HomeMy WebLinkAboutBLD-18-005706 i ONE & TWO FANIELY ONLY:B17ILD]1NG PE.RMIT
..,J Town of Yarmouth Bonding epartment -
1146 Route 28, South.Yaffioutb,MA 02661 1192 ��'
508-398-2231 ext. 1261 Fax 508-398-0836 • -- :' ;
Massachusetts Stats Building Code, 780 CMR
Building PermitApplicaiion To Construc4 Repair, Renovate Or Demolish _.,>,_
Ex u l `_d t1 - I - 19 a One-or TWo=Family Dwelling
1� 1 D This Section For Official Use Only
BmirTin 2-,Peonft cher. ,e3tj /P 5t7 6 Data Applied:
BifldingOfficial(hi„tName) S;'cn re - • • Dae
•SECTION 1: Si'l't,INFORMATION .
1.1 Property Address: 12 Assessors Maajc PanelNumbers
2l emeon On've Vesty rmovi i?, ' "/I 9�
1.1a Is this an accepted street? yes X no .
Map Nuaaber ParadNumber
L3 ZoningIafarrmarian:' L4 PropertyDgmeusiars:
Za�m;.;Ddstict PayArea asedUse Lotea(sgit) Ftent>,t(ft)
IStt
Bdi�s Seth asks(
�
FY�i SideYalds
ReasF
£..ali:i=d I Pcvrided IL4u;.i-a Provided
LLequ d I Pmv:ded
1.6 Water 81:7917L L c.40, 454) I L7 Flood Zone Ivfaruizdan: I LS S age Disposal System:
Ptb ic� Fiv=C-CI _ Outride F1aod Zane?
Chec6fr 7-CI M+Tima1 Q On 22disposal system
' Sx:CtQii 2: PROPflZT O vYl1/41:ERSFLp`
2-1 GiustiL�eco�, �/
N�S`trple.� /QLLa�y /,n Vesf ✓rep✓7 r1, 42 9 02C/75
Com) Cur,S
•
2/ lie/leen Drive 339-23531120 r17lytovneaol•con)
Na. and Sty: ielephane Fn,n1 Mb=
SECTION 3:DESCRIPTION Or PROF Oti H,it WO'_�'--(chi 22tit apply) •
New C. • ".o ❑ I F ct_gBtldm O?aer-Occaaied. C I Rya s(s) As) C I Adiido ❑
Deno1i at. 0 I Accessary Bldg. 0 I NinherofUrits_ I ()ter ❑ Specs-
Brie Desw.ipiias of Proposed. ail': i - , 1 r e, •6P• • '. a lr'
iclPN 'F MK
gnat s✓I .roe ad, %h5✓q 10 n a r ;or r'I-c en walls 'n tal v' ,er a
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h I E :m a rd Cost: • . -_ - ; _ • - �. _: •: .�„. . 1.0
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The Commonwealth of Massachusetts
Department of Industrial Accidents
eL 1 Congress Street, Suite 100
,__, ,� Boston, MA 02114-2017
�+:. www.mass.;ov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH 1lit PERMITTING AUTHORITY.
Applicant Information
] Please Print Legibly
Name(Business/Organ:zaaiion/Individual): CJ)hryl lM 5"Lty 4/1 /7
Address: 21 HetitonDr;re I ✓
City/State/Zip: /X emovthl/1/ 02673 Phone#: 339 -235- 3920
Are you en employer?Check the appropriate box:
Type of project(required):
i.fl I an,a employer with employees(full and/or part-time).* 7. D New construction
10 I am a sole proprietor or pateoership and have no employees working for me in8.fliemodeling
any capacity. [No workers'comp.Llstt2rlce required.]
3.0 I am a homeowner.dooinsurance all work myself[No workers'camp. required)t 9. ❑Demolition.
4. I am a homeowner and will be hiring comamy property.act rs to conduct all work on10 Building addition
I will
ensuro that an contraron either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.❑I am a general cortEctor rod I have hied the sub-enotactors listd on the attached sheet.
These sub-contactors have employees and have workers'comp.insurance? 13.❑Roof repairs
ED We re a corporation and its officers have exercised their dgbt of exemption per MGL e. 14.0 Other
152,§1(4),and we have no employes.[No workers'comp.insurance required.] •
'Any applicenethat checla box t 1 must also fill out to section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contactors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet shoving toe name of the sub-contactors and state whether or not those entities have
employees. if the sub-contractors have employees,they must provide their workers'comp.policy number.
I ant 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 certif4441
under the pains arid penalties of perjury that the information provided above is trueand correct
Sine: 21, i Try Date: . 00F1/2(
Phone#: 339- 235- 3 y e
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License m
Issuing Authority (circle one):
1.Board of Health 2. Building Department 3.CitylTown Clerk 4. EIectrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
•v
• 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 contact 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."
MGL chapter 152,§250(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 obnsttruct 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 contact for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contacting authority."
Applicants
Please all out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary, supply sub-contactors)name(s),address(es) and phone numbers) along with their cerdacate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Par erships(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 Deparaent of Industrial •
Accidents for connrnation 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
Indusuial 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 lis--Led below. Self-insured companies should eater 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 sere 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 permit 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
r• ' Boston, MA 02114-2017
•
Tel. # 617-7274900 ext. 7406 or I-877-MASSAFE
• Fax# 617-727-7749
Revised 02-23-15 www.mass.gov/dia
# ;` ,>F 1146 Route 28.,South Yarmouth,MA 02664 503-395-2231 at.1261
HOMEOWNER �NER LICENSE EPTION
PLEASE PRINT:
DATE:
•
JOB LOCATION: lien rnl-a p >i a) lleMeM D►. esf Qrmov7L�
/` STREET ADDRESS SE ON OF TOWN
"HOMEOWNER" S E 1 sL h ,' •.-2 3 20 (1-526-22 if
SME HOME PHONE WORK PHONE
PRESENT MAILING ADDRESS
CITY OR TOWN STATE 22 CODE
The=eat exemption for `Homeowner' was Wended to include owner—occa-o ed dweJli n es of one or two units
and to allow such homeowners to engage an individual for hire who does not possess a license,trrovided
homeowner shall act as supervisor. (Stare Building Code Section 110 R5.13.1)
Definition of Homeowner:
Persons) whoownsapaarcelofJani.oawhichhe/sheresidesorintendstoreside,oawhichti. eisorisintendedto
be, a one or two fazeily=ached or dei a rhed stVt C LW.e assessorgto such use and I or in, ,i stractarres_ A.person
constucts more than one home in a.two-year period Shan not be considered a.homeowner,such'homeowner'shall
submit to the buiding official, on a form acceptable to the banding oihcial,that be/she shalibe resoo lble for
2-1
such work neauued u-eder the buildius nerm,t (Section 110 85.1.3.1)
The t�n.dersip.ead `homeowner assanes respornsfraity for co,uyliance with the State Enildmg Code and,other
applicable corIP-s, by-laws,roles and regniators.
The mdersigne:d `homeowner' cer if.es that he / she m,rienstands the Town_ of Yar auth Building Department
Tninimnrn inspection procedures and re(.1Lcmen_12 and:(tot he / she will comply with said p_oced es aid
requirements. D�`
HONL'OWNhErS SIGNATURE ...)150
'a` 1
UE
APPROVAL OF BDING 01-r1CrL,_k
INSURANCE COVERAGE:
I have a cnaaeut liability insurance policy or its substantial equivalent, which meets the _ Tri eaof MGL
01142. Yes No
L you have checked yes, please indicate the type coverage by checkn the _ :orate bat
Aliability aLsurancepolicy .Other type of indenrity Bond
OWNER'S NSU ANCEWAjV Iain.aware that the licensee does not have the nsuancecovra er o Eby
Chapter 142 of the Mass. Gene al Laws and tact my Han-tiro on this permit a plica on waives this r_•-GL7ce-nnent
Check one:
Sir:stare of Owner or Owner's Arent Owner A2at
_ n e , o armo ,
508-398-2231 ezt 1261 Fat 508-398-0836
BUEDNG DEPA RT1YIF,1r 1
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
P:ssnat to MG.L. ChaPter 40, Section 54 and 780 CMA, Chapter 1, Section 111.5,
I hereby certify that the lIdebds resulting from the proposed wo k/demolition to be
conducted an 21 1 c(neph P(i'c lest etirdi IV 0.26 73
Work Address
is to be disposed of at the following locafon: T jan Klecycb by Bf Thh) /1/9'
.Said disposal site shall be a licensed solid craste facility- as defined by M.G T.
Chester 111, Section 150A.
# , /7144:47 °`/40h(
S1gn attire of Application Date
Permit No.
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2017-11-17-1136 11/17/2017 Page:9
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2017-11-17-1136 11/17/2017 Page:8
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2017-11-17-1136 11/17/2017 Page: 8
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2017-11-17-1136 11/17/2017 Page:9
Sears, Tim
From: Sears, Tim
Sent Thursday,April 12, 2018 10:32 AM
To: 'mgroun@aol.com'
Subject 21 Hemeon Drive
Stephen,
I have reviewed your permit application for 21 Hemeon Drive,and according to our records this is a rental property.This
means you do not qualify as a homeowner under the building code,and would require a licensed contractor to apply for
this permit.
Please update your application and submit for review
Thank you
Timothy Sears CBO
Building Inspector
Town of Yarmouth
508-398-2231 Ext. 1259
mailto:tsears@yarmouth.ma.us
1