HomeMy WebLinkAboutBuilding PermitsTOWN OF YARMOUTH
BUILDING DEPARTMENT
1146 Route 28, South Yarmouth, I11A 02664
508-398-2231 ext.1261 Fax 508-398-0836
Permit Nuriibe?72 15, 00 � L
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 PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Applicant
Phone Cell
Street Address
Email Address:
Cityffown
MA
I ZIP
Name of E ntol li dt� re�y(rot;t appl�anq
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Street Addr t
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Email Address: / CQiy1ne
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Name of Ownerts) of Property
Phone Cell
Street Address
—'17A
Email Address:
CitylT wn
1(A
ZIP
OtKer Contact Permit Fee Received No Yes
Description, location and purpose or proposed trench:
Please describe the exact location of the proposed trench and its purpose (include a description of what Is (or is intended) to
be laid in proposed trench (eg; pipes/cable Una etc_) Please use reverse side if additional space is needed.
Inv waz7��/iC�.
E D
v 0 6 2014
r'i
vl
i Insurance Certificate
I Name and Contact Informati n of urer.
Po Ei iration Date:
DIE Safe /:
Nai f Co t Person lax defined 20 C lA ►:
a
IN
1 of
Name of Competent Person (as defined by 520 CMR 7.02):
r r4z'4w
Massachusetts Hoisting License #
License Grade:
Ex iration Date: /
BY SIGNING THIS FORM, TIIE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WITH, OR, BEFORE COMMENCEMENT OF THE WORK, WILL BECOME FAMILIAR
WITH, ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED, INCLUDING OSHA REGULATIONS,
G.L. c. 82A, 520 CVIR 7.00 et seq., AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND
REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR
SUCH WORK WILL 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 TILE PROPERTY OF THE OWNER, AND ALSO, FOR THE
DURATION OF CONSTRUCTION, AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO
ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WITH THE
CONDITIONS ATTACHED HE, AND THE LAWS AND REGULATIONS GOVERING SUCH WORK
THE UNDERSIGNED APPLICANT, 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 PERMIT AND TILE WORK CONDUCTED THEREUNDER,
INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF
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, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK
CONDUCTED UNDER THIS PERMIT.
APPLICANT SIGNATURE
DATE
ATO I N ERENT)
DATE
10/
OWNER'S SIGNATURE (IF DIFFERENT)
DATE:
:=For. Cit /Town use == Do'not.write in this section':
'-PERMIT APPROVED BY.
$ Appbcatlon Fee > r
Y
PERMITTING AUTHORITY Date : <: `
PATRICK AHEARN
ARCHITECT
November 10, 2014
Mark Grylls
Building Inspector
Town of Yarmouth
Yarmouth, MA 02664
Re: Garage Renovation at 177 River Street, Yarmouth MA
Dear Mr. Grylls,
� t � r_
I
NOV 12 2014 !
F3ui�otrc oeFa�<�r�i��,r
�Y.
Please be advised regarding the above mentioned property; I verify with this letter and the attached
documents that the proposed / permitted renovation work does not meet the criteria of substantial repair as defined in
Section 1612 of the 2009 International Building Code. Also, the work being performed does not substantially repair
the foundation. I have determined this by the following:
$451,000.00 - Replacement Value (Determined by owner's Insurance Carrier— see attached)
$191,675.00 - Cost Estimate of the work by Wel Ien Construction —see attached)
With the information stated above the cost of work is 42.5% of the existing value.
Respectfully submitted,
AIA
Architect LLC
BOSTON OFFICE MARTHA'S VINEYARD OFFICE PATRICKAHEARN.COM
160 Commonwealth Avenue. Suite U Nevin Square. 17 Winter Street
Boston. Ma chusetts 02116 Edgartown. Massachusetts 02539
T6172661710 F6172662276 T5089399312 FS089399083
7 i+E
A,X..j1A
C R O U P
11/10/14
PATRICKAHEARN ARCHITECT
160 Commonwealth Avenue, Suite U
Boston, Massachusetts 02116
Re: Garage at 177 River Street, Yarmouth, MA
Dear Mr. Ahern,
F . •;: u:::; :..�. MA
\:.....'tar.,:,rwr, hi
As previously discussed, the garage at the above mentioned property currently has a
Replacement Cost Value of $451,000. (Four hundred fifty one thousand dollars). This
value was set on April 17, 2014 at the time of the most recent policy renewal and is
reflective of the information on file along with information collected at the most recent
site inspection. This value is representative of the condition the structure was in at the
time of the renevial.
If you have any further questions or need any additional information please feel free to
contact me.
Yours truly,
9"� ,
Michael Hackett
INTEROFFICE MEMORANDUM
TO: PATRICK AHERN
FROM: CHARLIE GADBOI
SUBJECT: ESTIMATE OF 77 R STREET
DATE: 11/9/2014
CC:
Patrick-,
As previously discussed after review of the property and construction documents I estimate the cost
of construction as described to be as follows:
Lift structure, remove floor, infill and slab
$30,000.
Rough Frame Carpentry (6 men, 2 weeks)
$22,500.
Lumber Material
$8,000.
Doors and \Windows
$30,000.
Mechanical
$12,500.
Sidewall and Roof (3 men, I week)
$10,000.
Electrical
$10,000.
Plumbing
$7,500.
Insulation
$5,000.
Wall Coverings
$7,500.
Interior Trim and Doors
$7,500.
Casework
$7,500.
Painting (4 men, 1 week)
$7,000.
Floors (880 square feet)
$8,000.
Hardware & Misc.
$1,250.
General Cond. & Builder
817.425.
Total
$1919675.
If you need any additional information please contact me.
Charlie
Page 1
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II
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Y.- u
ONE & TWO FAMILY ONLY — BUILDING PERMIT
APPLICATION TO CONSTRUCT, REPAIR. RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Town of Yarmouth Building Department
1146 Route 28 • South Yarmouth, MA 02664-4192
508-398-2231 ext.1261 Fax 508-398-0836
MCA Use odY(� �Rwuling Baud Infomudw
Permit NI S�Barbato _ ^ Type
Permit Fee Endarsanwt Us
�C. Q e Record»q Due
Deposit Recd. $ O� Dat� 7 Pftn K&
Net Due $2LO --- 09W
Assessor DePaft" Information:
to
New
1.4 Property Dimensk L
Lot Area Is$) Frenhge (n) Lot u„
This Section lot On= Up
Bulkln Pe r. Ds issued
Vv
CIO Qleriles Dew,.
Section 1- SRe Intorlrution Use tar )up: R-4 Type: S.
1.1 PrePKty Addryat
1.2 Zoring Information:
177 I;IV6je S~ KE6T
Rs - ya 4A,ea 1015 r.
. arfl Yg4MOy7u M4 U2.lo 6H
Zoning District Proposed Use
1.3 ttlWWbM settees in)
Front Yard
Side Yards
Rear Yard
Requked
Provided
PlegLired
Provided
Required
I Provided
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ZJQr
1A (NML- e. 40. s tt41
1.3 Flood Zone df brom o,s Pgre wft
Public Private
Zama -ALA%FE�.
Section 2 - OwneMplAuthorized
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WA OAVIs 7 W�/,✓Dt=ey�✓�c D,2
Na"! ri . MalargAddra Sc;UT JV
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signe 74 &INTelephone
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1clEcc EtI ca�.rs-r,�zuc,-r ac! r°o ao�G Sy 67 M�+►�L�:,I�ovc✓
Mailing Address ()1� 5-2nM
92Jb
Spreture Telephone Fax
Section 3- COnstructlon Servkes s r bv e
a�
APPIKsble ❑
W
arse NWnear
G —o �o
P-
Expiration Da
TO ephone
3.2 tered Horne Ion ement Contractor
Coeerpewy ttrrwe
wcLL F.�J c,,1 s�tiGTr e J
Not AppiaOleAddress �
Lxense Number
$ y6 0 - -% SO %
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Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure
P,rovlde this affidavit will result In the denial of the Issuance of the building permit.
Signed Affidavit Attached Yes ........ No ..........
secuon s- o • at Pto Whitt d,edt r )
Nsw Construction 0 1 No. of Bo*=ns No. d Bsfhoams
I:x MV MW (% R#Ws) O Mwattam ❑ Admtioe ❑
Accsmwq Bid¢ Type 6O
Denotillon
Other Specify:
Brief Description of Proposed Work
S 6\0-fragS T� r r✓G 6.I Lid
G`
� S
Seddon 0- Estimated CdnWuctIW Casts
Item Esd"od Coat (Dodsm) to be Check Below
compbted by panne applicant
1. 0 000 �r Conserva8or}Commleebn Flitrng
2. t]ewicel ,o oOO (N applicable)
3. Plurnbirg / Gas 30 004
4. MedwAcal HV -?�
� Old Kkvo Hlyhway d Hlabrtcal
.0100
S. Fire Pr bKdon Commission approval
e.Totals(1 ♦2+3♦4♦5) L130 000 (NaPPOC-hM)
T rout square Ft Ow h=w& awwo ' 19017
for
. as owner of the subject prop"
hereby authodze OwwAss C =&Cat to ad on
my behalf, In al matters relative to work authorized by this building permit appikatim
sediort
ftrGs
VN* tD• ly
ow
. as OwnedAuftdzed Agent
hereby declare that the statements and information on the foregoing application are true and accurate,
to the best of my knowledge and bond.
Signed unqor the pains and penalties of perjury,
5 1,46 Q Atig
Prw+l el� � V
stgnaare of
cue
9 - rJ - 99 2 al J
Permit No.
Date TOWN OF YARMOUTH '
AFFIDAVIT
Home Improvement Contractor Law
Suppkmeat to Permit Application
MGL c 142A requires that the 'reomsnvction, altaaba4 reaovatim, rows modaitiatioa, comv mou,
imprm=cat, removal, demolition or construction of an addition to nay pro-adstmg owner-oaarpied
building cmtsiiing at last coo but not more than fir dwcUing taws or swodtra which ate adjacent to
such residence or building' be done by rceatwW cattmd -% with certain exceptions, along with other
requirements nnA 1
Type of Work: Il.�^ iii�' EL Cost 300 00C)
R
Owner Name:
Date of Permit Application:
I hereby certify that:
Registr n is not required for the following reason(s):
Work excluded by law
Job under S1,000
Building not owner occupied
Owner pulling own permit
Other (specify)
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING_ WITH
T
UNREGISTERED CONACTORS FOR APPLICABLE HOME
IMPROVEMENT WORK DO NOT HAVE A, GEMS TO THE ARBITRATION
PROGRAM OR GUARANTY FUND UNDER I
MGL c. 142A.
Signed under penalties of perjury:
I hereby apply for a pefr & as the agent of the owner.
Ok"-s Amy z,
Date jContr=4 Name Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above
pro
�o1, �, a,s
Date Owner Name
TOWN OF YARMOUTH
BUILDING DEPARTMENT
CONSTRUCTION SUPERVISOR FORM
PLEASE PRINT.
Job Location 11.7 011672 3112Etf
Number Street Village
Owner of Property. 12oi3ct uet104 DAV tS
Construction Supervisor: 1---t'w
Name
()5-.7;.-BG
ense No.
Phone No.
Address: WELL-EiJ C.Q JLte-vGTioJ - Po 3oX "G7 MAr t RQr&-.0 W 1WA or7sZ
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 anyother 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 constntction
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:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.152
Yes �A No
If you have checked ygg, 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 15�gfeytlseneral Laws, and that my signature on this permit application waives this requirement.
l// Check one:
Signature of
Owner Q Agent Q(
Signature:
Building Official Approval:
77re Commonwealth ofMassachnsetta
f Department of Indnsirkd Accidents
Office of Investigations
600 Washington Street
Boston, MA 01111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (BusineworganizadowIndivithW): U6t.L 6-( Czd 5 JW Gvi oaf
Address: PA, 3 4 t; 9 (,- ,
Phone M
Are you as employer? Check the appropriate box:
I. ] I am a employer with ) L 4. 111 am a general contractor and I
employees (full and/or part-time).• have hired the subcontractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet,
ship and have no employees These sub -contractors have
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.t
required:]
3. ❑ 1 am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
3 a. ❑ 1 am a homeowner acting as a
general contractor (refer to #4)
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.]
b u— 9fo-3
Type of project (required):
6. ❑ New construction
7. j Remodeling
8. ❑ Demolition
9. 0 Building addition
10.0 Electrical repairs or additions
11.0 Plumbing repairs or additions
12.❑ Roof repair
13.0 Other
*MY 9PPUCAnt that checks box #1 must also rill out the salon below sbowina their wod=' comod
Homeowners who submit this affidavit indicatingY are doing sU wort and rhea him outida centrscton i Y intamsooe.
tCoatnctors that check this boa must attached as additional shoot showing the name of the must submit a new affidavit lndieatina such.
subcontractors and stud whether or not those entities have
emPbYas. Itthe sub-000traamrs have etnpWyew. they must pmvide their workers' comp. Policy number.
I an an employer that is providing workers' compensation Insurance for my
informadont employees Brow it the policy and fob site
Insurance Company Name: ft-t #ffACL/v�
Policy # or Self -ins. Lic. #:_ Ly6c- S00 DO 3� S 7,013 11
Expiration Date: 1 701
Job Site Address: 117 IQIJtf4 llvw-r Ci /StatdZi ry p: S oVV y�� 0 Z G 6 y
Attach a copy of the workers' compensation policy declaradotr 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
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDanof fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to d
ER the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certiff arrdf th* a,147ymtysnahla of pedtry, that the inforaradon provided above is dw and =off
.s0.81 y(oo -
N3
QU7ciai "so only. Do not writs in this area, to he completed by city or town o,QleiaL
OS
Zal y
City or Town: Permlt/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. Cityfrown Clerk 4. Electrical Inspector S. Plumbine 111SMetor
6.Other
Contact Person: Phone #•
TOWN OF YARMOUTH
BUILDING DEPARTMENT
1146 Route 28, South Yarmouth, ILIA 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 117 57126er
Work Address
Is to be disposed of at the following location: WAStE MAPJA46,1
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
.//"(,
0-
Signiit�ule of Application
Permit No.
3o sict4-rEmb6e zoi y
Date
Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction Supersisor '3
License: CS-057805
C RARLES E GAD,80
4 ANDREWS WAX R s
SOUTHBORO MA 0
,!754. Expiration
Commissioner 02/26/2016
13
C40C C1La ttq.c s
-/a cl a e-
r 0it'��r7c.�
Jfie
Office of Consumer Affairs and Ifusiness Regulation
10 Park Plaza - Suite 5170
Boston, Massa setts 02116
Home Improvement Massa
Registration
Registration: 173532
m (�� Type: Corporation
-,a Expiration: 10/11/2014
WELLEN CONSTRUCTION CO,
CHARLES GADBOIS
P.O. BOX 5967
MARLBOROUGH, MA 01752
DPSCAI 4 50M.0q*p101218
Tr0 232522
ate Address card. Mark reason for change.
Card
Lddress Renewal Employment
I/
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs and Business Regulation
Home Improvement Contractor Registration Program
10 Park Plaza, Suite 5170
Boston, MA 02116
APPLICATION FOR RENEWAL OF REGISTRATION
Home Improvement Contractor or Subcontractor MGL
Chapter 142A, 201 CMR 18
WELLEN CONSTRUCTION CO, INC.
CHARLES GADBOIS
P.O. BOX 5967
MARLBOROUGH, MA 01752
Registration: 173532
Expiration: 10/11/2014
Received:
REQUIRED RENEWAL FEE: ONLY CERTIFIED CHECKS OR MONEY ORDERS CAN BE ACCEPTED
ANY OTHER FORM OF PAYMENT, INCLUDING BUT NOT
$100 LIMITED TO PERSONAL OR BUSINESS CHECKS, WILL BE
RETURNED AS INELIGIBLE.
PLEASE OCABR will not process any renewal application if it is postmarked more than 60 days beyond the
NOTE: expiration of the HIC Registration. See 201 CMR 18.02(6)(b). Failure to submit a timely renewal application
will require a contractor (1) to obtain new HIC Registration card with anew HIC Registration number,
(2) to pay associated fees, and (3) to update all advertising with the new HIC Registration number.
No. of Employees: Fq
If the number of employees stated here is incorrect, please insert the correct number here:
CHANGES: If the Applicant is a Partnership, Corporation, or Trust, and the name of the individual responsible
for the applicant's work has changed, please specify those,changes below.
Social Security Number:
First Middle Last
Phone Number. ' -- ---__
CHANGE IN LAW ABOLISHES CSL's HIC RENEWAL FEE EXEMPTION. Asa result of a recent change in the taw
(Section 80 of Chapter 27 of the Acts of 2009), the holderi of Construction Supervisors Licenses are no longer exempt from
HIC Registration fees. CONSEQUENTLY ALL CONTRACTORS INCLUDING CSL's WHO ARE RENEWING THEIR
HIC REGISTRATIONS MUST PAY A RENEWAL FEE OF $100.00.
Purs nt t MassaGeneral Laws Chapter 62C § 49A, I certify under the penalties of perjury that, to the best
of m le e d ief, I have filed all s e tax returns and paid all state taxes required under aw.
Sig ture of Ap cant itle held if applicable Date
A FALSE ANSWER TO ANY QUESTION IN THIS APPLICATION CONSTITUTES GROUNDS FOR SUSPENSION OR
REVOCATION OF THE APPLICANT'S REGISTRATION. .
u20364131i' +:2113705291: 24 63171 )11'
r4ATER DEPARTMENT
BUILDRIG PERMIT APPLICATION
rr-= FIJ Z?-,;4=r%lir1 -,rr_hl r-W—V-M.1 11 C ILA W1=Sl 2i_Intiv-
.. rs .cz r. ara es.• ar. f .iL"e�l�.�•lf1 \�':S ti�i-ILLS
Proposed irnprovemer't: g1mi Wpirl'o, n�C4
Applicant: & (OpAlur1od
Address �'* %T 041610 Tel. 4: S007q40_ )W Date Filed: 10( f `
RESIDENTIAL AND / OR COMMERCIAL 6UILDING
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, Ocean, 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 Cepartment: Determines Compliance to State and Town Requirements for Personal,
Safety, Property Protection;, i.e. Smoke Detectors, Sprinkler Systems, Etc...
Signature of applicant Date
PLEASE NOTE:
COMMENTS:
Ra.
/C7
, �.
SERVI9E NO. _ ._ _
ME ��oo 223 ' L Davis , ,
G�( /SF� Robert. J, �+
/ Rita M Dav s
STREET 177 /ti✓ce
VILLAGE %Sba�n
METER NO.
• �v P� 3 �
\'7� t'd� 33f�v
s
gg Ina rA 1
/(' ✓.¢e, sfZc csf'
TOWN OF YARMOUTH
HEALTH DEPARTMENT
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
•'If you would like e-mail notification ojsign off, please provide e-mail address:
Owner Name: W WO1 V-1k DUMA
Owner
Address: T �d� Owner Tel. No.: 7107A� VO
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.
REVIEWED BY:
Please submit three (3) copies of plans, to include:
(L) 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.
.TE: / O/%// y�
PLEASE NOTE
COMMENTS/CONDITIONS: \ /+
C1 ot-v�G-sIL cv �� f� e Cvd �� / e x1 s-j t 1 a b o %-9,
ACORDIF CERTIFICATE OF LIABILITY INSURANCE
°"°
9/30/2014
0/2
THIS (tJ RT"'CATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CE�iTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. 1HISrCERTIFICATE 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 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
CAV Insurance Agency, Inc.
31 Washington Street
P .0. BOX 81314
Wellesley Hills MA 02481-0003
CONTACT House Account
PHONE IAIC No Eel- (781)237-4107 FAX (7311999-5558
E-MAIL
INSURERS AFFORDING COVERAGE
NAIC 0
INSURER AQuincy Mutual Ins Companies
Omro01
INSURED
Wellen Construction, Inc.
PO BOX 5967 -
488 Boston Post Road East
,Marlborough MA 01752
INSURER B Associated Employers Ins. Co.
INSURER C:
INSURER D:
INSURER E:
INSURER F:
COVERAGES CFRTIFICATF NIIMRFRCL1493000961 RFVICI11N NI IMRFD-
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTRLICYNUMBER
TYPE OF INSURANCEADDLSUBR
POLICY EFF
POLICY EXP
/ D
LIMITS
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITYDAMAGE
CUUMS-MADE 0OCCUR
EACH OCCURRENCE
$
TO RENTED
S
MEO EXP (Any one
S
PERSONAL 6 ADV INJURY
$
GENERAL AGGREGATE
S
GEN'LAGGREGATE UMITAPPLIES PER
POLICY PRO• tOC
PRODUCTS -COMPIOP AGG
S
_
f
A
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OWNED X SCHEDULED
AUTOS AUTOS
HIRED AUTOS X NON -OWNED
AUTOS
06209
/15/2014
/15/2015
COMBINED SINGLE LIMIT(Ea accident)
It 11000,000
BODILY INJURY (Per person)
$
I
BODILY INJURY (Per accidoM)
S
PROPERTY DAMAGE
S
S
UMBRELLA UAB
EXCESS UAB
OCCUR
CLAIMS -MADE
EACH OCCURRENCE
$
AGGREGATE
$
DED RETENTION
$
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y I N
ANY PROPRIETORIPARTNER/EXECUTIVE
OFFICERIMEMBER EXCLUDED?
(Mandatory In NH)
Mrs, desvibs under
DESCRIPTION OF OPERAT40NS below
NIA
C5005003775-2013
1/17/2033
1/17/2014
WC STATU- OTH-
E.L EACH ACCIDENT
3 500,000
E.L. DISEASE • EA EMPLOYE
S 500,000
E.L. DISEASE -POLICY LIMB
I S 500,000
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACCRD 101, AddlUonal Remarks Schedule, If ry a space Is rewlnd)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Bob 6 Rita Davis ACCORDANCE WITH THE POLICY PROVISIONS.
177 River Street
South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE
C Visvie, Jr./CAVCV1
ACORD 25 (2010105) 01988-2010 ACORD CORPORATION. All rights reserved.
INR026tminrm tH Tha Ar:nRn nema and Innn am ranleforad mar4e of Ar:nRn
WELLCON-01 SSHEVLIN
'4� RLY ' CERTIFICATE OF LIABILITY INSURANCE
DATE(MMIDDIYYYY)
9/30/2014
THIS dERTiFICATE 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 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
AXIA Insurance Services
933 East Columbus Ave
Springfield, MA 01105
CONTACT
NAME:
PHONE 41g 788-9000 FAx 413 886-0190
,C ANo):
E-MAIL
UDRE
INSURERS AFFORDING COVERAGE
NAIC a
INSURER A: National Grange Mutual Ins. Co
11982
INSURED
'
INSURER B
INSURERC:
Wellen Construction Co, Inc.
INSURER D:
488 Boston Post Rod East
Marlborough, MA 01752-8967
INSURER E:
INSURER F :
COVFROGFS CFRTIFICATF NI IMRFR• DFVIQINJ kll IaaDCD.
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCEADOLSUBR
POLICYNUMBER
POLICY EFF
M/
POLICY EXP
MM
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE 0 OCCUR
MPP9780L
02122/2014
02/22/2015
-
EACH OCCURRENCE
S 1,000,00
DAMAGE
PREMISESEa occurrence
f 600,00
MED EXP one raon
$ 10,00
PERSONAL a ADV INJURY
S 1,000,00
GENL AGGREGATE LIMIT APPLIES PER:'
POLICY❑JEST LOC
OTHER
GENERAL AGGREGATE
S 2,000,00
PRODUCTS. COMPIOP AGO
S 2,000,00
$
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
NON -OWNED
HIRED AUTOS AUTOS
COMBINED SINGLE LIMIT
Ea accidaM
$
BODILY INJURY Per person)
S
BODILY INJURY (Par sccidem)
S
PROPERTY DAMAGE
r pocidentl
S
S .
A
X
UMBRELLA UAB
EXCESS LIAB
X
OCCUR
CLAIMS -MADE
CUT9841D
02/22/2014
02/22/2015
EACH OCCURRENCE
S 51000,00
AGGREGATE
$
DED I X I RETENTION 10,000
PAI
S 6,000,00
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETORIPARTNERIEXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH)
If vs tleacriM ravler
DESCRIPTION OF OPERATIONS below
NIA
pTAT ERH
E.L. EACH ACCIDENT
$
E.L. DISEASE. EA EMPLOYEE
S
E.L.DISEASE.POLICY LIMB
S
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, AddOlonal Remarks Schedule, may be atlached U more space is reguIred)
Certificate Holder Is listed as additional Insured as it pretains to the General Liability.
Robert & Rita Davis
177 River 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
01988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
all
(IMMIT
'44Q CERTIFICATE OF LIABILITY INSURANCE 10/21/2o1a °"21/ 014
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 terms and conditions of the policy, certain policies may require an endorsamenL A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsomen s).
PRODUCER
CAV Insurance Agency, Inc.PNONE
31 Washington Street
P.O. BOX 81314
Wellesley Hills MA 02481-0003
t2oL,E House Account:
. (781)237-4107 C. % .(781)098-SSSB
L
INSURE S AFFORDING COVERAGE
NAIC0
INSURER A. in Mutual Ins Companies
o01
INSURED
Wellen Construction, Inc.
PO BOX 5967
488 Boston Post Road East
,Marlborough IAA 01752
INSURER El Associated Employers Ins. CO.
INSURERC:
INSURERD:
INSURERE:
N RER F
COVERAGES CERTIFICATE NUMBERCL14101700981 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.
'N LTR
TYPE OF INSURANCE
pp NUMBER
LN:Y EFF
M
POLICY E%P
LIMITS
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
CLNMS-MADE ❑OCCUR
EACH OCCURRENCE
&
DAMAGE I U KEN I Lu
PREMISES Me pvojiTenoel
S
MED EXP coe
$
PERSONAL& ADV INJURY
S
GENERAL AGGREGATE
S
GENL AGGREGATE LIMIT APPLIES PER
17 POLICY PROr ILOC
PRODUCTS -COMPIOP AGG
S
$
A.
AUTOMOBILE
LABILITY
ANY AUTO
ALL OWNED SCHEDULED
AUTOS X AUTOS
WRED AUTOS X NON -OWNED
AUTOS
06209
/15/2014
/15/2015
COMBINED I LE MI
1,000,000
BODILY INJURY (Pr palaan)
S
BODILY INJURY (Pr amdalt)
$
X
PROPERTY DAMAGE
S
s
UMBRELLA LIAR
EXCESS LIAR
OCCUR
CLAIMS -MADE
EACH OCCURRENCE
f
AGGREGATE
S
D I I RETENTION 5S
B
'
WORKERS COMPENSATION
AND EMPLOYERS' LY1BILITY Y I N
ANY PROPRIETORJPARTNERIMCUTNE
OFFICEPJMEMBER EXCLUDED? ED
(Mandatory„NH)
I ea.descnbe aWr
DESCRIPTION OF OPERATIONS below
NIA
CC5005003775-2013
1/17/2013
1/17/2014
I WC STATU- I OTK
E.L. EACH ACCIDENT
& 500,000
E.L DISEASE- EA EMPLOYE
S 500,000
EL. DISEASE -POLICY LIMB
$ 500,000
DESCRIPTION OF OPERATIONS I LOCATK)N$ /VEHICLES (Atlach ACORD 101, Additional Ramarb Scladule, gown yaca M ngWIW)
Town of Yarmouth
1146 Rte 6
South Yarmouth, MA 02664-4492
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
Visvis, Jr./CAVCV3 <f
ACORD 25 (2010105)
INS02fipninrm01 The ArnRn name and Innn ■m ran6farod marlm nF Amon
reserved.
WITNESS its hand and seal on the date set forth above.
Pippen's Way LLC
By:
Charles Gadbois, Manager
8
> /W pow"110-uueaN, olgAwjackaelM4
_ Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massacbusetts 02116
Home Improvement CQZLKactor Registration
WELLEN CONSTRUCTION CO, IN
CHARLES GADBOIS
P.O. BOX 5967
MARLBOROUGH, MA 01752
scAt 0 20M-W1t
Office of Consumer Affairs & Business Regulation
F ME IMPROVEMENT CONTRACTOR
egistration 173532 Type:
piration 10/'Ll2016 Corporation
WELLEN CONSTRUCTION CO, INC.;'
CHARLES GADBOIS`k1_' "
488 BOSTON POST RD EAST?;;.'' 4 o
MARLBOROUGH, MA 01752'U Undersecretary
Registration: 173532
Type: Corporation
Expiration: 10/11/2016 . Tr# 258621
e Address and return card. Dlark reason for change.
U nddress Lj Renewal Lj Employment Lj Lost Card
License or registration valid for individul use only
before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, I11A 02116
C�- "r
Not valid without signature
W1.3
11
rHatf — � f
OCT 09 2014
HEALTH DEPT.
I
I
I
I
------------ ---'
Y-2"
1
1
1
L---------- --------
r------------------
Enlarge UsUng
Bedroom #1
1
I
I
I
L------------------
in -
NEW SINGLE
DORMER
N
It
Renovate
Existing Bat
G3G�C�C�MI�D
OCT US Z014
HEALTH DEPT.
11
1. RE -USED EXISTING J
6 BARN 51YLE DOORS 15 -P;
n
l r� gqt.,r- 9/1-..
OF P TOWN OF YARMOUTH Building Department
BUILDING
_ _ _ _ _ . , (508) 398-2231 ext.1261
PERMIT NO 8-13-1171 _
PROPOSED USE
PERMIT
. ISSUE DATE ; _ .317/2013_ _ ; ; _
. ;
APPLICANT .LaBarge Engineering & Contracting, Inc.
'""""...."""..""""' """""'
-------------------
JOB WEATHER CARD
PERMIT TO Aerations
AT (LOCATION) 10177RIVERST ZONING DISTRIC RS-4
Bldg. Type: Residential
SUBDIVISION MAP LOT BLOCK 1034.291 BUILDING IS TO BE: CONST TYPE 5-B USE GROUP R-3
LOT SIZE
CONTRACTOR
one replacement window
REMARKS
AREA (SO FT) EST COST ($ $3,500.00 PERMIT FEE ($) $40.00
OWNER JDAVIS, ROBERTJ BUILDING DEPT BY
ADDRESS 17 Windemere Drive
Southborough MA
LICENSE 068313
11-aBrage, Todd i
237 Main StreeVRoute 28
West Harwich MA 02671
5084326360
PHONE 15084609320
INSPECTION RECORD FIELD COPY
Date _ Note Progress - Corrections and Remarks Inspector
_EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRFSS: _I _I I R1 yer SA r ee, % / .
ASSESSOR'S INFORMATION:
OWNER:
CONTRACTOR:
umce use unty }
Permit M '
J
Fee S YIQ
Permit expires 6 months from
Issue date.
M
TELM
esidential Commercial 0 Est. Cost of Construction $
Home Improvement Contractor Lic. M Z45 n Construction Supervisor Lie. # O W 313
Workman's Compensation Insurance: (check one) /
1 am the homeowner I am the sole proprietor 1 have Worker's Compensation Insurance v
Insurance Company Name: &a (Q, �t7"s Worker's Comp. Policy# u)rh—C13f,5V—S-16
WORK TO BE PERFORMED
0 Tent (Fire Retardant Certificate atwchcd) Cl Wood Swve Shed
-
0 Siding: a of Squares _RepLlccmcnt windoww.tt
C Replacement doors: N
0 Re -roof: N of Squares J lasuLition
( ) Stripping old shingles• () going over layers of existing roof ❑ Old Kings Highway/Historic District
Roofing/Siding ((Ike for Ilke)
•Tbe debris will be disposed of at: `t'Y ir'LA P ✓
Location of Facility
f decLue under penalties of perjury that the sLucmenu herein cont-lined are true and correct to the best of my knowledge and belief. I understand that any false answer(s)
will be just cause for denial or re�n of ease and for prosecution under M.G.L Ch. 268. Section 1.
Applicant's Signature;
Owmen Signature (or
Approved By: Date:
Building Official (or desigam)
HESEM�
M�R 0 7 201
BUI�PT yo
By
Zoning District
Historical District: Yes No
Water Resource Protecti istrict:
Yes No
Flood Plain Zone: e
Within 100 R. of Wetlands:
0 No
No
-63GO
ROPY
OWNER'S AUTHORIZATION - TO BE COMPLETED WHEN OWNER'S AGENT
OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I r`�e 4 �� -J (15 as Owner of the subject property, hereby
authorize Zo. C.h P to act on my behalf in all matters
relative to wprk authorized by this building permit application.
366
Data
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of investigations
600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Apniicant information pinoan Tswi... r ,.,.:..._
..1ty10t4tu41P._L /, rru r It lira nn,t_ Phone #• <nV - Li -:z _-) _I_Z /_ ^
A�re, y�o a employer? Check the appropriate boz:
1. Ly'I am a employer with 4. ❑ 1 am a general contractor and I
employees (full and/or art•time).• have hired the sub -contractors
2. ❑ 1 am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required:]
3. ❑ 1 am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
3a. ❑ 1 am a homeowner acting as a
general contractor (refer to #4)
listed on the attached sheet.
These sub -contractor have
employees and have workers'
comp. insurance t
5. Q We are a corporation and its
officers have exercised their
right of exemption per MGL
c.152, J 1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. Q Demolition
9. Q Building addition
I0.Q Electrical repairs or additions
11.Q Plumbing repairs or additions
12.Q Roof repairs
13.Q Other
Any appltcaot that checks box O mart also till out the section below showing their worker Co I
t mecum �°� �O�rion
Homeowners who submit this affidavit indicating they ate shin all wort and then bite outside eontnton aruu submit a new affidavit indicating such
MPIOY ctors that cheek this lwz must attached an additional sheet We the a the name or the sub-ea¢trsctors and state whether a not those entities have
employees It the sub eonttsctars have emPt%ees, they must Provide then worken' Comp. Policy number.
I am an employer that is providing workers' conspensatlon Insurance for MY employees Below is 1hg poUcy and Job ells information.
Insurance Company
Policy # or Self ins. Lic. #: L )OA 5
-M C, Expiration Date:
Job Site Address: 1-1-1 J 1 VjP r rPP — City/State/Zip: MA,
Attach a copy of the workers' compensation policy declaration page (showing the Policy numb 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 Sl,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and fin
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
a fi
Investigations of the DIA for insurance coverage verification
I do herby esnt & under the
and penahlss ofpeduly that the 1nformadon provided above is due and eorrnt
OJ)7dal ass ony Do not writs in this area, to be eornp/eted by city or town 0,0k/41
City or Town: Permit/License #
Issuing Authority (circle one):
I. Board of health 2. Building Department 3. CltyfTown Clerk 4. Electrical Inspector 3. Plumbing Inspector
6.Other
Contact Peron: Phone #:
J%.
Information and Instructions s
?&wxh tits General Laws chapter 152 requites all "Wytlts to provide woritrss' compamdon foc their cmpWyces.
Putstu at to this statute, an wxp47 r is de8aed a "...evay puma is the service of another under any c r. n' " of im
expsesa or implied, oral or wnittem"
An sayigw is defined as "era iodividuak pactnershiN 0a69ciad04 corporados Or other kp1 entity. err nap two Of men
of the &c p h* named in a jofae ezJeapria". sad iachadlag the kpd repiaaatstfva eta deceased employee. a rise
roccivwwkustmotubukVW04puuwsWp.amdadoaacotbwk0caftcuwkqicgcnWk7ftL Howwvee the
owor of s dwelWg boot having not man these thaee sprtmnrb sad who reside tlsersia6 oe the otxtaI - of the
dwelling hnn of another wbo employes persons to do walmnance; Canstrnc-1 as repair wads on soci dwelling boos"
at on the Smoak or building appurtenant ems- shall not because of suck empk7wmt be deeased to be ant employer"
&MGL chapter 152.125QQ also states that "nary attate w bed Haastng aPwy shall w(tkk M the balm w
renewal W • Hns"e K permit a operate. bertnaea err t. esseerset bslfdtags is tk" aesa"awaltk titr aq
sppUnat wbe ha" set predsed aeesptabie"rldeeee of nmplEaw with dw lamas" ccrerap ngskW
Addldoodlp. MOIL chepiea 132.12M sWes "Neither the eommoaweaW nor any d its politko suI M I k os shall
enw isso say contend ht the paltrwsaceotpubHa wait uaW acceptable evideaa ounce with this bwxz e"
cequkemats of this chapter be" ban pceaaI g - the cmoxtiog authority."
APPUMN
Pkes" tan one the woaksrs' coa>pansadasa atadnit may. by checking the baaa" that apply to your aitt"m an, it
may►l supply w(s) oms(s) a lkaw(a) and phase notoba(s) abog with their cadSca*s) of
w manta Limited Liability Coogesia (LLG) or t k&W LW9 ty Partnerships (LLY) with ao aopioysa orhet'haa the
membsa or paetaaa, are see required to arry watbre caageasadas laaannce. was, LLC or LLIP does here
ea policy is regoiced. Be adviaW that this a8ldavie mey be submitted to the Depertm od of bWowial
Accidmb the confitwadm of to orsoce corm@@. Abu be sere is sips sad date the ailid tvfL TW siIIdarit should
be taAsoad in the tiff► or tows thet the applkadon liar the ps mk at license is being regoatd, we the Dsp w*=w of
IdoekW AccWata Sl=W )err have any gaadone na .1 the law ar if yes are regrind ae obtain a worken'
compeaatlos policy. plan aB the Depattumd at the aambs Hard b-inwr. Sdtinasd campaoW sb=M easy their
seltiosureee" licean somber an tW appopriafe ilea
CUy of Taws Omdsh
Pkaw be sun that the affidavit is complete sad psiabd kgL . Tb Deptrtmeat has peorided a spw at the boom
of the al &v1A 1br you to fW art la tb" -rent the Of&e of lavadpdi has to coabet you teprdfng the sppigaae.
Pleae" be sure to 9M in the pwmzib acre numbs Which will be used a a mierme aombew. In addido% as
these caret submit ale pe=b1ccose appBcadons be nay give year, noel only submit use at>ldavie indicadog csa"at
policy Wzmdoa (itwc-nary) and under "lob SW AdLirae" the applicant shouW wtib "ail locahoot la (city at
towa)6' A copy of the aMdawk that hes boo o@icialty stagged or muted by the city at tows wry be potldd - tb" .
applicad as goof that a valid affidavit is an We der !bore permtes of lkwa A new amdwk miner be filled out rack
year. Whore a home owner or cidma is obblaiq a Hanes or permit not related w nay bnsbw of co===W venbwe
(La a dof Heroes or parak to b® fence sae.) said pasta Is NOT required to coatpkb thie alHdaviL
The Office of laradptbos would Wke to thank you In advance bur your coopaadoe sad should yam have any gnatiooq
pleaw do toe hesiow to Siva o a aLL
Ibe Depot Wdmsatelephone and &x numb=
The Commonwealth of MasswIztmsetts
Depa:t mad of Industtia! Accidents
Off! s of twestiptions
600 Wuhiangton Stied
Boston, MA M111
Tel. if 617-7274900 ext 406 or I .M-N(ASSAFB
Revised 11.22a16 Fax 0 617-727-7749
wwwriumgov/dta
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
WC 00 00 01 A 07 11
Issuing Company: Acadia Insurance Company
290 Donald J. Lynch Blvd, P.O. Box 9168
Marlborough, MA 01752-9168
WORKERS COMPENSATION AND EMPLOYERS
LIABILITY INSURANCE POLICY
Policy No.: WCA 0268516 -14
Previous Policy No.: 0268516-13
1. Name Insured and Address
LaBarge Engineering and Contracting, Inc.
237 Main Street
Route 28
West Harwich, MA 02671
Other workplaces not shown above:
Refer to Name and Location Schedule
RENEWAL
INFORMATION PAGE NCCI Carrier Code No.: 33391
Agency Name and Address
(508)791-2241
Sullivan Insurance Group, Inc.
Ten Chestnut Street, Suite 1010
Worcester, MA 01608-2804
FEIN: 043552990 Risk ID No.: 0262586 Bureau File No.:
Entity of Insured: Corporation
07401
POLICY PERIOD
2. The Policy Period is from 09/26/2012 to 09/26/2013 12:01 AM Standard Time at the insured's mailing address.
COVERAGE
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of
the states listed here: MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The
limits of our liability under Part two are:
Bodily Injury by Accident $ 500,000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 500,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
ALL STATES EXCEPT ND, OH, WA, WY AND STATES DESIGNATED IN ITEM 3A OF THE
INFORMATION PAGE.
D. This policy includes these endorsements and schedules: See "Schedule Of Endorsements"
WC 00 00 01 A 0711 Includes copyrighted material of The National Council on Compensation Page 1 of 4
Insurance, with their permission.
1�5 Massachusetts - Deparnnant of Public Safety
Board of Builaing Regulations ano Stan0ards
Con.+tructiun Supers i.ur
License: CS-063313
ter': r vs IJA
TODD A LABARCE
237 DIALN STI RT 28
W ItARWIGJI h1A 02671
Cainnlissioaer Expiraiicn
02/07/2014
Unrestricted - Buildings of any use group which
contain less than 35,000 cubic feet (991m3) of
enclosed space.
Failure to possess a current edition of the Massachusetts
State Building Code Is cause for revocation of this license.
for DP5 Licensing information visit www.Mass.Gov/DPS
I
OfrieeAs Was uine pmx r & B,(i eiiwt P lii"o�o License or registration valid for indiviJul use only
02A
HOME IMPROVEMENT CONTRACTOR before the expiration date. if found return to:
Registration:-149496 Type: Office of Consumer Affairs and Business Regulation
Expiration: V132014 Private Corporation10 Park Plaza - Suite 5170
Boston, DIA 02116
RGE ENGINEERING $ CONTRACTING INC
i -
1.,
TODD LABARGE`,
237 MAIN ST - RT 28 _
W HARWICH, MA 0267,1
Undersecretary of slid without signature
A
of r TOWN OF YARMOUTH Building Department BUILDING
�+ _ _ . _ .... (508) 398-2231 ext.1261
PERMIT NO B-12.779 - PERMIT
ISSUE DATE :-12/14/2011. ; P 0 D SE ;
APPLICANT Todd LaBarge.... .......
JOB WEATHER CARD
...
PERMIT TO Repair
AT (LOCATION) 0177RIVER ST ZONING DISTRICT RS-4 Bldg. Type: Residential
SUBDIVISION MAP LOT BLOCK i034.291 BUILDING IS TO BE: CONST TYPE 5-B USE GROUP R-3
LOT SIZE
CONTRACTOR
REMARKS strip and reroot, 30 squares, paper and vent to code LICENSE 068313
(P3
LLaBrage, Todd
237 Main Street/Route 28
AREA (80 FT) EST COST ($ $30,000.00 PERMIT FEE ($) $35.00 West Harwich MA 02671
5084326360
OWNER_ DAMS, ROBERT J BUILDING DEPT BY
ADDRESS 7 wyndemere Drive
Southborough MA PHONE 5064609320
INSPECTION RECORD FIELD COPY
Date Note Progress - Corrections and Remarks Inspector
L
DEC 1 201
EXPRESS
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Fact. 1261
CONSTRUCTION ADDRESS:
ASSESSOR'S INFORMATION:
↦ 3 -Parcel:— _
OWNER:
CATION
unift use say
Perml&f r1,y
Fee$
Permit expires 6 rnoodu tram '
1130e dale.
- CMA O
CONTRACTOR: I rnsnf��.nyt►+w+i j: mac•, - S�.-0-�-}�
NAME IQ V V MAILWOAD RFSS TEL#
OO
Residendal Commercial GdER Cost of Construction (z)00
Home Improvement Contractor Lies NJ49 4 Q (n Construction Supervisor Lk. N Inq
WO&M-an's Cotnpeasadon Itutuance: (check one)
I am the homeowner I am the sole proprietor vI'Fave Worker's Compensation (nsorance
Insumnce Company Nuw; A( d l�s — Ocnip= \f ___Worker's Comp. PolicyO
WORK TO BE PERFORMED
❑ Tcat tFire R"daru Ccruicate au"bod) .,. Wood Stove She1
%Wing: N of Squares Replacement wlodows: N
C Replacement doors: N
is;IR naC Y of &ryares-21() a InsuW)un ---
(tl$"uippin$ Did shingles• () going ovtY----laycrs of esisdng roof Old Kings NighwayMl:toric District
RooMglSidiq (Like for Like)
'The tkbris will be disposed of at: Sl 7 l PC
Wcadoa of Facility
I dccive under penalito of perjury that die stmemtmu bmin contained are true and correct to the best of my knowledge and belle[ I undeaund that any false aaswer(s)
will be just cause for denisl or5TOC�ioa of my hccasWW for prosxadoa under biO.L Ch. 269. Section 1.
Applicant's Siylar=.
y Owners Sigrwturt(or
Approved By: V*C'
BulWiag Official(or daignee)
Zoning District: ff w
Historical District: Yes f� Hood Plain Zone: Yes No
Wua Resource Protection District: Within 100 gL of Wedaa)s:
yes )f(o YNo
JAI
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Aoalicant Information Please Print Legibly
Name(Business/Organizadombdividusi):L41 Qr'OP_ .44*1.A.Ae+ T._.
Ci
Phone
Are yo a employer? Check the appropriate box:
1. i am a employer with 4. ❑ 1 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- listed oa the attached sheet —
ship and have no employees
working for me in any capacity.
(No workers' comp. insurance
required:]
3. ❑ 1 am a homeowner doing all work
myself. [No workers' comp.
insurance required] t
3 a. ❑ I am a homeowner acting as a
general contractor (refer to H4)
These sub -contractors have
employees and have workers'
comp. insurance.=
5.0 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 reculred.1
Type of project (required):
6. ❑ New construction
—7.-E] Remodeling-
8. ❑ Demolition
9. Building addition
10.0 Electrical repairs or additions
I Q3 Plumbing repairs or additions
12.0 Roof repairs
13.❑ Other
t
Any applicant that checks box N t must also rill out the action below showing their workers' compeasatiod Policy information.
t Homeowners who submit this atlidavit indicating they am doing AU work and then him outside contractors mtut submit a oew atTidavit iodiating such
tContractors that check his box must attached as additional shot showing the acme or the wb-contractors and stars whether or not thow entities have
employees. If the wba ontractors have employcM they must provide their workers, coalp. policy ra,mber.
I am an employer that isproviding workers' compensation insurance for my employees. Below Is the policy and Job site
Informaniwc
insurance Company
Polity N orSelf-ins. Lic. ii: ViPA 8 ale yC; 1 r -1 Expiration Dater/Apl a
Job Site Address: -1clop {- City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number an 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 S 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.
! do bsrsbr csrtify�Q� and prnaitlts ojper/ury that tht in provided abovela Mm and corns
QQ?cial use only. Do not writs In this arson to he completed by city or town of vial
City or Town: Permit/License 0
issuing Authority (circle one):
L Board of Health L Building Department 3. City/Pown Clerk 4. Electrical inspector S. Plumbing inspector
6.Other
Contact Person: Phone #:
HIC Registration Lookup
Page 1 of 1
The Official Webslte of the Office of Consumer Affairs 8 Business Regulation (OCABR)
A1ass.Gov
Consumer Affairs and Business Regulation
Home > Consumer> Home Improvement Contracting >
Home Improvement Contractor Registration Lookup
The list Is current as of Tuesday, December 13, 2011.
You can search/filter the registration list by any of the criteria below.
Search by Registration Number [149496
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Click on the registration number to view complaint history. You can also view arbitration and Guaranty
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Search Results
REGISTRANT NAME
RESPONSIBLE
REGISTRATION ADDRESS
EXPIRATION
STATUS
INDIVIDUAL
NUMBER
DATE
LABARGE
LABARGE, TODD
149496 1237 AWN ST • RT 28 01/13/2012
Current
ENGINEERING @
W HARWICH, MA 02611
CONTRACTING INC
O 2011 Commonwealth of Massachusetts
http://scrvices.oca.state.ma.us/hic/licenseclist.aspx 12/14/2011
DEG-14-2011 12:24
'y
ram'
LABARGE ENGIN. and CONTR.
�INUmachusctts - Dep:ttTtncut of Public Safety
Board of Building &..utatiunx unit Standards
�71J
`Vll Construction Supervisor License
Licunrn: CS 68313
• K*&tfieten LO: 00 •i �'inj
..
TODDA LABARGE
237 MAIN ST/ RT 28 . �
":" '•
W HARW ICH, MA 02071 . '' +
.... Etpkaiion: 2(7I2012
Oinuu6sluarr Tra: 15M
� 1
PjHddctad to: 00
po- Unrestricted
1G -1 2 Fwally 11otnes
Failam to possess o current edition of the
Massachusetts State Building Code
is cause for revocation of this Ream&
-
$cfcr to: W W W.MasslGovA)PS
C
\i
I•i f
•
•
508 432 6792 P.02
• 1
I C-14-2011 12:24 LABPRGE ENGIN. and
CONTR. SW 432 6792 P.03
r
✓/N tOGw+woA4.+o� p�✓iFQJOLN�t(6arQ
.
License or registration valid for Individul use only
- office Of Consumer Affairs 8G �Y31gW It[il4lanOO
f Con Af f l
before the expiration Oak. if found return to:
HOME VEr CONTRACTOR
4
RoOisttatlor449A00
Office of Consumer Affairs and Business Regu4tion
10 Yark Ylaaa - Suite 5170
Ezpira0op- .Kui 12 Tr# 291587
BostM oorA02116
Typq�.iF�•-j?'flwBfR_Cr4�A4,[alion
,
I.ABARGE ENG1NV- RING 8:CrbUTRACTING We
TODD tABARG "
i • •.f , 1%
237h+WNST-RT;28';T•`-•. � - -•r�-- =-���•�"�--
W HARWICH, MA 02B%1% r' uudenecreary
Not vah without signature
M 1•
12:24 LABARGE ENGIN. and CONTR.
508 432 6792 P.04
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
WC 00 00 01 A 0711
Issuing Company: Acadia Insurance Company
290 Donald J. Lynch Blvd, P.O. Box 9168
Marlborough, MA 01752.0168
WORKERS COMPENSATION AND EMPLOYERS
LIABILITY INSURANCE POLICY
RENEWAL
INFORMATION PAGE NCCI Carrier Code No.: 33391
Policy No.: WCA 0268616 -13
Previous Policy No.: WCA 0268516.12
1. Name Insured tind Address
Agency Name and Address 07401
LaBarge Engineering and Contracting, Inc.
(508) 791-2241
237 Main Street
Sullivan Insurance Group, Inc.
Route 28
Ten Chestnut Street, Suite 1010
West Harwich MA 02671
Worcester MA 01608-2804
Other workplaces not shown above:
Refer to Name and Location Schedule
FEIN: 043552990
Risk ID No.: Bureau File No.: 0262586
Entity of Insured: Corporation
POLICY PERIOD
2. The Policy Period Is from 09/26/2011 to 0926/201212:01 AM Standard Time at the insured's mailing address.
COVERAGE
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of
the states listed here: MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed In Item 3.A. The
limits of Tr liability under Part two are:
Bodily Injury by Accident $ 500,000 each accident
Podily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 500,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, If any, listed here:
ALL STATES EXCEPT ND, OH, WA, WY AND STATES DESIGNATED IN ITEM 3A OF THE
INFORMATION PAGE.
D. This policy includes these endorsements and schedules: See "Schedule Of Endorsements'
WC 00 00 01 A 0711 Includes copyrighted material of The National Council on Compensation Page 1 of 4
Insurance, with their permission.
TOTAL P.e4
? os r TOWN OF YARMOUTH Building Department BUILDING
(508) 398-2231 ext.261
PERMIT NO FB-05-765_
;.• ISSUE DATE ; _ 12/3/2004 _ ; PROPOSED USE ........ _ _ _ PERMIT
APPLICANT 'David "Sauro " " " " " " ::: f j ::: JOB WEATHER CARD
.................. I!='
i PERMIT TO Alterations
AT (LOCATION) 100177RIVER ST - ZONING DISTRIC RS-4 Bldg. Type: Residential
SUBDIVISION MAP LOT BLOCK 1034.291 BUILDING IS TO BE: CONST TYPE 5•B USE GROUP R-4
LOT SIZE
CONTRACTOR
LICENSE 072868
Sauro, David
20 North Main Street
South Yarmouth MA 02664
508398"
four replacement windows
REMARKS
AREA (SO FT) EST COST ($ l$14
OWNER IROBERT J DAVIS
ADDRESS 17 Windemere Drive
Southboro 77777TMA 101772
PERMIT FEE ($) $35.00
BUILDING DEPT BY
INSPECTION RECORD
FIELD COPY
Date I _ Note Progress - Corrections and Remarks I Inspector
lu
1
coom�mewrwt[1A a/9//a uclw..11/ omcial Use ,Only
/p
. 0ruiewa� o/..Jlor So**" Permit No. - r l •- (4 Z I
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS Rev.1107] lave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massochrnens Electrical Code (M 527 CdIR I zoo
(PLEASE PRINT iN INK OR TYPE ALL 1NFORAM770 � Date:
City or Town o[: f4//1M22t To the Ins ector of Wira.
By this application the undcaigmcd Biro notice of his or her intention to perform the electrical work described below.
Location (Street A
06nor or Tenant
Telephone No.
use's Address 7
fJ
c I
this permit In conjunctlon wit building permit? Yes ❑ No
(Check Appropriate Box)
o
N o
rposs of SuRdlag��ldL�! /.Vb
Utility Authorization No.
o -�� E
dug Service �r� Amps /�U /� O Volq
Orerhsad ❑
Undgrd No. of Metars
Amps / Vold
Overhead ❑
Undgrd ❑ No. of Meters
N
bar of Feeders and Ampacity
C1�
f
and Nature of Proposed Electrical Work: 1JI
r'n.wnIA11" nfAa A11A..r.. PAU, - L......r.._.a a.. A -
No. of Recessed Luminaires
No. of CeMusp. (Paddle) Fans
--
Transformers KVA
No. of Laminates Outlets
No. of Hot Tubs
Geaenton KVA
No. ofLumlwlres.
Swimming Pool Above ❑ mod. ❑
und.No.
Ba o ery Units rgency B
of Receptacle Outlets
Me. of OB Barnes
FM ALARMS
Nw of Zola
No. of switch"
No. of Gas Swoon
S46 f Off0 M a • Devicesand
No. of Ranges
Me. of Air Coed. Toota
Nw of Alerting Devices
Nw of Wets Dbposars
RNnTotan:
trm
ono
r 0etaliffed
n Devices
No. of Dlshwashon
SpacdAres Hosting KW
Local ❑ C77ouutlon ❑Other
No. of Dryers
"stooMe
Hosting Appliances KW
Not -of Derlees er Equivalent
coo water KW
Herten
coo coo
Sign Ballasts
p� yyWngt
Nw of Devices or Itetvalent
No. Hydromassage Bathtubs
Ns. of Motors Total HP
folea==uD asa
of Doyle E e rallot
OTHER:
.rrraca aaurrrona detau y darnel, or as rsgrtrtd by the Inspector of Jrlrrs.
Estimated Value of cc rical Work: (When required by municipal policy.)
Work to Stax (o U Inspections to be requested in seeotdaua with b1EC Rub 10. and upon completion
INSURANCE COVERAGE: Unless waived by the owner, no pcmnit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed opaztioa" coverage or its substantial equivalent. The
undersigned catifcs that such cov pis in (orce. and has exhibited proof of same to tho permit issuing oMco.
CHECKONE: INSURANCE BOND ❑ OTHER ❑ (Speciijr.)
1 radf j. under the pains and ptne/dea olper/w7, that 11 b lnfonrretlo this pUc at onl tour era
FiR1N NAME: %O ,Lg % /r✓ LIC NO.: t 3-.3/ �TJIi
Lluruea't tr'i7Xao2G% P� /�.•I'✓i.✓ Signature s� LtG NO.:
(I/applkad/t, sneer "tsemp"In the / tnst number fin eJ Qua. TtL Nw• �d� 3G Y 7rfT�
Address gc5og,,,a,UL TeL Nw:774/ 99V T"607.
fperMO.L. c. 147, s. 57.61. s 'ty work ires Department of Public Safety' " Lica:se:tore Telephone Nor PEI�N/T FEE: S �
DEC 0 3 004
I, L'- .LL_rT.
L.
EXPRESS BUILDINGPERNIIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 261
CONSTRUCIMMADDRESS / 7 % /�/L �? -5 /.
lfJ
FaS'
�5� {
Y«mh .:pue. 6 tiom
• ieaie �.
ASSESSOR'S RQFORMATION:
_ Mv: c� y = a9i
owxER.APB 2�47 _� > Fs' o A 4 0/-•».z .508-�60 �i3aG
NAM PMEWADDRM TEL M
CONTRACT J 9I/�"/VfIO Gf !//GdI,yC, SG•)/9-e�OU i .�0� 3 9,-C;v 92
// NAME MAEUM ADDRESS TEL#
O Rsid at ❑ commercial Est coat of Construction S / `�j 000
Home Imgo.cwwc Cantractal is r 10(o Gz2 V construction Sopu.isac I is i Cs d 7 6 (o
Workmm's Compeasaban 1 (heck me)
❑ 1 am the homeowner ❑ 11 am the sok pq=ietarDmre worker's campoasafm huo m=
InLwance Company Namc�/,fi ,4�25 %�j 9S G Ieo 0 Warkws comp. Poticy/
WORK TO BE PERFORMED
O Teat (i=o Rdsdmt Certificate noodled)
Dmafm wood SWn shad
Sitting: q orB"M bpaghmnua, wwmm- IV
O RepLoemat doors: A
13 Rogwf! Hof sqm=
( ) stripping add rh &o () going over IqM oleridiag roof
wnw debris wa ba digw"ofst �� rn/�rY�L B.Ci — O /C.c• S/Y
location of Facility
I dedwe nad" paddies " Ad "wmcnab herein wdaioed are tm and uarcd b ffie Oat of my knowledge and belie[ 1 aad"dmd that say fah* answa(s)
will be jest cm f« tkmisl of rq loeae esd" Mo.L CIL 262, sec hm 1.
Apptiamt•s sgnstum D.W _A;-1/--?/lJ y
OwnasSiVuhwe(or attachmmt) Date /.3/3/OY
Appmvai 133r Dd ,
BWdiog Official (« desigeee)
Zoning Distcic —g S) K
Historical District ❑ Yes f�No Flood Plain Zone: '4 Yes ❑ No
Water Resource Protection, District Within 100 ft. of Wetlaod&
❑ Yes ji No J'es ❑ No
3MI
i;
SOF YAR14OUTH
FIELD COPY
`1330 •� S-�
BUILDING, .l
PERMIT " Dp-
DATE August 3. 2001 PERMIT NO. B-02-118
APPLICANT Dii Baport Building Co. ADDRESS 20 North Main Street S.Y. 02664 CS072866
(NO.) (STREET) - ICONTR'S LICENSE)
OF
PERMIT TO repairs - , -E tt I STORY NUMBER DWELLING
UNITS
(TYPE OF IMPROVEMENT) NO. )PROPOSED USE)
AT (LOCATIO477 River Street S.Y. 02664 DIO TING R CT RS 40
IND.) (STREET)
BETWEEN AND
(CROSS STREET) (CROSS STREETI
LOT
SUBDIVISION 34/291 LOT BLOCK SIZE
BUILDING IS TO BE FT. WIDE BY FT. LONG BY FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION
TO TYPE 5B USE GROUP R4 BASEMENT WALLS OR FOUNDATION
(TYPE)
REMARKS:- Strip find re —roof, pnner and vent LO COdP_
AREA OR
VOLUME ESTIMATED COST $79500.00 FEE PERMIT $ 25.00
(CUSICISOUARE FEET) _
OWNER Robert Davis
ADDRESS 22 Ledge Hill Road Southboro, MA BUILDING DEPT
.,� INSPECTION RECORD
DATE I NOTE PROGRESS - CORRECTIONS AND REMARKS I INSPECTOR
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
0 I Yarmouth Building Department
1146 Route 28
AUG0 3 2001 D
South Yarmouth, MA 02664
(336 4a (508) 398-2231 Ext. 261
/J/. �e sX. --To , Y•�.emo
ASSESSOR'S INFORMATION:
Map: 0341 Parcel: o257/
� GcdgP fililG ,2d.
OWNER: IleOzgPCT N-7'. �'4v/S �u>Ll,eoa?a..9h /h•q,
telicsidetuial
❑ Commercial
Ld
PRESENT ADDRESS
fire
Permit if / (1
Fee S f , -
Permit expires 6 months fron
issue date.
�235 •3 �5/- 8
TELx
Est Cost of Construction S_ %y s0 0
�1l
Home Improvement Contractor Lie. # / 0 & Oo2 S/ Construction Supervisor Lis #_ (2j n W e6 (0
Workman's Compensation Insurance: (check one)
❑ 1 am the homeowner ❑ I am the sole proprietor Wfhave Worker's Compensation Insurance
Insurance Company Name: Worker's Comp. Policy# L!/C/`1'G C}� 4�d
WORK TO BE PERFORMED
O Tent (Fire Retardant Certificate attached)
Duration
0Siding: #of Squares
O Replacement windows: 0
O fte-roof A ofSquare 41 �SG�_
/,Mtrippmg old shingles*
O Replacement doors: 0
() going over layers of existing roof
'The debris will be disposed of at: Y.g e, 72Pu0 � 2Ui+s �.
Location of Facility
1 declare under penal of perjury that the statements herein contained arc true and correct to the best of my knowledge and belief: I understand that any false answer(s)
will be just cause for des revocation of my Qccyseaarj for prosecution under M.O.L. Ch. 268, Section 1.
Applicant's
Owners Signature
Approved By Date:
u ding O cial (or designee)
Zoning District:
Historical District: 91ZoYes ❑ No Flood Plain Zone: R Yes ❑ No
Water Resource Protection District: Within 100 R of Wetlands:
❑ Yes Q/!`lo ❑ Yes IB' No
3101
e
m
QI
a
m
0
O
m
O
z
F
0
O
4
FIELD COPY ..
PERMIT a�
DATE aTt'immzr 286 L2QQO-- PERMIT NO.
APPLICANT DdVi�Sauro ADDRESS 2O NO_ Main S r pt�'Snllth YArmpu}h_
'(NO.) (STREET) =8NU66 (CONTR'S LICENSE)
Addition NUMBER OF
PERMIT TO (_) STORY DWELLING UNITS
(TYPE OF IMPROVEMENT) NO. (PROPOSED USE)
AT (LOCATION) 177 RIVER STREET, SOUTH YARMOUTH D ZONINGISTRcT -25
(NO.) (STREET),
BETWEEN AND
(CROSS STREET) (CROSS STREET)
it Y iA ffr� -Sni L�� b A 1 •• wfflflT
SUBDIVISION ���- '� `�� LOT o ` BLOCK r 02& tPSIZE
BUILDING IS TO BE FT. WIDE BY FT.,LONG BY FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION
TO TYPE 5-B USE GROUP R-4 BASEMENT WALLS OR FOUNDATION
(TYPE)
REMARKS: 1ST FLOOR --EXPANSION OP KITCHEN i BREAKFAST ROOM, 5 DECKS,
2ND FLOOR --ADDITION OF SITTING AREA TO BEDROOM, 1 DECK
50.00 AREA OR . PERMIT 285• 75
VOLUME ESTIMATED CO ST FEE
(CUSIC/SQUARE FEET)
Robert J. DavisOWNER
ADDRESSZZ Ledge Roa • Southborough, MA 01772 BUILDING S / '
0
INSPECTION RECORD
DATE r NOTE PROGRESS • CORRECTIONS AND REMARKS
INSPECTOR
cito
r.
ONE & TWO FAMILY ONLY - BUILDING PERMIT
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Town of Yarmouth Building Deparunent •'
1146 Route 28 - Yarmouth, NIA 02664-4,192 ,
Tel: (508) 398-2231 x261, • Fax: (508) 398-2365
Office Use Only
Permit No. b-WdObbate/"" S
Permit Fee $ �8S �-�
Deposit Rec'd. $/O a Date I-IIm
Net Due $ 0�?7SS1 ♦J
Planning Board Information
Plan Type
Endorsement Date
Recording Date
plan No.
Other
Assessors Department Information:
Map tot Map Lot
Z
o/d New
t A Property Dimensions:
LotArea (sf) Frontage(ft) Lot Coverage
This Section for Office Use Only
Building Permit Number:
Date Issued:
Signature: Q
Certificate of Occupancy
is is not required
Building Official ate
Section 1 - Site Information
I Use Group: R-4 Type: 5-B
1.1 Property Address:
Z 7 Jl r-Vca- Si�
1.2 Zoning Information: \
-RS O9 5:;21 ✓1. )*)WC
Zoning District Proposed Use
f- i s nu `F;I
1.3 Building Setbacks (it)
Front Yard
Side Yards
Rear Yard
Required
Provided
Required
Provided
Required
Provided
i y _
'0-0 r
1.4 Water Supply (M.G.L. c. 40. S 54)
Public Private
1.5 Flood Zone Information: Comments:
Zone: ,d BFE: —4L_
Section 2 - Property Ownership/Authorized Agent
2.1 Owner of Record: ,
T. zz ,,// K'd.
Nam (print) Mailing Address
- So a ho Y-o a
Signature Telephone
2.2 Authorized Agent:
%at/OIAQ614 ?14;1dI;l4 Qo za N Mat' St -
Name (print) Mailing Address
ntOw OZ
Signature Telephone
Section 3 - Construction Services
3.1 L censed Construction_ Supervisor:
tom. C�.11ilw..r_C_7
Not Applicable ❑
`
e1 O 1 ��, p^
oG N `t''1r� ""o�
License Number
� S G
Addres
�acl-3
Expiration Date
Signature Telephone
3.2 Registered Home Improvement Contractor:
Company Name
Not Applicable ❑
License Number
Address
Signature Telephone
Expiration Date
9- 15-99
1of2
OVER
V
Section 4 - Workers' Compensation Insurance Affidavit (M.G.L. c. 152 S 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 5'- Description of Proposed Work (check all applicable)
New Construction ❑ I No. of Bedrooms No. of Bathrooms
Existing Bldg. ❑ Repair(s) ❑ I Alterations ❑ Addition
Accessory Bldg. ❑ Type
Demolition
Other Specify:
Brief Description of Proposed Work:
s. o K1' sr° ax-eli CPO,
'✓s -P•'�`fr-ttic
VA a. ryo-P deck,
Costs
Estimated Cost (Dollars) to be Check Below
completed by permit applicant
Z S' Cr+To Ir' Conservation -Commission Filing
(if applicable)
cs�27
❑ Old Kings Highway & Historical
Commission approval
(if applicable)
To be Completed When
for Building Permit
Section 6 - Estimated Construction
Item
1. Building
2. Electrical
3. Plumbing / Gas
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5)
7. Total Square Ft. (new houses & addfions)
Section 7a - Owner Authorization -
Owner's Agent or Contractor Applies
1, ')Re be #4 1, au t , as owner of the subject property
hereby authorize ��e++�+ 6 c� i �d ��L4�°�-^�`% to act on
my behalf, In all matters relative to work authorized by t is building permit application.
2141da..n.Yte- / - i/- aoa o
Signature of 0wrWr Date
Section 7b - Owner/Authorized Agent
)Declaration
1, 16Lr/e4-, dd Z I' Ha Cc/ / D4 4 c -ry , as Owner/Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate,
to the best of my knowledge and belief.
Si ned under the pains and penalties of perjury.
%i .4V//�s S.�v/Qo
Pri name n
�� guy /— �✓^�-Goc
Signature of Owner/Agent Date
9- f5-99
2 of 2
OB
TOWNOF YARMOUTHBUILDING DEPARTMENT
UILDING PERMIT APPLICATION SIGN OFF
Applicant: - lCc ve v,14 M/ ��� c1 G eb Building Permit No.:
Address:.Q() oor`4h► Y\'0 i n St. ;" Tel. No.: 319_ zZ 9 3 Date Filed: /
Bldg. Site Location: 127 Ri ile r S, a.rwt • Map No.: 3 4 Lot No.: oZ Q)
The following information outlines the procedural steps required to obtain a permit to build, alter, or add
to a structure within -the -Town of -Yarmouth. The. Building Department -will determine compliancetothe
following: (A) Zoning Requirements (B) Historical Districts (C) Flood Zones. The Building Department
will be responsible for assisting the applicant through.the following departments:
RESIDENTIAL AND/OR COMMERCIAL BUILDING
WATER DEPARTMENT: Determines Compliance of Water Availability. (applicant to obtain)
ENGINEERING DEPARTMENT: Determines Compliance for Parking and Drainage.
CONSERVATION CONBUSSION: 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.
----------------------------------------
77ae follouring Departments must sign off, in the respective order, prior to building inspector issuing the required
building permit:
REVIEWED BY: \_ • n n
1. WATER DEPARTMENT: �0 1�.+. T DATE: Q/- .,3.00 N/A;
2. ENGINEERING DEPARTMENT: DATE: N/A:
3. CONSERVATION: DATE: N/A:
4. HEALTH DEPARTMENT: ' DATE: -18 -0 N/A. -
INDUSTRIAL AND/OR COMMERCIAL PERMITS
5. WIRING INSPECTOR: DATE: N/A:
6. PLUMBING INSPECTOR: DATE: N/A:
7. FIRE DEPARTMENT: DATE: N/A. -
PLEASE NOTE
All stumps and/or brush must be disposed of at an approved site. .0
COMMENTS: aO�. ixe, r:..�u c [y�1'�. [✓.(ctrs, �.�-�-i� .
C�e ''lam - S ✓1%`r� T Mow- j- A-e ti-c 10c "re' <' N n c2d C4 t h �►,, --
rw(1-P'e!,y.i..r�(-1-$'►SP 1�� 1f�-�'rrdlL 0 /Jr✓M1T/CfUeb
R4 A1
, �/99 Applicant Signature �—e--- ten— Date
TOWN OF YARMOUTH BUILDING DEPARTMENT
PL -%N REVIEW & BUILDING PERMIT APPLICAnON REVIEW NOTE
Address: / 7% Zra 7 ( �X
�� v
Map/Lot: 3�> —� • .
Date of Initial Review: Other Approval Date 1
Inspector. t)
Notes:
/riL , �S
2 x
Zoning Decrial (if applicable �X �'S a e� �70 L
:Section 104.3.2, pars. Change, Extension or Alteration (pre-existing,
nonconforming)
The proposed' requires a Special Permit from
the Zoning Board of Appeals.,.
:Other
X
Building Code Denial (if applicable)
--�b.cafk ftarbudd ------ Town of Yarmouth wetland sy.Law
Bureau of Resource ProWdon — Wetlands Chapter 143
. WPA Form 2 w Determination of Applicability
Massachusefts Wetlands Protection ActM.G.L c. 131, §40 inn
U General information
Front
YARMOUTH
Ca="W Ca ron
1. Applicant
Robert Davis
VTNgeR°2.11 Road
MI&VA&W
Southborough
WON
MA 01772
SUN roCQ*
2. Property Owner.
Same As Above
AbmrWPrgoary0wr(dd�ertam�p�ianq
Aht VAMW
SLa To Cott
Defetminatlon
Pursuant to the authority of M.G.L C.131, §40, the
Yarmouth
has caaidued your Request for a Deternn nation of
Applicability, with Its supporting documentation, and has
made the following Determination regarding:
177 River Street
SWuth Yarmouth, MA 02664
34 291
AueQariM*ft/ Peal
3. Title and Final Revision Date of Plans and Other Document
Site/Location Plan for
Robert Davis, 177 River St.,
S.Yarmouth
Ka=ch i f fs Department d En1ft=6VW PMtr H4V Town of Yw=ourtb wetland sy-Lzw
• Bureau of Resource Pmtecdon — Wetlands Chapter ins
• , , WPA Form 2 - Determination of Applicability
Massachusetts Wetlands ProtectionActM.G.L c. 131, §40
Determination (cont)
The following Oetemmination(s) Ware applicable to the
proposed site and/or project relative to the Wetlands
Protection Act and Regulations:
Positive Determination
S. The area and/or work described on plan(s) and
document(s) referenced above, which includes all or part of
the work described In the Request, Is subject to review and
approval by
Note: No work within the jurisdiction of the Wetlands __--� — - — --- -
Protection Act may proceed until a final Order of Conditions --- --
(issued following submittal of a Notice of Intent or pursuant to the following wetlands law, bylaw, or ordinance
Abbreviated Notice of Intent) has been received from the (name and citation of law).
Issuing authority (I.e., conservation commission or the
Department of Environmental Protection).
= 1. The area described on the plan(s) referenced above,
which includes all or pant of the area described In the
Request, is an area subject to protection under the Act.
Therefore, any removing, filling, dredging, or altering of
that area requires the filing of a Notice of Intent.
2. The delineations of the boundaries of the resource
areas listed directly below, described on the plan(s)
referenced above, which Includes all or part of the area
described in the Request, are confirmed as accurate:
Therefore, the resource area boundaries confirmed In this
Determination are binding as to a8 decisions rendered
pursuant to the Wetlands Protection Act and its regulations
regarding such boundaries for as long as this Determina-
tion is valid. However, the boundaries of resource areas not
listed directly above are mgt confirmed by this Determina-
tion, regardless of whether such boundaries are contained
on the plans attached to this Determination or to the
Request for Determination.
3. The work described on plan(s) and document(s)
referenced above. which Includes all or part of the work
described In the Request, Is within an area subject to
Protection under the Act and will remove, fill, dredge, or
after that area. Therefore, said work requires the filing of a
Notice of Intent.
C 4. The work described on plan(s) and documents)
referenced above, which includes all or part of the work
described in the Request, is within the Buffer Zone and will
after an Area subject to protection under the Act. Therefore,
said work requires the filing of a Notice of Intent
C 6. The following area and/or work, ff any, is subject to
municipal bylaw but mg); subject to the Massachusetts
Wetlands Protection Act:
C 7. If a Notice of Intent is filed for the work In the Riverfront
Area described on plans and documents referenced above,
which includes all or part of the work described In the
Request, the applicant must consider the following
alternatives (Refer to the Wetlands Regulations at
10.58(4)c. for more information about the scope of
alternative requirements) :
13 Alternatives limited to the lot on which the project is
located.
Q Alternatives limited to the lot on which the project Is
located, the subdivided lots, and any adjacent lots formerly
or presernty owned by the same owner.
C Alternatives limited to the original parcel on which the
project Is located, the subdivided parcels, any adjacent
Parcels, and any other land which can reasonably be
obtained within the municipality.
C Alternatives extend to any sites which can reasonably
be obtained within the appropriate region of the state.
Massacbnseffs Depaftenf of EnvironmeaW ProtecHon Town of Yarmouth Wetland By-law
Bureau of Resource Protection — Wetlands Chapter 143
WPA Form 2 = Determination of Applicability
Massachusetts Wetlands Protection ActM.G.L a 131, §40
0 Determination (coot.)
Negative Determination :1 5. The area described in the Request is subject to protection
NOW No further action under the Wetlands Protection Act under the Act Since the work described therein meets the
Is required by the applicant However, It the Department of requirements for the following exemption, as specified in
Environmental Protection is requested to issue a Supersed- the Act and regulations, no Notice of Intent is required:
Ing Deterndnation of Applicability, work may not proceed
on this project unless the Department fails to act on such
— request within 35 days of the date the request is post- EOV'L'"h'
marked for certified mail or hand delivered to the Depart= -- ------ -- --
mend. Work may then proceed at the owner's risk only
upon notice to the Department and to the conservation n 6. The area and/or work described in the Request is not
commission. Requirements for requests for Superseding subject to review and approval by
Determinations are listed at the end of this document.
C 1. The area described In the Request is not an area subject
to protection under the Act or the Buffer Zone.
C 2. The work described in the Request is within an area
subject to protection underthe Act, but will not remove, fig,
dredge, or after that area. Therefore, said work does not
require the filing of a Notice of Intent.
X3. The work described in the Request is within the Buffer
Zone, as defined in the regulations, but will not after an
Area subject to protection under the Act Therefore, said
work does not require the fling of a Notice of Intent
4. The work described In the Request Is not within an Area
subject to protection under the Act (including the Buffer
Zone). Therefore, said work does not require the filing of a
Notice of Intent, unless and until said work afters an Area
subject to protection under the Act
NA=0fAranln0#
pursuant to a municipal wetlands law, ordinance, or bylaw,
(name and citation of bylaw).
Authorization This Determinatio st 1,1 d
"
This Determination is issued to the applicant and delivered
as follows:
Z by hand delivery on
A0
f7 by certified mail, return receipt requested on
11-23-99
nm
This Determination is valid for three years from the date of
Issuance (except Determinations for Vegetation Management
Plans which are valid for the duration of the Plan).
This Determination does not relieve the applicant from
complying with all other applicable federal, state, or local
statutes, ordinances, bylaws, or regulations.
"I"
e s gne by a mahonty of the
conservation commission. A copy must be sent to the
appropriate Department of Environmentai Protection
regional office (see appendix A) and the property owner (if
different from the applicant).
11,
zl
. 1 d /
11-23-99
A/assachUSdb Deparfineat of &d D=gala/ PfOMCHon Town of Yarmouth Wetland By -Law
Bureau of Resource Protection — Wetlands Chapter 143
WPA Form 2 - Determination of Applicability
Massachusetts Wetlands Protection Act M.G.L a 131, §40
U Appeals
The applicant, owner, any person aggrieved by this Determina-
tion, any owner of land abutting the land upon which the
Proposed work Is to be done, or any ten residents of the city or
town In which such land is located, are hereby notified of their
right to request the appropriate Department of Environmental
Protection Regional Office to issue a Superseding Determina_
bon of Applicability. The request must be made by certified
mail or hand delivery to the Department, with the appropriate
Tiling fee and Fee Transmittal Form (see Appendix E Request
for Departmental Action Fee Transmittal Form) as provided In
310 CMR 10.03(7) within ten business days from the date of
Issuance of this Detenninadon. A copy of the request shah at
the same time be sent by certified mail or hand delivery to the
conservation commission and to the applicant If hatshe Is not
the appellant The request shall state clearly and concisely the
objections to the Determination which is being appealed. To the
extent that the Determination is based on a municipal bylaw,
and not on the Massachusetts Wetlands Protection Act or --
regulations, the Department of Environmental Protection has no
appellate jurisdiction.
of YgR,y
3�c
PLEASE PRINT:
Job Location:
TOWN OF YARMOUTH
BUILDING DEPARTMENT
CONSTRUCTION SUPERVISOR FORM
sll
Number Street Village
Owner of Property: Roher- f- - . 2)aulls
Construction Supervisor: �)avi d -razLen f 91772-6 3 4g-?'zt7
Name License No. Phone No.
Address:
Licensed Designee:
(If other than Supervisor)
Name
& r vn 57; 1.
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 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 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 Ua No ❑
If you have checked ygg, please Indic 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
Chanter 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 4a-
V/'*`Signaturc: _���� Building Official Approval:
M
The Commonwealth of Massachusetts
Department of Industrial Accidents
exceellerestYffsUess
600 Washington Street
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Applicant information: PlessrEHM11es±iffifR
cite Rhone 4
O 1 am a homeowner performing all work myself.—
O 1 am a sole proprietor and hase no one working in any capacity
2r'fam an employer pros iding workers' compensation for my employees working on this job.
address: Q) O Ma t.11 5 7—. '
i E "Aff . .
_ •
I am a sole proprietor. general contractor. or homeowner (circle one) and have hired the contractors listed below who have
the following worker:' compensation polices:
company name•
address•
ems: phone N-
ice Co. policy #
Failure to secure coverage as required under Seetioo 25A of MGL 152 can lead to the Imposition of criminal pesalnes of a One up to s1,5Uo.0o and/or
one years' Imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a floe of $100.00 a day against me. 1 understood that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby c i y under the gains and enalties ojperjuiy that the information provided above is true and correct.
Signature
Print name �✓ !� �9v'ee hone #
official use only do not write in this area to be completed by city or town official
city or town: YARMOUTQ
❑ check if immediate response is required
permit/license # -Building Department
❑Liceosing Board
261 • . ❑Selectmen's Office
Icna% 39a 2231 ❑Ileallh Department
phone 0: _ _ ext. -Other
contact person:
lrmuad 3.95 PW
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
entplo%ees. As quoted from the "law• an emplat•ee is defined as every person in the service of another under any
contract of hire, express or implied, oral or written.
An enrplaver is defined as an individual. partnership, association, corporation or other legal entity, or any two or more of
the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual , partnership, association or other legal entity, employing employees. However the
o%%ner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance , construction or repair work on such dwelling house
or on the -srounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.
%IG1. chapter I5- section -'5 also states that every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required.
Additionall%. neither the commonwealth nor any of its political subdivisions shall enter into any contract for the
performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter ha%e
been presented to the contracting authority.
Applicants
Please till in the workers' compensation affidavit completely, by checking the box that applies to your situation and
supplying company names, address and phone numbers as all affidavits may be submitted to the Department of
Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The
affidavit should be returned to the city or town that the application for the permit or license is being requested.
not the Department of Industrial .accidents. Should you have any questions regarding the "law" or if you are required
to obtain a workers' compensation policy, please call the Department at the number listed below.
City or Towns
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of
the affidavit for you to fill out in the event the Office of investigations has to contact you regarding the applicant. Please
be sure to fill in the permit/license number which will be used as a reference number. The aMdavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number.
The Commonwealth Of Massachusetts
Department of Industrial Accidents
ftT ce of IMSUNIU111Ot
600 Washington Street
Boston, Ma. 02111
fax 0: (617) 727-7749
phone #: (617) 7274900 ext. 406, 409 or 375
BUILDING
TOWN OF Y A R M O U T H ELECTRICAL
GAS
1146ROUTE28 SOUTHYARNIOUTH NIASSACHUSETTS02664-4451
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 i �i '✓ee— ST- S
Work Address
is to be disposed of at the following location: --3r-t-
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
V
Signature of Applicant
Permit No.
Date
• Suggested Affidavit for Home Improvement Contractor Permit Application
For omce Use only NAME OF CITY/TOWN
Permit No
Date
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
NGLc.14ZArequiresthat the 'reconstruction alteration renovation repair modernization. conversion. inrrmement.removaI.demolitInn.
nrconstructton of an addition to anv nretastm owner -occurred huddinz contammr at least one but not more than four dwelling units ..or
-in mucturn Which are adiacent to such residence or budding' be done by repstered contractors. with certain exceptions. along with ether
requtremcnts ---------- =----I — ---- — ---- - --
Type of
Address of Work 1 7 7��✓� 57�7 S �/Crinossh
Owner Name: o her y�/ 2 a") ,S
Date of Permit Application:
I hereby certify that:
Registration is not required for the following rcason(s):
_Work excluded by law
_Job under S1,000
_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. 1d2A.
Signed under penalties of perjury:
I hercby apply for a per 't as the agent of the owner.
/ // a00G
V Date Contractor Name Registration No -
OR:
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property.
Date Owner Name
,
iE?i0 tlN '31IIA131N33
�3NO1.Nb�t'Eii ;
o>IAtf 9tAil i
00
1561/90/SO i001/90/SE lS�2L1+� �7.:�7
a1YP11�SB a3atdz3 j)eidN
3SN33I1 IOSIA13dAS WIIIJAb1SN03
A13115.31110d 30 1N3911IVd30 !
-+ Restricted ro: 00 1 8 9 92 6--
00 - 3S,000 cl enclosed spi"
(M6L C.112 SAOL) '
IA - Masoary only
1 ' 16 - 1 1 2 Faoily-Noies
Failure to possess a correat editlaa of the
Massichisetts Stale Bufldia0 Code ;
I :s cause for revocation of this iiceose.
1
:j ;
I
I
MAScheck COMPLIANCE REPORT
Massachusetts Energy Code
MAScheck Software Version 2.01 Release 2
CITY: Yarmouth
STATE: Massachusetts
HDD: 6137
CONSTRUCTION TYPE: I or 2 Family, Detached
HEATING SYSTEM TYPE: Other (Non -Electric Resistance)
DATE:12-29-1999
PROJECT INFORMATION:
an addition for: --
ROBERT AND RITA DAVIS
177 RIVER STREET
S. YARMOUTH, MASS.
COMPANY INFORMATION:
NORTHSIDE DESIGN ASSOCIATES
141 MAIN STREET
YARMOUTHPORT, MASS.
Permit #
Checked by/Date
NOTES:
CALCULA ONS APPLY TO THE ADDITION ONLY. SEE ADDITIONAL MASCHECK
SHEET FOR EXISTING CONDITIONS. VALUES OF THE ADDITION
AND THE VALUES OF THE EXISTING TOGETHER, THE PROGRAM PASSES THE
PROPOSED ADDITION AS IT AFFECTS THE EXISTING UA BY ONLY 4 POINTS.
COMPLIANCE: FAIIS
Required UA - 82
Your Home = 89
Area or Cavity ConL Glazing/Door
Perimeter R Value R Value U-Value UA
CEILINGS 235 33.0 0.0 8
WALLS: Wood Frame, l6" O.C. 395 15.0 0.0 30
GLAZING: Windows or Doors 127 0.320 41
FLOORS: Over Unconditioned Space 235 22.0 0.0 10
The heating load for this buildin a cooling load if appropriate = been determined using the applicable
Standard Design Conditions fo C e uipment selected to heat or cool the buitdingshall be no
greater than 125% of th d s t 780CMR 1310 and .4.
Builder/Designer Date
MECcheck INSPECTION CHECKLIST
Massachusetts Energy Code
MAScheck Software Version 2.01 Release 2
DATE: 12-29-1999
Bldg.
DepL
Use
"CEILINGS:
1. R-33
Comments/Location
I Wes:
[ ] I 1. Wood Frame, 16" O.C., R 15
Comments/Location
I
WINDOWS AND GLASS DOORS:
[ ] I 1. U-value: 0.32
For windows without labeled U-values, describe features:
# Panes Frame Type Thermal Break? [ ] Yes [ ] No
CommcpW-Zocation
FLOORS:
[ ] I 1. Over Unconditioned Space, R-22
Comments/Location
I
AIR LEAKAGE:
[ ] I Joints, penetrations, and all other such openings in the building envelope that are sources of air
leakage must be sealed When installed in the building envelope, recessed lighting fixtures
shall meet one of the following requirements:
1. Type IC rated, manufactured with no penetrations between the inside of the recessed fixture
and ceiling cavity and sealed or gasketed to prevent air leakage into the unconditioned space.
2. Type IC rated, in accordance with Standard ASTM E 283, with no more than 2.0 cf n (0.944
L/s) air movement from the the conditioned space to the ceiling cavity. The lighting fixture
shall have been tested at 75 PA or 1.57 lbs/ft2 pressure difference and shall be labeled.
VAPOR RETARDER
[ ] I Required on the warn -in -winter side of all non -vented framed ceilings, walls, and floors.
MATERIALS IDENTIFICATION:
[ l I Materials and equipment must be identified so that compliance can be determined. Manufacturer
I manuals for all installed heating and cooling equipment and service water heating equipment must
be provided Insulation R values and glazing U-values must be clearly marked on the building plans
or specifications.
I
DUCT INSULATION:
[ ] I Duds shall be insulated per Table J4A.7.1.
DUCT CONSTRUCTION:
[ ] I All accessible joints, seams, and connections of supply and return ductwork located outside
conditioned space, including stud bays or joist cavities/spaces used to transport air, shall be sealed
using mastic and fibrous backing tape installed according to the manufacturer's installation
instructions. Mesh tape may be omitted where gaps are less than 1/8 inch. Dud tape is not
permitted The HVAC system must provide a means for balancing air and water systems.
I
TEMPERATURE CONTROLS:
[ ] I Thermostats are required for each separate HVAC system. A manual or automatic means to
I partially restrict or shut off the heating and/or cooling input to each zone or floor shall be provided.
I
I HVAC EQUIPMENT SIZING:
[ ] I Rated output capacity of the heating/cooling system is not greater than 125% of the design load as
I specified in Sections 780CMR 1310 and J4.4.
SWIMMING POOLS:
[ ] I All heated swimming pools must have an on/off heater switch and require a cover unless over 20%
of the heating energy is from non-depletable sources._ Pool pumps require a time clock.
HVAC PIPING INSULATION:
[ ] I HVAC piping conveying fluids above 120 F or chilled fluids below 55 F must be insulated to the
I levels in Table 1.
CIRCULATING HOT WATER SYSTEMS:
[ ] I Insulate circulating hot water pipes to the levels in Table 2.
Tahlo I • Mim;ni n lnc ilntim Thir•Jrnecc fry HVAC Pinac
Fluid Temp.
Insulation Thickness in Inches by Pipe Sizes
Piping System Types
Range ( F)
2" Runouts
1" and Less
1.25" to 2"
2.5" to 4"
Heating Systems
Low Pressurefremperature
201-250
1.0
1.5
1.5
2.0
Low Temperature
120-200
0.5
1.0
1.0
1.5
SteamCondcasate(for feed water)-
--Any-
---1.5---
--2.0--
1.0
-1.0--
Cooling Systems
Chilled Water or Refrigerant
40-55
0.5
0.5
0.75
1.0
Below 50
1.0
1.0
1.5
1.5
Table 2: Minimum Insulation Thickness for Circulating Hot Water Pi
Insulation Thickness in Inches by Pipe Sizes
Heated Water
Non -Circulating
Circulating Mains and Runouts
Runouts
Temperature ( F)
Up to 1"
Up to 1.25"
1.5" to 2.0"
Over 2"
170-180
0.5
1.0
1.5
2.0
140-160
0.5
0.5
1.0
1.5
100-130
0.5
0.5
0.5
1.0
NOTES TO FIELD (Building Department Use Only)
ACORD_ CERTIFICATE OF LIABILITY INSURANCE„ °^0212 /9
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The Addia Group, Zac.
Suite 200
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pogt Conahohocken PA 29428-2976
aai610-832-2100 paz:610-825-9136
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S�•aOr�sddrriih 02664
ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE
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INSURERS AFFORDING COVERAGE
-COVERAGES - -
THE POUCIER OF EiSURANCE USTED BEUM WIVE BEEN E..SIED TO THE l6URED 1MAED ABOVE FOR THE POULY PEWW I1N CATER. NOTWFTH5TMW1W
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YAMM-2
Town of YaraaAth ... ° •
ATTMI; Permit Dept.
1146 Routa 28
S. Yarmouth, MA 02664
SNaaDAWGFDEAWWDODONDPOMEBJErANCEuimsu0+ uwzw u
DATED*iFmw.7HETSsvmDmwdmwTLLOWEAVcnToMAiL 30 OAYawamTa
NOTICES T07M CERn ATE HCUIER NAAEDTO THE I.M. OUT FALL E¢TO DO SO SKM.L
WOSENOosEwna/ORUAKM0FAWM0UPON THE INSURMFTSAGEMMOR
ATMEM
"U^OROM REPRESEWA
Gary W. Warren, CAWImtH-
nTL,rARO 25S (MM ' . ACORD CORPORATION 1991
/�ssae•� �-s'CS'
Abu ttorIs
Name
Lot # p2q.P
If this is a
:orner lot,
write in name
of street.
PLOT PLAN
FOR LOT # oa IF %
Indicate location of garage or accessory building
Additions with dashed lines --------------------
Sewerage disposal (cesspool)
Well 0
SIDE YARD
FT.
O
(lot..... .....ft. rear)
I
�113
REAR YARD
ft
I
.COT :;0aW /
36
HOUSE SIDE YARD
J!2 FTO
SET BACK
/ellf)
(lot .....°? / 0........ ft. frontage)
/ 7 7 #q/ cS?4.
(NAME OF STREET)
Information
Supplied by
r\
b
Abuttor I s
Name
Lot #
a 9a
If this is
corner lc
write in
name of
other
street.
MARK NORTH POINT
si�rx PLAN �Nctvd�ri
,It The Commonwealth of Massachusetts Mlice use
Only
Department of Public Safety
occupancy 1. ree Checked
BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 1= 3/90 itaa.e stank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
NI work to be performed In accordance with the Maasachurcru Electrical Code. 527 CMR 12:00
(PLEASE PRINT IN INR OR TYPE ALL INFOPUX&TION) Date ' 1-i " 1 % - Oo �
City or Town of Irart.nbu`fa. To the Inspector of Wires:
The undersigned applies for a permit to perform three electrical work described below.
Location (Street 6 Number) 11�1 71I V zn, tL Ca A�
Ocrer or Ienant 'r;L, V, �gNh S
Owner's AddressAPoJZ.—.------._-_--
Is this permit in conjunction with a building permit: Yes No ❑ (Check Appropriate Box)
Purpose of Building ON1 s-4 rGA� �-f ^^�D�t. Utility Authorization NO.
T..f ...ff. .f. I.-- 1`l.1.e.A M IInAs.T; m.
New Service Amps / Volts Overhead ❑ Undl D No f ers
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work �---�
By
No. of Lighting Outlets g
No. of Hot Iubs
No. of Transformers ota
KVA
No. of Lighting Fixtures
SwimmingAbove In-
grnd. ❑ grnd. ❑
Generators KVA
No. of Receptacle Outlets VJ
No. of Oil Burners
No. of Emergency Lighting
Battery Units
No. of Switch Outlets %0
No. of Gas Burners
FIRE ALARMS No. of Zones
No. of Detection and
Initiating Devices
No. of Sounding Devices
No. of Self Contained
Detection/Sounding Devices
Local ❑ MunieConnecctiotio n Other
No. of Ranges 0
No. of Air Cond. Ttons
No. of Disposals I
No. of HeatTotalTTons Total
No. of Dishwashers I
S ace/Area Heating KW
P
No. of Dryers
Heating Devices KW
No. of Water Heaters KW
No, of No. o
Si ns Ballasts
Low Voltage
Wirin
No. Hydro Massage Iubs
No. of Motors Total HP
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws
I have a current Li ili,t.Y Insurance Policy including Completed Operations Coverage or its substantial
equivalent. YESNO U I have submitted valid proof of same to this office. YES ❑ NO ❑
If you have c ecked YES, please indicate the type of coverage by checking the appropriate box.
INSURANCE BOND ❑ OTHER ❑ (Please Specify)
(Expiration Vate
Estimated Value of Electrical Work S M0,00
Work to Start Pry /5,' Inspection Date Requesteds Rough A SAP Final
Signed under the penalties of perjury:
FIRM NAME gQY5t,"s eL -X(Ltc LIC. NO. QI'28'L6
Licensee ST�7's£ti so—Icwri Signature LIC. NO.
Address �a D $Cx l�3 ��neu J /)n Pr C Bus. Tel. No. r5?b-Za->>
Alt. Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub-
stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit
application waives this requirement. Owner Agent (Please check one)
Telephone No. PERMIT FEE S
Signature of Owner or Agent
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, (MEC), 527 CMR 12.00
TOWN OF YARMOUTH
(OFFICE USE ONLY)
Fee: $__
U
U
PERMIT NO.
y9M.
d� —DI
0
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date:
To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work
described below.
_Location (Street & Number)
Owner or Tenant 13a 3 CJ.�1J1 S
Owner's
(LI V « s
S A W&e— ✓ -r l) Qeu�
Is this permit in conjunction with a building permit? ❑ Yes L"J No (Check Appropriate
Purpose of Building Utility Authorization No._
Existing Service Amps / Volts Overhead ❑ Undgrd ❑
JUL 2 0 2000
New Service Amps J Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity,
Location and Nature of Proposed electrical Work: n"4
Comhletion afthe followimc tahle may be waived bu the rntbe tnr of IN"t
No. of Recessed Fixtures
pa
No. of Total
Transformers KVA
No. of Lighting Outlets
No. of Hot Tubs
Generators KVA
No. of Lighting Fixtures 14
A ve In-
SwimmingPool end. ❑ rnd. ❑
No. of Emergency Lighting
Battery Units
No. of Receptacle Outlets 'L
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches Z
No. of Gas Burners
No. o D and
etection
Initiating Devices
No. of Ranges
Total
No. of Air Cond. Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
Num er
Ions
KW-
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Municipal
Local ❑ Connection ❑ Other
No. of D
Dryers
rY
Heating Appliances KW
8 PP
ecNo. Systems;
No. of Devices or E uipvalent
No. of Water
Heaters KW
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. H dromassa a Bathtubs
Y g
No. of Motors Total HP
Telecommunications Wiring
No. of Devices or Equivalent
Attach additional detail if desired, or as required by the Inspector of Wires.
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 the permit issuing office.
/1 CHECK ONE: INSURANCE E3"� BOND[] OTHER❑ (Specify:)
(Expiration Due)
Estimated Value of Electrical Work: T100 , OQ (When required by municipal polity.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I certify, under the pains and enalties of perjury, that the information on this application is true and complete. /^�
FIRM NADIE: G C oc �s4GTil L LIC. NO. � >s � $�
Licensee: 13F o!-ter Signature LIC.NO. fL2970G
(If applicable enter "exempt" in the license numb�Itne.) Bus. Tel. No.: 3.GS — 70'71
11 Address: • 6 ►'3aX {-Z 3 5,, fie_!) 71►—s Alt. Tel. No.:
OWNER'S 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. 1 and the (check one) owner O owner's agent.
Owner/Agent
Signature Telephone No.
(Rev. 04/00)
7�I
TOWN OF YARMOUTH
APPLICATION FOR PERMIT TO DO PLUMBING
(OFFICE USE ONLY)
Fee: $���
PERMIT NO. P' 00 — 166
Building %� _ Owner's
AT: Location IT) �l rcam S1 Name
- -- - Type of Occupancy
New ❑ Renovation x Replacement ❑
Plans Submitted Yes ❑ No ❑
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SUB-BSMT.
BASEMENT
I
1ST FLOOR
I
I
I
I
I
2ND FLOOR
I
3RD FLOOR
(PRINT OR TYPE)
Installing Company Name E-/VjAjg/au) 8-9
Check One:
/l Corp. n�IIr0/��
/❑ Partnership
D Firm/Company.
Business Telephone 3y-723K Name of Licensed Plumber
INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent. Check One: Yes No El
If you have checked YES, please indicate the type of 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 voerage required by Chapter 142 of
the Mass. General Laws, and that my signature on this permit application waives this requirement.
Signature of Owner orOwner's Agent
I hereby certify that all of the details and information I have submitted
(or entered) in above application are true and accurate to the best of
my knowledge and that all plumbing work and installations performed
under Permit issued for this application will be in compliance with all
pertinent provisions of the Massachusetts State Plumbing Code and
Chapter 142 of the General Laws.
Check on Owner ❑ Agent ❑
Stgnafre of Licensed
Plumber
7939
License Mmber
Type: Master Journeyman 0
DATE:
DATE
LOT I
ISSUED TO:
ADDRESS
REASON FOR CALL
BUILDING PERMIT
OCCUPANCY PERMIT:
PLUMING PERMIT:
GAS PERMIT:
ELECTICAL PERMIT:
FIRE DEPARTMENT:
OTBER:.
CALL BACKS INSPECTION FEES
IST CALL BACK $20.A0
2ND CALL BACK $30.00
3RD CALL BACK $40.00•
ALL OTHER, CALL BACKS.440.00
FEB 2 5 2000
3
3/412015 SlipGen- Portal Hone
Town of Yarmouth
Template [Building Dept]
P.�M
UK
Slipsheet Identifier [sg22434]
Document Category Building Permits
Map -Block Number 034.291
Street Number
0177
Street Name
RIVER ST
Department
Building
Parcel ID
4911
Backfile Batch Scan
No
Document?
Additional Naming Info
Index Operator
Operator, Yarmscan
Date - Time
2015-03-04 - 14:23
httpJAaserfiche12/S1ipGenl 1/1