HomeMy WebLinkAboutBLD-19-002541 A CERTIFIED AS BUILT IS REQUIRED
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SECTION S:.CONSTRUCTION SERVICES
•
5.1 Construction Supervisor License(CSL) C-5- 33/3 //3 nA
VD//J1/ /r'//% ( .(2)'IV LicenseN�✓umb✓✓errr b`xpiration Date
Name'ofLCSL Holder
?ase avie) ,$ I at List CSL Type(see below)
Nprid Sp / l• `17, DL/3t; Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
vy/a, R Restricted l&2 Family Dwelling
City/To State,ZIP M Masonry
RC Roofing Covering
• p 2/ WS Window and Siding
5 ,76�p.�/ AU. ( ex#7W, SF InsulFuelBurningAppliances
A/s'J 0 � jY�' I Insulation
Telephone Email address D Demolition
5.2 Registered Home,I;�rov nt n ctor(HIC) in›.-9:3
/CA? 19'
HIC Company N /(HI�'C, ygi;C/L Name HIC Registration- Number Expiration�late
No.and Street J/!�/ c '/ChirS-e/d 1.A9iG/tth
Email address l
City/Town, State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(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 Issuanc of the building permit.
Signed Affidavit Attached? Yes No ❑
. SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FO�R�JBUILDINGG PERMIT ..
I,as Owner of the subject property,hereby authorize N 41 ( 4 "<P/v.2„/ e.,
to act y behalf,in a afters relativ o ork authorized by this building permit application.
._ çip)4 11 (9c�vfrrc5ol$
Print Owner's N (Electronic SignaturDate
SECTION 7b:OWNERI OR AU' ORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
con .ed'. application is true and accurate to the best of my knowledge and understanding,.
Pr,wner'sorAuthorized . t'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(HIC)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
✓ to_,, _ Department oflndustrialAccidents
Ersa_7101—=" 1 Congress
Boston,MA 02114-2017 ite 0
'44_47;,., • www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information J Please Print Legibly
Name (Business/Organization/Individual
) ` u0 /0j11c A/21'w
Address:af'jr' G-1/17 51— �—✓
City/State/Zip:#/ , P_2,-/T- Phone #: �<d re2W
Are you n employer?Check the appropriate box: Type of project(required):
1 am a employer with 0 "'mployees(full and/or part-time).* 7. ❑New construction
2.9 lam a sole proprietor or partnership and have no employees working for me in 8, ❑Remodeling '
any capacity.[No workers'comp.insurance required]
3.9 I am a homeowner doing all work myself.[No workers'comp.insurance required.]f 9. Demolition
4.❑I am a homeowner and will be hiring contractors to conduct all work on myproperty. 1 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.❑I em a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp.insurance? 13.❑Roof iepaira^
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other G�C%eJv
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 their workers'compensation policy information.
f 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.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
Information.
Insurance Company Name: 1i%L� T� .irP . .°-C'J
Policy#or Self-ins.Lie.#: p Q txpir 77a 9 -2,6' /p r
Job Site Address: 3-9 ,Ay 6 P4 syr/Li/ City/State/Zip: water, '4Y 6 Zle s
Attach a copy of the workers' com ensation 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.
1 do hereby a,ttfy 1 der the pains and penalties of perjury that the information provided above is truee and correct.
Signator : Date: /d�/�/ er
Phone#: 508- Y� d.frAit
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/ own Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
o Yfe
iR TOWN OF YARMOUTH
} ' _ BUILDING DEPARTMENT
�•` ? 1146 Route 28, South Yarmouth,MA 02664 508-398-2231 ext. 1261
fi
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE:
JOB LOCATION:
NAME STREET ADDRESS SECTION OF TOWN
"HOMEOWNER"
NAME HOME PHONE WORK PHONE
PRESENT MAILING ADDRESS
CITY 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 85.1.3.1)
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
APPROVAL OF BUILDING OFFICIAL
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL
Ch.142. Yes No
If you have checked its,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 required by
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:homeowarlicexemp
, . �dT-rAR o TOWN OF YARIYIOVTH
:via c BUILDING DEPARTMENT
"'� — x 1146 Route 28,South Yarmouth,MA 02664
�, _� 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 1113,
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at 5.7 6401 kcX4en/ Grf 14€
Work Address
Is to be disposed of at the following location: IAtt dz t ' ",
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter I l I, Section 150A.
IP i!matureofA AO70 70
pp cation CK
Date
Permit No.
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smBHtOm of Consumer an 8 Business Regulation
I
HOME IMPROVEMENT CONTRACTOR +
t TYPF
I dividual i
i I it I y
183s,±-X10/2712019 i
JOHN MACKENZiF a;.,. 4 1
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JOHN MACKENZIE �- •
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6R-cc-Q.-it--i
1 248 CAMP ST Li ate=- :+�
{ W.YARMOUTH,MA 02673�.""�
Undersecretary ii
ii
C Massachusetts Department of Public Safety
1 _ Board of Building Regulations and Standards
;1
License: CS-085363 r ;
Construction Supervisor j %1
r
JOHN A MACKENZIE
248 CAMP ST.L-1 .r ; d. j .
WEST YARMOUTH MA 02673; - �,'• '
v.�y -
XN77
/ i,trdali 0j42"— Expiration:
Commissioner 01/03/2019
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pi.y, . • TOWN OF YARMOUTH
3i
o WATER DEPARTMENT
d—�is-1, 99 Buck Island Road
`53 `g. . West Yarmouth, MA 02673
Telephone: (508) 771-7921 • Fax: (508) 771-7998
• BUILDING PERMIT APPLICATION
DEPARTMENTAL SIGN OFF TRANSMITTAL SHEET
Ly
Bldg. Site Location 3q /�����/ 4 /Map #: Lot #:
Proposed Improvement: lS 0 57' �!� _,e-20� 0T A
Applicant: 0- # Hi1/ /iC-e A/Z✓�, lJ
-Cede sr� —Address A2 �'t/>L Te!. r.5��8J36 � gds tr.
t
�/ Date Filed: /OP
RESIDENTIAL AND / OR COMMERCIAL BUILDING
Water Department: Determines Compliance of Water Aval!ability and or Existing Location
Engineering Department: Determines Compliance for Parking and Drainage
Weuanas, Streams, Pont's, Rivers, Ucean, Bogs, Bays, Marshland, Etc,..
Health Department: Determines Compliance to State and Town Regulations, i.e., Requirements.
for Septage Disposal and other Public Health Activities '
Ditp3.rr.,er.., De -.rn neSCen`p!'anCe to State and Tc.r,- Pegg -nett_ f:- Pc:-sorra)
Safety, Property Protection;, i.e. Smoke Detectors, Sprinkler Systems, Etc
PLEASE NOTE:
COMMENTS: •
•
•
Reviewed by: Water Division Date
At:Ynh TOWN OF YARMOUTH
4 OCl 'i ti 1018
HEALTH DEPARTMENT
HEALTH DEPT.
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site Location: 3 ? ,�-?/-L'y teIAcere!1 Zer rte
Proposed Improvement: �� t 6�i 7a r% tc Celt' ice/Pe-
of Ao44,4-
Applicant:loid cc-
Tel. No'$a 2c 3>0'0s8
Address:2I CCtA'K cc 4 '-1 Gd/'Sc ' 73 Date Filed: /116 ��
**If you would like e-mail notification of sign off please provide e-mail address:
Owner Name: A4 di2y &Z o,/Pe eV&
,,
Owner Address: 5" �G �� "� Owner Tel. No.:
RESIDENTIAL AND/OR COMMERCIAL BUILDING
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
Please submit three (3) copies of plans, to include:
(1.) Site Plan showing existing buildings, water line location,
and septic system location;
(2.) Floor plan labeling ALL rooms within building
(all existing and proposed)—
Note:Floor plans not required for decks,sheds, windows, roofing;
(3.) If necessary, Title 5 application signed by licensed installer
with fee.
REVIEWED BY: �� DATE: / °/h// ''
/ PLEASE NOTE
COMMENTS/CONDITIONS:
6u`!dA`n,9
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' c,.°47,- TOWN OF YARMOUT ECEIVED
1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451
Telephone(508)398-2231 Ext. 1292-Fax(508)398-0836 OCT 1 8 2018
OLD KING'S HIGHWAY HISTORIC DISTRICT COM I-grNG'SHI
H
NG S HI
APPLICATION FOR
CERTIFICATE OF EXEMPTION
Application is hereby made for the issuance of a Certificate of Exemption under Sections 6 and 7 of Chapter 470 of
Acts of 1973, as amended, for the proposed work as described below and on plans, drawings, or photographs
accompanying this application.
Type or print legibly: / / ' / ���
Address of proposed work: 37 / %L4_6 62-hrt Zt/ Map/Lot#
Owner(s): �✓l 'czosr^V jC.—flat/ Phone#: / / A
All applications Must be submitted by owner or ac ompanied by letter from owner approving submittal of application.
Mailing address: cS/9.14 e Year built:
Email: / ��J Preferred notification method: Jr�Phone Email
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Agent/Contractor. \JL2JCiV/ /v6 ,e6:7-1/7:- tt / h Phone
y#: bfr
Mailing Address:J 7d Cie, 5/ 4 ..f^ Wim(/ -"Tett d a(' .43
Email: err j £ ( 2 �6 f.1j1�� t- C Gpreferred notification method: Phone "'Email
Description of Proposed Work(Additional pages magbe attached if necessary):
/ 51C' ,V0",11 /1.
G�-ecC -`c Avl CEIVED
��
OCT 18 2018
TOWN CLERK.
SOUTH YARMOUTH, MA
Signed(Owner or agent) 11 / - Date: 10 1 g-'t
> Owner/contractor/agent is aware that a permit may be required from the Building Department.(Check other departments,also.)
> This certificate is good for one year from approval date or upon date of expiration of Building Permit,whichever date shall be later.
For Committee use only: / p(]
Date: 10-/g -/f{ ✓Approved Approved with changes APPROVED
Amount as Reason for denial: OCT 1 S 2918
Cash/CK#: YARMOUTH
OLD KING'S HIGHWAY
Rcvd by. . 1
Date Signed: y2/13/2air Signed: 6-065?
APPLICATION#: C// 3
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40,007-474, (`.
A ATOWN CLERK
SOUTH YARMOUTH, MA
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RECEIVED ,OS.0o� WILLIAM `gym,:
° o WILCOX rad
OCT 1 7 2018P No. 31341 e
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HEALTH DEPT ' /5,5 GiSTER J �
4AL LANG ..
TO THE BEST OF MY INFORMATION, "PROPOSED" PLOT PLAN
KNOWLEDGE, AND BELIEF THE YARMOUTH, MASS.
STRUCTURES SHOWN ON THIS PLAN LOT 62; PL. BK. 187 . PG. 149 •
HAS BEEN LOCATED ON THE GROUND DATE OCT. 11, 2018 SCALE 1" = 20'
AS INDICATED��� JOB 8076-00 CLIENT MACKENZIE
10/11/2018 i1 ` \ , �� SWEETSER ENGINEERING
203 SETUCKET ROAD
DATE PROFESSIONAL LAND SURVEYORPO BOX 713 SOUTH DENNIS, MA 02660
OFF. 508-385-6900 FAX. 508-385-6991
C: I S8 I PROJ 1 8076-00 I dwg 1 8076-CPP.DWG 0 2018 SWEETSER ENGINEERING
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����08IN °yA WORK MUST CONFORM TO ALL �� ROBIN °yG
`s WILLIAM in Ifq WILLIAM m
S WILcox -&)",„,'f °SO,, YLAW ; REGULATIONS e wlLcox N
I o No.31341 0/ /__;'�� lL /&—. , ..<7 `, , No. 31341
9°�,SS �,sTtia Q,� YARMOUTH WATER D ' IATA p°"�sFc,sTe *5' - ij
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TO THE BEST OF MY INFORMATION, "PROPOSED" PLOT PLAN
KNOWLEDGE, AND BELIEF THE YARMOUTH, MASS.
STRUCTURES SHOWN ON THIS' PLAN . .. .. . LOT 62; PL.'BK.' 187 PG: 4149 ` .
HAS BEEN LOCATED ON THE GROUND DATE OCT. 11, 2018 SCALE 1" = 20'
AS INDICATED. JOB 8076-00 CLIENT MACKENZIE
10/11/2018 /° VaCM SWEETSER ENGINEERING
203 SETUCKET ROAD
DATE PROFESSIONAL LAND SURVEYOR OFF. 5P080
-38X9070 13 SOUTH DENNIS, MAX0526-6308
5-6991
C: 1 58 1 PROJ 18076-00 I dwg 18076-CPP.DWG 0 2018 SWEETSER ENGINEERING
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• --REVIEWED FOR BUILDING AND ZONING CODE COMPU- ' T • '
ANCE. ERRORS OR Gh"dISSIONS DO NOT RELIEVE THE l_-1 LE—CY�� ________ —
APPLICANT FROM THE RESPONSIBILITY OF*AS BUILT —1- ^ . 1 .
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