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Home My WebLink AboutBLD-19-1694 r . ONE & TWO FAMILY ONLY-BUILDING PERMIT �Zb�I� Town of Yarmouth Building Department •of' �il ''r 1146 Route 28, South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508-398-0836 ',ilk� Massachusetts State Building Code,780 CMR / r e D L Building Permit Application To Construct,Repair,Renovate Or Demolish Sq.„--...A, � f— eY� : a One-or Two-Family Dwelling i S SEP 26 70 8 This Section For Official Use Only Building Permit Number: R/A - /91:6/49q Date Applied: • PtiiLDINGDEPAR-HENT By i-A6-18 Building Official(Print Name) Signature, Date SECTION 1:SITE INFORMATION • • 1.1 Property Address: n 1.2 Assessors Map&Parcel Numbers I12 w: mslu_1MegR4Iwi . `f 9 1.1a Is this an accepted street?yes JD no • Map Number / Parcel Number's 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.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❑ • SECTION 2( PROPERTY OWNERSIDPr • 2.1 Owner'of Record: 'its: t►+ Ian►a Kl;o1fi lAcio. lcavs ik\ks i MSI o2695 Name(Print) City,State,ZIP 6I p•-•6 avt-c4, D2. ') 19 -238 -6972 No.and Street Telephone Email Address . SECTION 3:.DESCRIPTION OF PROPOSED WORK'(check all that apply) .. • . New Construction❑ Existing Building Owner-Occupied ❑ I Repairs(s4 Alteration(sag Addition ❑ Demolition ❑ Accessory Bldg.0 Number of Units_" Other ❑ Specify: Brief Description ' of Proposed Work : ?. pie J S \D a w% P P �� Vl'l ft �1 �� 4 I o ' 1 .14•c,Inat- , RECEIVE D . . SECTION tESTIMATED CONSTRUCTIONC S S..SEP.-.�:9:.ZU10 . Estimated Costs: Item Offiel -Pi_?'r ` DEPARTMENT (Labor and Materials) _,•:•:`�'. - '• . 1.Building $ - O 0 0t t.1.:Building Permit Fee:8151 °'In e ti,hew frt..,s ckt��.,,iiied: 2.Electrical $ t ,r..D11 Standard CityfrownApplication$ee , :,• ..-'. v,� ❑Total Project Cost:(Iteyax multiplier... ; : x 3.Plumbing $ 2,,Coo 2: Other Fees: S • ,- 5 • 4.Mechanical (HVAC) $ List ' 5.Mechanical (Fire Suppression) $ Total All Fabs:$ ass •CheckN°'. • • Check Amount: CashAmotmt: • ' 6.Total Project Cost: $ 8pa C1 paidinFull . IS OittstandingBalance Due: IIS r ' SECTION 5: CONSTRUCTION SERVICES // 5.1 Construction Supervisor License(C L) CS-0 33 3(O g W �� to �p��1 �R�17VQ .Y License Number Expiration Date Name of CSL Holder ,,p 1 On� �T 1 r )1,Fr List CSL Type(see below) v` No,and Street KJ � ��1T( ; Type Description .;?Lt.--1440/7A, rb N o u, /S U Unrestricted(Buildings up to 35,000 cu.ft) City/Town,State,ZIP R Restricted 13c2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances So$ 3E9 odµL 114 l4IIp1M eg/414d'CeM I Insulation Telephone Email address I D Demolition 5.2 Registered Home Improvement Contractor CHIC) t "l 1 C lc , S -be"gob �,,ekt�h.r HIC Registrati7on Number E piration Date RIC Company Name orlIW�IICRegistrant Name fool W Y, 'wnov h `2-d t-c k.,►le►tiw rt-C� Annit ,C444 Nonan Street 4 i rt ,'V4 oh 7S sok 4Lbit' E laddre CiTy own,State,zIp Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AB'PlJAVIT(M.G.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 0 No ❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN • OWNER'S AGENT OR CONTRACTOR APPLIES FOR JBUILDING`` PERMIT I,as Owner of the subject property,hereby authorize ra4. C1 tie..pa to act on my behalf;in all matters relative to work authorized by this building permit application. gh9tecf Print Owner's Name(ElectronicSignature) Date SECTION 7b:OWNER'.OR AUTHORIZED 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. 9/! i&' Print Owner's or Authorized Agent's Name(Electronic Signature) Date • NOTES: 1. 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(MC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) 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" The Commonwealth of Massachusetts 1-c4n11=17 Department of Industrial Accidents Street,Suite = �- 1 Boston,rs MA 02119-2017 00 v4 www.mass.gov/dia vol Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMII I'NG AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): V..0\04..i-k- k2. t .k1 j Address: 1 00-1 w alk Y-ArtWla L 1ti 12-0A d City/State/Zip: y Q Mo✓t `�o I NA 026 7SPhone #: cos I 9 00# 2 Are you an employer?Check the appropriate box: Type of project(required): ��,�1.❑I am a employer with employees(full and/or part-time).* 7. New construction I am a sole proprietor or partnership and have no employees working for me in $, New any capacity.[No workers'comp.insurance required.] u-7 3. I am a homeowner doingall work myself. t • 9. Demolition ❑ y [No workers'comp.insurance required.] 4.0 1 am a homeowner and will be hiring contractors to conduct all work on m Y property.PY• I will 10 ❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.0 We are a corporation and its officers have exercised their right of exemption per MOL C. 14. Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] "Any applicant that checks box#1 must also fill out the section below showing theirworkers'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 attached 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'comp.policy number. l am 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. Ido hereby certify under t pains an nalties of perjury that the information provided above is true and correct Signature: '- 4 Date: 7//q// r Phone#: 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#: • • Information and Instructions 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 ajoint 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,MGL 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 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. 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. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia : .• , }°t'YA-k. . TOWN OF YARMOUTH o ; cvg y BUILDING DEPARTIIIENT f t $ 1146 Route 28,South Yarmouth,bIA 02664 ts3 ;? 508-398-2231 ext. 1261 Fax 508-398-0836 BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G.L. Chapter 40,Section 54 and 780 CMR, Chapter 1, Section I 11.5, I hereby certify that the debris resulting from the proposed work/demolition to be conducted at t i t ki; ,-Js (o w Cctud 21, Work Address Is to be disposed of at the following location: VA �-Vitt t)ek.fr `7„vvt T Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter l 11, Section 150A. Alf glidin A L mimetAlt. / f/ c� Si attire of Applicati ate / Permit No. 1.UIn1eWn Wed1111 UI WIda JlllUICUS . Finzweneveagf'ildg¢vdeze e/.4 1®J Division of Professional Licensure Office of Consumer Affairs&Business Regulation - Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR ' Constristt6d'tlpervisor TVIE:IndiAduai •e•I r. tort fimiratiort GS-033388 Ejs fires: 06/11/2020 r a - _� 05/06/2020 tl ' it ROBERTKEL W" - S �l'•'1' L ROBERT F KELLEHER17 rJ • � WI r1007 W.YARM UTH RDv; i,•� y ^ 7.4 PORT MA 02676 �� ROBERT F.KELL - '/�: \2.ClQ -- y t f Iiti\'a.1O~�` •-'s 1007 W EST YAR&KiLln ifJ' �] ° ,- YARMOUTH PORT,MA 2675Undersecretary ' n a, „ ' l/"" Commissioner 3 1 7./ (A.) I% NS vim,-A 1 V 6,vn 0 LA Ire W Q S� 1 P TOWN OF YARMOUTH REVIEWED FOR BUILDING AND ZONING CODE COMM- ;I LE COPY ANCE. ERRORS OR OMMISSIONS DO NOT RELIEVE THE `( APPLICANT FROM THE RESPONSIBILITY OF'AS BUILT' • Vv COMPLIANCE. ^t DATE ' S'li �� BILDING __ 1 t U\1/4\Q lir 7....3:si � a _ _i �r 6 � 1 fa� �, ' A1c'