HomeMy WebLinkAboutBuilding PermitsTOWN OF YARMOUTH
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APPLICATION FOR PERMIT TO DO PLUMBING
Fee:
PERMIT
(OFFICE USE ONLY)
Date
Building Owner's
AT: Location /10/1-s3 Name AyL7.YiflA,t/
�j Cv, rif/z�-ta vJ�N
Type of Occupancy RF Si�>r.vcE
P� �q New® Renovation ❑ Replacement ❑
Plans Submitted Yes ❑ No ❑
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SUB-BSMT.
BASEMENT
1ST FLOOR
/
2ND FLOOR
3RD FLOOR
(PRINT OR TYPE)
Installing Company Name G4.1A4 r-7EA2 L O✓Ko
Address t 97 OL-D c4ca,0VK RO
Check One:
❑ Corp.
❑ Partnership
HP-4owv/T MA . 0.t6 of EX Firm/Company
Business Telephone (-Sef') 726-V1399 Name of Licensed Plumber C.J,kq- t t &-e roil"
INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent. Check One: Yes No ❑
If you have checked YES, please indicate the type of coverage by checking the appropriate box.
A liability insurance policy PQ 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 otOwnerorOwner'sAgent
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 ❑
Signature 16f Licensed
Plumber
175G $
License Number
Type: Master[X Journeyman El
08/28/2008 00:03 FAX
`)2 Lu;!c( Q c a �
BARNSTABLE, SS.
E
e /, /ve
gppy
COMMONWEALTH OF MASSACHUSETTS
STEVFN S. SAMPSON AND JAYNE MULLEN-
SAMPSON,
Plaintiff,
V.
SPIROS BALODIMAS. LT AL.
Defendm-As.
To: Keeper of Records )
Building Department
Town Hall
Yarmouth, MA
0001/00a
� -
RE VED
AUG 29 2008
3UILUING IiLPT.
w — —
SUPERIOR COURT
CIVIL ACTION NO.
05-0596-A
tow•, G � Y—,, otjTk
TRIAL SUBPOENA DUCES
TECUM
YOU ARE HEREBY COMMANDED, in the name of the Commonwealth of
Massachusetts, in accordance with the provisions of the Massachusetts Rules of Civil
Procedure, to appear and testify before the Barnstable Superior Court, located at 3195
Main Street, Barnstable Massachusetts, within and for the county of Barnstable, on
September 2, 2008, at 9:00 A.M, and from day to day thereafter until the above -named
action is heard by said court, and you are further required to bring with you the following
records " for the time period of January ], 2003 through January 1, 2006 all applications for
building permits, building permits, inspection reports, correspondence, complaints and Property
Owner Affidavits for 72 Lake Road, West Yarmouth, MA
Hereof fail not, as you will answer your default under the pains and penalties in
the law in that behalf made and provided.
Please contact Attorney Susan Merritt-Glenny upon receipt of this subpoena at (508)
362-S7SS.
Date:Alcaja •ei �' 0
[Signed] 1.6 b
Notary Public .
My commission Expires: Jean Angela Marshall
Notary Public
My Commission Expires
March 12, 2010
AUG-29-2008 07:48 ATTY JOHN CRENEY
15083621125 P.01
r
TELECOPY COVER SHEET
John C. Creney, P.C.
Attorney at Law
86 Willow Street
Yarmouth Port, Massachusetts 02675
If there is a problem with transmission or if all pages are not received, please call 508.362-1122 for
retransmission. rax 508-362-1125
TO: Susan Merritt-Glenny, Esq.
COMPANY:
FROM: John C. Creney
RE: Sampson v. Balodimas
Number of pages including this cover page: 2
FAX #: 508 362-5756
DATE: August 29, 2008
This mecurge is intended only fur the use of the individual or entity to which It Is addressed, and may contain information that it
PRIV11.F.GFO. CONFIOENIIAI. and nmempl from disclosure under applicuble law. If the reader of this mevwge is not the
intended recipient, or the employee or agent responsible for delivering the message to the intended recipient, you are hereby
notified tlral any ditscmination. ditttibutitm of Copying of this communication is strictly prohibired. If you have received this
cummunicanon in error, pleave notify us immediately by t0cphonc, and return the original to us by mail witlwrut making a copy.
Thank you.
Comments:
With respect to your subpoena duces tecum directed to the Building
Department seeking records for 72 Lake Road, West Yarmouth, the Building
Commissioner, James D. Brandolini, is currently on vacation and is expected
to return on September 3.
By means of a copy of this memorandum, I ask the Building
Department to compile the records which you seek and to make those
records available to you. Since I will be out of the office most of today, I
suggest that you check with the Building Department and the Town Clerk to
obtain those records.
Cc: Building Department
Jane E. Hibbert, Town Clerk
AUG-29 _2008 07:48 -_
08/213/2008 00:03 FAX
ATTY JOHN CRENEY
15083621125
P.02
1-au, r.uuuuuc
mvi
001/004
9C,2
2008
COMMONWEALTH Of MASSAC.AUSETTS
r•
BARNSTABLE, SS. SUPEWOR CLMrr
CIVIL ACTION NO.
05-0596•A
STEVF.N S. SAMPSON AND JAYNE MULLEN-
SAMPSOV,
Plaintill,
U
SPIROS BALODIMAS. ET AL.
Defendants.
To: Keeper of Records )
Building Department
Town Hall
Yannouth, MA
too-..) G 1✓ 7n--fkCL1Tk
TRIAL SUBPOENA Ot JCIiS
TECUM
A
YOU ARE HEREBY COMMANDED, in the name of the Cotmm(nwealth
Massachusetts, in accordance with the provisions of thc. Massachusetts Rules of Ci
Procedure, io appear and testify before ilia Barnstable 'uperior Court, located at 31
Main Sired, Barnstable Massachusetts, within and for the county of Barnstable,
September 2, 2008, at 9:00 A.Mr and from day to day thereafter until the above -nary
action is heard by said court, and you are further requlrec_ to bring with you the follow
records " for the tune period of January 1, 2003 through Utuary 1, 2006 all applications
building permits, building permits, inspection reports, correspondence, eompl4ims and Frope
Ownrr Affidavits for 72 Lake Road, West Yarmouth, MA
Hereof fail not, as you will answer your default under the pains and penalties
the law in that behalf made and provided.
Please contact Attorney Susarr Mrrritr-Glenny upon receipt of Ilrls subpoena at
362-57SS.
Pop
Date: f � V-0 j •d �,
(Sigrted] �8.1��
Notary Public
My commission Expires. Jean NotarAngoy
Publimarac
all ,
Notary Public
MLVY arch 1z i0 aP� I
TI'ITN
n nn
�- VRAUG 17 RECD
COMMONWEALTH OF MASSACHUSETTS
SUFFOLK, ss. Board of Building Regulations and Standards
Docket No. 2006 — 007
Douglas Williams, )
Complainant )
V. )
Albert Roy Brown, )
Respondent )
ORDER
This matter is before the Board of Building Regulations and Standards ("Board")
because of a complaint filed by Douglas Williams, P. O. Box 1069, Centerville, MA
02632, on January 23, 2006. The matter alleges that Albert Roy Brown (Construction
Supervisor License No.65525) violated 780 CMR with respect to construction at 72 Lake
Road, S. Yarmouth, MA ("Complaint"). A hearing on the Complaint was scheduled for
September 15, 2009, and notices of the hearing were mailed on August 3, 2009.
On August 10, 2009, the attorney for Respondent filed a Request to Reschedule the
Hearing/Motion for a Continuance, requesting that the Board reschedule the hearing to
some time after September 15, 2009, but not during November 1 to 20, 2009 ("Motion").
The Motion states, "Due to the short notice of this matter, especially considering that it has
been pending since early in 2006, as well as to prior schedule commitments on my part,
there will not be enough time to prepare for this hearing date. Also, in that we do not et
have a cony of the complaint or your other file documents, there may be additional matters
that entitle us to adequate preparation time"
By way of background, CSL Number 65525, issued to Albert R. Brown, has been
suspended by the Board, under Board Docket No. 2008-606, from December 1, 2008
through December 1, 2009.
Another copy of the documents on file with the Board regarding the Complaint will
be mailed to Respondent.
The Motion is ALLOWED and the hearing is rescheduled to October 7, 2009,
10:00 a.m. at the Department of Public Safety's hearing room, located on the second floor
mezzanine level of One Ashburton Place, Boston, MA.
SO ORDERED
Board of Building Regulations and Standards
by its designee,
Christopher N. Popov
Hearings Officer
Dated: August 13, 2009
2
Deval L. Patrick
Governor
Timothy P. Murray
Lieutenant Governor
James Brandolini
1146 Rt. 28
Yarmouth MA 02664
Complainant:
Douglas Williams
P.O. Box 1069
Centerville MA 02632
Registrant/Contractor
Roy Brown
34 Horatio Lane
Centerville MA 02632
Registrant's HIC / CSL #:
Subject Property Address:
Complaint Number:
Hearing Date and Time:
Greetings:
a7,%w /6/!/!1'1..TfDD .��o %6/1/IP7•/15C�
NOTICE OF HEARING
/ 65525
72 Lake Road W. Yarmouth MA
2006-007-C
10/7/2009 10:00 AM
Kevin Burke
Secretary
Thomas G. Gatzunis, P.E.
Commissioner
Gary Moccia, P.E.
Chairman
Stanley Shuman, P.E.
Vice Chairman
Friday, August 14, 2009
Pursuant to 780 CMR I MRS and/or 110.R6, a hearing will be held based upon the information contained in
the above referenced complaint. Your attendance at the hearing is mandatory. The hearing will take place
before a hearing officer at the office of the Department of Public Safety, One Ashburton Place, Boston, MA at
the above noted date and time. Please report directly to the hearing room on the second floor overlooking the
main lobby. (Go through the double doors after exiting the second floor elevator and take a left). The hearing
will be held in order to determine whether administrative action should be taken against the registrant's Home
Improvement Contractor registration and/or Construction Supervisor's License. Violations of the law or
regulations which are substantiated at the hearing could result in the imposition of a suspension, revocation, or
reprimand of the registration and/or license, and the assessment of a fine.
The complainant must be prepared to present evidence to support the allegations described in their
complaint. The registrant/licensee has the right to be represented by an attorney at the hearing and may present
written and oral testimony and any other relevant evidence to mitigate the claims made against them. Any party
may present witnesses with relevant information in support of their case. The complete complaint file is
available for review, upon reasonable notice and at a mutually convenient time, at the offices of the Department
of Public Safety during regular business hours.
All requests for information or motions must be addressed to the following address and shall be in writing with a
copy provided to all parties:
Department of Public Safety
ATTN: Hearing Officer
One Ashburton Place, Room 1301
Boston, MA 02108
Telephone calls relative to pending cases will only be returned in cases of emergency. Due to the great
number of complaints being processed through the program, a hearing date will only be continued under
extraordinary circumstances. Any motion to continue a date shall be made in writing at least ten (10) days prior
to the hearing date.
All parties must bring proper identification to the hearing. Construction Supervisor's Licensees and Home
Improvement Contractors must bring their license and/or registration to the hearing. Thank you for your
anticipated cooperation.
Very truly yours,
BOARD OF BUILDING REGULATIONS
ANDSTANDARDS
07/
Deval L Patrick
C�iX�
Governor
Timothy P. Murray
Lieutenant Governor
James Brandolini
1146 Rt. 28
Yarmouth MA 02664
Contractor's name:
HIC / CSL #:
Property Address:
Complainant:
Complaint Number:
Greetings:
Roy Brown
/ 65525
72 Lake Road W. Yarmouth MA
Douglas Williams
2006-007-C
Thomas G. Gatzunis, P.E.
Commissioner
Alexander MacLeod, R.A.
Chairman
Gary Moccia, P.E.
Vice Chairman
Robert Anderson
Administrator
Wednesday, August 12, 2009
ME9 TR
AUG 1 j
14
Please be advised that the Board of Building Regulations and Standards has received a complaint against the
above -listed HIC registrant. Your immediate attention to this matter is requested. In furtherance of its investigation
of the complaint, the Board asks that you kindly forward it any documentation relative to the above -listed property
that you have in your possession. Please reference the complaint number and name of the HIC registrant in your
reply.
Please note that on July 1, 2009 the home improvement contractor complaint program will be moving from the
Department of Public Safety ("DPS") to the Office of Consumer Affairs and Business Regulation ("OCA") located at
10 Park Plaza, suite 5170, Boston, MA 02116. As of that date any activity involving this case will be processed
through the OCA, not the DPS. (Complaints relative to CSL holders will continue to be processed through the
DPS.)
Kindly refer to the DPS website (www.mass.gov/dps) for answers to any questions you may have about this
matter or the complaint procedure in general. You will be notified in writing should your appearance at a hearing
become necessary.
Thank you in advance for your invaluable assistance.
Very truly yours,
►. P
Deval L. Patrick
Governor
Timothy P. Murray
Lieutenant Governor
KSecevin urke
e/1Ger tJ 0�l7/l!Z(rlLb�4?tZ�iC/G OL �� G2dd�LGGQP. d
rcBtary
Thomas G. Gatzunis,P.E.
Commissioner
Gary Moccia, P.E.
Chairman
James Brandolim'
1146 Rt. 28
Yarmouth MA 02664
Complainant:
Douglas Williams
P.O. Box 1069
Centerville MA 02632
Rcgistrant/Contractor
Roy Brown
34 Horatio Lane
Centerville MA 02632
Registrant's HIC / CSL #:
Subject Property Address:
Complaint Number:
Hearing Date and Time:
Greetings:
,qVd&,-z, -Awae a4.e d. O�fO�f6f�
94. 51. /ate/r��nsu
NOTICE OF HEARING
/ 65525
72 Lake Road W. Yarmouth MA
2006-007-C
9/15/2009 10:00 AM
Stanley Shuman, P.E.
Vice Chairman
Monday, August 03, 2009
FA
�'0 5 RE CT
Pursuant to 780 CMR 110.R5 and/or 110.116, a hearing will be held based upon the information contained in
the above referenced complaint. Your attendance at the hearing is mandatory. The hearing will take place
before a hearing officer at the office of the Department of Public Safety, One Ashburton Place, Boston, MA at
the above noted date and time. Please report directly to the hearing room on the second floor overlooking the
main lobby. (Go through the double doors after exiting the second floor elevator and take a left). The hearing
will be held in order to determine whether administrative action should be taken against the registrant's Home
Improvement Contractor registration and/or Construction Supervisor's License. Violations of the law or
regulations which are substantiated at the hearing could result in the imposition of a suspension, revocation, or
reprimand of the registration and/or license, and the'assessmcnt of a fine.
The complainant must be prepared to present evidence to support the allegations described in their
complaint. The registrant/licensee has the right to be represented by an attorney at the hearing and may present
written and oral testimony and any other relevant evidence to mitigate the claims made against them. Any party
may present witnesses with relevant information in support of their case. The complete complaint file is
available for review, upon reasonable notice and at a mutually convenient time, at the offices of the Department
of Public Safety during regular business hours.
A41 requests for information or motions must be addressed to the following address and shall be in writing with a
copy provided to all parties:
Department of Public Safety
ATTN: Hearing Officer
One Ashburton Place, Room 1301
Boston, MA 02108
Telephone calls relative to pending cases will only be returned in cases of emergency. Due to the great
number of complaints being processed through the program, a hearing date will only be continued under
extraordinary circumstances. Any motion to continue a date shall be made in writing at least ten (10) days prior
to the hearing date.
All parties must bring proper identification to the hearing. Construction Supervisor's Licensees and Home
Improvement Contractors must bring their license and/or registration to the hearing. Thank you for your
anticipated cooperation.
Very truly yours,
BOARD OF BUILDING REGULATIONS
ANDSTANDARDS
TOWN OF YARMOUTH
BUILDING DEPARTMENT
1146 Route 28, South Yarmouth, MA 02664
508-398-2231 ext. 261 Fax 508-398-0836
August 17, 2009
Commonwealth of Massachusetts
Department of Public Safety
Board of Building Regulations & Standards
One Ashburton Place Room 1301
Boston MA 02108-1618
Re: 72 Lake Road West Yarmouth Complaint No. 2006-007-C
FILE COPY
M
To Whom It May Concern:
As requested of August 12, 2009, please find enclosed, copies of our file contents relating to this
complaint.
Very truly,
GOo
James D. Brandolini, C.B.O.
Building Commissioenr
TOWN OF YARMOUTH Building Department BUILDING
_ _ _ .. _ _ . , (508) 398-2231 ext.261
PERMIT NO B-06-814 _ _ PERMIT
�y ISSUE DATE : • 12/12/2005.: PROPOS ;
APPLICANT Carol Newman D
............ . P.. JOB WEATHER CARD
PERMITTO A i"scJpermittr'asfef
AT (LOCATION) 00072LAKE RD ZONING DISTRICT R-25 Bldg. Type: Residential
SUBDIVISION MAP LOT BLOCK 1049234 BUILDING IS TO BE: CONST TYPE 5•B USE GROUP R-4
LOT SIZE
permit transfer - refer to permit # B-05-254, B-05.1311 and B-05-1448
REMARKS
AREA (SO F) EST COST ($ 1$8.000.00 PERMIT FEE ($) [$50.00
OWNER CAROL R NEWMAN LDING DEPT BY
ADDRESS 00072 LAKE RD
W est Yamwuth A MA 02673
CONTRACTOR
LICENSE 0
PHONE 150a2557478 77-71
Certificate Issue Date^ h{„1 �� ev ,—
CERTIFICATE of OCCUPANCY;
Departmental Approval for Certificate of Occupancy and Compliance
Inspector Date Permit Number Approved By _ Remarks
URIC,
r�
To be filled in by each division Indicated hereon upon completion of its final Inspection.
eTOWN OF YARMOUTH Building Department BUILDING
(508) 398-2231 ext.261
PERMIT NO :f-
_ 05-1011-, PERMIT
ISSUE DATE .... 00 . _ ; PROPOSEDGSE _ _ _ _ _ _ _
APPLICANT , Alb
•""""
ert Brow"n ... ... JOB WEATHER CARD
1P
PERMITTO Alterations
IAT (LOCATON) 00072LAKE RD ZONING DISTRIC R-25 Bldg. Type: Residential I
SU13DI%/ISION MAP LOT BLOCK 1049.234 BUILDING IS TO BE: CONST TYPE ri---Bl USE GROUP R-4
LOT SIZE
CONTRACTOR
REMARKS 2nd floor revisions - no additional bedrooms - relocation of rooms - refer to permit k B-05-254. LICENSE 065525
Brown, Albert
AREA (`✓' Q FT) COST ($ $5,000.00 PERMIT FEE ($) $150.00 34 Horatio Lane
Centerville MA 02632
OWNER CAROL R NEWMAN BUILDING DEPT BY 5087756582
ADDRESS 00072 LAKE RD
est Yarmouth MA 102673
INSPECTION RECORD
FIELD COPY
Date I Note Progress - Corrections and Remarks I Insoector
I
r
.
r
This Section for Office Use only
Building Permit b
Date Issued:
5 — �S
Signature: �-
Building Official Date
Certificate of Occupancy
Is Is not required
Section 1 - Site Information
I Use Group: R-4 Type: 5-B
1.1 Property Add Iss:
la
1.2 Zoning Information:
Zoning District Proposed Use
1.3 Building Setbacks (it)
Front Yard
Side Yards
Rear Yard
Required
T Provided
Required
Provided
Required
Provided
1.4 Water Supply (M.G.L c. 40. S 541
Public Private
1.5 Flood Zone toComments:
Zone: BFE:« y�
Section 2 - Property Ownership/Authorized Agent
2.1 Owner of He rd:QA ,�'L
-- �
Name (prin � Mailing Address
Ld AA�W-A.)(A)%
&
:fb
Signature Telephone
2.2Authorized Age -
7-3
Name rint) Mailing Address
Signature Telephone Fax
Section 3 - Construction Services
3.1 fyened Constru Ion Supervisor.
/ / f ii1
3.2 Registtfred Home Improvement Contractor:
Company Name
9( 1A ���5�
Address
i
RL�
0d-(ot73
83
Not Applicable ❑
License Number
Expiration Date
a-�a.-off
Not Applicable Lii
IE
Expiration Date b - ;t'--a
Section 4 Workers' Compensation Insurancfl Affidavit (M.G.L c. 152 S 25C (6)
Workers Compensation Insurance affidavit must becompleted 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)
ENewonstruction ❑ No. of Bedrooms No. of Bathrooms
g Bldg. ❑ Repair(s) ❑ Alterations ❑ Addition ❑
Accessory Bldg. ❑ Type Demolition Other Specify:
Brief Description of Proposgo Work:
Section A - Estimated Construction Costs
Item Estimated Cost (Dollars) to be
completed by permit applicant
1. Building
2. Electrical
3. Plumbing / Gas
4. Mechanical (HVAC)
T Fire Protection
6.Total=(1 +2+3+4+5)
7. Total Square R. (new houses & addtions)
Section 7a Owner Authorization -To be Completed Wh
Owner's Agent or Contractor Applies for BuilclLng Permit
Check Below
❑ Conservation -Commission Filing
(if applicable)
❑ Old Kings Highway & Historical
Commission approval
(if applicable)
, as owner of the subject property
hereby authorize �� to act on
my behalf, 1n all mattep relative to work authorized by this building permit application.
Date
Signature of Owner'
FSection 7b - owner/Authorized Agent Declaration
aT4N=/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.
Signed under the pains and penalties of perjury.
Print name t
01hatuAre of 0 g t Date
9-1.5-99 2 of 2
.•cr � � 1 V W 1V V r.� i� .__ ..l V V j
�•-...•,t+ BUILDING DEPARTMENT
PLEASE PRIM}
CONSTRUCTION SUPERVISOR FORM
•
Job Location: ��� P.& , I , ,% , A _
Owner of Property:
Construci
Address:
Licensed i
(If other that
2.15 Responsibility of each license holder:
....slat 1-40.
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:
I have a current • bility insurance policy or its substantial equivalent which meets the requirements of MGL Ch.152
Yes No
If you have checked yam, 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�aVe the insurance coverage required by
Chapter 152 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
ilgnature of Owner or Owner's Agent Check one:
Owner ❑ Agent 0
Signature:
Rltilrlinn /lA[:..:..r �
For Office Use Only
Permit No.
Date TOWN OF YARMOUTH
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MGL c. 142A requires that the 'reconstruction, alteration, renovation, repair, modem
improveirrtion, conversion,
improvement, removal, demolition or construction of an addition to any pre-existing owner -occupied
building containing at least one but not more than four dwelling units or structures which are adjacent to
such residence or building' be done by registered contractors, with certain exceptions, along with other
requirements.
Type of Work: rya S►�
Address of We
Owner Name:
Date of Permit Application: 5--
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job under $1,000
Building not owner occupied
Owner pulling own permit
Other (specify)
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH
UNREGISTERED CONTRACTORS FOR APPLICABLE HOME
IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION
PROGRAM OR GUARANTY FUND UNDER MGL c. 142A.
Signed under penalties ofperjury:
I hereby apply for a permit as the agent
of the owner:
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
The Commonwealth of Massachusetts
Department of Industrial Accidents
Ol11COd/null/slNis
600 Washington Street
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Applicant Information: PleaseiPRI1PPWs3sSK
iucutinn. —�? :1- Y4t.iL-- 1 c—Q
0)5'-dGd4R
m a homeo%kgr performing all work myself.
t a sole proprietor _-d hag a no one %%orkine in any capacity
I am an emplo%cr pro%idine workers' compensation for my employees working on this job.
A n N A
address• Z q AA=`a
city ILp — phnnrr. rja�s� -7 —2
am a sole proprietor. g 1 cone actor. omeowner (circle one) and have hired the contractors listed below who ha% e
he folluss ing %%orker ces:
r attire to secure coverage as required under Section 25A of MGL 152 ran lead to feet impodtlan of eriaslaml pnaltles of a On opts SIANNAN aad/a
one years' Imprisonment as well as civil penalties in the form of s STOP WORK ORDER mind a Ilse of SItINAN a day against me. I eaderstamd tat m
copy of this statement may be forwarded to the Office of Investigations of flue DU for coverage verificadeL
t do hereby terrify under the pains and pltalties of perjury that the information provided above is true and correct.
Print name
*NR
onicial use only . do not %rite in this area to be completed by city or town official
city or town: YAlutovTlt _ perml0cense N n8uilding Department
DlJeessing Board
check if immediate response is required 261 pselectmen's Omce
(508) 398--2231 estt, nOther Department
contact person: pboaeN;_ nOtber
Information and Instructions
Massachusetts General laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the **law**. an employee is defined as every person in the service of another under any
contract of hire. express or implied. oral or written.
An entplorer is defined as an indis idual. partnership. association. corporation or other legal entity. or any two or more o'
the Foregoing engaged in a joint enterprise. and including the legal representatives of a deceased employer, or the
recei%er or trustee of an individual . partnership. association or other legal entity, employing employees. However the
ow ner of a dwelling house having not more than three apartments and who resides therein. or the occupant of the
dwelling house of another %%ho employs persons to do maintenance . construction or repair work on such dwelling house
or on the amunds or building appurtenant thereto shall not because of such employment be deemed to be an employer.
�1G1_ chapter I : = ;cction :: also states that even 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.
Additionally. 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 hat
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 covera¢e. Also be sure to sign and date the aftidaviL The
affida% it 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.
orlowns., ...
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. Plea
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned tt
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 question!
please do not hesitate to give us a call.
e Department's address. telephone and fax number.
The Commonwealth Of Mttssichusetts
Department of Industrial Accidents
#MCI of Ilmsl 13den
600 Washington Street
Boston. Ma. 02111
fa: N: (617) 727-7749 -
phone #: (617) 7274900 e:L 406, 409 or 375
A ORD- CERTIFICATE OF LIABILITY INSURANCE 17
DATE(MWDDM)
PRODUCER 5/12/200
THIS CERTIFICATE IS ISSUED AS A M4TTER OF INFORMATION
McShea Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
320 West Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW
*Hyannis, MA 02601
SOR-79n-1 n,4n INSURERS AFFORDING;COVERAGE
Roy Brown Home Repair
34 Horatio Lane
Centerville, MA 02632
508-775-6582
Fax# RnR-77S_1aac
INSURER A:
INSURER B:
INSURER C:
INSURER D:
TANY REQUIREMENT, TERM OR CONDITION OF HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDECT TO WHICH THIS IIIICATED. NOTWITHSTANDING
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES CDESCRIBED HEREIN T OR OTHER nIS SUBJECT TO ENT WITH AL THE TERMS. EXCLUS ON3AND CONDITIONS OF SUf ICATE MAY BE ISSUED CH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, 11
INSR
LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE P LICY EXPIRATION
DATE MMIDD D MMIDD ; LIMITS
GENERAL LIABILITY
EACH OCCUR ENCE $ COMMERCIAL GENERAL LIABILITY
FIRE DAMAGE {Any one ere) _
CLAIMS MADE ®OCCUR $00
MED EXP (Any pna person) i ()D D O
A MPK34477 05/05/04 05/05/05 PERSONAL 6ADVINJURY $300.000
B
GEN'L AGGREGATE LIMIT APPLIES PER:
n F
JECT I PRO- 1 LOC
POLICY
AUTOMOBILE LIABILITY
ANY AUTO
ALL OW NED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNED AUTOS
GARAGE LIABILITY
I ANY AUTO
EXCESS LIABILITY
OCCUR 1-1 CLAIMS MADE
DEDUCTIBLE —
RETENTION S
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
OF
GLNERALAGG EGATE S
PRODUCTS -CWROPAGG sann nnn
COMBINED SINPLE LIMIT I f
(Ea accidenl) )
BODILY INJURY f
(Per person) ,
BODILY INJURY, f
(Per amidenl) I
PROPERTY DAMAGE f
(Per awdent)
AUTO ONLY - EA ACCIDENT S
OTHER THAN FA ACC $
AUTO ONLY: . qGG S
EACHOCCURRjNCE $
AGGREGATE S
f f
� S
S
886X262-2-02 I05/31/04 I05/31/05 E.L. EACH ACCIbENT f
F_ L. DISEASE • EMPLOYEE. S
E.L. DISEASE - POLICY LIMIT I $
E
E HOLDER I I ADDITIONAL INSURED: INSURER LETTER: CANCELLATION i
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BOCANCELLED BEFORE THE EXPIRATION
Town of Barnstable DATE THEREOF, THE ISSUING INSURER WILL ENDEA�OR TO MAIL 10� DAYS WRITTEN
Budding Department NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE;LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND vPON THE INSURER ITS AGENTS OR
REPRESENTATIVES. I I
ACORD 25-S (7197)
0 ACORD CORPORATION 1988
BUILDING
TOWN OF Y A R M O U T H ELECTRICAL
GAS
1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS02664-4451
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 LALS-- L& -
Work Address
is to be disposed of at the following location: _( [,,r-( N de.t_j" 1 '� -�
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
,..
Si atuiLe of Applicant
Permit No.
�a
Date
MORE IMPROVEMUT CONTRACTOR
Rallalmtlan: 1206eo
RWfMbry a211200e
Typs: DMA
ALBERT ROY BROWN HOME RE
ICIMRT BROWN
U HORATIO LN �.
CENTERMLE,MA0m2 AaWolrtnWr
BOARD O! KftDW0111O UTION
LIwo: CONSTRUCTION SUPERVISOR
Nwnbot: as "MI25
m"' ' - ! 02/12/I942
N411w:02112MM rr.m: 1"23
RsaMaMrt 00
ALBERT R BROWN
TIO LN
CRNNTE�RVILLE, MA 02022
Aart�YTlahaeot
TO'J VZOTS44009 AHVJW00"UlHJ7:1'7N011 WV 021ZT SOOT. 20 AHN
TOWN OF YARMOUTH
Building Department
Town Hall
" Yam iAh. MA 02M4
(509) 39 ZnI eA261
BBUILDING PERMIT
TRANSMITTAL
Temp Permit No.: T 05-573
Applicant Name:
Albert Brown
Applicant Phone:
5087756582
Building Location:
00072 LAKE RD
Owner's Name:
CAROL R NEWMAN
Owners Addres
00072 LAKE RD
West Yarmouth MA 02673
Owners Telephone: (508) 778-0602
REVIEWED BY:
1. WATER DEPARTMENT:
2. ENGINEERING DEPARTMENT:
3. CONSERVATION:
4/4ILTH DEPARTMENT: _
5. BUILDING DEPARTMENT:
6. FIRE DEPARTMENT:
COMMENTS:
(OFFICE USE ONLY
Recorded By:
IC
Permit Fee:
$0.00
Deposit Rec
$25.00
Payment Type:
Check ChkNo.: 1225
Net Owed:
($25.00)
Application Date: 5/3/2005
Issue Date:
Expiration Date
PLEASE NOTE
RECEIPT OF COPY: SIGNATURE OF APPLICANT.
Comments:
049.234
2nd floor revisions - no additional bedrooms -
relocation of rooms
DATE:
DATE:
DATE:
DATE:
DATE:
DATE:
N/A:
WA:
N/A:
N/A:
WA:
WA:
DATE:
Date Printed: 5/5/2005
ANCE.
DATE
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eights From VELUX America Inc.
HOME INSPIRATION PRODUCTS SERVICE PROFESSIONALS BLIND SHOP
ROOF WINDOWS ROOF WINDOWS SKYLIGHTS SUN TUNNELS BLINDS & SHADES GLASS & FLASHING ACCESSORIES FIND
AND SKYLIGHTS
PRODUCTS
GPL• TOP HINGED ROOF WINDOW
VELUX's Comfort coc
glas:ings protoct ago
heat gain and heat I
fading and condense
making rooms more
comfo►table year -rot
Exterior cladding
offers protection and
streamlined, law -prof
appearance
Top sash opens far
maximum ventilation,
pivolinBB inward for
easy cleaning
Exclude Comfort Glass
consists of two ponds of
tampered sake glass
duo-sealand inieeled
with Aron ga s; a double
layer of Low-E coating
provides excellent thermal
performance
Select wood frame and
sash provides aesthetic
appeal and insulation
wive
MORE INFO
ePRICE LISTS & SIZES
NWHY CHOOSE VELUX
DINSTALIATION PROCESS
eWHERE TO BUY
WARRANTY INFORMATION
ePRINTIORDER A BROCHURE
eENERGY EFFICIENCY
NPRODUCT SPECIFICATIONS
Meets Egress Requirements! The sash opens to a 45a angle to satisfy Egress requirements for emergency
escape.
SEARCH SITE MAP
O 2001 VELUX Group ® VELUX and VELUX logo are registered trademarks
Page •1 of 1
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http://www.velux-america.com/ 7/15/1714
y ghts From VELUX America Inc.
HOME INSPIRATION PRODUCTS SERVICE PROFESSIONALS BLIND SHOP
IV`
Roo► WINDOWS ROOF WINDOWS SKYLIGHTS SUN TUNNELS BLINDS & SHADES GLASS & FLASHING ACCESSORIES FIND
AND SKYLIGHTS
MODEL GPL
Dimensions
jSlzeCOdej Outside Frame Rou h O nl
. SEARCH SITE MAP
�---- (Pl, sob
m 2001 VELUX Group a VELUX and VELUX logo are reglstered trademarks
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TOWN OF YARMOUTH Building Department
PERMIT NO
_ (508) 398-2231 ext.261
54 � _
ISSUE DATE ,,--jZW1t3/2004 _ ; POSED USE
APPLICANT ,Ro own
BUILDING
PERMIT
JOB WEATHER CARD
PERMIT TO ' New Construction .
I AT (LOCATION) 00072LAKE RD ! ZONING DISTRIC R-25 Bldg. Type: Residential I
SUBDIVISION MAP LOT BLOCK
LOT SIZE
BUILDING IS TO BE: CONST TYPE 5-B USE GROUP R-4
raze & replace - new construction: 2 baths, 3 bedrooms, 1 diningroom, 1 one bay garage, 1
REMARKS kitchen, 1 livingroom as per plans dated 07/09/04.
AREA (SO FT) EST COST ($ $218,000.00 PERMIT FEE ($) $830.00
OWNER ICAROL R NEWMAN UILDING DEPT BY
ADDRESS 12604 Highvale Drive _ /
Las Vegas NV 89134
C rtif( t I D
CONTRACTOR
LICENSE 065525
Brown, A. Roy
34 Horation Lane
Centerville MA 02632
5087756582
e ca a ssue ate a2z�6i Y ;,O CERTIFICATE of OCCUPANCYM
Departmental Approval for Certificate of Occupancy and Compliance
Inspector
Date
I Permit Number
Approved By
Remarks
BUILDING
/- 2
PLUMBINGIGAS
ELECTRICAL
ENGINEERING
OTHER ,rr
e
01 —//0
G
Go eidl v v
To be filled in by each division Indicated hereon upon completion of Its final Inspection.
WN
TOWN OF YARMOUTH Building Dep men BUILDING
(508)398-22 6
PERMIT NO-05---- - ..- PERMIT
ISSUE DATE ; 8/18/2004 PROPOSED USE
APPLICANT . Roy Brown -•-------------------•-••-- JOB WEATHER CARD
PERMIT TO ; New Construction '
AT (LOCATION) 100072LAKE RD ZONING DISTRIC R.25 Bldg. Type: ResWent(al
SUBDIVISION MAP LOT BLOCK 1049.234 BUILDING IS TO BE: CONST TYPE 5-B USE GROUP R-4
LOT SIZE
raze & replace - new construction: 2 baits, 3 bedrooms, 1 diningroom, 1 one bay garage, 1
REMARKS kitchen, 1 livingroom as per plans dated 07/09/04.
AREA (SO FT) EST COST ($ $216,000.00 PERMIT FEE ($) $830.00
OWNER ICAROL R NEWMAN BUILDING DEPT BY
ADDRESS 2604 Highvale Drive
Las Vegas NV 89134
INSPECTION RECORD
CONTRACTOR
LICENSE 065525
Brown, A. Roy
34 Horation Lane
Centerville MA 02632
6087756582
FIELD COPY
.:Note
Progress.-
War
/.
-�,�, _
_.�J.
D
I� JUN U 005
&-A* a 87&) I � C--� zo-
Gz ��� e-ar-c__
f
of'YgR,� ONE & TWO FAMILY ONLY - BUILDING PERMIT
' o APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Town of Yarplouth Building Department
MATTAC„°[, 2 1146 Route 28 • Yarmouth, NIA 02664-4492
r)r0
Tel: (508) 398-2231 x261 • Fax: (508) 398-0836
Q Office Use Only Planning Board Information Assessors Department Information:
Permit No. -05-.2Date -fkx) Plan Type Map Lot
1� Endorsement Date " L
x
Permit Fee $ %JL/" Recording Date New
Deposit Rec'd. $ a5 w Dated' Ian No. 1.4 Property Dimensions:
Net Due $ go-5-.. Other Lot Area (sf) Frontage (ft) Lot Coverage
This Section for Office Use Only
Buildinq Per umber:
Date Issued:
Signature '0�/Ferti
Building Official Date
is to of Occupancy
is not required
Section 1 - Site Information
I Use Group: R-4 Type: 5-B
1.1 Property Address:
94, t� _l
1.2 Zoning Information:
25
Zoning District Proposed Use
1.3 Building Setbacks (ft)
Front Yard
Side Yards
Rear Yard
Required
Provided
Required
Provided
Required
Provided
W ,
/s'
ZC'
1.4 Water Supply (M.G.L. c. 40. S 54)
Public Private
1.5 Flood Zone I ormation: corn s:
I Zone: BFE: /V "9-
Section 2 - Property Ownership/Authorized Agent
2.1 Awner of Rec
IM-k
K4WbAtQ C21 Dy NA
Name( t) Mailing Address '
CUL, _
Signature Telephone
2. t�orized Acyo /J
Name (Il' riint) ailing d s `
' 3 G Ac, Od • < <1 ✓1 1
Signature Telephone Fax i', I
2004 iJ
'j 172064
Section 3 - Construction Services
3.1 truiAConstripition Supervisor: U
FiU1LD,NG Grc. T. .
Not Applicable ❑
r.
3 n
/ 016
( ro Ol
License Number
A r ss
Ex
i iop
da e, f�
t v I
Sig re Telephone
N 24 2004
3.2 Registered Home Improvement Contractor:
Com any ame
No
Applica��ILONG DEPT. 61
Lic um er
A res
Telephone
Expiration Dat
(Q
bigfiature
4:1I
7
V
r 1 of 2 OVER
Section 4 - Workers' Compensation Insurance Affidavit (M.G.L. c. 152 S 25C ( ))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure ,a,M
to provide this affidavit will result in the denial of the issuance C,mthe building permit. .
Signed Affidavit Attached Yes .......... No ..........
Section 5 DescriDtion of Proposed Work (check all aoolicable)
New Construction K I No. of Bedrooms No. of Bathrooms
Existing Bldg. ❑ I Repair(s) ❑ Alterations I Addition ❑
Accessory Bldg. ❑ Type
Demolition
Other Specify:
Brief Description of Proposed Work:
f v ,
Section 6 - Estimated Construction Costs
Item Estimated Cost (Dollars) to be
pleted by permit applicant
1. Building '
2. Electrical
3. Plumbing / Gas �, Q
4. Mechanical (HVAC) , DD
5. Fire Protection
6.Total=(1 +2+3+4+5)
7. Total Square Ft. (new houses& additions)
Section 7a - Owner Authorization - To be Completed When
Owner's Agent or Contractor Applies for Buildina Permit
Check Below
❑ Conservation -Commission Filing
(if applicable)
❑ Old Kings Highway & Historical
Commission approval
(if applicable)
JL Ji Jy , as owner of the subject property
hereby authorize "00 pTPP�( A L llah AS to act on
my behalf,'(n all m tters Mative tow ork authorized by this building permit application.
VA ) I dA4Z����(.1/ PD y
ignature of Owner Date
Section 7b -
I
Declaration
, 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. '
Signed under the pains and penalties of perjury.
Print name
Signature of Owner/Agent
Date
w
9- 15-99
=1
o TOWN OF YARMOUTH
BUILDING DE13ARTNIENT
f .
CONSTRUCTION SUPERVISOR FORM
PLFASE PRINT.
Job Location: lo[ ► ax-A-- tLiz -
Number Street Village
Owner of Property: Cad �l>z�e of�n�C1
Construction Supervisor:
Address:
Licensed Designee:
(If other than Supervisor)
Name
2.15 Responsibility of each license holder:
t_5 OleSSaS 145z;9
License No.
License No.
Phone 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 lie, the license
holder, is not the permit holder but only a subcontractor or contractor to the permit holder.
2.15.3 The license holder shall immediately notify the building official in writing of the discovery of any
violations which are covered by the building permit.
2.15.4 Any licensee who shall willfully violate subsections 2.15.1, 2.15.2 or 2.15.3 or any other section of these
rules and regulations and any procedures, as amended, shall be subject to revocation or suspension of
license by the board.
2.16 All building permit applications shall contain the name, signature and license number of the
construction supervisor who is to supervise those persons engaged in construction, reconstruction,
alteration, repair, removal of demolition as regulated by section 109.1.1 of the code and these rules and
regulations. In the event that such licensee is no longer supervising said persons, the work shall immediately
cease until a successor license holder is substituted on the records of the building department.
2.17 The license holder shall be responsible for requesting all required inspections. Failure to do so may
be deemed a violation of the permit conditions.
I have.read and understand my responsibilities under the rules and regulations for licensing construction
supervisors in accordance with section 109.1.1 of the state building code. I understand the construction
inspection procedures and the specific inspection as called for by the building official.
INSURANCE COVERAGE:
I have a cu7No
iability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.152
Yes ❑
If you have checked M, please indicate the type coverage by checking the appropriate box.
A liability insurance policy ',W,( Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 152 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner ❑ Agent
Signature: Building Official Approval:
'For Office Use Only
Permit No.
Date TOWN OF YARMOUTH
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MGL c. 142A requires that the 'reconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition or construction of an addition to any pre-existing owner -occupied
building containing at least one but not more than four dwelling units or structures which are adjacent to
such residence or building' be done by registered contractors, with certain exceptions, along with other
requirements. 4
Type of Work: I t'rb`�'5�.� ce � �\� Est. Cost �D ��• 06
Address of Work
Owner Name:
Date of Permit Application: 1.9
I hereby certify that:
Registration is not required for the following rcason(s):
Work excluded by law
Job under $1,000
Building not owner occupied
Owner pulling own permit
Other (specify)
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH
UNREGISTERED CONTRACTORS FOR APPLICABLE HOME
IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION
PROGRAM OR GUARANTY FUND UNDER MGL c. 142A.
Signed under penalties of perjury:
I hereby apply for a permit as the agent of the owner:
Date Contractoi Name
•t
IA46o(7
Registration No.
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above
property:
Date
Owner Name
The Commonwealth of Massachusetts
Department of Industrial Accidents
axed 011"enfpi ffess
600 Washington Street
Boston. Mass. 02111
Workers' Compensation Insurance Affidavit
1 am a homeowner performing all work myself.
1 am a sole proprietor and ha%e no one working in any capacity
[am an employer pro%iding workers' compensation for my employees working on this job.
company names
iddresc:
city: phone N:
incurs nr• rn policy N
1 am a sole proprietor. general contractor. or homeowner (circle one) and have hired the contractors listed below who ha%e
Failure to secure coverage as required under Section 25A of MGL 152 an lad to the imposition of criminal penalties of aline up to SI.500.00 and/or
one years' Imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. 1 understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby eertifAundep the pains a)ql penalties of perjury that the information provided above is true and correct.
E
Print name
oM021 use only do not write in this area to be completed by city or Iowa official
city or town: YARMOUTII
0 cheek if immediate response is required
to ,a I- C) q
't,
permitAicense N nBuilding Dcpartmeat
pucenslog Board
261. OSclectmeu's Office
(508) 398
Health Department
2231 t
phone N; _ — _ ex - r-10ther
contact person:
Inomd 3.95 FIAT
Information and Instructions
10
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the "law", an employee is defined as every person in the service of another under any
contract of hire, express or implied. oral or written.
An enrph t-er 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
ow tier 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 grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.
MGL chapter I5' section 25 also states that even• 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 tint produced acceptable evidence of compliance with the insurance coverage required.
Additionalh. neither the commom%ealth 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 affdavits 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
I ffice If IMS9119122
600 Washington Street
Boston, Ma. 02111
fax tl: (617) 727-7749
phone #: (617) 7274900 ext. 406, 409 or 375
TOWN OF YARMOUTH
1146ROUTE28 SOUTHYARMOUTH NIASSACHUSETTS02664-4451
Telephone (508) 398-2231, Ext. 261 — Fax (508) 398-2365
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
BUILDING
ELECTRICAL
GAS
PLUMBING
SIGNS
Pursuant to M.G.L. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section 111.5,
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at
work Address
is to be disposed of at the following location: l-1fAA ` r� 2A
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
S' na re of Applicant
Permit No.
Date
1COR CERTIFICATE OF LIABILITY INSURANCE
DATE(MM/DD/YY)
vRoolfcER '•
THIS CERTIFICATE IS ISSUED AS A Mfi(TTER OF INFORMATION
McShea Insurance A enc Inc.
9 y�
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NbT AMEND, EXTEND OR
320 West Main Street
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Hyannis, MA 02601
Q_ -
INSURERS AFFORDING tOVERAGE
INSURED Roy Brown Home Repair
INSURERA:
34 Horatio Lane
INSURER B:
Centerville, MA 02632
INSURER C: r
508-775-6582
INSURERD: E
INSURER E:
iFnxif—
VVVG
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDR:ATED. 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, EXCLUSIONSrND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
IIJSR
R
TYPEOFINSURANCE
POUCYNUMBER
PO EFFE TIVE
A M/
POLICY EXPIRATION
MM/DD
LIMITS
GENERAL
LIABILITY
EACH OCCURRENCE
f
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE ® OCCUR
FIRE DAMAGE (My one fire)
f
MEO EXP (My cps person)
S
A
MPK34477
05/05/04
05/05/05
PERSONAL BA VINJURY
$
GENERAL AGGREGATE
$
GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PR
JE TO-
LOC
PRODUCTS • COMP/OP AGG
f
AUTOMOBILE
LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT
(Ea ealdent) !
S
ALL OWNED AUTOS
SCHEDULLDAUTOS
HIRED AUTOS
NON-OWNEDAUTOS
BODILY INJURY]
(Per person) I
f
r
BODILY INJURY
(Per accident)
S
PROPERTY DAKUGE
(Peraccidenl) r
f
GARAGE LIABILITY
AUTO ONLY -Et ACCIDENT
S
ANV AUTO
SS
OTHER THAN 7 EA ACC
AUTO ONLY: AGG
S
$
EXCESS LIABILITY
OCCUR CLAIMS MADE
EACH OCCURRENCE
$
AGGREGATE
f
S
DEDUCTIBLE
RETENTION S
S
S
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
886X262-2-02 05/31/04 05/31/05
B
TORY LIMAS ER
E.L. EACH ACCI ENT S
E.L. DISEASE • EA EMPLOYEE S 00,000
OTHER
E.L. DISEASE • 0LICY LIMIT
S
i
f
DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS
,
t+t
1
7
CERTIFICATE Nnl nco ....,._.....-...._.._
I
Town of Barnstahlel (cu��
Building Department
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES
THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1 n DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THBLEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND YPON THE INSURER ITS AGENTS OR
REPRESENTATIVES. .� I
ACORD 25-S 171971
D ACORD CORPORATION 1988
r g f l �
Board o[liu mg egu atio sin tas ards
HOME IMPROVEMENT CONTRACTOR
Registration: 126560
Expiration: 6/21/2006
-Type: DBA
ALBERT ROY BROWN HOME RE
' 9MRT BROWN'
34 HORATIO LN rG _.-,��in••� _
CENTERVILLE, MA 02632 Administrator
0
7
I '�i a c�"ronsinawcealGi o�..iiauaaii�se!!a
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
" Number. CS 065525
Birthdate: 02/12/1942
Expires: 02/12/2006 Tr. no: 14425
Restricted: 00
ALBERT R BROWN ✓
34 HORATIO LN
CENTERVILLE, MA 02632 Administrator
TOWN OF YARMOUTH
Building Department
Town Hall
Vol." Yarmouth, MA 02664
(508) 398-2231 exL261
BUILDING PERMIT
APPLICATION RECEIPT
Temp Permit No.: T-05-015
Applicant Name: Roy Brown
Location: 00072 LAKE RD
Owner's Name: CAROL R NEWMAN
Owner's Addres 2604 Highvale Drive
Las Vegas NV 89134
Owner's Tglephone: (617) 905-3652
(OFFICE USE ONLY
Recorded By. Ic
Permit Fee:
$0.00
Deposit Rec:
$25.00
Payment Type:
Check ChkNo.: 802
Net Owed:
($25.00)
Application Date:
6/24/2004
Issue Date:
Expiration Date
Comments:
raze & replace - new construction:
ZONING APPROVED
This Is NOT a building permit. Application subject to plan review. Contact Building Department for permit status. Official
Building Permit will be Issued upon plan review completion, approval, and complete payment of Net Owed on Permit Fee.
Date Printed: 7/1/2004
pF' ARC j.6�, oI TOWN OF YARMOUTH
o� y I BUILDING DEPARTMENT
BUILDING PERMIT APPLICATION DEPARTMENTAL SIGN OFF
/) TRANSMITTAL SHEET
Building Site Location:
Address:
The Building Department will be responsible for assisting the
applicable departments.
No• Lot No• �
�)LW 7/
Filed:
your plans and or application to the following
RESIDENTIAL AND/OR COMMERCIAL BUILDING
WATER DEPARTMENT: Determines Compliance of Water Availability and or existing location.
ENGINEERING DEPARTMENT: Determines Compliance for Parking and Drainage.
CONSERVATION COMMISSION: Determines Compliance to Wetlands Acts; i.e., If Lot(s) Border any Type of
Wetlands, Streams, Ponds, Rivers, Oceans, Bogs, Bays, Marshland, Etc
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
FIRE DEPARTMENT: Determines Compliance to State and Town Requirements for Personal
Safety, Property Protection; i.e., Smoke Detectors, Sprinkler Systems, Etc.
PREVIEWED BY:
Vol,'. WATER DEPARTMENT: DATE: N/A:
►' 2. ENGINEERING DEPARTMENT: DATE: N/A:
V 3. CONSERV
INDUSTRIAL AND/OR COMMERCIAL PERMITS
180/�D/N 6
S R DATE: N/A:
6. PLUMBING INSPECTOR: DATE: N/A:
7. FIRE DEPARTMENT. DATE: N/A:
PLEASE NOTE
14
If
RECEIPT OF COPY: SIGNATURE OF APPLICANT:
JUL 0 12004
White copy - Baildlog DepL - Pwk w" - Water Dept - Yellow Copy - tialth Dept - Pick Copy - Engio B DcpL - Goldrnrod - Firo DepUCoavavation
. a.'1" ;1' •ter. ... 1 i •�w f. �'1 -� •.�•.- .�.`!�' �.,�.. F.. ..'.......:y:... ��
I~ O R �, a ,u
0
Building Site Location:
Proposed Improvement:
Address:
TOWN -OF YARMOUTH
r BU)'LDING'DEPARTMENT
BUILDING PERMIT APPLICATION DEPARTMENTAL SIGN OFF
ll TRANSMITTAL SHEET
No: Lot No:
Filed:
The Building Department will be responsible for assisting the applicanttiy dapatching your plans and or application to the following
applicable departments.
RESIDENTIAL AND/OR COMMERCIAL BUILDING
WATER DEPARTMENT: Determines Compliance of Water Availability and or existing location.
ENGINEERING DEPARTMENT: Determines Compliance for Parking and Drainage.
CONSERVATION COMMISSION: Determines Compliance to Wetlands Acts; i.e., If Lot(s) Border any Type of
Wetlands, Streams, Ponds, Rivers, Oceans, Bogs, Bays, Marshland, Etc
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
FIRE DEPARTMENT: Determines Compliance to State and Town Requirements for Personal
Safety, Property Protection; i.e., Smoke Detectors, Sprinkler Systems, Eta
-------------------------------------------- ------------------------------------------------------------------------------------------.
sREVIEWED BY:
'r
►'��1. WATER DEPARTMENT: DATE F7 N/A:
22. ENGINEERING DEPARTMENT: DATE: N/A:
V 3. CONSERVATION. DATE: N/A
k14. HEALTH DEPARTMENT DATE: N/A
INDUSTRIAL AND/OR COMMERCIAL PERMITS
►' 3. R: DATE: N/A
6. PLUMBING INSPECTOR DATE: N/A
7. FIRE DEPARTMENT: DATE: N/A
COMMENTS
RECEIPT OF COPY: SIGNATURE OF APPLICANT:
DATE:
Whits copy - Buadmg Dcpt - Pwk copy - WatQ Dept - Ydlow Copy - Haft DepL - Pmk Copy - Eogln=iug DepL - Goldenrod - Fit DcpuCoa9mNdim
it
applicable departments.
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 Ads; 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, Eta
REVIEWED BY:
1 WATER DEPARTMENT: DATE: N/A:
2. ENGINEERING DEPARTMENT:
N/A:
44. • HEALTH DEPARTMENT DATE: N/A:
N/A:
6. PLUMBING INSPECTOR DATE: N/A:
7. FIRE DEPARTMENT: DATE: N/A:
PLEASE NOTE
COMMENTS:
RECEIPT OF COPY: SIGNATURE OF APPLICANT: DATE:
Whae cPy-BoasmgDcPr. - Pwkaw-waWDept - Ydruw Copy - Haft DcpL - PiA Cuff - E� D� - -F;re ,rm.,
.0F. ,oIS TOWN OF RMOUTH
0 �� �� BUILDING DEPARTMENT
O � y
BUILDING PERMIT APPLICATION DEPARTMENTAL SIGN OFF
A TRANSMITTAL SHEET
Building Site Location: Map No: Lot No: 2311
Proposed Improvement:
Applicant: 6ZG `7/(.�GrlJlt�tt�
i-7is r
Address: Tel.No.: a Filed:
The Building Department will be responsible for assisting the applicant y dispatching your plans and or application to the following
applicable departments.
RESIDENTIAL AND/OR COMMERCIAL BUILDING
WATER DEPARTMENT: Determines Compliance of Water Availability and or existing location.
ENGINEERING DEPARTMENT: Determines Compliance for Parking and Drainage.
CONSERVATION COMMISSION: Determines Compliance to Wetlands Acts; i.e., If Lot(s) Border any Type of
Wetlands, Streams, Ponds, Rivers, Oceans, Bogs, Bays, Marshland, Etc
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
FIRE DEPARTMENT: Determines Compliance to State and Town Requirements for Personal
Pr
...........................................................���Protccti e., Smoke Detectors, Sprinkler Systems, Etc.
!- _ _.1..........1. _L......................... . ............ .... . ...........................
REVIEWED BY:
1
/
WATER DEPARTMENT:
DATE: N/A:
an
/'3. CONSERVATION:
DATE: N/A:
- HEALTH DEPARTMENT:
DATE: N/A
/ 2PIZ-PlAl
ruA:
6. PLUMBING INSPECTOR: DATE: WA:
7. FIRE DEPARTMENT-. DATE: N/A:
COMMENTS:
RECEIPT OF COPY:
SIGNATURE OF APPLICANT:
11U.A
webs Door - Du9&* DcpL - Pmt ropy - W&W DepL - Ydlga Corr -Hadth DopL L Pak CAPy- ems - Gddmrod . Firo DcPuconmwvxboo
Y
i'
9FF1C�l�.EOf11.;
PROPERTY ADDRESS;
ALCULATION FOR PERMIT COST
...�.�
TYPE OF ROOM ETC
ADDITION
ALTERATIONS
BATH
BED ROOM
360 S
CERTIFICATE OF OCCUPANCY
7 Fa i
COMPUTER ROOM
DECK OPEN
3
DECK WITH ROOF
DEMOLITION
DEN
a0
�i
DINING ROOM
19 2 g0
FAMILY ROOM
FIREPLACE
0 d
FOUNDATION ONLY
GARAGE NO. OF BAYS
GREAT ROOM
MUD ROOM —
;' OFFICE
E?r.` PORCH CLOSED
PORCH OPEN
STORAGE AREA
SUN ROOM HEATED
SUN ROOM UNHEATED
SWIIAMING POOL ABOVE GRi
SWIMMING POOL INGROUND
WINDOW REPLACEMENT
NO
1
Member Calculations Report
Mid -Cape Home Centers
PO BOX 1418
465 ROUTE 134
SOUTII DENNIS, DIA 02660
5083986071
5083994559
Level Tame: ATTIC LOADS Status: Ready to Plot
Application: Floor non -Residential: No
J61 71' ` I
Design Date: 7/29/2004 1:40:14 PT1 Report Date: 7/29/2004 1:45:48 Pi11
Obiect: Flush Beam #39
General:
Product: 1 3/4" x 11 7/8" 1.9E Microllam LVL Plies: 2
Deflection Criteria: Standard, Live Load L/360, Total Load U240
Member Weight (plf) per ply: 6
Design Value
Control Value
Result
Moment (Ft-Ibs)
13115
20525
Passed
Shear (Ibs.)
-8862
9081
Passed
Live Load Dcflection (")
.08"
.22"
Passed
Total Load Deflection (")
.12"
.33"
Passed
Reaction (Ibs.)
8876
8876
Passed
Bearings:
Bearing
Location
Input Length
Required Length
I Column By Others # 18
0
1 3/4"
1 3/4"
2 Column By Others # 40
6' 7"
1 3/4"
3 3/8"
Reactions:
Assumed Member Weight (plf): 14
Location Dead Load
Live Load
Total Load Uplift
1 (Ibs.) 1/4" 921
1707
2628 0
2 (Ibs.) 6' 6 3/4" 3042
5841
8882 0
Loads:
Roof Load Duration Factor: 115%
Load Location
Live
Dead
Type
Concentrated (Ibs.) 5' 1"
7548
3871
Roof
Notes:
Design Methodology: ASD
IMPORTANTI The analysis presented above is output from software developed by Trus Joist (TJ). Allowable product values
shown are in accordance with current TJ materials and code accepted design values. The specific product application, input design
loads and stated dimensions have been provided by others, have not been checked for conformance with the design drawings of the
building, and have not been reviewed by TJ Engineering.
See Trus Joist Framer's Pocket Guide for Product Trademark Information
TJ-Xpert 635 (#689) A Page I SPADA REMO.JOB
J
Member Calculations Report
Mid -Cape Home Centers
PO BOX 1418
465 ROUTE 134
SOUTH DENNIS.51A 02660
5083986071
5083984559
Letcl Name: FIItsF FLOOR titans: Reads to 1'101
Application: Fluor Non -Residential: No
1 G J
R 7' 21, J 7' J
Design Date: 7/29/2004 1:43:48 P51 Rcport Date:7/29/2004 1:51:381'SI
Object: Drop Beam #26
General:
Product: 1 3/4" x 11 7/8" 1.9E Microllam LVL
Plies: 2
Deflection Criteria: Standard, Live Load L/360,
Total Load L/240
Member Weight (plf) per ply: 6
Design Value
Control Value
Result
Moment (Ft-Ibs)
-14288
17848
Passed
Shear (Ibs.)
7563
7897
Passed
Live Load Deflection (")
.1"
.23"
Passed
Total Load Deflection (")
.12"
.35"
Passed
Reaction (Ibs.)
16635
16635
Passed
Bearings•
Bearing
Location
Input Length
Required Length
1 Wall # 6
0
3 1/2"
3 1/2"
2 Column By Others # 18
7 2"
3 1/2"
7 3/4"
3 Column By Others # 19
14' 2"
1 3/4"
6 5/16"
Reactions:
Assumed Member Weight (plf): 14
Location Dead Load
Live Load
Total Load Uplift
1 (Ibs.) 2"
2034
5354 7387
0
2 (Ibs.) 7' 2"
6175
14179 20353
0
3 (Ibs.) 14' 13/4"
5958
10682 16640
0
Loads:
Roof Load Duration Factor: 115%
Load
Location
Live
Dead
Type
Distributed (plf)
0 to 3 1/2"
1186.7 to 1186.7
490 to 490
Floor
Distributed (plf)
3 1/2" to 4' 8"
1638.7 to 1638.7
706.8 to 706.8
Floor
Distributed (plf)
4' 8" to 9' 2"
1605.9 to 1605.9
677.9 to 677.9
Floor
Distributed (plf)
9' 2" to 13' 10 1/2"
1639.9 to 1639.9
707.3 to 707.3
Floor
Distributed (plt)
13' 10 1/2" to 14' 2"
1501.5 to 1501.5
651.9 to 651.9
Floor
Concentrated (Ibs.)
14' 2"
2041
4073
Roof
See Trus Joist Framer's Pocket Guide for Product Trademark Information
TJ-Xpert 6.35 (#689) A Page 1 SPADA REMO..JOB
Alember Calculations Report
Alid-Cape home Centers
1'0 BOX 1418
465 ROUTE 134
SOUI11 DENNIS. NIA 01660
5083986071
5083984559
Level Name: SECOND FLOOR Status: Readv to Plot
Application: Fluor Non -Residential: No
j 2 1
Design Date: 7/29/2004 1:41:16 PNI Report Date: 7/29/2004 1:49:15 PM
Obiect: Flush Beam 418
General:
Product: 1 3/4" x 11 7/8" 1.9E Microllam LVL
Plies: 2
Deflection Criteria: Standard, Live Load U360, Total Load U240
Member Weight (pl1) per ply: 6
Design Value
Control Value
Result
Moment (Ft-Ibs)
7245
17848
Passed
Shear (Ibs.)
2018
7897
Passed
Live Load Deflection (")
.2 1"
.53"
Passed
Total Load Deflection (")
.33"
.79"
Passed
Reaction (Ibs.)
2078
3850
Passed
Bearings:
Bearing
Location
Input Length
Required Length
1 Wall # 5
16' 3"
5 1/2"
5 1/2"
2 Wall # 11
0
2 3/4"
2 314"
Reactions:
Assumed Member Weight (plt): 14
Location Dead Load
Live Load
Total Load Uplift
1 (Ibs.) 15' 11"
814
1211
2025 0
2 (Ibs.) 1 1/4"
760
1334
2094 0
Loads:
Roof Load Duration Factor: 115%
Load
Location
Live
Dead
Type
Concentrated (Ibs.)
161 1/4"
0
108
Floor
Concentrated (Ibs.)
161 1/4"
299
299
Roof
Concentrated (Ibs.)
16' 1 1/4"
228
0
Floor
Concentrated (Ibs.)
16'1 1/4"
-66
0
Floor
Concentrated (Ibs.)
3' 9"
0
108
Floor
Concentrated (Ibs.)
3' 9"
741
297
Floor
Distributed (plf)
0 to 2 3/4"
46.7 to 46.7
16 to 16
Floor
Distributed (plo
2 3/4" to 3' 9"
23.3 to 23.3
8 to 8
Floor
See Trus Joist Framer's Pocket Guide for Product Trademark Information
TJ-Xpert 6.35 (#689) A Page 1 SPADA REMO.JOB
Member Calculations Report
1)lid-Cape Hotne Centers
PO BOX 1418
465 ROUTE 134
SOUTH DENNIS, MA 02660
5083986071
5083984559
Level Name: SECOND FLOOR Status: Ready to Plot
Application: Floor Non -Residential: No
2
15' 9 Vz"
Design Dale: 7/29/2004 1:41:16 I'M Report Date: 7/2912004 1:48:33 Pal
Obiect: Flush Beam #12
General:
Product: 1 3/4" x I 1 7/8" 1.9E Microllam LVL Plies: 3
Deflection Criteria: Standard, Live Load U360, Total Load L/240
Member Weight (plf) per ply: 6
Design Value
Control Value
Result
Moment (Ft-Ibs)
20858
26772
Passed
Shear (Ibs.)
4700
11845
Passed
Live Load Deflection (")
.5"
.52"
Passed
Total Load Deflection (")
.68"
.77"
Passed
Reaction (Ibs.)
17032
17032
Passed
Bearines•
Bearing
Location
Input Length
Required Length
I Flush Beam # 14
0
0
2 9/16"
2 Wall # 11
15' 9 1/2"
5 1/2"
8 118"
Reactions:
Assumed Member Weight (plf): 14.
Location Dead Load
Live Load
Total Load Uplift
1 (Ibs.) 0 1448
3908
5356 0
2 (Ibs.) 15' 5 1/2" 5457
11543
17000 0
Loads:
Roof Load Duration Factor: 115%
Load Location
Live
Dead
Type
Concentrated (Ibs.) 15' 4"
2920
1521
Roof
Distributed (plf) 15' 4" to 15' 91/2"
225.3 to 225.3
77.3 to 77.3
Floor
Distributed (plf) IV 3 1/2" to 15' 4"
225.3 to 225.3
77.3 to 77.3
Floor
Distributed (plf) IV to 10' 3 1/2"
230.6 to 230.6
79.1 to 79.1
Floor
Distributed (plf) 4' to 10'
230.6 to 230.6
79.1 to 79.1
Floor
Distributed (plf) 3' 8 1/2" to 4'
230.6 to 230.6
79.1 to 79.1
Floor
Distributed (plf) 0 to 3' 8 1/2"
225.3 to 225.3
77.3 to 77.3
Floor
Distributed (plf) 15' 4" to 15' 9 1/2"
702.5 to 702.5
327 to 327
Floor
See Trus Joist Framer's Pocket Guide for Product Trademark Information
TJ-Xpert6.35 (#689) A Page 1 SPADA RENIO.JOB
Member Calculations Report
Mitt -Cape Home Centers
PO BOX 1418
465 ROUTE 134
SOUTH DENNIS, NIA 02660
5083986071
5083984559
Level Name: SECOND FLOOR Status: Ready to Plot
Application: Floor Non -Residential: No
c
t� 7' 7"
Design Date: 7/29/2004 1:41:I6 PNI Report Date: 7/29/2004 1:48:03 PNI
Object: Flush Beam #14
General:
Product: 1 3/4" x I 1 7/8" 1.9E Microllam LVL
Plies: 3
Deflection Criteria: Standard, Live Load U360,
Total Load U240
Member Weight (pil) per ply: 6
Design Value
Control Value
Result
Moment (Ft-Ibs)
15098
30788
Passed
Shear (Ibs.)
6575
13622
Passed
Live Load Deflection (")
.08"
.24"
Passed
Total Load Deflection (")
.12"
.36"
Passed
Reaction (Ibs.)
6945
7350
Passed
Bearines:
Bearing
Location
Input Length '
Required Length
1 Wall # 4
0
3 1/2"
3 1/2"
2 Wall # 13
7' 7"
3 1/2"
3 1/2"
Reactions:
Assumed Member Weight (plo: 14
Location Dead Load
Live Load
Total Load Uplift
1 (Ibs.) 2"
2678
4252
6930 0
2 (Ibs.) 7' 5"
2079
2635
4714 0
Loads:
Roof Load Duration Factor: 115%
Load
Location
Live
Dead
Type
Distributed (plf)
0 to 3 1/2"
0 to 0
81 to 81
Floor
Distributed (plf)
7' 3 1/2" to 7 7"
0 to 0
81 to 81
Floor
Distributed (plf)
3 1/2" to 2' 3 1/2"
0 to 0
81 to 81
Floor
Distributed (plf)
213 1/2" to 713 1/2"
0 to 0
81 to 81
Floor
Distributed (plf)
0 to 3 1/2"
0 to 0
133.3 to 135
Roof
Distributed (plf)
2' 3 1/2" to 319 1/2"
0 to 0
147 to 156
Roof
Distributed (plf)
3 1/2" to 2' 3 1/2"
0 to 0
135 to 147
Roof
Distributed (plf)
7' 3 1/2" to 7' 7"
0 to 0
135 to 133.3
Roof
See Trus Joist Framer's Pocket Guide for Product Trademark Information
TJ-Xpert 635 (4689) A Page 1 SPADA REMO.JOB
Member Calculations Report
Alitl-Cape home Centers
PO BOX 1418
465 ROUTE 134
-- - - _.. -- -- - SOUTU DENNIS,11IA 02660 —
5083986071
5083984559
Level Name: SECOND FLOOR
Application: Floor
1
Status: Ready to Plot
Non -Residential: No
Design Date: 7/29/2004 1:41:16 PAI Report Date: 7/29/2004 1:47:38 PNI
Object: Flush Beam #16
General:
Product: 1 3/4" x 11 7/8" 1.9E Microllam LVL Plies: 3
Deflection Criteria: Standard, Live Load L/360, Total Load 1J240
Member Weight (plf) per ply: 6
Design Value
Control Value
Result
Moment (Ft-Ibs)
3947
30788
Passed
Shear (Ibs.)
1625
13622
Passed
Live Load Deflection (")
.02"
.21"
Passed
Total Load Deflection (")
.03"
.31"
Passed
Reaction (Ibs.)
2760
7350
Passed
Bearines•
Bearing
Location
Input Length
Required Length
1 Wall # 3
0
3 1/2"
3 1/2"
2 Wall # 15
6' 7"
3 1/2"
3 112"
Reactions:
Assumed Member Weight (plf): 14
Location Dead Load
Live Load
Total Load Uplift
1 (Ibs.) 2"
1192
1554
2747 0
2 (Ibs.) 6' S"
1192
1554
2747 0
Loads:
Roof Load Duration Factor: 115%
Load
Location
Live
Dead
Type
Distributed (plf)
0 to 3 1/2"
0 to 0
81 to 81
Floor
Distributed (plf)
3 1/2" to 6' 3 12"
0 to 0
81 to 81
Floor
Distributed (plf)
6' 3 1/2" to 6' 7"
0 to 0
81 to 81
Floor
Distributed (plf)
0 to 3 1/2"
0 to 0
67.5 to 67.5
Roof
Distributed (plf)
3 1/2" to 6' 3 1/2"
0 to 0
67.5 to 67.5
Roof
Distributed (plo
6' 3 12" to 6' 7"
0 to 0
67.5 to 67.5
Roof
Distributed (plf)
0 to 3 1/2"
224.4 to 224.4
107.9 to 107.9
Roof
Distributed (plf)
3 12" to 6' 3 12"
224.4 to 224.4
107.9 to 107.9
Roof
See Trus Joist Framer's Pocket Guide for Product Trademark Information
TJ-Xpert635 (#689) A Page I SPADA REMO.JOB
Member Calculations Report
Mid -Cape Nome Centers
PO BOX 1418
465 ROUTE 134
SOUTH DENNIS, NIA 02660
5083986071
5OS3984559
Level Name: SECOND FLOOR Status: Ready to Plot
Application: Floor Non -Residential: No
c J Y A.
14' 7 1/4" , 7 2,,14"
Design Date: 7/29/2004 1:41:16 PAI
Report Date: 7/29/2004 1:47:23 PNI
Object: Flush Beam 417
General:
Product: 13/4" x I 1 7/8" 1.9E Microllam LVL
Plies: 2
Deflection Criteria: Standard, Live Load U360,
Total Load U240
Member Weight (plf) per ply: 6
Design Value
Control Value
Result
Moment (Ft-lbs)
-5463
17848
Passed
Shear (lbs.)
-2425
7897
Passed
Live Load Deflection (")
.05"
.48"
Passed
Total Load Deflection (")
.14"
.71"
Passed
Reaction (lbs.)
7046
7046
Passed
Bearines:
Bearing
Location
Input Length
Required Length
1 Wall # 3
29' 6"
5 1/2"
5 1/2"
2 wall # 5
0
51/2"
51/2"
3 wall # 10
14' 7 1/4"
3 in"
5 1/16"
4 wall # 11
16' 3"
5 1/2"
5 M"
Reactions:
Assumed Member Weight (plf): 14
Location
Dead Load
Live Load
Total Load
Uplift
1(lbs.)
29' 2"
1047
761
1807
0
2 (lbs.)
4"
1025
727
1752
0
3 (lbs.)
14' 7 1/4"
3037
4046
7082
0
4 (lbs.)
16' 3"
0
1465
1465
0
Loads:
Roof Load Duration Factor: 115%
Load
Location
Live Dead
Type
Concentrated (lbs.)
29' 4 1/4"
0 108
Floor
Concentrated (lbs.)
29' 4 1/4"
0 3
Roof
Concentrated (lbs.)
29' 4 1/4"
150 72
Roof
Concentrated (lbs.)
29' 4 1/4"
150 186
Roof
See Trus Joist Framces Pocket Guide for Product Trademark Information
TJ•Xpert6.35 (k689) A Page 1 SPADA REMO.JOB
Design Date: 7/29/2004 1:41:16 PDI
Report Date: 7/29/2004 1:47:23 Will
Concentrated (lbs.)
29' 4 1/4"
172
0
Floor
Concentrated (lbs.).
1 3/4"
0
108
Floor
Concentrated (lbs.)
1 3/4"
0
3
Roof
Concentrated (lbs.)
1 3/4"
150
168
Roof
Concentrated (lbs.)
1 314"
127
0
Floor
Distributed (plf)
0 to 29' 6"
0 to 0
81 to 81
Floor
Concentrated (lbs.)
5' 2 3/4"
0
54
Floor
Concentrated (lbs.)
5' 2 3/4"
78
31
Floor
Concentrated (lbs.)
24' 3 1/4"
0
54
Floor
Concentrated (lbs.)
24' 3 1/4"
121
48
Floor
Concentrated (lbs.)
14' 9"
2041
904
Roof
Concentrated (lbs.)
12' 6"
937
405
Floor
Distributed (plf)
0 to 5'
46.7 to 46.7
16 to 16
Floor
Distributed (plo
5' to 16 1/4"
23.3 to 23.3
8 to 8
Floor
Distributed (plf)
16' 1/4" to 29' 6"
46.7 to 46.7
16 to 16
Floor
Concentrated (lbs.)
5'
146
76
Floor
Notes:
Design Methodology: ASD
IMPORTANT! The analysis presented above is output from software developed by Trus Joist (TJ). Allowable product values
shown are in accordance with current TJ materials and code accepted design values. The specific product application, input design
loads and stated dimensions have been provided by others, have not been checked for conformance with the design drawings of the
building, and have not been reviewed by TJ Engineering.
See Trus Joist Framer's Pocket Guide for Product Trademark Information
TJ-Xpert 633 (#689) A Page 2 SPADA REMO.JOB
Member Calculations Report
Mid -Cape Home Centers
PO BOX 1418
465 ROUTE 134
SOUTH DENNIS, NIA 02660
5083986071
5083984559
Level Name: SECOND FLOOR Status: Ready to Plot
Application: Floor Non -Residential: No
j 1 2
F
Design Date: 7/29/2004 1:41:16 PJI Report Date: 7/29/2004 1:46:57 PM
Object: Flush Beam #9
General:
Product: 1 3/4" x 1 17/8" 1.9E Microllam LVL
Plies: 3
Deflection Criteria: Standard, Live Load U360, Total Load LJ240
Member Weight (plf) per ply: 6
Design Value
Control Value
Result
Moment (Ft-Ibs)
11656
26772
Passed
Shear (Ibs.)
-3173
11845
Passed
Live Load Deflection (")
.16"
.4"
Passed
Total Load Deflection (")
.24"
.6"
Passed
Reaction (Ibs.)
4034
7350
Passed
Bearines'
Bearing
Location
Input Length
Required Length
1 Wall # 2
0
3 1/2"
3 1/2"
2 Wall # 6
12' 3 1/2"
3 1/2"
3 1/2"
Reactions:
Assumed Member Weight (plf): 14
Location Dead Load
Live Load
Total Load Uplift
I (Ibs.) 2" 1234
2743
3977 0
2 (Ibs.) 12' 1 1/2" 1247
2762
4010 0
Loads:
Load
Location
Live
Dead
Type
Distributed (plf)
0 to 1'
238.4 to 238.4
81.8 to 81.8
Floor
Distributed (plf)
1' to 1' 3"
203.4 to 203.4
103.6 to 103.6
Floor
Distributed (plf)
1' 3" to 10' 9"
203.4 to 203.4
103.6 to 103.6
Floor
Distributed (plf)
10' 9" to I V
203.4 to 203.4
103.6 to 103.6
Floor
Distributed (plf)
I F to 12'
203.4 to 203.4
103.6 to 103.6
Floor
Distributed (plf)
12' to 12' 3 1/2"
324.5 to 324.5
152 to 152
Floor
Distributed (plf)
0 to 1'
203.4 to 203.4
103.6 to 103.6
Floor
Distributed (plf)
1' to 1' 3"
243.7 to 243.7
83.6 to 83.6
Floor
Distributed (p1Q
1' 3" to 10, 9"
243.7 to 243.7
83.6 to 83.6
Floor
See Trus Joist Framer's Pocket Guide for Product Trademark Information
TJ-Xpen 6.35 (#689) A Page 1 SPADA REMO.JOB
Member Calculations Report
Mid -Cape Home Centers
PO BOX 1418
465 ROUTE 134
SOUTII DENNIS, NU 02660
5083986071
5083984559
Level Name: SECOND FLOOR Status: Ready to Plot
Application: Floor Non -Residential: No
` 1J
.10
Design Date: 7/29/2004 1:41:16 Pd1 Report Date: 7/29/2004 1:46:39 P,AI
Object: Flush Beam #8
General:
Product: 1 3/4" x 9 1/2" 1.9E Microllam LVL Plies: 3
Deflection Criteria: Standard, Live Load L/360, Total Load L/240
Member Weight (plf) per ply: 4.8
Design Value
Control Value
Result
Moment (Ft-lbs)
12123
20312
Passed
Shear (lbs.)
4038
10898
Passed
Live Load Deflection (")
.2"
.33"
Passed
Total Load Deflection (")
.32"
.49"
Passed
Reaction (lbs.)
5227
6300
Passed
Bearines•
Bearing
Location
Input Length
Required Length
1 Wall # 1
10,
3"
3"
2 Wall # 7
0
3"
3"
Reactions:
Assumed Member Weight (plf): 14
Location
Dead Load Live Load
Total Load Uplift
(lbs.) 9' 10 1/2"
1977 3248
5225 0
2 (lbs.) 1 1/2"
1977 3248
5225 0
Loads:
Roof Load Duration Factor: 115%
Load
Location
Live
Dead
Type
Distributed (plf)
9' 9" to 10'
0 to 0
81 to 81
Floor
Distributed (plf)
3" to 9' 9"
0 to 0
81 to 81
Floor
Distributed (plf)
0 to 3"
0 to 0
81 to 81
Floor
Distributed (plf)
9' 9" to 10'
0 to 0
4.5 to 4.5
Roof
Distributed (plf)
3" to 9' 9"
0 to 0
4.5 to 4.5
Roof
Distributed (plf)
0 to 3"
0 to 0
4.5 to 4.5
Roof
Distributed (plf)
9' 9" to 10'
390 to 390
203.1 to 203.1
Roof
Distributed (plf)
3" to 9' 9"
390 to 390
203.1 to 203.1
Roof
See Trus Joist Framer's Pocket Guide for Product Trademark Information
TJ-Xpert 6.35 (#689) A Page I SPADA REMO..JOB
a
T T
By
A complete Ti-Rpert
See True
:raminq'plau requires the Trus Joist Framer's Pocket
13t Framer's Pocket Guide for Product TradeB4rk Information
. r . _ .
53' 6"
All 6•
ESO
i
I '
I !
6'
JOIST P40 ED1I LIST -
Plot ID Length Product Plies Cty
M1 28, 1 3/4' x 11 7/8" 1.9E Microllam LVL 3 3
M2 16, 1 3/4' x 11 7/8' 1.9E Microllam VA 2 2
JOB COMMENTS
SPIROS BALOD:WS
SPADA RE9O/AJD.
LE'JEL COMMENTS
72 LANE RD
W YAPMOL"TH Ha
PL4I:S LATECI OS-12-0/
CREATED BY
id-Caoe Home Centers
PO BOX 1/18
/65 ROUTE 134 -
SOUTH
DENNIS, MA 02660
5083986071 -
FAX: 5083934559�
V
TJAXpert.
SYMBOL LEGEND
Point Load
. _ Line Load
!_ = Area Load
B50 Beam By Others
U Required Bearing Length in inches
U (Adequate bearing has been Provided if
bearing length is not indicated.)
LVEL NOTES
File Name: SPADA RFMO..JOB
Level Name: FIRST FLOOR
Plotted: 7/29/2004 13:51
Design Status:
FIRST FLOCP.... 7/29/2004 13:43
SECOND FLOCP... 7/29/2001 13:41
ATTIC LOADS.... 7/29/2004 13:40
ROOF LOADS..... 7/29/2004 13:37
NOTE; Level design times indicated above provkoe
assurance for proper level stacking.
Design Methodelog,: CL
Flv.r Area Lcadino Is:
IOpsf Live Load and 12 pst Dead Load
Maximum Joist Deflection:
L/I60 Live Load
L/2/0 Total Load
Ti-Pro Ratinq Information:
Weignted Average: NA
Lowest Rating: NA
Highest Rating: NA
Glued a Nailed Decking is Required
Direct ADDlied Ceiling is Not Required
Floor Decking: 23/32' Panels (24" Span Rating)
Layout Scale: 3/16" = V --
FOR THE TJ-XPERT WARRANTY
SEE FRAMER'S POCKET GUIDE
TJ•Xpert 6.35 (4689) C6.35 D6.15 $6.35 P6.35
Mid- �e
ENTERS
J
A complete TJ-Xpert framing plan requires the Trus Joist Framer's Pocket Guide
See Trus Joist Framer's Pocket Guide for ProdtZct Trademark Information
53' 6• —
13' 6"
6' 10 -1_-.
I
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I Jv'IST AND SEAM LIST I
Pat ID Len 1'1, FroJact
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ri r-1 I it L41
M3 la' I Ii 4" 1 /;" o M' z r; l lcn P:L
M4 i 314" 11 i ,L::1 Hart, L',1
41, E"
HA7 ER LIST - Simpson Strong -Tie Cor..pany, Inc.L
F1 t I- ;ty FUJcCt Lahti T:F Fiils "race Nills Mezaer I115 5,•Ces
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CULXpert
®
��a
CREATED BY
JOB CC684ENTS
Hid -Cane Home Centers
PO BOX 1418 SPIROS BALODIMQS
465 ROUTE 134 SPADA Rk770/ADD.
SOUTH DENHIS, MA 02660 72 LAKE RD
5083906071 N YAPHCUTH MA
FAX: 5083984559
SYMBOL LEGEND I
Point Load
. _ Line Load
1. ' Area Load
PRO Beam By Others
ODetail Callout Label
(See Framer's Pocket Guide)
R .. Pequired Bearing Length in inches
L-1 (Adequate bearing has been provided if
bearing length is not indicated.)
LEVEL NOTES
File Name: SPADA REMO..JOB
Level Name: SECOND FLOOR
Plotted: 7/29/2004 13:19 _
C'esign Status:
FIRST FLOUR.... 7/29/2004 13:43
SECOND FLOCP...7/29/2004 13:41
ATTIC LGACS.... 7/29/2004 13:40
ROOF LOADS..... 7/29/2004 13:37
NOTE: Level design times indicated above provide
assurance for Frcpez level stacking.
Design Methodology: ASL
Fluor Area Loading Is:
35psf Live Load and 12 psf Lead Load
MdXlm'am Jcist teflection:
L/45'0 Lire Load
L/24) Total 1o3J
TJ-Pro Patin.; Information:
Weighted Averaqe: NA
Lcvest Patina: SA
Fi71e=t Fa -its: NA
LeJ i N it d le-kins is Fegaucd !
ulre22 A F11eJ ceillrq is :It r gvitel
Fl rr le —king: 23/i2" Panels (-4" Sp31 Pating:'
Layout Scale: 3116" = V
6
0
5
.IrITUWAVINN: 1/ 01OKKCII
P.O. Box 02632-1069
wmv.capecodhomebuilder.com
JUN 0 M2005
c-mail homcbuilda@comcast.net
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DOUG WILLIAMS CUSTOM BUILDING CO.
P.O. Box 1069, Centerville, Massachusetts 02632-1069
Centerville, Mass 508-775-1500 /1-866-524-0070
www.capecodhomcbuilder.com e-mail homcbuilda@comcast.net
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DOUG WILLIAMS CUSTOM BUILDING CO.
P.O. Box 1069, Centerville, Massachusetts 02632-1069
Ccntcnille, Mass 508-775-1500 /1-866-524-0070
i&ww.capccodhomebuildcr.com c-mail homcbuilda@comcast.net
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DOUG WILLIAMS CUSTOM BUILDING CO.
P.O. Box 1069, Centerville, Massachusetts 02632-1069
Centerville, Mass 508-775-1500 /1-866-524-0070
www.capccodhomebuilder.com c-mail homebuilda@comcast.net
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DOUG WILLIAMS CUSTOM BUILDING.
P.O. Box 1069, Centerville, Massachusetts 02632-1069
Centerville, Mass 508-775-1500 /1-866-524-0070
www.capecodhomcbuildcr.com c-mail homcbuilda@comcast.net
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TOWN OF YARMOUTH B epartment BUILDING
( 2231 ext261
PERMIT NO B-05-1448_ PERMIT
ISSUE DATE ;- ........ _ : PROPOSED USE S
-------'
APPLICANT ,DouQIaslNiiliame6r. JOB WEATHER CARD
----------------------------
PERMIT TO MlscJpermit Vansfef
I AT (LOCATION) 100072LAKERD ZONING DISTRICTEfl Bldg. Type: Residential I
SUBDIVISION MAP LOT BLOCK
LOT SIZE
BUILDING IS TO BE: CONST
permit transfer -change of contractor • refer to Building Permit M B-05-254 & B-05.1311
REMARKS
AREA (SO FT) EST COST ($ $0.00 PERMIT FEE ($) $50.00
OWNER ICAROL R NEWMAN BUILDING DEPT BY
ADDRESS 00072 LAKE RD
South Yarmouth MA 102664
INSPECTION RECORD
USE GROUP R-4
CONTRACTOR
LICENSE 016981
Williams, Douglas Sr.
POB 1069
Centerville MA 02632
5087751500
FIELD COPY
Date
Note Pr gress - Corrections and Remarks
Inspector
oK
AV
/"'L /J dim
o+•�s-- �4
oF'YgR,� ONE & TWO FAMILY ONLY - BUILDING PERMIT
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
p y Town of Yarmouth Building Department
M.,,,,.�,. , 1146 Route 28 • l-aduouth, NIA 02664-4492
yA Tel: (508) 398-2231 x261 • Fax: (508) 398-0836
b_'I )1-0-441IL4 -� A
Office Use Only Planning Board Information Assessors Department Information:
Permit NO. Date Plan Type Map Lot
'T71 Endorsement Date VFZ
Permit Fee $ �U R rding Date New
Deposit Rec'd. Date n No. 1.4 Property Dimensions:
Net Due $ Other Lot Area (sf) Frontage (ft) Lot Coverage
This Section for Office Use Only
Building Pe u ber:
Date Issued:
Signatur_ _
e•
*Building
Certificate of Occupancy
is is not required
Official ate
Section 1 - Site Information
I Use Group: R-4 Type: 5-B
1.1 Property Address:
Z t✓ Z9�--e U
1.2 Zoning Information:
kdS
Zoning District Proposed Use
1.3 Building Setbacks (it)
Front Yard
Side Yards
Rear Yard
Required
Provided
Required
Provided
Required
Provided
1.4 Water Supply (M.G.L. c. 40. S 54)
Public Private
1.5 Flood Zone Information: Comments:
Zone: BFE:
Section 2 - Property Owners4p4N4U=dzaQ Agent
2.1 Owner of Record: 0 T
Aro u eJ
Name (print) JUN 0 , 5 D Mailing Address
S—'7y7a— In r'i— 405—
,signature Telephone
2.2 Authorized Agent:
0( 7r°r��rr' vLra�
Name(p ) Mailing Address
175—)So
Signature Telephone Fax
Section 3 - Construction Services
3.1 Licensed onstruction Supervisor: ,/
7r5 sr
Not Applicable ❑
7,X�l`� A,4
\ ll ,/
License Number
/
Address
5 ��'�
Expiration Date
Signature Telephone
3.2 Registered Home Improvement Contractor:
Company Name
I cE-L, ��t(d e�
Not Applicable ❑
Licens Number Z e1
Address �••
�� 11C `J
Signature Telephone
Expiration Date
- c-e Y
1of2 OVER
I
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 thg 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) ❑ Alterations ❑ I Addition ❑
Accessory Bldg. ❑ Type Demolition Other Specify:
Brief Description of Proposed Work:
Sactinn B - Fstimated Construction Costs
Item
Estimated Cost (Dollars) to be
completed by permit applicant
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 & additions)
�C40 5=,2A V
Check Below
❑ Conservation -Commission Filing
(if applicable)
❑ Old Kings Highway & Historical
Commission approval
(if applicable)
Section 7a - Owner Authorization - To be Completed When
Owner's Agent or Contractor Applies for Building Permit
I, , as owner of the subject property
hereby authorize
my behalf, in all matters relative to work authorized by this building permit application.
to act on
Signature of Owner Date
Section 7b'- Owner/Authorized Agent Declaration
I, , 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.
Signed under the pains and penalties of perjury.
ALP17a-3 3P
Print name (4,
Signature of O r/Ag6nt i Date
u
3r°fYgke TOWN OF YARMOUTH
0
r...... i BUILDING DEPARTMENT
CONSTRUCTION SUPERVISOR FORM
PLEASE PRINT: � 2 �ar`� ' J � S • �w _ �
Job Location:
Number Street Village
Owner of Property: e tU e i /Ka..�
Construction Supervisor:
Address: � (OL `l k 1( 4 r k, —
Licensed Designee:
(If other than Supervisor)
2.15 Responsibility of each license holder:
License No.
License No.
Phone No.
2.15.1 The license holder shall be fully and completely responsible for all work for which he is supervising.
He shall be responsible for seeing that all work is done pursuant to the state building code and the drawings
as approved by the building official.
2.15.2 The license holder shall be responsible to supervise the construction, reconstruction, alteration,
repair, removal or demolition involving the structural elements of building and structures only pursuant to
the state building code and all other applicable laws of the commonwealth, even though he, the license
holder, is not the permit holder but only a subcontractor or contractor to the permit holder.
2.15.3 The license holder shall immediately notify the building official in writing of the discovery of any
violations which are covered by the building permit.
2.15.4 Any licensee who shall willfully violate subsections 2.15.1, 2.15.2 or 2.15.3 or any other section of these
rules and regulations and any procedures, as amended, shall be subject to revocation or suspension of
license by the board.
2.16 All building permit applications shall contain the name, signature and license number of the
construction supervisor who is to supervise those persons engaged in construction, reconstruction,
alteration, repair, removal of demolition as regulated by section 109.1.1 of the code and these rules and
regulations. In the event that such licensee is no longer supervising said persons, the work shall immediately
cease until a successor license holder is substituted on the records of the building department.
2.17 The license holder shall be responsible for requesting all required inspections. Failure to do so may
be deemed a violation of the permit conditions.
I have read and understand my responsibilities under the rules and regulations for licensing construction
supervisors in accordance with section 109.1.1 of the state building code. I understand the construction
inspection procedures and the specific inspection as called for by the building official.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.152
Yes No ❑ I I
If you have checked yam, please indicate the type coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 152 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
of Owner or Owner's Agent
Owner ❑ Agent ❑
Signature: Building Official Approval:
For Offide Use Only
Permit No.
Date TOWN OF YARMOUTH
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MGL c. 142A requires that the 'reconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition or construction of an addition to any pre-existing owner -occupied
building containing at least one but not more than four dwelling units or structures which are adjacent to
such residence or building' be done by registered contractors, with certain exceptions, along with other
requirements.
Type of Work: -4 (� Est. Costy604-+� —
Address of Work *T'7- L L-(L
Owner Name: ra4-Iy ( 04-tJ PA a'^
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job under $1,000
Building not owner occupied
Owner pulling own permit
Other (specify)
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH
UNREGISTERED CONTRACTORS FOR APPLICABLE HOME
IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION
PROGRAM OR GUARANTY FUND UNDER MGL c. 142A.
Signed under penalties of perjury:
I hereby apply for a permit as the agent of the owner:
(9_ % —05 �j cs� la5 �..CDAC } tsSr 9f C, I6Z21 7
Date Contractor Name Registration No.
N•
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above
property:
Date
Owner Name
The Commonwealth of Massaehuseas
Department of Industrial accidents
emceallaresdaffoss
600 Washington Street
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
L , c..l t I
locateowcse fv Z L-1 4 61d
C t� et � I I ` - phone 0
O 1 am a homeowner performing all work myself.
I am a sole proprietor and ha%e no one working in any capacity
am an employer prop iding workers' compensation for my employees working on this job.
nmmninv nnmp- -(C� �ii <L.L. ✓T7✓�/ eo !r-'v-\� W, eo
1 Vu a(
city,
A 0 �Ir s�� �� phone 0: 7 % 5 IS d v
insor tree co Ai j4A policy # dw a- &CV 5'0 O 3 G�20o S
I am a sole proprietor. general contractor. or homeowner (circle one) and have hired the contractors listed below "ho ha,.e
the follow in_ workers' compensation polices:
company narne-
addr ss•
cis► phone # -
insurance co policy.
-
Failure to sceure coverage as required under Section 25A of MGL 152 an lad to the imposition of erimiaal penalties of a nag ap to SIANAO and/or
one years' Imprisonment as well as civil penalties io the form of a STOP WORK ORDER and a not of S100.00 a day against mt. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
t do hereby certify under the pains and penalties ojperjury that the information provided above is true and correct
Signatures Date
(� `.1S Pr 7 ��Oy
Print name S S ( W r hone
omcial use only do not write in this area to be completed by city or town oMelal
city or town: YARMOUTfi _
❑ check if Immediate response is required
contact person:
permit/lictnse # CIBuilding Department
❑Licensing Board
261 ❑Selectmen's Office
❑Health Department
phone#:_ (508) 398-2231 eat. rJOther
0n .sed 3•95 P1A1
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the "law", an en►ploa•ee is defined as every person in the service of another under am
contract of hire. express or implied. oral or written.
An etnplover is defined as an individual. partnership, association. corporation or other legal entity, or any two or more of
the foregoin^_ 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
owner of a dwelling house having not more than three apartments and who resides therein. or the occupant of the
daellina house of another who employs persons to do maintenance , construction or repair work on such dwelling house
or oil the _rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.
%lG1_ chapter 1 section 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.
Additionally. neither the comntomyealth nor any of its political subdivisions shall enter into arty 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
supply in -.!company names. address and phone numbers as all affidavits may be submitted to the Department of
Industrial Aceidents 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 afldavits 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 Accidenis
I face of INVISUIttlens
600 Washington Street
Boston, Ma. 02111
fax N: (617) 727-7749
phone.Hi-(6M 7274900 ext. 406, 409 or 375
TOWN OF YARMOUTH
BUILDING DEPARTMENT
1146 Route 28, South Yarmouth, NIA 02664 508-398-2231 ext. 260
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE:
JOB LOCATION: '
NAME STREET ADDRESS / SECTION OF TOWN
"HOMEOWNER"
NAME HOME PHONE/ WORK PHONE
PRESENT MAILING ADDRESS
CITY OR TOWN
The current exemption for `Homeowner' was extended
and to allow such homeowners to engage an individ
homeowner shall act as supervisor. (State Building
Ot STATE ZIP CODE
include owner — occupied dwellings of one or two units
hire who does not possess a license, provided that such
Section 108.3.5.1)
Definition of Homeowner:
Person(s) who owns a parcel of land on which h / she resides or intends to reside, on which there is or is intended
to be, a one or two family attached or detached structure assessory to such use and / or farm structures. A person
who constructs more than one home in a two-year period shall not be considered a homeowner; such "homeowner"
shall submit to the building official, on a form acceptable to the building official, that he / she shall be responsible for
all such work performed under the building permit. (Section 108.3.5.1)
The undersigned `homeowner' assumes responsibility for compliance with the State Building Code and other
applicable codes, by-laws, rules and regulations.
The undersigned `homeowner' certifies that he / she understands the Town of Yarmouth Building Department
minimum inspection procedures and requirements and that he / she will comply with said procedures and
requirements.
HOMEOWNER"S SIGNATURE
APPROVAL OF BUILDING OFFICIAL
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch.142.
Yes ❑ No ❑
If you have checked yes, 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 142 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 ❑
hhomeownrlicexemp
BUILDING
TOWN OF Y A R M O U T H ELECTRICAL.
GAS
1146ROUTE28 SOUTHYARIIIOUTH MASSACHUSETTS0266411451
Telephone (508) 398-2231, Ext. 261 — Fax (508) 398-2365 PLUMBING
SIGNS
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
Pursuant to M.G.L. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section 111.5,
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at % Z La1t_0- 7'ek . S • ,L4:�f
Work Address
is to be disposed of at the following location:' !1 `ur- 4-c- L- b�
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
rp�7-0 7�
Date
Permit No.
v
Doug v ttttants Ctt5tutit BuildingCo.
RO...Box ID69 utcrville, Massac:huwUs 02632-1069
SOR_775-1500 R.66-574-0070 fax SOR-775-150*1
www capecadhornzbcsitder.com
e-mail ho-mebuiida a eomcast.net
Aarcemeut
1,-F�and Carol Newnan give Douglas L. Willia3usy "- Doug Mr"anis Custom
Buildina Company permission to place the building permit for. 721ake Road in his name,
as the .aweementwith.the prior contractor has bemterminated.
1
flare.
&A
/03
g71ONS
BOARD OF BUILDING REGUL
i. SUPERVISOR
''.
` CONSTRUCTION
';3 License: p16981
;► �' Number:: CS
Birthdate:0310711947 18047
i° Expires: 63/07/2906 Tr' no:
Restricted:..00
IIAMS SR C
DOUGLAS L \NIL 4C*mjs verPO BOX 1A069 ctngj
CENTERVILLE, MA 02632
�ovn�no?tcuea� �./a�ucaelta
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
RegistrAnk 102227
Expllratlon: 711I2006
Lj -Type: D
S' STOW 'BUILDING
DOUGLgS
Douglas Williams 1,
BOX 1069
CENTERVILLE, MA 02632�
Administrator
• TOWN OF YARMOUTH
F` Building Department
Town Hall
Yarmouth, MA 02664
(508) 398-2231 ext.261
BUILDING PERMIT
TRANSMITTAL
Temp Permit No.:
T-05-639
Applicant Name:
Douglas Williams Sr.
Applicant Phone:
5087751500
Building Location:
00072 LAKE RD
Owner's Name:
CAROL R NEWMAN
Owner's Addres
00072 LAKE AD
South Yarmouth MA 02664
Owner's Telephone: (617) 905-3652
(OFFICE USE ONLY
Recorded By:
Ic
Permit Fee:
$50.00
Deposit Rec:
$50.00
Payment Type:
Check ChkNo.: 4495
Net Owed:
$0.00
Application Date:
6/7/2005
Issue Date:
Expiration Date
Comments: Map/Lot: 049.234
permit transfer - transfer contractor - refer to
Building Permit # B-05-254 & B-05-1311
REVIEWED BY:
1. WATER DEPARTMENT: DATE: N/A:
2. ENGINEERING DEPARTMENT: DATE: WA:
3. CONSERVATION: DATE: WA:
HEALTH DEPARTMENT: DATE: WA:
5. BUILDING DEPARTMENT: DATE: WA:
6. FIRE DEPARTMENT: DATE: N/A:
PLEASE NOTE
COMMENTS:
RECEIPT OF COPY:
SIGNATURE OF APPLICANT:
DATE:
Date Printed: 6/8/2005
DOUG WILLIAMS CUSTOM BUILDING CO.
P.O. Box husetts 02632-1069
• Cent 1 s 5- 5 5 1.866-524-0070
www.capecodhomebuildcr.com a-mail
homebuilda@comcast.net
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P.O. Box 1069, Centerville, Massachusetts 02632-1069
Centcrvillc, Mass 508-775-1500 /1-866-524-0070
www.capecodhomcbuilder.com ' e-mail homebuilda®eomcast.net
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P.O. Box 1069, Centerville, Massachusetts 02632-1069
Ccnterville, Mass 508-775-1500 /1-866-524.0070
capocodhomebuil'der.com a -mail homcbuilda@c0mcast.net
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P.O. Box 1069, Centerville, Massachusetts 02632-1069
Centerville, Mass 508-775.1500 /1-866-524-0070
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TOWN OF YARMOUTH Building Department BUILDING
(508)398-2231 ext.261
PERMIT NO _B-06-814 - . PERMIT
.....ISSUE DATE ;_22—.; PRO U...........
APPLICANT CaroiNmJOB WEATHER CARD
PERMIT TO INiscJpenNt transfer
AT (LOCATION) 100072LAKE RD l KING
SUBDIVISION MAP LOT BLOCK 1049.234 BUILDING IS TO
LOT SIZE
Permit transfer - refer to permit Y B-05-254, B-05-1311 and B-05-1448
REMARKS
DISTRICT R-25 Bldg. Type. Residential
BE: CONST TYPEFE76-1 USE GROUP R-4
AREA (SO FT) EST COST ($ $8,000.00 PERMIT FEE ($) $50.00
OWNER ICAROL R NEWMAN BUILDING DEPT BY
ADDRESS 100072 LAKE RD
WestYambuth I MA 102673
INSPECTION RECORD
Date Note Progress - Corrections and Remark
CONTRACTOR
LICENSE 0
PHONE 15082557478
FIELD COPY
OF'YAR,�
. � o
O
M�TTIKMIf�{
• �� �yIYp1.'
0
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 • Yarmouth, NIA 02664-4492
Tel: (508) 398-2231 x261 • Fax: (508) 398-0836
Office Use Only Planning Board Information Assessors Department Information:
Permit No Dates ype Map L Lot
Permit Fee $ � E orsement Date T y
Recording Date New l
Deposit Rec'd. $ SIN Date o 1.4 Property Dimensions:
Net Due $ n er Lot Area (sf) Frontage (ft) lot Coverage
This Section for Office Use Only
Building Per be
Date Issued:
_
Signature:
Certificate of Occupancy
Is is not required
q
B ilding Official Date
Section 1 - Site Information
I Use Group: R-4 Type: 5-B %\
1.1 Property Addres
1.2 Zoning Information:
Zoning District Proposed Use
W �S� )►ft& DQ-11.1. PAO3
1.3 Building Setbacks (it)
Front Yard
Side Yards
:E Rear Yard
Required
Provided
Required
Provided
Required
Provided
1.4 Water Supply (M.G.L. c. 40. S 54)
Public Private
1.5 Flood Zone Information: Comments:
Zone: BFE:
Section 2 - Property Ownership/Authorized Agent
2.1 Owner of Recor
C' PN E.),j b N1\)
Name (print)
Signature
Y, E I 1rJ.
Mailing Address
.- CP
Telephone
2.2 Authorized Agent:
Name (print)
Signature Telephone
Mailing Address
Fax
Section 3 - Construction Services
3.1 Licensed Construction Superviso �y
Not Applicable ❑
1 `L
License Number
Address BU
By
Expiration Date
Signature Telephone
f
3.2 Registered Home Improvement Contractor:
Company Name
Not Applicable ❑
License Number
Address
Signature Telephone
Expiration Date
1 of 2 OVER
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) ❑ Alterations ❑ I Addition ❑
Accessory Bldg. ❑ Type Demolition
Brief Description of Proposed Work:
r 07_0 /3/
Sprtinn R lf=stimatpd Cnnstnictinn Costs
Item
Estimated Cost (Dollars) to be
completed by permit applicant
1. Building
2. Electrical
3. Plumbing / Gas
4. Mechanical (HVAC)
5. Fire Protection
6.Total=(1+2+3+4+5)
6 0
7. Total Square Ft. (new houses & additions)
Section 7a - Owner Authorization - To be Completed When
Owner's Agent or Contractor Applies for Buildinq Permit
Other
Specify:
Check Below
❑ Conservation -Commission Filing
(if applicable)
❑ Old Kings Highway & Historical
Commission approval
(if applicable)
, as owner of the subject property
hereby authorize
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner
Section 7b Owner/Authorized Agent Declaration
to act on
Date
, 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.
Signed under the pains and penalties of perjury.
(' 4L_ R • rJ Ew h LINJ
Print name n
Signature of
Date
--gr}5
rq 2 of 2
For Office Use Only
Permit No.
Date TOWN OF YARMOUTH
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MGL c. 142A requires that the 'reconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition or construction of an addition to any pre-existing owner -occupied
building containing at least one but not more than four dwelling units or structures which are adjacent to
such residence or building' be done by registered contractors, with certain exceptions, along with other
requirements. S
Type of Work: � 10 I to �D (� Est. Cost '^' &t DO D
Address of Work 7 a L _Nt) , �I 110 rU 11 0 oLG 73
I OF
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job under $1,000
Building not owner occupied
Owner pulling own permit
Other (specify)
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH
UNREGISTERED CONTRACTORS FOR APPLICABLE HOME
IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION
PROGRAM OR GUARANTY FUND UNDER MGL c. 142A.
Signed under penalties of perjury:
I hereby apply for a permit as the agent of the owner:
Date
OR:
Contractor Name
Registration No.
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above
property:
D
Date Owner Name
The Commonwealth of Massachusetts
Department of Industrial Accidents
amcea/laresdpulois
600 Washington Street
Boston, Mass. 02111
`74-' Workers' Compensation Insurance Affidavit
Applicant information: PIe9iCPR 1 =��
C3 I am a sole proprietor and have no one uorkine in any capacity
I am an employer pro% iding workers' compensation for my employees working on this job.
company name:
address:
cot phone 0h
insurance ca policy 0
I am a sole proprietor. general contractor. or homeowner (circle one) and have hired the contractors listed below who hate
the following worker' compensation polices:
company namee
address•
city. phone #
n« ranee en policy Ji
Failure to secure coverage as required under Section 25A of MGL 152 as lad to the imposition of criminal penalties of Aline ap to 51.500A0 and/or
one years' imprisonment as %ell as civil penalties in the form of a STOP WORK ORDER and a fine of sI00.00 a day against me. I understand that a
copy of this statement may be forwarded to the Once of Investigations of the DIA for coverage verification.
I do hereby certify under the ns and penalties ojperjury that the injortnadon provided above is trite and Corr Ct
Signaturq��� Date ,L j•Z�01.3
,Print name -.0 1, I N &X)b wi Phone N a, " 7 Y7(I
official use only do not %rite in this area to be completed by city or town official
city or town: YARHOUTII
p check if immediate response is required
contact person:
permilAicense 0 rlBuildiog Department
pucensing Board
261 OSelecimen's Office
❑Health Department
phone#;_ (508) 398-2231 eat. nother
o"nni 3M P1A1
Information and Instructions :
I
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the "la%v', an employee is defined as every person in the service of another under any
contract of hire, express or implied, oral or written.
An emphover 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
d%%ellina house of another who employs persons to do maintenance , construction or repair work on such dwelling house
or .in the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.
NIGI_ chapter 1 section 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.
Additionally. neither the common%%ealth nor any of its political subdivisions shall enter into any contract for the
performance of public %%ork until acceptable evidence of compliance with the insurance requirements of this chapter hay e
been presented to the contracting_ authority.
Applicants
Please fill 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 yvorkers' 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 affidavits may be returned to
the Department by mail or FAX unless other arrangements have beat 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 Accidenis -
181ce of 111VIZU119823
600 Washington Street
Boston, Ma. 02111
fax ff: (617) 727-7749
phone th (617) 7274900 ext. 406, 409 or 375
;og'Y`AR
�`1 w�fA n{t1f/�I
F
PLEASE PRINT:
DATE:
JOB LOCATION:
TOWN OF YARMOUTH
BUILDING DEPARTMENT
1146 Route 28, South Yarmouth, NIA 02664 508-398-2231 ext. 260
NAME
"HOMEOWNER"
NAME
SENT MAILING ADDRESS
HOMEOWNER LICENSE EXEMPTION
STREET ADDRESS
Ml,ly .630h-2-S�-
HOMEPHONE
4poy�(-A
SECTION OF TOWN
PHONE
73
CITY OR TOWN STATE ZIP CODE
The current exemption for `Homeowner' was extended to include owner — occupied dwellings of one or two units
and to allow such homeowners to engage an individual for hire who does not possess a license, provided that such
homeowner shall act as supervisor. (State Building Code Section 108.3.5.1)
Definition of Homeowner:
Person(s) who owns a parcel of land on which he / she resides or intends to reside, on which there is or is intended
to be, a one or two family attached or detached structure assessory to such use and / or farm structures. A person
who constructs more than one home in a two-year period shall not be considered a homeowner; such "homeowner"
shall submit to the building official, on a form acceptable to the building official, that he / she shall be responsible for
all such work performed under the building permit. (Section 108.3.5.1)
The undersigned `homeowner' assumes responsibility for compliance with the State Building Code and other
applicable codes, by-laws, rules and regulations.
The undersigned `homeowner' certifies that he / she understands the Town of Yarmouth Building Department
minimum inspection procedures and requirements and that he / she will comply with said procedures and
requirements.
+HOOWNER"S SIGNATURE
APPROVAL OF BUILDING OFFICIAL
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch.142.
Yeso No ❑
If you have c ecked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy X Other type of indemnity ❑ Bond 0
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required
by Chapter 142 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 0
h:homeov=Iicexcmp
TOWN OF YARMOUTH
1146ROUTE28 SOUTH YARDIOUTH MASSACHUSETTS0266414451
Telephone (508) 398-2231, Ext. 261 — Fax (508) 398-2365
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
BUILDING
ELECTRICAL
GAS
PLUMBING
SIGNS
Pursuant to M.G.L. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section 111.5,
I hereby certify that the debris resulting from the proposed work/demolition to be
conductedI R I -jr, K k 9 U 1 h1, VN 0A 93
Work Address
is to be disposed of at the following location: 1
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
Signature of Applicant
Permit No.
/0'r
Date
Service #:
Map / Parcel
TOWN OF YARMOUTH
WATER DEPARTMENT
99 Buck Island Road
West Yarmouth, MA 02673
Telephone: (508) 771-7921 • Fax: (508) 771-7998
❑ New Structure
03-007796
049.234
01-30-06
Carol R. Newman
2604 Highvale Drive
Las Vegas, NV 89134
NOTICE
❑ Existing Structure
Service Address: 72 Lake Rd. W. Yarmouth
Certified Mail #: 7005 1820 0005 5573 1319
This is to advise you that the Town of Yarmouth Water Division or their authorized
agents have installed a new water service or rehabilitated an existing water service at
the above address. Materials used during this installation are not conductive.
Town of Yarmouth Water Division regulations prohibit the use of this water service
as a grounding device for your electrical service.
It is recommended that you contact an electrical contractor to ensure that your
electrical service grounding is in compliance with Massachusetts Electrical Code, CMR,
S27-12.00 Article 250.
A copy of this service is being forwarded to the'rown of Yarmouth Wiring Inspector.
Sincerely,
Dan Mills
Superintendent
Cc: Wiring Inspector
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, (MEC), 527 CMR 12.00
U/V,(OFFICE US Oj1JLY)TOWN OF YARMOUT By
/2 V PERMIT NO. S-05 Ld
NOV 18� ,
(PLEASE PRINT IN INK OR TYPE ALL INFORMAT(ON) �.
To the Inspector of Wires: By this application the undersigif�d�g�T .notice It or her
work described below.
the electrical
Location (Street & Number) "702 1-•e7A-e leoeza
Owner or Tenant 81 r V enrL!] / .S P-4 D /J Telephone No. 5-6,778- d 60 7i
Owner's Address Z2== '�`� e lam[ && "14cp CZ M
Is this permit in conjunction with a building permit? !�'Yes QNo
\v Purpose of Building /yew Utility Authorization No.
tExisting Service Amps / Volts OverheadO Undgrd 0 No. of Meters
New Service P-0— Amps t% / '�60 Volts Overhead❑ Undgrd Q^ No. of Meters f
Number of Feeders and Ampacity
Location and Nature of Proposed electrical Work: /ML0 lAonig. 11 %V�� v S-en, I/ram-�
Com letion o the oflowing table may be xaived by the Inspector oWires
(Check Appropriate Box)
No. of Recessed Fixtures
No. of Ceil.-Susp,(Paddle) Fans
o. oT To-ar
Transformers KVA
No. of Lighting Outlets
No. of Hot Tubs
Generators KVA
No. of Lighting Fixtures
Above n-
SwimmingPool rnd. ❑ rnd. ❑
o. o Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No, of Zones
No. of Switches
No. of Gas Burners
o. of Detection an
Initiating Devices
No. of Ranges
No. of Air Cond. Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pu mp
Totals:
um r
Tons
— —
— —
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Munic
❑ Connectioal n
Local ipOther
No. of Dryers
rY
Heating Appliances KW
g PP
Secutity Systems:
No. of Devices or Equipvalent
No. of Water
Heaters KW
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or uivalent
1jI 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 be issued unless the licensee provides
�O proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in
force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND[] OTHERQ (Specify:)
(Expiration Date)
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
-,.j I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: e, V , e i c erg Ae4e ' LIC. NO. / y70i/ 14
Licensee: 1 60 in 0, � r a -;�c 9, Signature ECt Q L' !LIC. NO.y7o 7
v (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: So
Address: Alt. Tel. No.: q— �P
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. I am the (check one) owner owner's agent. 0
Signature Telephone No.
[Rev. 04/001
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, (MEC), 527 CMR 12.00
(OFFICE USE ONLY)
r pTOWN OF YARMOUTH
J,L JAN 31 05 -J1
(PLEASE PR /NYIC_0Rlk ALLINFORMAT/ON) Date: ev "Ta.ti OS
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 & Numberl Zz
Owner o.
Owner's
Is this permit in conjunction with a building permit? 8-Yes ❑ No (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead❑
New Service Amps / Volts Overhead❑
Number of Feeders and
Location and Nature of Proposed electrical
Undgrd ❑ No. of Meters
Undgrd ❑ No. of Meters
j,.n
Comnletionof the fof/owin¢table may be waived by the Inspector of Wires
0 of Recessed Fixtures
No. of Ceil.-Susp.(Paddle)n
No. of Total
Transformers KVA
No. of Lighting Outlets
No. of Hot Tubs
Generators KVA
No. of Lighting Fixtures
Above n-
Swimming Pool gmd. ❑ md. ❑
o. o Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Bumers
o. ot Detection an
Initiating Devices
No. of Ranges
Total
No. of Air Cond. Tons
No. of Alerting Devices
No. of Waste Disposers
eat mp
Totals:
um er
— Le
ons
—
— —
No. of Self -Contained
Deicction/Alertin Devices
No. of Dishwashers
Space/Area Heating KW
Municipal r--1 Other
Local ❑ Connection LJ
No. of Dryers
Heating Appliances KW
rity Sysems:
SecuNo. of Detvices or Equipvalent /
No. of Water
Heaters KW
No. of No. of
Signs Ballasts
Data Wiring
No. of Devices or Equivalent
No. Hng:
dromassa a Bathtubs
y g
No. of Motors Total HP
Telecommunications Wiri
No. of Devices or uivalent
Attach aaamonat aetau t1 aestrea, or as reyuirea ty the inspector of wires.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may be issued 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.
CHECK ONE: INSURANCE 5g3— BOND❑ OTHER[] (Specify:)
'' LL (Expiration Date)
Estimated Value of E ectn Work: lk (When required by municipal policy.)
Work to Start: / ' Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I certify, under th p 'sand pgn,allies of ry, that the information on this application is true and complete.
FIRM NAME LIC. NO. /3 / 7- 4f,
Licensee: /Z� /.�%� Z� Signature LIC. NO.
(If applicable, enter "ex t" in the license number line.) Bus. Tel. No.: :;�tl
Address Z� 1 S Alt. Tel. No.:
OWNER'S INSURANCE WAIVER: I am aw c that the Licensee does not have the liability insurance coverage normally required by law. By my signature
below, I hereby waive this requirement. I am the (check one) owner ❑ owner's agent. Q
Owner/Agent
Signature Telephone No.
[Rev. 041001
Page 1 of 1
Cipro, Linda
From: Kelleher, Robert
Sent: Tuesday, December 27, 2005 5:13 PM
To: Cipro, Linda
Subject: RE: occupancy for 72 Lake Road
Yes it has been done and yes it did pass. Thanks, Bob K.
-----Original Message ----
From: Cipro, Linda
Sent: Tuesday, December 27, 2005 4:24 PM
To: Kelleher, Robert; Raiskio, Peter; Sherman, C Randall
Subject: occupancy for 72 Lake Road
Have you done a final for occupancy inspection @ 72 Lake Road? If so, did it pass and can I sign for
you? Thanks - Linda
Linda Cipro
Building Department
ArLuinistrativc Assistant
12/28/2005
o R TOWN OF YARMOUTH
2�o BUILDING DEPARTMENT
o! 1146 Route 28, South Yarmouth, MA 02664
`63•---^ fit= Tel. 508-398-2231 ext. 261 Fax 508-398-0836•
June 16, 2005
Mr. Doug Williams
Doug Williams Custom Building Co.
P.O. Box 1069
Centerville, MA 02632
Re: 72 Lake Road
Dear Mr. Williams:
Thank you for the opportunity to tour the residence under construction at 72 Lake Road, West Yarmouth. The list,
dated June 7, 2005, of particular items that you were concerned about, was indeed helpful.
There are in fact some important items that need to be addressed, such as (# 13) the lack of jack studs for the god floor
gable end window headers. You have indicated that such items will be reviewed by a structural engine. A manber of
the other items on your list, such as (#6) the lack of nailing in LVLs and floor girders, and (# 18) missing draft stops,
can be remedied by you in your capacity as a Licensed Construction Supervisor. Several items, such as (#27) the
nailing of the roof cap, are not visible at the time ofnormal inspections, and are the full responsibility of rho contractor.
You have indicated concern that Building Permits B-05.254 and B-05-1311 were issued to an unlicensed contractor
who was also not properly authorized to act as agent of the homeowner. Please be advised that these permits wear, in
fact, issued to Albert Brown, holder of Construction Supervisor License CS065525, and that Ma. Carol Newman, the
homeowner, signed both applications authorizing M. Brown as her agent.
Thank you for notifying us, as per 780 CMR Section 115.2.15.3 Notiflcadon of Violations, of the items you bave
flagged. As you know, since you have taken over the job at 72 Lake Road, you have now assumed full responsibility
for it. It is now incumbent on you, as the Licensed Construction Supervisor, to remedy any and all violations of
Massachusetts State Building Code. You have told us that a Structural Engineer has bean oonsulted We will await an
affidavit from hmvher that the violations have been corrected. Please contact us at that time, so that we may ninspo t
the property.
Thank you.
Very truly j
Andrew L. Amault
Local Building Inspector
cc: Ms. Carol Newman
Town of Yarmouth Building Department
TOWN OF YARMOUTII
BUILDING DEPARTMENT
1146 Route 28, South Yarmouth, NIA 02664
Tel. 508-398-2231 ext. 261 Fax 508-398-0836
August 11, 2005
Mr. Doug Williams
Doug Williams Custom Building Co.
P.O. Box 1069
Centerville, MA 02632
Re: 72 Lake Road
Dear Mr. Williams:
I am writing to ask you to provide this department with an update on the conditions at 72 Lake Road. In my letter to
you, dated June 16, 2005, I responded to your concerns about building code compliance and the quality of the work of
the previous contractor. At the time, it was my understanding that you would remedy all building code violations in
your capacity as a Licensed Construction Supervisor. You also told me that you would engage a Structural Engineer to
advise on the more serious deficiencies.
I asked you to have the Structural Engineer provide us with an affidavit attesting to the correction of these issues, at
which time we would reinspect the property. Please contact me at the address on the letterhead, or at 508-398-2231
x265, so that we may resolve this matter.
Thank you.
Very tndy yours
Andrew L. Arnault
Local Building Inspector
cc: Ms. Carol Newman
Town of Yarmouth Building Department
MICHELE C, TUDOR, P.E.
Consulting Structural Engineer
123 Cottonwood Lane - Centerville, Massachusetts 02632-1979 - (508) 771-7601 - Fax (508) 771-7163
mctudor@comcast.net
July 14, 2005
Town of Yarmouth
Building Dept.
1146 Route 28
So. Yarmouth, MA 02664
Attention: Mr. James Brandolini
Building Commissioner
RE: Newman Residence, Yarmouth, MA
Dear Mr. Brandolini,
Please be advised that the above captioned pmject has been inspected on June 10, 2005 and again on July 07, and
verified by telecom w/ the contractor this date to review repairs completed
This office has inspected all structural components for structural integrity and safety, and finds them adequate, as
amended.
I trust that the above addresses your needs at the present time. Should you have any question on any of the above,
please do not hesitate to call.
nnFL
��� Pam.
Mfchelc C. Tudor, X.
12005-99 _ 0F M�
cc: D. Williams
No.301A SZ,,UCTu t �,
Doug `Williams Custom Building Co.
P.O. Box 1069 Centerville, Massachusetts 02632-1069
508-775-1500 866-524-0070 fax 508-775-1503
www.capecodhomebuilder.com
e-mail homebuiidancomcast.net
Town of Yarmouth
Building Department
Building Commissioner
1146 Route 28
South Yarmouth
Massachusetts 02664 August 24, 2005
Dear Commissioner,
I am in receipt of Andrew L. Arnault's letter of August 11, 2005. My last
conversation with the Yarmouth Building Department was that the Town wanted
an engineer to certify the building and the Town was not going to re -inspect 72
Lake Road, S. Yarmouth, Permit # B-05-1448 dated 6-9 05, original permit by
Roy Brown #13-05-254 of 8-18-04
When I first brought the issued of code violations to the Town of Yarmouth, the
inspector I spoke with told me he had inspected the property and it was fine with
him and had no intention of going back to look at the issues. ( attached permit
signed) This was not correct and the code violations have mostly been corrected.
The costs to correct what the Town of Yarmouth passed as correct may exceed
$50,000.00
I am enclosing the engineer's report that certifies the structural correctness of the
property. This being said, there are some building code issues, (non structural)
that have not been addressed and may not be addressed unless the owner directs
me to correct them. In addition other problems have been discovered. The
improper application of sidewall shingles and trim lead to the water wall leaking
and it had to be stripped and re -shingled and re -flashed. It lacked proper
application of shingles, improper nailing of windows, and lack of air infiltration
paper. I have complied a photographic diary of the house and its repairs to date.
Most of the exterior shingled walls are improperly applied as is the roofing, and
roof cap. It was also found that the center of the house (stairway area) was off
level by 1.5 inches in 3 feet. The house had to be leveled. We also found the
existing lally columns approved by the Town of Yarmouth had nail
spacers at the tops due to the column being cut too short. II 1115
AUG 2 6 2005
2
There are no baffles between rafters per code. The exterior trim is so badly
applied it will most likely beremoved and then .baffles installed and then re -
trimmed.
The rear stoop footing is not sufficiently formed into the ground and had wood
forms buried in the ground beside it. The owner' intention is to make a deck over
the pad so as not to disturb the grade close to the water and stay within the
allowed footprint of the stoop, (7x10).
The fireplace extension was remove and replace and inspected by the Town.
I installed all structural members and others needed to re -enforce the frame that
was so poorly done.
As you are aware of the Code violations and the facts leading to a permit issued
legally, however, most likely improperly as the. owner had no knowledge of the
person taking out the permit. I would like to know if you are perusing
any action against the builder or the permit holder. As required by regulation I am
filing a complaint, and as chief enforcement officer of the Building Code in
Yarmouth I assume you are taking action against your inspectors for negligent
inspections of the frame, stricture, foundation and insulation. As I have an
interest in this matter I would appreciate being informed.
Respectfull
Douglas L. Williams Sr.
Encl: engineering certificate
Signed permit
Cc: Mrs. Carol Newman
Mr. Sal Spada
BBRS
Certified 7004-1160-0006-1240-5760
A'O
C
August 11, 2005
Mr. Doug Williams
Doug Williams Custom Building Co.
P.O. Box 1069
Centerville, MA 02632
Re: 72 Lake Road
Dear Mr. Williams:
TOWN OF YARNIOUTII
BUILDING DEPARTAIENT
1146 Route 28, South Yarmouth, AiA 02664
Tel. 508-398-2231 ext. 261 Fax 508-398-0836
I am writing to ask you to provide this department with an update on the conditions at 72 Lake Road In my letter to
you, dated June 16, 2005, I responded to your concerns about building code compliance and the quality of the work of
the previous contractor. At the time, it was my understanding that you would remedy all building code violations in
your capacity as a Licensed Constriction Supervisor. You also told me that you would engage a Structural Engineer to
advise on the more serious deficiencies.
I asked you to have the Structural Engineer provide us with an affidavit attesting to the correction of these issues, at
which time we would reinspect the property. Please contact meat the address on the letterhead, or at 508-398-2231
x265, so that we may resolve this matter.
Thank you.
4 ^ ;2
Very truly yours,
'�zz' - j4z:�
Andrew L. Amault
Local Building Inspector
cc: Ms. Carol Newman
Town of Yarmouth Building Department
June16,2005
Mr. Doug Williams
Doug Williams.Custom Building Co.
P.O. Box 1069
Centc nUc, MA 02632
Re: 72 Lake Road
Dear Mr. Williams:
TOWN OF YARMOUTH
BUILDING DEPARTMENT
1146 Route 28, South Yarmouth, NIA 02664
Tel. 5087398-2231 ext. 261 Fax 508-398-0836
w.
4 :s
Thank you for the opportunity to tour the residence under construction at 72 Lake Road, West Yarmouth. The list,
dated June 7, 2005, of particular items that you were concerned about, was indeed helpfuul.
There arc in faux some important items that need to be addressed, such as (# 13) the lack of jack studs for the god floor
gable end window headers. You have indicatod that such items will be reviewed by a structural engineer. Anumber of
the other items on your list, such as (#6) the lack of nailing in LVLs and floor girders, and (# 18) missing draft stops,
can be remedied by you in your capacity as a Licensed Construction Supervisor. Several items, such as (#27) the
nailing of the roofcap, are not visible at the time of normal inspections, and are the full resp°nsibilky ofthe con actor.
You have indicated concern that Budding Permits B-05-254 and B-05-1311 was issued to an unlicensed contractor
who was also not properly authorized to act as agent of the homeowner. Please be advised that these permits were, in
fact, issued to Albert Brown, holder of Constnxxion Supervisor License CS065525, and that Ms. Carol Newman, the
homeowner, signed both applications authorizing Mr. Brown as her aged
Thank you for notifying us, as per 780 CMR Section RS.2.1S.3 Notilkatlon of Violations, of the items you have
flagged As you know, since you have taken over the job at 72 Lake Road, you have now assumed full responsibility
for it. It is now incumbent on you, as the Licensed Construction Supervisor, to remedy any and all violations of
Massachusetts State Building Code. You have told us that a Structural Engineer has been mnsultod We will await an
affidavit fiom him/her that the violations have been corrected. Please contact us at that time, so that we may reinspect
the property.
Thank you.
Very truly yom.
dC- 3
Andrew L. Amauult g . +-j of jj p
Local Building Inspector
cc: Ms. Carol Newman
Town of Yarmouth Building Department
MWA
J
To: Jim Brandolini
Building Commissioner
Town of Yarmouth
From: Carol Newman and Sal Spada
72 Lake Road, West Yarmouth
1 508 778 0602
Re: 72 Lake Road - 2nd Floor Revisions
Jim,
April 25, 2005
Thank you for meeting with us on Thursday to review our plans for revisions
to our 72 Lake Road project.
Attached is the information that you indicated would be necessary to review
the changes.
One note, however. We got a little `confused' over the application of some
of the codes that we discussed and ended up getting copies of the Mass.
Code that we thought applied to this situation. We are attaching these so you
can confirm if we used the correct ones.
We have also attached:
■ A drawing of the revised second floor showing room placement
and dimensions.
■ A cross section view of the `new' third bedroom showing height
of windows from finished floor and the distance from knee wall of
the finished 5' and 7'6" ceiling heights.
■ Copies of the roof window specifications. Note that the code for
natural light specified "an exterior glazing area of not less that
8% of the floor area", but the Velux online product specs did not
include the exterior glazing area for the S06 roof window. So we
called Velux, got the additional glazing info and added it to the
attached product specification page.
Based on what we could see, it seemed that we might be ok with the
emergency egress, sloping ceiling and natural ventilation requirer nts, but
0L�(-HTM
APR 2 5 2005 D
I
the natural lighting requirement might be an issue. We couldn't tell if the
area of the room with walls less than 5 ft should be counted for the lighting.
We thank you very much for your assistance. It is our understanding that
once you have reviewed this information, you will let us know whether or
not there are any changes or additions needed. We will then have our
contractor resubmit the planned revisions, including your suggestions.
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Skylights From VELUX America Inc.
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M.
MICHELE C. TUDOR, P.E.
Consulting Structural Engineer
123 Cottonwood lane - Centerville, Massachusetts 02632-1979 - (508) 771-7601 - Fax (508) 771-7163
mmctudor@comcast.net
July 14, 2005
Town of Yarmouth
Building Dept.
1146 Route 28
So. Yarmouth, MA 02664
Attention: Mr. James Brandoturi
Building Commissioner
RE: Newman Residence, Yarmouth, MA
Dear Mr. Brandolim,
Please be advised that the above captioned project has been inspected on June 10, 2005 and again on July 07, and
verified by telcoorn w/ the contractor this date to review repairs completed.
This office has inspected all structural components for structural integrity and safety, and finds them adequate, as
amended.
I trust that the above addresses your needs at the present time. Should you have any question on any of the above,
please do not hesitate to call.
/$I
• MicbCIO
C. Tudor, .E.
12005-99 ✓tnm
cc: D. Williams
SO, 3477 ��
S'�µVcTu .01
Doug Williams Custom Building Co.
P.O. Box 1069 Centerville, Massachusetts 02632-1069
508-775-1500 866-524-0070 fax 508-775-1503
www.capecodhomebuilder.com
e-mail homebuilda(@comcast.net
Town of Yarmouth
Building Commissioner
November 13, 2005
Commissioner,
At this time I am canceling the permit on 72 lake Road, permit # B-05-1448.
The owner will be transferring the permit.
Respectfully,
Douglas L. Williams Sr.
7004 1160 0006 1240 5791
NOV 1 5 2005 �i
r TOWN OF YARMOUTH Building Department BUILDING
, • , , , , , , , • (508) 398.2231 ext.261
PERMIT NO 6i . fag$, PERMIT
...:... ..........
ISSUE DATE 6/9/2005, , : PROPOSED USE
APPLICANT .Douglas Williams ...Sr... JOB WEATHER CARD
jdisclpermittranslef
PERMIT TO
AT (LOCATION) 100072LAKE RD r: ZONING DISTRIIC R-25 Bldg. Type: Residential "
SUBDIVISION MAP LOT BLOCK 1049.234
LOT SIZE O
BUILDING IS TO BE: CONST TYPE1 5•B I USE GROUPS R-4
permit transfer -change of contractor - refer to Building Permit # B-05-254 & B-05-1311
REMARKS
AREA (SO FT) EST COST ($ $0.00 PERMIT FEE ($) $50.00
OWNER ICAROL R NEWMAN _ BUILDING DEPT BY
ADDRESS 100072 LAKE RD
South Yarmouth MA 02684
YOUR SPECIAL ATTENTION Is called to the following:
CONTRACTOR
LICENSE 016981
Williams, Douglas Sr.
POB 1069
Centerville MA 02632
5087751500
This permit is granted on the express condition that the said construction shall, in all respects, conform to the Ordinances of this
Jurisdiction Including the Zoning Ordinance, regulating the construction and use of buildings, and may be revoked at any time upon
violation of any provisions of said ordinances.
Weatherproof placard given at the time permit is Issued must be displayed on premises. The Department must be notified and inspection made of prior
construction work as requested on weather card.. All new buildings and additions and alterations to existing buildings require a minimum of three called
Inspection, namely, 1) Footings, drain We systems, foundation and basement walls, when walls are at least two feet high, but before back fillings the `
wall and before proceeding with the superstructures. 2) Framing prior to lath or finish covering but after firestopping, electrical, plumbing and
mechanical systems are Installed. 3) Final Inspection when building or structure is completed.
On Jobs Involving reinforced concrete work, Inspection must be made after steel is in place and before concrete is poured.
The Department reserves the right to reject any work which has been concealed or completed without first having been Inspected and approved
by the Department In accordance with the requirements of the various codes.
Any deviation from the approved plans must be authorized by the approval of revised plans subject to the same procedure established for the
examination of the original plans. An additional permit fee is also charged predicated on the extent of the variation from the original plans.
Permits are not valid If construction work is not started within six months from date permit is Issued.
Request for Final Inspection should be made by postcard or phone call to this department when the construction work is completed and heating
apparatus has been Installed. Painting or decorating is riot required before the Final Building Inspection.
Final Inspection and certificate of occupancy must be obtained before occupying buiding.
APPLICANT COPY
open), Location: 72 LAKE RD AfAP ID: 49/ 234/ / /
Lam m! 7539 Other ID: 43/ N153/ / / Bldg #: 1 Card 1 of 1 Print Date: 11/26/200310.
CURRENTOWNER
T PO
UTILITIES
STRT✓ROAD
I LOCATION
URRENTASSESSMENT
MA AN CAROL
DORCHESTER STREET
ULYCY, NIA 02171
Descrintion
Code
Appraised 6alue
Assessed falue
815
YARMOUTH,
US LAND
tESIDNTL
IESIDNTL
1013
1013
1013
243,300
95,400
300
243,300
95,400
300
SUPPLEMENTAL DATA
Account 8 0782300
Subdivision 220
Ward
Irminct
71SID:
"SI
Total
339A00
3397000
RECORD OF OWNERSHIP
BK-VOLIPA
L DATE
alu
v171SALEPRICE
VC.
PREPFOUSA
E ME
I T
R
MAJAN CAROL
0
YrlCode
Ass ss Yalu
li
Code
Assessed Value
Yr.
Code
Assessed
2003
2003
1003
1013
1013
lO1J
66,200
59,400
300
002
002
002
1013
1013
1013
66,200
61,900
300
001
001
001
1013
1013
1013
f
125000,
Total,
129,400
Totat.
EXEMP77ONS
OTHER
ASSES AIE
This signature acknowledges a visit by a Data Collector or Ass
Year
71telDescription
Amount
Code
Description
Number
Amount
Comm. Int.
APPRAISED VALUESUAIMARY
Appraised Bldg. Value (Card)
Appraised XF (B) Value (Bldg)
Appraised OB (L) Value (Bldg,)
Appraised Land Value (Bldg)
Special Land Value
Total Appraised Card Value
Total Appraised Parcel Value
Valuation Method:
%
CostAlarliet Vf
ra
ON LAKE NOTES
0220
et Total Appraised Parcel Value
BUILDINGPERMITRE ORD
ITICHANGEHIS
RY
PermitlD
Issue Date
71ye
Des r tion
Amount
Insp, Date
% Como.
I Date Comp.
Comments
Date
ID Cd
PurposelResi
815/02
5113194
SS
RD
00
01
Neasurr Listed
leasur*1Vlsit
LAND
LINE VALUATION SECTION
t «
Use Code
Description
Zone
D
[Frontare I
Depth
Uni s
nit Pric
/ Farfor
S.1
F for
bad,
dilSpecialPritrine
Adj. Unit Price
land Y
1
1013
5FR WATER
8,712.00
SF
8.84
1.15
4
2.50
0044
1.10 POND
FRNT
27.93
Total Card Land Unity
3,712.00
SF
Parcel Total La» d Area
8,712 SF
Total Land Vela
operry Location: 72 LAKE RD
7slon LD: 7539
31AP ID: 49/ 234/ / /
Other lD: 43/ N1531 / /
#. 1 Card 1
1 Print Date. 11/261200310
odel
1
esidentdal
cat &AC
ride
3
4verage
rameType
aths/Plumbing
tones
I Story
xvpancy
0
iling(Wall
loonmTrms
xterior Wall 1
4
Wood Shingle
Ke Common Wall
2
Wall Height
' )OfStructure
3
able/liip
)of Cover
3
ksphfFGWCmp
CONDO/MOBILE HOME DATA
terior Wall 1
5
ryMa /Sheet
Iement
Code
Description
Factor
2
nterior Floor 1
14
arpetomplex
Floor Adj
2
nit Location
eating Fuel
4
lectrie
umber oflhuts
eating Type
7
lectr Basebrd
umber of Levels
CType
1
one
/90%mcrship
edtooma
3
Bedrooms
VA L U4 TION
athrooms
I
Bathroom
nadj. Base Rate
100.00
'O
Rooms
ize Adj. Factor
1.11974
nude (Q) index
093
ath Type
itchen Style
j. Base Rate
104.14
Bldg. Value New
130.279
Year Built
1970
ff Year Built
1974
rml Physcl Dep
nn 0bbs�
m
Sped. Conti Cade
pecl Cond %
28
0
MIXED
E
1013
SFRWATER
100
Overall % Cond.
72
Bldg Value
93.800
OB-OUTBUILDING & YARD ITEMS L IXF-BUILDING EXTRA FEATURES B
Code
Des Ilon
I/B
Units I
Unitprice
Ye
RI I
5l.Cnd
A r. falue
FPLI
FIREPLACE 1 ST
B
1
2,200.00
1974
1
100
1,600
PATIPATIO-AVG
L
140
250
1994
1
100
300
BUILD
SUB -AREA
SMMARYSE
ON
ode
8 Descr n
Ltvinr Area I
GrossArea
. E Are
Unit Cost
Unde r c Value
BAS
Irat Floor
947
947
947
104.14
98.621
FGR
arage
0
440
176
41.66
18329
FOP
orch, Open, Flatsbed
0
39
8
2136
833
UBM
asement, Unfinished
0
600
120
2013
12,497
FGR
SAS
BAS
UBM
LOON
N%
TOWN OF YARMOUTH ZONING
ZONE
R-25
SETBACKS
FRONT -
30'
SIDE -
15'
REAR -
20'
50•E
)0
___
2 2004
L-OCT
{
ci
J
i
I HEREBY CERTIFY THAT
THE DWELLING DEPICTED ON THIS
PLAN WAS LOCATED ON THE GROUND
BY SURVEY ON OCT. 20. 2004
AND EXISTS AS SHOWN AS OF THE
DATE OF LOCATION.
THIS PLAN IS FOR PLOT PLAN
PURPOSES ONLY AND NOT FOR
RECORDING. DEED DESCRIPTIONS
OR ESTABLISHING PROPERTY LINES.
TOP FOUNDATION 12.36
M
;n ROAD HIGH POINT 8.8
M
ABOVE HIGH POINT 3.56
of ozwo
TO THE BEST OF MY PROFESSIONAL KNOWLEDGE
INFORMATION AND BELIEF THE DWELLING SHOWN
HEREON CONFORMS TO THE HORIZONTAL SETBACKS
OF THE ZONING BY-LAW FOR THE R-25 DISTRICT.
C r
y ., tiu•'°��� PLOT PLAN
F�'S1Ea�° IN
SCALE: 1'-40' OCT. 21. 2004
EAGLE SURVEYING, INC
0^3 Raut. ar
qpkyo
mmuthpert. MA. 02875
(s00) 342-8+32
(e00) 432-6333
THIS PLAN IS VOID IF NOT
STAMPED AND SIGNED IN RED
7z
asy
0 20 40 80 PROJECT NO. 02-052
OFFICE MEETING NOTES
ADDRESS: DATE:�—
Names of Attendees:
Zoning District:
Flood Zone:
c
Meeting Topic:
OFFICE MEETING NOTES
ADDRESS: % �7 ? _ DATE: /_ a G _ c.3
Names of Attendees:
Zoning District:
Flood Zone:
Meeting Topic: _v�g�
2
sr —
30 -)0
LAMPIMN,Mqw--
/ 2 v� S?-,Pw�
lov
r7-
\/ - 14.7
TANK . Vc, CRUSHED STONE OR'"
COMPACTED BASE
n
L v ' 00 CB/DH FAO 'j TOTAL LOT AREA
CB/OH FNC - •��. SO' pR11i /
Bw RR stIXE g6 $togy y 9Y AREA ABO ✓E WET
IN UP �21// /� 7a•±Cl. r� •- "CFSSPOOL .'L�1��0 p.L
EL•B.OD Ak;Vp . 88/fjl{` N 0/. p1f EXISTING AND PROPOSED at
E G
6 d a 1 2I.Br OF AREA ABOVE R't
AD
40 MIL -PCI.r�. ' l '•' L: 1 -i t `'0' - \ -_ \ -
VAPOR BARRIER i "'..l.. L •y
SOIL REWYAL D go/'�.` = �
SEE NOTE 10. \ LO A500 Cc Tri4K
t
0
1 ''•l: � :,'fin A 1P. <�a\\ 1 . >
Ell
ul
HATER LIME- I} }r '�'..: _ pKt N
A
COASTAL
b., � •.. .; �_� r, Boa _ ,- -.� � _ = __
T.7 Ait�N ' 11t2
Cf
ILA
I4LS
EDC+E
2.2
,✓ LAKE
(TIDAL)
BE WITHIN
9' MINIMUM COVER
MIN. 2' OF
I�
Il
• ACCESS COVERS MUST
PEASTONE
6' OF FINISH GRAD
4- PERF PIPE
//
FIRST 2' TO
3/4' - 1 I/2' DfA.
10.73
BE LEVEL
DOUBLE WASHED STONE
lI
9.4 .2x
1f
D:Z;
0.6
8.7
ll
AM PIPE
s
40 MILL POLY
I�
.
0 .
4 ' SOLI D P / PE
VAPOR BARRIER
I
tAFFt
7
B
3 OUTLET 19'x
24• LEACH FIELD
A
D-BOX
4.7
0
1500 GAL
SEPTIC TANK
6' CRUSHED STONE OR
B
COMPACTED BASE
PROFILE : NOT TO SCALE
6Y RR IsP I KE
IN UP 421/I
EL-6.69 MOM-
6.
AA4A
TOTAL LOT
AREA ABOVE
AREA ABOVE
£XISTINO AND PRM
- 24.89 OF AREA Al
THE COASTAL 6ANK.
WAN LAKE
S (TIDAL)
VARIANCES REOU I RED :
TITLE 5.- MAXIMUM FEASIBLE COMPLIANCE
SECTION 15.211:11/ MINIMUM SETBACK DISTANCES
10' IS REOUIRED BETWEEN THE SAS AND THE PROPERTY LINE. 5' IS PROVIDED.
A 5• VARIANCE IS' REOUESTED.
10' IS REOUIRED BETWEEN THE SEPTIC TANK AND THE BUILDING. 6' IS PROVIDED.
A 4• VARIANCE /S REOUESTEO.
TOWN OF'YARMOUTH SUBSURFACE DISPOSAL OF SEWAGE REGULATIONS
REGULATION 3.7: DISTANCES AND LOCATION OF DISPOSAL FACILITIES
!00' IS REOUIRED BETWEEN THE EDGE OF WETLAND AND THE SAS. 75' IS PROVIDED.
A 25' VARIANCE /S REOUESTED.
opet;docatinp: 72 LAKE RD
ision ID: 7539 `
MAP ID: 49/ 234/ / /
Other ID: 43I N1531 / /
Bldg #: 1 Card 1 of 1 Prim Date: 09/257200212
CURREWOWNER
TOPO
U77LITIE4
STRTIROAD
I LOCATION
CURRENTASSESSAfENT
E1{MAN CAROL R
1 DORCHESTER STREET
UINMMA 02171
DescN tion
Code
Appraised Value
I Assessed Value
EIS
YARMOUTH,
LAND
ZESIDNTL
ZESIDNTL
1013
1013
1013
66,200
59,400
300
66,200
59AN
300
SUPPL EMENT4L DATA
Acootut # 0782300
uMvisian no
%ot
ci
LYM.
VISIC
rant
1 125,9001
125700
RECORD OF OWNERSHIP
BK-VOLIPAGE
SALEDATE
u
ail SALEPRICE
VC
PREVIOVSASSESSAfENTS
MISTOR
EWAUN CAROL R
0
Yr.
Code
Assessed Value
Yr.
Code I
Assessed Value
Yr. I
Code
Assessed i
002
002
002
1013
1013
1013
66,200
61,900
300
001
001
001
1013
1013
1013
66,200
61,900
300
000
000
000
1013
1013
1013
oral
12 400
Tofalk,
12 400
oral
EXEMPTIONS
O ER
ASSESSMENTS
This signature aek tawkdges a iisit by a Data Collector or Am
Year
TyPeDeserfrHon
Amount
Code I
Description
Number
Amount
Comm. Int,
APPRAISED VALUE SUMMARY
Appraised Bldg. Value (Card)
Appraised XF (OB (BL) Value (Bldg)
ised
Appraised Land Value (BlValue dg)
Special Land Value
Total Appraised Card Value
Total Appraised Parcel Value
Valuation Method.
CwUMarltet V
° '
ON LAKE NOTES
0220
et Total Appraised Parcel Value
BUILDING PERMIT RECORD
VISITICILINGE
HISTORY
PermirlD I
IssueDats
nre
Description
Amount
Insp. Date
% Como .
Date Como.
Comments
Date
ID
Cd.
PurposelRes
W512002
Si13/1994
SS
RD
00
01
easurFListed
easur►IVhk
LAND
LINE VAL UA 77ON SECTION
B0
Use Code
Description
Zone
D
lFronfaze
Devth
Units
I Unit Price
L Factor
S L
C. Factor
Nbad.
Adf.
Notes- AdilSpecial PrIcInx
Ad . Unit Price
Land Vc
1
1013
SFRWATER
8,712.00
SF
4.02
1.05
4
1.50
0044
1.20 POND
FRNT
7.60
Tonal Card Land Units
8.712.00
1 SF
Parcel Total =Area
012 SF
Total Land V
opergL"Ain: 72 LAKE RD
ltwon l0: 7539
swr7
Shingle N common wall
av Heigh
Basebrd
Bedrooms
Bathroom
ALIP ID: 49/ 234/ / /
Other ID: 43/ N1531 / /
I CONDOMOBILEHOMEDATA I
f. Base Rate
60.00
Adj. Fs"
1.11974
Is (ty Index
0.93
Bae;.
ValueR N
78.162
7 Built
1970
Year Built
1974
1 Physcl Dep
26
A Obslrc
0
i Obslnc
0
1 Cand. Code
iCmd%
roll%Cond.
74
rcc. Bldg Value
57,800
0.0011974 I 11 100
2.50 1994 1 100
9471 9471 9471 6i48
0 440 176 24.99
0 39 8 12.82
0 600 120 12.50
7,493
#: 1 Card 1 of 1 Print Date 09115/200212
ttt�Writr
esr •"""�^" k.i..... s _,. ,.�-,� ,.� �+ans� 3- r aV^ '� a,
zd-
i
0000,
6rN2015 SlipGen- Portal Hone
Town of Yarmouth
Template [Building Dept]
Slipsheet Identifier [sg264741
Document Category Building Permits
Map -Block Number 049.234
Street Number
0072
Street Name
LAKE RD
Department
Building
Parcel ID
7539
Backfile Batch Scan
No
Document?
Additional Naming Info
Index Operator
Operator, Yarmscan
Date - Time
2015-06-03 - 15:09
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