HomeMy WebLinkAboutBLD-19-2695 1
ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department m r
1146 Route 28, South Yarmouth,MA 02664-4492 �+
508-398-2231 ext. 1261 Fax 508-398-0836 ";.
Massachusetts State Building Code,780 CMRtisiO
Building Permit Application To Construct, Repair, Renovate Or Demolish
a One-or Two-Family Dwelling RECEIVED
This Section For Official Use Only
Building Permit Number: - 6' /6.4,95- .Date App • : 2018
C 1.1 L
�LM JQA� .. V � .. . . {1-4,-1 . BUILDING DEPARTW
Building Official(Print Name) Signature .. er ,_ flfle _
SECTION 1:SITE INFORMATION
1.1 Pro er ddress: 1.2 Assessors ap&Parcel Numbers
ZZg T Q CT- `((inATr. •pEa �L �
1.1a Is this an accepted street?yes V no . Map Number /55 Parcel Number
2 ). 1.30eg Information: 1.4 Property Dimensions: /C
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 c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private Q
Zone: _ Outside Flood Zine? Municipal❑ On site disposal system i
Check if yes
SECTION 2: PROPERTY OWNERSIIIPt.
2.1,`1vtpeLe eirDd:v,a _ �e Q�cbRv 14 . ra0iC
Name(Print) `�T�jM City,State,ZIP 1 iC�
72$ 1?it.1e. r9 Er 9*— 361-274 2
No.and Street Telephone Email Address
SECTION 3:.DESCRIPTION OF PROPOSEDJWORK2(check all that apply)
New Construction 0 Existing Building Owner-Occupied 11 Repairs(s) ❑ Alteration(s) 21 Addition ❑
Demolition 0 Accessory Bldg. 0 Number of Units I Other [( Specify:I:4P --Iz ,Ev()bet_
Brief Description of Proposed Work'':
se. 4 Vs 12X, 1 tar vin lyt noun . •r, J% •e .is tnr
- a..- . . , -tub t%tee ;k. tp11h a. -ft led S o
UM Arlo W tall; S —ty CP 141 luin, v 'Skimp pA i l•r, t11/.
SECTION 4:ESTIMATED CONSTRUCTION COSTS , . •
Item Estimated Costs: Official I se Only "
(Labor and Materials)
1.Building $ :1 Building Pemut Fee:$ ! c o Indicate how fee is idet ii�t dt IV E D
2.Electrical $ a Standard City/Town Application Fee t
❑Total Project Cost'(Item 6)x multiplier x NOV 14 2018
3.Plumbing $ 2: Other Fees $ J5--:- .
List
4.Mechanical (HVAC) $ NT
5.Mechanical (Fire
Suppression) $ 1--- Total All Fees $
ClieckNo: CheckAmotnit: Cas.Amo t:
6.Total Project Cost: $ 3)000,-- p Paid'inFull _ . Otitstanding Balance Due: __
•
• SECTION 5:.CONSTRUCTION SERVICES
5.1 Construction
`Supeviisor'License�(JCSSL)) \ 000682.. o,-Qg•Zp7-0
• �i .{ M.. 6 O}I A C} License Number Expiration Date
Name of CSL Holder
1-ED /r ,en,•L1. ��n_\U tnD List CSL Type(see below) 14
No.and Street lNt Type .. Description
3 PEWS WP P4 4 SS 0 2 1 U Unrestricted(Buildings up to 35,000 cu.R)
City/Town,State,ZIP 7 J 1 R Restricted I&2 Family Dwelling
M Masonry
'L'Z1z-C] RC Roofing Covering .
7� WS Window and Siding
�'
1 SF Solid Fuel Burning Appliances
�rnUeo h� hob, torn I Insulation
Telephone Emai ad ss D Demolition
5.2 Registered Home Improvement Contractor(RIC)
Bgeemze M. '$OticAt } 111458 •
12-Zti -1 at
HIC Registration Number Expiration Date
mc Compçy Name or mc ge tai
170 �"►�71?11lCuntlt �0.f�
d trees Email address
vewn M11/2 0 11 771-PA -0757
City/Town,State,ZIP Telephone
SECTION 6:WORKERS' COMPENSATION INSURANCE Alt WAVIT(M.G.L.c.152.§ 25C(6))
2 Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
G this affidavit will result in the denial of the Issuance of the building permit.
• Signed Affidavit Attached? Yes ❑ No...........❑
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 (� N I. 4011
to act on my behalf;in all matters relative to work authorized his-Wilding permit application.
nc ► e C->�. i M / � MT 21 1?
Print Owner's Name(Electronic Signature) • • �" . , Date
• • SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pain¢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.
gRe-fs9Qq ly . -Boo K¢}th}- C"kt-r-v 117012.
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.eov/oca Information on the Construction Supervisor License can be found at www,mass.aov/dos
2. When substantial work i planned provide the information below:
Total floor area(sq.ft.) p 0 IE (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft) 4' 186(j to Habitable room count
Number of fireplaces I Number of bedrooms
Number of bathrooms 3 Number of half/baths 1
Type of heating system 44t9'j— 1429
r, Number of decks/porches 0
Type of cooling system h0 Pt Enclosed Open 1/
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
• The Commonwealth of Massachusetts
pi a
mall= / Department of Industrial Accidents
_:. .=— •
1 Congress Street, Suite 100
Tir, -'��= • Boston,MA 02119-2017
, • www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Busness/Organization/individual): ege A , TcootatIA
Address: )10 BnAtd F9 uJ rata
City/State/Zip: ?)R4) svi2) P4Ar, , Phone#: 77+ - 2,)2.--(17 7
•
Are you an employer?Check the appropriate box: Type of project(required):
•
1.9Ijfm a employer with employees(full and/or part-time).* 7. 9 New construction
2. I am a sole proprietor or partnership and have no employees working for me in $. [ Remodeling
any capacity.[No workers'comp.insurance required.]
3.9 1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition
4.9!am a homeowner and will be hiring contractors to conduct all work on m Y property. I will 10 ❑Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.9 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
These sub-contractors have employees and have workers'comp.insurance) 13.❑Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other f } 0 M
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.
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.
/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.
I do hereby e-tify under the pains and penalties of perjury that the information provided above is true and correct
Signature: M 6 tirbdirttei/ Date: (pit Z11 2019
Phone#: nil-—Z1Z— 075?
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):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
•
•
o4•YA4.t TOWN OF YARMOUTH
• $ r BUILDING DEPARTMENT
0
i' A $ 1146 Route 28, Yarmouth,
South MA 02664 508-398-2231 ext. 1261
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE:
, JOB LOCATION: Id ;dna le Gre,I,t,.,.. 09ace' ?in.e St Vet rn„ou,f6, Port •
NAME / STREET ADDRESS t SECTION OF TOWN
"HOMEOWNER" Sox)3G1".17Yi
NAMEOMEPHONE WORK PHONE
PRESENT MAILING ADDRESS .20 g �J n e ST
I/4A Lop. rsi IN Int\rt MA [ ) �p7S
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 85.1.3.1)
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 _Ar_
APPROVAL OF BUILDING O1~r1CIAL
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 Yes,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
bt T'1?
�o TOWN OF YARMOUTH
:4g BUII,DING DEPARTMENT
: Y ?'ri �y 1146 Route 28, South Yarmouth,NIA 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
zz
conducted at � 121toE e-r - `/A,fZ-NtotYri\.t b,-r
Work Address
Is to be disposed of at the following Iocation:S TEY.r4 � ^50 vilS
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
14
LMst 1 ' cILj12 (DCT. ZI 2018
Si 91! to ` of Application Date
Permit No.
c;Te ornnuwnea/JAofQ.&JeacAaoelli _..._
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:Individual before the expiration date. If round return to:
Beaistration ExpirationOffice of Consumer Affairs and Business Regulation
111458 i 1228/2019 - 10 Park Plaza-Suite 5170
GREGORY M BOOKACH Bo ton,MA 02116
GREGORY M.BOOKACH \Q.CIp--- JA .erf
f /
170 GREENLAND POND RD. [, v
BREWSTER.MA 02631 Undersecretary ;eland without signature
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TOWN OF YARMOUTH
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REVIEWED FOR BUILDING AND ZONING CODE COMPLI
1 ANCE. ERRORS OR OMMISSIONS DO NOT RELIEVE THE -
a APPLICANT FROM THE RESPONSIBILITY OF'AS BUILT' ': sjs
-.' Ni COMPLIfNCE.
I ni DATE: I I—6-IS .i
O ;, w BUILDING 0 FICIAL '
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