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HomeMy WebLinkAboutBLD-19-001425 • • ONE & TWO FAMILY ONLY-BUILDING PERMIT VII(Town of Yarmouth Building Department -y " , P I t ( • • 1146 Route 28,South Yarmouth,MA 02664 4492 � ! 508-398-2231 ext. 1261 Fax 508-398-0836 �L1'+ ■ 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 D Building Permit NumbeDate Applied E C E �� E Number. 732,7)-4/9-0-0,423 . ClaiS-1 CI • b' SQAr3 ..• . Z 4 .. 9_.lo_IS.. SFP. 0-4 2018 ButldngOfficial(PrintName) . Signature.. .: t. . •• SECTION 1:Sag SORMATION • . BUILDING UEPAH1 MENT 1.1 Property Address: �1.2 Assessors Map&Parcel Numbers G.- . It ._ t . .rm4, / ✓ 1.1a Is this an accepted street?yes�-- no Map Number Parcel Number 13 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacla(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private CI — Outside Flood Zone? Municipal❑ On site disposal system ❑ ' Check if yes❑ ' . •SECTION 2i PROPERTY OWNERSHIP[ • ' 2.1 Own'err of Record: S,n-L-q 1"4 I kr C3c1 HI Ci rmcwih IY)a. Cha 6 6 te • /Name(Print) City,State,ZW 6...v...- 3 Rr4,n)-t.vcxt.f hr • 502760 ,3,2;(7 tactricccol5111 6DgmctA tefihn No, and Street Telephone Email Address SECTION,3:.DESCRIPTION OF pRQPOSEii W)RIC(check all that apply) New Construction Cl I Existing Butldinbil Owner-Occupied y Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition 'Ta I Accessory Bldg.❑ Number of Units_ I Other ❑ Specify. Brief DesuiiptionofProposed Work2: I4cehg CQama4acRSItdet— door ('lack -enlranco hep lin n dnrnn5eol Pro>•t ocrtWt >xivW AA4es1 va ttoa % tit jrCJnceIc cry. Stria r,F rapm VLt fete in part.e. liins / hoc r4 With St•1vc4• \rcc %< wild1t1Shin\-lcvi t P 11.2.-04..r.�. el/ lie t4, J47 6 .. SECTION4::EST 1ATEDCONSTRVCITONCOSTS. • • 'Lo f Item Estimated Costs: (Labor and Materials) •';,-,•',....•.:,•„...1,-1-1 a Only'•:. 1.Building $ I ��� , ev :1:BmldiasPeilrtFee-$�(7. Indicate how feeisdetermined: 2.Electrical $ Standard cityrtimit Application Fee: 3.Plumbing ❑.TotalProject Cost'(Item6)xsul#Iier... : • x $ 2: Other.Fees: 5 . 3s--.?.. ..:...:.7-7-. . 4.Mechanical (HVAC) $ List ' 5.Mechanical. (Fire Suppression) Tbta1 All Faes:$ •ClieckN6:.' . Check Amount Cash.Amoua ' tv 6.Total Project Cost: $ /c 5"Go" e0 bPaid-mPufl • Outstanding I Balance Dae: • SE r s. :.CONSTRUCTION SERVICES . 5.1 Construction Supervisor Lice• _ • License Number Expiration Date Name of CSL Holder List CSL Type(see below) No.and Street Type . .. Description U Unrestricted(Buildings up to 35,000 cu.ft) City/Town,State,ZIP R Restricted I ea Family Dwelling NI Masonry RC Roofing Covering • WS wnAn,vanAccdinv-- I Telephone Email address D ` 52 Registered Home Improvement Contracto (BIC) 771) Q©g 610 / BIC Company Name or HIC Registrant Name S 771/ p( No.and Street - br MG eiue$I)ib ®' s J ' City/Town,State,Zte Telephone SECTION 6:WORKERS' COMPENSATION INSURANCE AF' ad 1 1 i.7 !widen ide Workers Compensation Insurance affidavit must be completed and submitte �v/ n this affidavit will result in the denial of the Issuance of the building permit Signed Affidavit Attached? Yes ❑ No 0 SECTION 7a:OWNER AU illORIZATION TO BE OWNER'S AGENT OR CONTRACTOR APPLIES F� I,as Owner of the subject property,hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application • Print Owner's Name(Electronic Sigaatte) Date • • SECTION7b: OWNER'.ORAU'1HORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. ✓ .eta-y q/y II$ Print Owner's or Authorized Agent's Name(Electronic Signature) Date ' NOTES: • I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(BIC)Program),will not have access to the arbitration program or guaranty fiord under M.G.L.c. 142A Other important information on the TEC Program can be found at www.mass.aov/oca Information on the Construction Supervisor License can be found at www,mass.eov/dos 2. When substmtial work is planned,provide the information below: Total floor area(sq.ft) (including garage,finished basement/attics,decks or porch) Gross living area(sq.R) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost' �,_ --r•-•••••c••• Lej iru.u.saruasracaeuenrS •• r = rte_ ( I Congress Street,Suite 100 • • 11.• 3be Boston, M4 02114-2017 • %Cato* • www.mass.g,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): Sgndrca M r ()0r Address: 3 reniu hili C)y • S1-11 Vet rvnoifh tyle( t/ �4 City/State/Zip: Sr c._141 Lick rmet nil nig Phone #: 5°3 '7 &o Are you an employer?Check the appropriate box: Type of project(required): • l.❑I am a employer with employees(full and/or part-time).* 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] 8. Remodeling 1,./ 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required]: 9.1Z Demolition ✓ 4.2'1 am a homeowner and will be hiring contractor to conduct all work on my property. I will 10 0 Building addition ensure that all contractors either have worker'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 5.0 I am a general contractor and I have hired the sub-contactors listed on the attached sheet 12.0 Plumbing repairs or additions These sub-contractor have employees and have workers'comp.insurance) 13. Roof repairs 6.0 We are a corporation and its officers have exercised theirright of exemption per MOL c. 14.Q Other 152,§I(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checlm box SI 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. :Contractor that check this box must attached an additional sheet showing the name at the sub-contractor and state whether or not those entities have employees. If the subcontractors have employees,they must provide their worker'comp.policy number. Iam an 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. 152,§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 certtfy under the pains and penalties of perjury that the information provided above is true and correct Signature �nr��g� u. jai) Date: 9/Wig Phone ft: 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' -"K .L V ►7 11 WS' 1 C11tJ LVJACl 111 �� BUILDING DEPARTMENT ? 1146 Route 28, South Yarmouth,MA 02664 508-398-2231 ext. 1261 . .a C- • • HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DATE: c IJ JOB LOCATION' n4rca f ii il-QY 3!Be-en-)-u,nac Dr ovTrl VI GVYnei knii (Yl c` NAME , STREET ADDRESS SEel ON OF TOWN "HOMEOWNER" Sandra ' lkY 3(3 rcn+ fl r • So -7)/ 1800 r a5 a.'l q NAME HOME PHONE WORK PHONE PRESENT MAII,ING ADDRESS 3 8 nod(t_)a t I7r Sim-tip army ct+t+ Mot , 1 Ma cc Colav 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 110 R5.1.3.1) 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 110 R5.1.3.1) 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 _c, APPROVAL OF BUILDING OFFICIAL INSURANCE C• • RAGE: I have a c �ty insurance policy or its substantial equivalent, which meets the requirements of MGL Ch.142. No If you have ch ves, 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 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:homeownrlicexemp • • - iu.tui utauuit amu Ins truenons •�• Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. • Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, .express or implied,oral or written." An employer 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 owner 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." MOL chapter 152,§25C(6)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,MOL chapter 152, §25C(7)states"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 have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit 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 Accident. 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. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials 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. In addition,an applicant that must submit multiple permit/License applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit The Department's address,telephone and fax number: • The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. r 617-7274900 ext. 7406 or 1-377-NLASSAFE Fax r 617-727-7749 Revised 02-23-15 w w.mass.gov/dia K-= - c BUILDING DEPARTMENT • F -ai 4y 1146 Route 28,South Yarmouth,MA 02664 508-398-2231 ext.1261 Fax 508-398-0836 • • BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT. Pursuant to MEL 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 3 nio- c ri I•)r Scxt'' \(Qcr Y1C-)V I'\ f\ . Work Address Is to be disposed of at the following location: 10-011 tJ-C y'ct y Y}1av bsposa Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. 4114 IF Signature of Application Date Permit No. ; . , ; : ? ; I ; ' I —.' , I I i I 1 i .m , ,I ; I ; , 1 I r. ,1 • ' . ; ; ; , . , 1 ) • I ; ; } 1 I --1 1 TOWN OF YAriMOUTH r 1 1 tlq ' I II I I I 1 • .; : 4 , I REVIEWED FOR 131.11t,DING AND ZOINING CODE COMPLI- ; I 1 1 :ANCE; ERRORS OR OMMISSIONS DO NOT RELIEVE THE i HI 1 %.,3--• Or' :APPLICANT FROM THE RESPONSIBILITY F'AS ear , 4-1S :COMPLIANCE i I I , , I I 1 kil I , , • IDATE.:q-10-isi i 1 1 1 . I ' .1._ !BUILDING FICIAL 31kt "„...1 -;; ._ I : t 1 r ,1 ILE CO FPY , • itvichou I , . . . ; - , : at/ frert , i . . 1 , . 1 I , i , 1 ; . • -.• .• i _,p,:.• -k-wo slat u-dit}deloGis 1 .f i• _ I I 1 , i , 1 , ,-,- , i 1 , . ! i . , , , , I 1 . • . . . , . • i . I 1 1 ' 5 I lei 1 a 1 . 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