sign 0 Repainting existing sign
4. Structtae; ❑ Fence Q wall CI Flagpole p Other
TYPE OR PRt\T ucni Y DATE l2 — 10
ADDRESS OF PROPOSED WORK Z I t3� .ASSESSORS MAP NO._L?,(,_
OWNER Ra%741J1 V2.>O j .. A Y I�tit-
—ASSESSORS LOT NO.___J�
HOME ADDRESS -ZAP, Sim++, r. _+r too . TELEPHONE NO. 394-0E.1S
AGENT OR CONTRACTOR—. Uto r�GL �,.i; S TELEPHONE NO 39�(
USE ATTACHED SHEET IN PACKET FOR ABUTTING OWNERS
Y1;RV,DUQYNRD
DETAILED DESCRIPTION OF PROPOSED WORK Give all particulars of cork to be done including materials to
be used. In case of signs, give locations of existing signs and proposed locations of new signs. (Attach additional sheet, if
necessary).
�t P-►��"�- f t7� ��wn5. (2.r�1�ut all t.u„�w,•
Signed
Span: helow line for Committee use only Ow -Contractor-Agent—
Received by OKHC
Date %n��
Check # /' /_ 2
APPROVED
is
0 11"ORTANT: If Certificate is approved, approval is
provided in the Act.
D/0 3
the 10 day appeal period
DISAPPROVED p Please return to: Yarmouth OKHC District Committee
Yarmouth Town Hall, 1146 Route 28, S. Yarmouth, MA 0266.1
FILE COPY BILE COPY �46
SPECIFICATION SHEET (YARMOUTH OKHC) - SUBMIT 3 COPIES
Please fill out the form in its entirety providing color chips where
"eces=, INDICATELAAWCAPING, EkTERIOR LIGHTING & ELECnUCMETER ONSITEPLANS
FOR NEIY Ou
NAME OF OWNER(S):-�'�-�
FOUNDATION (Ism MAX EXPOSED): ONCRETE/O DRIVEWA . ,03 FP 13 AM 9:28
WALK WAY: STEPS (INDICATE BRICK/CEMENT/OTII ):
SIDING TYPE:���j-elk eS h,<<uc1n< < f COLOR:
CHIMNEY (INDICATE i C S CCd/WOO AC D) - ��cw� COLOR:
ROOF MATERIAL: PITCH (7/12 MIN.) COLOR: rJc fit-,
1'l vaxc c� 'Lyt %� MAX. EXP.
WINDOWS (GRILLES REQUIRED) -INDICATE SIZES IF NOT LISTED ON ELEVATIONS:
P45- q mq- >
DOORS (INDICATE SIZES AND STYLE IF NOT LISTED ON ELEVATIONS): COLOR: N Pv-.tc.ak
TRIM: (ALL WINDOWS & DOORS TRIMMED WITH IX4 / IX5)
MATERIAL OF TRIM: (WOOD, VINYL, ALUMINUM)
SHUTTERS (WOOD/VINYL) (PANELED/LOUVERED)
GUTTERS (WOOD/ALUM):
GARAGE DOORS: SIZE & STYLE:
STORM WINDOWS & DOORS: /V/or
(INDICATE SIZES IF NOT LISTED ON ELVATIONS)
SKYLIGHTS: TYPE/SIZE: /u6
DECK: SIZE & MATERIAL: ?6u-z-or s-
FENCING (MAX. HEIGHT 61: STYLE:
(SHOW LAYOUT & RUNNING FOOTAGE ON SITE PLAN)
COLOR: j-),r,,,".4
COLOR:'-,�;,�
COLOR: t-A "4-ei
COLOR:
U�
COLOR:
COLOR:
COLOR: i
COLOR: —
RETAINING WALL: (P.T. OR FIELDSTONE -CONCRETE INAPPROPRIATE)
(SHOW LAYOUT & RUNNING FOOTAGE ON SITE PLAN)
Lct�,L i3c)u') d� s 1 �-D t1g h e ri� s1
SIGNS: (indicate size, style, colors) COLOR:
SIGN POST: (indicate size, style, color)
ADDITIONAL INFORMATION:
COLOR:
REV. 6/99
TOWN OF YARMOUTH
OLD KING'S HIGHWAY REGIONAL HISTORIC DISTRICT COMMITTEE
SYNTHETIC SIDING GUIDELINES
While applicants are encouraged to use building materials indigenous to the area, the use of
vinyl and other types of synthetic siding may be allowed by the committee, if deemed
appropriate, provided that the following guidelines are agreed upon and adhered to by all
applicants and their agents. It is ultimately the applicant's responsibility to ensure that the
following criteria are met regarding the installation of vinyl siding and other vinyl or synthetic 103 FEB 13 44 9:26
products. (Refer to OKH Bulletin Guidelines)
The installer must appear at the hearing, and owner/applicants are strongly u
to attend.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
The applicant must be made aware —by the installer —of the hazards posed by its use.
That proper steps must be taken to insure that all rotting or decaying wood be removed
prior to installation.
That all termite, carpenter ant, or other insect infestation must be eliminated prior to installation.
Flaking and peeling dry rot be removed and features to be restored.
Appropriate steps shall be taken to insure that the particular synthetic siding being installed
has adequate ventilating holes to allow proper breathing.
That the original wood detailing and ornamentation of the building be preserved, and the
edge of the synthetic siding must be sculpted so as to properly fit the existing wood
molding.
That the synthetic siding be of sufficient quality and design to protect and preserve the
future appearance and historic integrity of the building in a manner that will not negatively
distinguish it from other buildings in the neighborhood.
Synthetic siding shall follow manuficturer installation instructions.
• • • No pieces less than 48" shall be used in the installation except as the design of theli�
structure allows. All seams, to whatever extent possible, shall be lapped away from the APPROVED Il primary view of the faVade. YA,iG;0i11H COi.;:,? I iiP
' • *All vinyl siding shall be installed per Vinyl Siding Institute (VSI) guidelines. Vinyl C;;f In t)
siding shall be a minimum of .042 gauge and from the same dye lot or carry a U
manufacturer's warranty against "checker boarding." All vinyl siding shall have a brush
stroke finish with no visible "J" channels. Face nailing of vinyl siding is not allowed.
Vinyl soffits are not encouraged. A straight flat soffit profile is preferred.
Include soffit type with incorporated venting on your application.
We, t e undersigned, hereby agree to the above conditions except as stated in #12.
Applican Date
7"4 1� 2PA9
Agent/Installer Date
A -
SPA Q�\
ON
- Np...+•.4.
i
Y�
X
0
S�;t3
.00
.00
103 FM L8 wa 9::
zoo
f IV s /oP sf o.. ,00n..✓ is 8.2 �Qaur
TO THE BEST OF MY INFORMATION; "AS BUILT" PLOT PLAN
YAK--���T�+ MASS.
KNOWLEDGE, AND BELIEF THE Lo r 32, �. � 3J0, _ -9
Ce✓.,Jv,? na.J .SHOWN ON THIS
e PLAN HAS BEEW.AOCAT0• ON THE R. ✓. OHEARN /NC.
t SWAN RIVER PLAZA
j GROUND AS IN616AT6. 35 ROUTE 134, UNIT 2
1 :...c•; _% SOUTH DENNIS, MASS. 02660
OAT
Ei SCALE:
°8 zt 86 •`x su_��' JOB NO. Zoo'— L CLIENTS
DATE REGISTERED LAND SURVEYOR DR. BY,vj -A I S ^ �
r
11
AN 9:26
- - - - - - - - - - - - - - - - J
All
BONN! oil
In
Windowswl new,
sanw. size
new, same size
218" x 6'8" 9-lice style door, w/
12" 3-lice side panel
FRONT ELEVATION Existing Proposed (chimney exists)
103 FEB 1 rm 9:27
h
L
o
m
Ss+-
Q =
o
u
me
�
,�
REAR ELEVATION
Zia^ =11-0°
103 FEB 1 as 9:27
co
g
N
L 46
m0.
6�
c 5 Casings (typical)
x 5 Corners (match)
' 903 FEB
t:
� iA
H
9-
0
$
}
m
o
mc
9-}
Q
Z
�
Ca Q
9:27
i
LEFT ELEVATION
Cu
i
-'03 FEB 13 y 9:27
N
�p
S
N
Y
cs
u
A
ix
8
N
H
c.
c
+-
co
g
N
� =
a
Q
w
o
co Q
e
� R �ti i 0 l-
ip
Old King's Highway Regional Historic District CommftzeeJ` J TH+h'
Ci__RK
in the Town of Yarmouth for a
203 1,UG 14 1ui 9: 30
CERTIFICATE OF APPROPRIATENESS D C r
Application is here made in triplicate,for the issuance of a Certificate of pr E C E VE�
A4p byAppropriateness under ection 6
of Chapter 470, Acts and Resolves of Massachusetts, 1973, for proposed work as described below and on
Plans. drawings or photographs accompanying this application for.
CHECK CATEGORIES THAT APPLY:
1. Exterior Building Construction : 0 New Building Addition 0 Alteration
10A type ofb mWmg: 0 house 0 Garage C1 cal 0 Other
2. Exterior Painting: 0
3. Signs or Billboards: 0 New Sign 0 Existing Sign 0 Repainting existing sign
4. Struct 0 Fence 0 Wall 0 Flagpole 0 Other
T]TEORPRWrLEGIBLY DATEGQ. f 2
ADDRESS OF PROPOSED WORK 2 t SeT aC1=c r 2 D ASSESSORS MAP NO.3L
OWNER Rt --QT (a , LG! IMP ASSESSORS LOT NO.
HOME ADDRESS ,?14 SC -I t KET 121�) yPST HA TELEPHONE NO.
02.�7S-
AGENT OR CONTRACTOR CoC-026G TELEPHONE NO 3a -0�-���
ADDRESS ? PiE-0 V t4 �LLPe D9�(-
..-_ USE ATTACHED SHEET IN PACKET FOR ABUTMG,OWNERS
DETAILED DESCRIPTION OF PROPOSED WORK Give all particulars of work to be done including materials to
be used In case of signs, give locations of cisting signs and proposed locations of new signs. (Attach additional short, if
y)-
pPPRO'��-D p�
YARMDUTN COtx1n11j1���
Signed
Owner ontractor-Agent
Space below line for Committee use only.
Rexeived by OKHC
D;
Ch
By
Al
DISAPPROVED
provided in the Act.
0 Please return to: Yarmouth OKHC District Committee
Yarmouth Town Hall, 1146 Route 28, S. Yarmouth, MA 02664 31
i- of
4�(1
34PAIU)
SPECIFICATION SHEET (YARMOUTH OKHC) - SUBMIT 3 COPIES
Please fill out the form in its entirety providing co/q.., chips where
' IIeCeSSQJJ''�)77. INDIG4TELANDSCAPING,F�ICIERIORLIGHTING&ELE7cfu
ATF.RONSITEFLINS'
FORNEIYIIOUSF . %-_ERK
NAME OF
FOUNDATION (18" MAX. EXPOSED): ONCRETE/O R
2M ;I1r; 14
'' MEIVED
WALK WAY. `� 11 STEPS (IINDICATE BR.ICK/CEMENT/OTHkp)• • "
V IN�� •tl Ci ..� 0(l �"y-v.."r rl �OhFL �
SIDINGTYPE: COLOR:"
CHIMNEY (INDICATE BRICK/STUCCO/WOODFACED) COLOR:
ROOF MATERIAL: PITCH (7/12 MIN.) COLOR: he Ve-t-,
t'1A"rc" eL- ,P; %'� 5 MAX. EXP.
WINDOWS (GRILLES REQUIRED) -INDICATE SIZES IF NOT LISTED ON ELEVATIONS:
(o over b p,6- qa„i,'> VItAyl
DOORS (INDICATE SIZES AND STYLE IF NOT LISTED ON ELEVATIONS): COLOR: N P -tc.-%A
TRIM: (ALL WINDOWS & DOORS TRIMMED WITH IX4 / IX5)
MATERIAL OF TRIM: (WOOD, VINYL, ALUMINUM)
SHUTTERS (WOOD/VINYL) (PANELED/LOUVERED)
GUTTERS (WOOD/ALUM):
GARAGE DOORS: SIZE & STYLE: !v%
STORM WINDOWS & DOORS: �y/�1�
(INDICATE SIZES IF NOT LISTED ON ELVATIONS)
SKYLIGHTS: TYPE/SIZE:
DECK: SIZE & MATERIAL: FbcZc �4 Rotes' S�
;-a
FENCING (MAX. HEIGHT 61: STYLE:
(SHOW LAYOUT & RUNNING FOOTAGE ON SITE PLAN)
COLOR: tj,A,%u-V
COLOR:'-,�
COLOR: t "c-t-k
COLOR:
COLOR:
COLOR:
COLOR: i
f ,.Vvru I
COLOR: —
RETAINING WALL: (P.T. OR FIELDSTONE -CONCRETE INAPPROPRIATE)
(SHOW LAYOUT & RUNNING FOOTAGE ON SITE PLAN)
SIGNS: (indicate size, style, colors) COLOR:
SIGN POST: (indicate size, style, color) COLOR:
ADDITIONAL INFORMATION: i .,_)
REV. 6/99
--k-
7
Y/.'Fllv101JTH
TUM'\1 �'.-"LERK
2M AUG 14 111 9. 34P
EIVED
7�j- I.> I Leo
f -C zleowe�
//oC4 "Fo 'l;L
TO THE BEST OF MY INFORMATION,
KNOWLEDGE, AND BELIEF THE
Ad ""'a o'? r? 0 .SHOWN ON THIS
PLAN HAS BTE� 6CA.T-%'- ON THE
'
GROUND AS INDICAT b.ti
ea MTA area \/ % f-) � V �_� 1 1
" . Old King's Highway Regional Historic District Commftzee l l I
V + : I CLERK
in the Town of Yarmouth for a
I q
CERTIFICATE OF APPROPRIATENESS 2t�3 hUG 1UPI 9: 30
RECLIVEP
Application is hereby trade in triplicate, for the issuance of a Certificate of Appropriateness under Rdon 6
of Chapter 470, Acts and Resolves of Massachusetts, 1973, for proposed work as described below and on
Plans, drawings or photographs accompanying this application for.
CHECK CATEGORIES THAT APPLY:
1. Exterior Building Construction : D New Building Addition D Alteration
Iodinate hype of building: D House D Garage D-Commercial D Other
2. Exterior Painting: D
3. Signs or Billboards: D New Sign D Existing Sign ❑ Repainting edging sign
4. St u== D Fence D Wall D Flagpole D Other
TYPE OR PRINT LEGIBLY DATE r - 7'aa —O3
ADDRESS OF PROPOSED WORK. _21 B SE t_tC45r R D ASSESSORS MAP NO.3_
OWNER- RQS9,:7QT 2nLCHOZ yFtRT ASSESSORS LOT NO.
HOME ADDRESS I SG�RX' KE i i`I'� Y Pl_gT HA TELEPHONE NO. --:iq 4-a jl"�
O?1o7,T
AGENT OR CONTRACTOR_ (o % D d3�/ i S mac- TELEPHONE NOq `(-O�,
ADDRESS Q NE.J Vetj-i�,Q (�° ems• c V1(li C Q� �C-n
USE ATTACHED SHEET IN PACKET FOR ABUTTING.OWNERS
DETAILED DESCRIPTION OF PROPOSED WORK: Give all particulars of work to be done including materials to
be used In case of signs, give locations of &\isting signs and proposed locations of new signs. (Attach additional sheet, if
may)-
A1AEMbHtFNT- F6 PeeVlCuScV ApP(Z0eD CF_RT1F?C4TE�
p?PRO'S rD �p�
YARh10UTN COt1i,11R��
vc RD
Signed
Space below tine for Committee use only. Oahu ontractor-Agent
Received by OKHC
Date 'a3 -o This Certificate is
Check it Ira
By
APPROVED
DISAPPROVED
D 'E"FORTAW. If Certificate is approved, approval is subject to the 10 day appeal period
provided in the Act.
D Please return to: Yarmouth OKHC District Committee
Yarmouth Town Hall, 1146 Route 28, S. Yarmouth, MA 02664 U I (b 0
-U0 11
3-AIu)-
�
SPECIFICATION SHEET (YARMOUTH OKHC) - SUBMIT 3 COPIES
Please fill out the form in its entirety providing colgj, chips, �Ilere
ileCeSSa7)'d)7 INDICATELANDSCAPING, EX7MORMGHTTNG& ELECnUC f IDNSITE�NS
FORNEIY, SES. I U •1 {- CRK
NAME OF
FOUNDATION (i8w MAX. ExPOSED): iTE/AOHER
�u73 "ilr, 14 /a
civcC�y-y-
WALK WAY: STEPS (INDICATE BRICK/CEMENT/OTE"): ;
V I my I •C, G�i .' n N F', ,rwf- X asio-v
SIDING TYPE: S� �'i(°5 hiluclu c COLOR:
CHIMNEY (INDICATE BRICK/STUCCO/WOODFACED) COLOR:
ROOF MATERIAL: PITCH (7/12 MIN.) COLOR: rjc �e-(,
1'lAxcu �i •,� iMAX. EXP.
WINDOWS (GRILLES REQUIRED) -INDICATE SIZES IF NOT LISTED ON ELEVATIONS:
& 0 v2Y b Pia-- qe„�L> V i Nyj
DOORS (INDICATE SIZES AND STYLE IF NOT LISTED ON ELEVATIONS): COLOR: N Pr--vc.JA
TRIM: (ALL WINDOWS & DOORS TRIMMED WITH im / im)
MATERIAL OF TRIM: (WOOD, VINYL, ALUMINUM)
SHUTTERS (WOOD/VINYL) (PANELED/LOUVERED)
GUTTERS (WOOD/ALUM):
GARAGE DOORS: SIZE & STYLE: !v%
STORM WINDOWS & DOORS: A/l
(INDICATE SIZES IF NOT LISTED ON ELVATIONS)
SKYLIGHTS: TYPE/SIZE:
DECK: SIZE & MATERIAL: Fbo-uOv Roar
FENCING (MAX. HEIGHT 61: STYLE:
(SHOW LAYOUT & RUNNING FOOTAGE ON SITE PLAN)
COLOR: r p,-.,"-4
COLOR:'��;
COLOR: t-A "4-e4
COLOR:
COLOR:
COLOR:
COLOR: 11�kl}oc-<LInI i
COLOR: —
RETAINING WALL: (P.T. OR FIELDSTONE -CONCRETE INAPPROPRIATE)
(SHOW LAYOUT & RUNNING FOOTAGE ON SITE PLAN)
SIGNS: (indicate size, style, colors) COLOR:
SIGN POST: (indicate size, style, color) COLOR:
ADDITIONAL INFORMATION:
REV. 6/99 (►,f'� " _ _" _ _
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AS BUILT" PLOT PLAN!
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' TO THE BEST OF MY INFORMATION, Ydf2l eo✓rN MASS.
KNOWLEDGE, AND BELIEF THE Lo r 32, �. J�� Q 4Z z9
Co✓.aa� no.J _SHO.WN ON THIS �
i PLAN HAS BEEtf'• tOCAT ON THE R. ✓. OHEARN /NC.
SWAN RIVER PLAYA
j GROUND AS INOICATtb. ' 35 ROUTE 134, UNIT 2
1 :...�. SOUTH DENNIS, MASS. 02660
GATE zs G SCALE
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r DATE REGISTERED "LAND SURVEYOR DR. B .
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RECLIVED
Mahogany Steps, Pine Risers
Right Elevation
9
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Rear Elevation
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Permit No. (�57(— 1056
Occupancy and Fee Checked
[Rev* 1071 leave blank) --
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be peribnocd in accordance with the Massachuxns Electrical Code (ME 527 C IR 12.t10
(PLEASE PRINT IN INK OR E ALL INFORt 011� Date: 33 1
City or Town of: U y To the Inspector of irej.
o Br this application the undersign gives notice of h' ar h iatcn oa to perform the` electrical work described below.
Location (Street A Number) 2 2 e \ apt
Owner or Tenant OHO Tr77 Q. g or Telephone No.
c:0 nor 'sAddress CJ ,3 t3
y,thls permit In conjugcilaa with a building permit? Yes [ —No (Cheek Appropriate Bos)
11u
--Purpose of Building Utility Authorization No.
Exbdng Servke Amps / Volts Overhead ❑ Undgrd ❑ No. of Dieters
New Strylie Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
91
1S.p.rltss.nt o/�tn .Jersncel
BOARD OF FIRE PREVENTION REGULATIONS
Number of Feeders and Ampacity
Location and Nature of Protsrtsed-
$
Work.
,NG� VPVICPS �stXCVY1C�
No. of Recessed Luminaires
__-'- '��.. ..._ ...........
No. of CeLL-Susp. (Paddle) Fans
....... ..... .........run ...r ,ru 5v nII[J.
06 ° of
Transformers KVA
No. of Luminalre Outlets
No. of Had Tubs
Generators KVA
No. of Luminaires
swimming Pool Above ❑ °' ❑
rnd. rnd.
a o snargcoey g
Batt Units
No. of Receptacle Outlets
No. of OU Burners
FIRS ALARMS
Na of Zones
No. of Switches
No. of Gas Harness
es fTAT I Isten Deana
ices
No. of Ranges
Me. of Aft Cond. Tons .
No. of Alerting Devices
No. of Waste Disposer
ump um r tons140.013
Totab:
Space/Arts Heating KW
ontalned
Doteedon/Alerdn Devices
No. of Dishwashers
�e� ❑ Connection n ❑Other
No. of Dryers
Heating Appliances KW
SecurityNf 1)wkaor Equivalent
No. o Water KW117.11.
Heaters
o o. o
SivaBallasts
Data Whin
No. of De�vieas or B ulvalent
No. Hydromsssate Bathtubs
No. of Dfotoa Total HP
c �mm pncad or wid
E uir��nt
OTHER:
Ittach addktonat detait if dabed or as required by the Inspector of;nra.
Estimated Value of Electrical Work: (When required by municipal policy.)
of it to Start Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
l t icensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
I certo. under the pains and penaldes ojperlury, that the lnjormedon on this applkatlon is true and eampkit
FIRM NADIE: (` L k e ^ � = L. rut, LIC. NO.
:
LkemeesCt Ill (1L �;1(l Cv Slgnatnn LIC. NO.:
H (I%opplicable. enter "exempt_ to the levee number tin t.)
\ddress:2G�S� �rtir,,otr��,( �, �.1 bZFj�SBuLTel.NO.•
"Per M.O.L. r~ 141. s. 57.61. secrui wor Alt Tel NO.:
ry requires Department of Public Safety "S" License: Lie. No.
OWN KRIS INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below. I hereby waive this requirement. I am the (check one owner owner's a ent.
Owner/Agent
signature Telephone No. PERH/T FEE: S
ZGM15 SlipGen- Portal Hone
Town of Yarmouth
Template [Building Dept]
Slipsheet Identifier [sg19475]
Document Category
Building Permits
Map -Block Number
136.34
Street Number
0218
Street Name
SETUCKET RD
Department
Building
Parcel ID
16648
B_ackfile Batch Scan _No
Document?
Additional Naming Info
Index Operator
Date - Time
Operator, Yarmscan
2015-02-09 - 09:26
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