HomeMy WebLinkAboutBLD-19-001045 •
•" ,r ONE &TWO FAMILY ONLY-BUILDING PERMIT /a��
L Town of Yarmouth Building Department o r
1146 Route 28, South Yarmouth,MA 02664 4492
- 508-398-2231 ext. 1261 Fax 508-398-0836 L.
Massachusetts State Building Code,780 CMR
Building Permit Application To Construct,Repair, Renovate Or Demolish _;
a One-or Two-Family Dwelling _ '
This Section For Official Use Only R 5 (, 1- ,u_—_i I
Building Permit Number /9' 5 ,'t7 • Date A d:
@lri:z.0 i_5,,
Building Official(Print Name) • • Si•gnature' • , .. C i ; •iipt!at- ' t" =T
• • .SECTION 1:SITE INFORiMATION • • ev __ ,
1.1 Proper�try dress: r 1.2 Assessors a &Parcel Numbers /
7 Lo„,/btrwe- eElh , °20(
1.1a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq S) Frontage(ft)
•
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Nater Supply: (MG.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ •
Check if yes❑
. ' . • SECTION2C PROPERTY OWNERSHIP'
2.1 Owner'of Recor �f �( �•
fa Mout Re rtppip'- /wr/kc kill, AO-i-S', of et7 3 '
amet) C:ty,State,ZIP
7 6t Pin soB=ar7—o8e0-
No.and Street Telephone Email Address
SECTION 3:.DESCRD?TION OF 1?RQPOSED?flak'(check all that apply) • -'
New Construction❑ Existing BuildmL9
g j Owner-Occupied C31:1Repairs(s) Alteration(s) ❑ I Addition
Demolition L9/ Accessory Bldg.C Number of Units ( I Other ❑ Specify. /
Brief Des�on of Proosed Wore: rps-jett�ociea,v£tanw�v7e t.J(S ThewN
• . SECTION 4i ESTi SATED CONS'1.RUCTION COSTS.
Estimated Costs:
(Labor and Materials) _
Item • • Ofnual'7se Oi ly
,`,.
I.Building S � dp0, on :i ..BmldingPeiraitFee-SIcO. IndicatehOwfeaisdeterwned:
2.Electrical S i)-06,00 •%Standard City/TgwnApphcationEe:; , ' - .
❑Total Projebt Cost Item 6J x multiplier... • . s_T
3.Plumbing $ ?, Other Fees: S 3S
I ist :. : .. ....:. .. ,. .. . . .
4;Mechanical (HVAC) 5 ,
5.Mechanical (Fire ?.:;.:.. . .
$
Suppression) Total AIl Fe'e's:$
CheckNa:.• • Check Amount Cat Anoint '
6.Total Project Cost: S /3100, 00 ppaidinPull . . ' !OirtstandingBalanceDue: I��—
SECTION 5:.CONSTRUCTION SERVICES
'�• 5.1 Construction Supervisor License(CSL) CS-o73
O
F R�7& ( . a7( License Number on Date
..4 Name of QSLyyHolder
T
• 'It Sotail eepf( LRa e..
List CSL Type(see below)
No.andStreet
/ � Type , .. Description
•
( .e1�'i ec- /L t/ f/7` cz s. o TAY U Unrestricted(Buildings up to 35,000 cu.R) .
R Restricted I°u2 Family Dwelling
City/Town State,ZIP
M Masonry
RC Roofing Covering
WS Window and Siding
Sob-737—6So ro o SF Solid Fuel Burning Appliances
7 JG x f'�p t-0,. r ,77. �e7 I J Imitation
Telephone Email address D I Demolition
, 5.2 Registered Home Improvement Contractor(BIC) /3,3�'S
it iyyy eJaX HIC Registration Number x 'on Date
4IC+p y NorB ttantName
PT S)eu:Th eme (.a,�C rTg C0 X l Y� co ne7
No.and�s,�'xH 1/ el Email address .
es" e Mars' 0034- ,S '-7374So7
City/Town,State,2113 Telephone
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(IYLG.L.c.152.§ 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 TV No...........0
SECTION 7a:OWNER AU LUORIZATION TO BE COMPLE LED WHEN
' • OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PER ET ..
I,as Owner of the subject property,hereby authorize /C b7 er Coy
epct on my be al f in all matters relative to work authorized-43y this building permit application.
Mad ' rf Yank— 1-/7 //�
Print Owner's Name(Electronic Si_ rime) Date
• ' 'SECTION 7b: O WNER1 OR AU thiORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is tree and accurate to the best of my knowledge and understanding.
Roy er' Cox
Print 04)ner's or Authorized Agent's Name(Electronic Simattue) ate
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contactor
(not registered in the Home Improvement Contractor(MC)Program),will not have access to the arbitration
program or guaranty fond under M.G.L.c. 142A.Other important information on the RIC Program can be found at
wwwmass.sov/oca Information on the Construction Supervisor License can be found at www.mass.aov/des
2. When substantial work is ' 'used, .rovide the information below:
Total floor area(sq.f) cr. ", (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft) I Frbitable room count 6
Nnmher of fireplaces Number of bedrooms 3
Number of bathrooms / Number ofhalfbaths
Type of heating system E rcaA.(`a;r 6Vg y y Number of decks/porches I
Type of cooling systeml'ei.?,/v T Enclosed Open J
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
_ t= epartinent o IndustrialAccidents
• •' rr • 1 Congress Street,Suite 100
`! E+:1_f= Boston,MA 02119-2017
�"".+�...0 www.rrrass.o ov/dia '
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): M2J et-- Cl 0(
Address: 1? Sdu�i egs7 Leta e--
J •
City/State/Zip:Ce,/tetoilk /l«, e24,201..._ Phone #: So8-737-6 So)
Are you an employer?Cheek the appropriate box:
Type of project(required):
t.9I am a employer with employees(full and/or part-time).*
7. 0 New construction
2.4Z I am a sole proprietor or partnership and have no employees working for me in
any capacity.[No workers'comp.insurance required.] 8. �Remadeling
LE lam a homeowner doing all work myself[No workers'comp.insurance required.]t 9. ❑ Demolition
4.0 I anta homeowner and will he hiring contractors to conduct all work on my property. I vnll 10 0 Building addition
ensure that all contacton either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
IQ I am a general contactor and I have hired the sub-cortacton listed on the attached sheet 1312.D Plumbing repairs or additions
These sub-contractors have employees and have workers'comp.insurance.. 13.❑Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL e. 14.0 mer
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checla box#I must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
.Contractors that check this box must ar'ached an additional sheet showing the name Of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'camp.policy number.
I am at employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. I52, §25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby cer ' under the ains and penalties of perjury that the information provided above is true and correct
Signature: /e{J Date: 9/a2O,(8-
Phone#: So —p3)---e50'
Official use only. Do not write in this area, to be completed by city or town officiaL
•
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2, Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
}o ' 2,,r; viii U 111
o ,Q_y •
BUILDING DEPARTMENT
,<<24' 1146 Route 28,South Yarmouth,MA 02664 SO8-398-2231 ext 1261
•
HOMEOWNER LICENSE EXEMPTION •
PLEASE PRINT:
•
DATE:
JOB LOCATION:
NAME STREET ADDRESS SECTION OF TOWN
"HOMEOWNER"
NAME HOME PHONE WORK PHONE
PRESENT G ADDRESS •
CITY TOWN STATE ZIP CODE
The current exemption fo 'Homeowner' was extended to include owner—occupied dwellines 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 supe isor. (State Building Code Section 110 R5.1.3.1)
Definition of Homeowner:
Person(s)who owns a parcel of Ian. .n which he/she resides or intends to reside,on which there is or is intended to
be, a one or two family attached or der hed structure assessory to such use and/or farm structures. A person who
constructs more than one home in a two- ear period shall not be considered a homeowner,such"homeowner"shall
submit to the building official,on a form.•ceptable to the building official,that he/she shall be responsible for all
such work performed under the building. pe 4.'t. (Section 110 R5.1.3.1)
The undersigned 'homeowner' assumes respo. •bility for compliance with the State Building Code and other
applicable codes,by-laws,rules and regulations.
The undersigned 'homeowner' certifies that he / she ..derstands the Town of Yarmouth Building Department
minimum inspection procedures and requirements and .at 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, wi:ch meets the requirements of MGL
Ch.142. Yes No
If you have checked vesplease indicate the type coverage by checking the appy,.nate box.
A liability insurance policy Other type of indemnity Bo..
OWNER'S INSURANCE WAIVER I am aware that the licensee does not have the insurance coverage requiredby
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
h:homeownracexemp
2w .y L V TV 11 'Jr
• i • € °e BUILDING DEPARTMENT
' c - - = 2 1146 Route 28,South Yarmouth,MA 02664
%so, 1 508-398-2231 ext 1261 Fax 508-398-0836
•
•
•
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
Pursuant to MGL Chapter 40,Section 54 and 780 CMR, Chapter 1, Section 1115,
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at 7 Cid-we R7-
Work
7 Work Address
Is to be disposed of at the following location: aeaetist,Qe arose? (
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
g/14//7tY IPS•oe/
Signature of Application Date
Permit No.
•
Office of Consumer Affairs&Business Regulation
I •t HOME IMPROVEMENT CONTRACTOR
ALI s . TYPE:IndMdual .
-1.W. Aenistratton Exoiratlort
08/06/2019-
_ €=:_ ;., ___
'eGER T.COk iii-s'ii•;'._ .r
5.4 cfr
ROGER T.COX
19 SOUTHEAST LANEr-}: j (�
CENTERVILLE,MA 02632 Undersecretary
•
Commonwealth of Massachusetts
®� Division oft oJRsslonat•Licensure
Bqe/6190l \icj Regulations and Standards
COnstrMlctbnt'apervisor15,
CS-073885 ^ Eyires: 03/12/2020
ROGERTCOX •.1r r tri,„
19 SOUTHEAST LANE i;,, V.,f�
CENTERVILLE MA 02362 v ir. '}V
Commissioner eh
` I
G . TOWN OF YARMOUTH
v ' , REVIEWED FOR BUILDING AND ZONING CODE COMPLI-
ANCE. ERRORS OR OMISSIONS DO NOT RELIEVE THE
6� oy APPLICANT FROM THE RESPONSIBILITY OF'AS BUILT'
)/ b
° 3/
De COMPLIANCE,
1�p0 , � . DATE______ - 4
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