The URL can be used to link to this page

Home My WebLink AboutBLD-19-002517 CA4(CtiN/ I°12•Ct1e e. ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department o. r 1146 Route 28,South Yarmouth,MA 02664-4492 44, 508-398-2231 ext. 1261 Fax 508-398-0836 trill 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 Building Permit Number: GD:=I.`j^'OV2 5E7 .Date Applied: , 11N :SO (3 : ' lb=a..5- 4)* Building Official(Print Name) ignature :` Date SECTION 1:SITE INFORMATION : - ; 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 43 ICticiCOMitir cacLC 1)-S .S - 1.1 a 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 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.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public* Private O Zone: _ Outside Flood Zone? Municipal 0 On site disposal system/ft- Check if yes0 • SECTION 2: PROPERTY OWNERSHIP't 2.1 Owner'of Record: . tfk W72— 6110reS Mani n.4-an Pnr ) NMI O,7.10"75 Name(Print) City,State,ZIP L%2 Vencorvnseti—Ord e 01f�o-c ria deitt-rS6loresLwl0.mettl.c on No.and StreetTelephone Email Address : : SECTION 3:DESCRIPTION OF PROPOSED WOR&(check all that apply) ' New Construction 0 Existing Building 0 Owner-Occupied O Repairs(s) 0 Alterations) O Addition 0� Demolition 0 Accessory Bldg.0 Number of Unit_ Other 0 Specify: RECEIVED Brief Description of Proposed World: Gut AND 111 0&- - i34T1fftW4S --N 0 iJflU1T t;IIM-( —NO STaGIWI4t- 1.00Ali 3 0 2018 W. v,� SECTION'4f ESTIMATED CONSTRUCTION COSTS e V . Item Estimated Cost: "Official Use Only 24 (Labor and Materials) = ,. I.Building $ I S,Cr10 i., Building Permit Fee $I Co Indicate how fee is determined: 2.Electrical SIS 0 Et Standard CrtyPrown Application 1 es,_:--, d. ,,, —--, 0 Total Project Cosh(Item 6)x multiplier It i•x• i.:* J \( f U 3.Plumbing $ yddQ 2 OtherFees $ 3 � C-iI' ' 4.Mechanical (HVAC) $ List ! "-- ._y; ' CT iYAl 5.Mechanical (Fire i :;' ` ` • • • r,, Suppression) $ Total All Fees $ ` uLi' OIN(>C“;771.:ILNT 'CheckNo' Check Amount Amount-, — --- 6.Total Project Cost: $00r c00,dd 0 Paid in Full , dl Outstanding Balance Due: lis , . SECTION 5:.CONSTRUCTION SERVICES • . 5.1 Construction Supervisor License(CSL) 07 Sl y(00159111a .vv) bb License Number Expiration Date 'Name of CSL Holder Sr List CSL Type(see below) No.and Street t4�1/y �./�As& ` Type Description t?Akt C'V1`77v"T ,uco? fry Unrestricted(Buildings upto35,000cu.R) It Restricted l&2 Family Dwelling Cip•/rown,State,ZIP M Masonry RC Roofing Covering WS Window and Siding I SF Solid Fuel Bunting Appliances 71Y-3 53 -(p�la 6040caprhnsrfttnit1 .cbrl . I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(FITC) 1Tl-t��►u14 IAMiti 14973 4-�1-trp MC Company Name or MC Registrant Name HIC Registration Number Expiration Date No.and Street Email address City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.4 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 pr- No O 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 J e/t to w to act on my behalf:in all matters relative to work authorized by this buillling permit application. • 1)91-wn 1.11-Kars /etjfry�� io/�• / b t Print Owner's Name(Electronic Sign ) Da • • SECTION 7b:OWNERt 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. 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(PIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the IBC Program can be found at www.mass.eov/oc4Information on the Construction Supervisor License can be found at www,mass.gov/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" NS: The Commonwealth of Massachusetts • f �W Department of Industrial Accidents - - Office of Investigations • G =�Iir. Id . Via=Sq • 600 Washington Street - 1_�1— Boston,lllA 02111 . www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information • . Please Print Legibly Name(Business/organization/individual): < f EFFRE1' 1 (j112447 Address: .9I e!Lew-ew- ST City/State/Zip: ( iitinClttl*Pd2T MA- 0:}(0� • Phone#: R19 —SQ -6)— ?r)- Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 4. 0 I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. 0 New construction 2.7,1 am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have g. 0 Demolition working for me in any capacity. employees and have workers' insurance.: 9. 0 Building addition • comp.[No workers'comp.insurance required.] . S. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL c. 152 §l(4 , 12.0 Roof repairs t insurance required.] ) and we have no employees.[No workers' 13.0 Other • comp.insurance required.] 'Any applicant that checks box#1 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 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. Jam 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: '13 !C /Cettic ]r UNCLE - 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of • Investigations of the DIA for insurance coverage verification. J do hereby certi A 1 the pains and penalties of perjury that the information provided above is true and correct. Signature � Date: 10—b --q F phone#: / . . OffrFai use only. Do not write in this area,to be completed by city or town oBeiaL • 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#: . - 0 .-rust TOWN OF YARMOUTH 141 o4 ,, ! c BUILDING DEPARTMENT � y 1146 Route 28,South Yarmouth,MA 02664 F 4 508-398-2231 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 111.5, I hereby certify that the debris resulting from the proposed work/demolition to be conducted at 113 'COL/COME-IT Curr Work Address Is to be disposed of at the following location: YAMavU} Dui Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. /0- —ts( igna ! pplication Date Permit No. • iCJae rroaxmonwea/lAe o/Cfict gac%%4tellt Office of Consumer Affairs a.Business Regulation S HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:IndMdual before the expiration date. if found return to: pealstration g xOlratIOR Office of Consumer Affairs and Business Regulation 149773 02/21/2020 10 Park Plaza-Suite 5170 JEFFREY W RAGG Boston,MA 02116 A AO a i of I JEFFREY L W RAGG \lL.CGPk�—^ - 54 EILEEN STREET (, 1 out signature YARMOUTHPORT,MA 02675 Undersecretary ®, Commonwealth of Massachusetts Division of Professional Licensure 4 Board of Building Regulations and Standards Construction'Supervisor - CS-075746 !' ,.- YARMOUTH YARMOUTH PORT MA 02675 .1...t. _ . oeil Commissioner I,5-1 , 2.--4 of Parire-d ic(?_). ek-iiLiIvo r s 6 — (Th Qj kp C..) ` I /*>) . TOWN OF YARMOUTH REVIEWED FOR BUILDING AND ZONING CODE COMPLI- ANCE. ERRORS OR OMMISSIONS DO NOT RELIEVE THE APPLICANT FROM THE RESPONSIBILITY 0 'AS BUILT' COMPLIANCE. DATE: t0 -• aS' I) BU DING OFFICIA FILE COPY