HomeMy WebLinkAbout2016 - Certified As-Built Plan and Building Permit ti0 s � t/j
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ONE & TW4 FAMILY ONLY-BUiLDING PERMIT
Town of Ysrmouth$niiding Department a
`p 1146 Route 28,South Yarmouth,MA.02664-4492 � �
� SO&398-2231 ext. 1261 Fax 548•398-0836
� � Massachusetts State Building Code,780 CMR
Building Permit Application To Construct,Repair,Renovate Or Demolish
CC c,� a One-or TwaFamily 13welling
� W
-� ti..
..~.1 Z T�}l3 S�IOA FOT Off1C18I USC(�I
m � Buitdiag Petmii Ntunber: L -/li- Date Applied:
�t
Q Lt� �I l� SQA'�S ✓�i�� ,��6��6
� W Bnilding Official(print Name) Signaturz ��
W � SECTION 1:SITE INFORMATTON
t`r.. O
, � W 1. Prnperty Address. i.2 Assessors Map&Psrcel Nambers
W co �� 5'�A-o,�� IS� W ��/
V 1.1 a 1s this an ac street? ��T Map Number Paml Number
¢ yes no___,..
1.3 Zoning Information: ---� 1.4 Property Dimens�ons: �
rs t�€hilX��- o o �' 90
Zoning District ProQosed Use Lot Area(sq R Fmntege(R)
1S Building Setbacks(tY)
Front Yard Side Yanis Rear Yard
Rcquired Pmvided Req�tited Providtd � Requlttd Pmvided '
o �3 0 1 S-' 2 4 1 Z
1.6 Water Supply:(M.G.L c.40.§54) 1.? Flood Ztane Informstion: 2.8 Sewage Disposal System:
Pubiic�9. Private D �na ✓ Outside Flood Zone? Municipal 0 On site disposal system �
Check if yes0
� sEcrroN 2: r�orEx�owrn�xs�'
� 2.i Owaer'of rd: -- �
� ���rA� +�Y�562 �.� br�-�` � X `IAoL-�o� � �. w� � ��6 �
Neme(Print) / City,S� �
�( 5'rT'J��./�(S � � ►A�/ ,�S'-`�3 7 'Y/.6 S- W�r�0�'27y C�9 ��O�Titt i/,C'o-�,-�
� No.and Strtet Talephone Email Address
-,��
�
� SECTION 3:DESCRIPTION OF PROP03ED WORK=(check a�l that apphy} '
New Construction� Existirmg Building❑ Owner-pccupied 0 Repairs(s) O Altesation(s) ❑ Additioa t7
Demofition � Accessory Bldg.O Number of Uaits Othtr O Specity: � 0�- �
Brief Description of Proposed Workz: � / 5'� �� � C K7(t 6 � t
-� �..� 0 6Z �--�_�a iP �i �� �n �ni o u /' � �'0 2
� r22seNr r� u r �
SECTION 4:ESTIMATED CONSTRUCTION CCISTS
Item Estimated Costs: O!°6eial Use Onl
r and Mataials Y
1.Building $ �— �-�t� l. Building Permit Fee:$ Iadir,ate how fee is determined:
2.Etectrical $ �v Standard CityrI'own Applicatiom Fea
L7 Total Pro;ject Cost�`(Item b)x m�rltiplier x �
3.Plnmbing $ �� 2. Other Fecs: $
4.MechanicaI {HVAC) $ d� LisG
5.Mechanical (Fire
Sv ion � Total AII Fees:�
6.Tota1 Project Cos� S J/' �`� Check No.�Check Amoutrt: Cash Am l l
0 Paid'm Fult Outstanding Bata�►ce Ihae:��„�„� � �,ta �l�
���,�1
� IO� Z
/
, _ � SECTION S: CONSTRUCTION SERVICES
S.1 Construction Supervisor License(CSL)
Lianse Numbcr Expiratiun Date
� Name of CSL Holder
List C5L Typc(see below)
� No.and Sueet Typ� Descriptia�
U Unrestsid.ed Build' to 35 000 cu.tk
� Citylfown,State,ZIP � R Restricted 1&Z Famil Dw '
M Maso
� RC Roofia Coverin
WS Window aad 5idin
SF SoJid Puel Bumfng Apptiances
I lasulation
Tcl hone Finai1 address D Demolition
{ 5.Z Registered Home Imprnvement Contractor(SICj
�
HIC Company 1Vame or HtC Registrant Name
HIC Registration Alumbu Eacpiration Date
No.and Smet — �t��
Ci lTown State ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION 1NSURANCE AFFIDAVTT(11�G.L.c.152.§25C(�)
� Workers Compensation Inswance affitiav;t musC be completed and submitted with this application. Faitnre to provide
I this affidavit will resutt in the denial of the Issuance af the bnilding ptimit.
Signed Affidavit Attached? Yes..........❑ No...........❑
� . SECTTON 7a:OWNER AITTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR C�NTRACTOR APPLIES FOR BUII.DIl�iG PERMTT
I,as Owner of the subject Pr'aP�Y�1�bY authorize
to act on iny behal�in atl tnatters relazive to work authorized by this buitd'ung permit application.
Print Owner's Name(Electronic Signature) - D�
• SEGTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
f BY entering rny aame betow,I i�ereby aaest under the pains and pena,ities of perjury that a[1 of the information
� contained in this applicatipn is tnxe aad ace ta the best lrnowle e and understanding.
� � . �-� 2g - ��
. Print Owner's utheriud Agcnt s Nawe(Elecuonic Sigaetuce} �
N
; 1• An Owner who obtains a bwilding permit to do hisfher own worlc,or an owner who haes an unregistered contiactor
; (noc registered in the�Iome Improvement Contractor(H1C)1'rogram),will not have access m the arbitration
� P�B��'g�ty fond under M.G.L.c. t4ZA.Other important information on the HIC Program can be found at
vt�ww.mass.gQv/�Iaformation on the Consiruction Supervisor License can be found ai www.mass.eov/dos
2. When substantial work is plann d, vide the in,formation below:
i Total floor area(sq.R.) �..r..(it►cludin8 garago,finished basementlattics,decks or porct�)
� Gross living area(sq,ft,)� Habitable room count l
; Number of fireplaces� (�rt ' Number of bedrooms ��
j Number of bathi-ooms Number of half/baths
1 Type of heating system Number of decks/porches � �
; Type of cooling system_ 9 Enclosed � Open��
� 3. "Total Preject Square Footage"may bc substituted for�"fotal Project Cost" '
i
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