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Home My WebLink AboutBLD-19-3164 i 944(. t.t,C 0/2.6/' • ONE &TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department or sti 1146 Route 28,South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508-398-0836E�"rER Massachusetts State Building Code,780 CMR \ Building Permit Application To Construct,Repair,Renovate Or Demolish \` r a One-or Two-Family Dwelling RE C VE �s ,Tnhi S�ection For Offrcial Use Only I Building Permit Numbeyl.�' :!. .161-V v f I Date App i LNUV .2018 'TSr • - -Nrs - ` But ti`c.a�i'oL,'NT Building Official(Print Nemo) Signatwe SECTION I:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers R E C E 1 V E t i4 as , at-r- b 2 q' ( In _ 433 i 1.1a Is this an accepted street?yes_ no _ Map Number. Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: NOV 2 6 2018 ` _ 'Ek351.L Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) BUILDING DEPARTMEIi ; 1.5 Building Setbacks(ft) - Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(MO.L c.40,454) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Public,/ Private IDex, Check if yes❑ Municipal 0 On site disposal system SECTION2 :PROPERTYOWNI:RSHIP' 2.1 Owner'of Record: Kedek t rr70.44%) % y6Mr/GWA, &# /V W75 Name(Print) 4://f/P0 State,ZIP • A9`/144110t4 ofiIh Q4.! alas) ba7 l@'cG,r{-ea-lel, 43entmicil.6441 s� No.and Telephone Email Address ti SECTION 3:))ESCRIPTION OF PROPOSED WORIC2(check all that apply) New Construction 0 Existing Building Owner-Occupied 14 Repairs(s) 0 Alteration(s) Addition 0 _ Demolition 0 Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Works: I4CQi-FGhtaAh�,b-1tr; d��loDn ' anti tem0Je ttee COX hn .Se�j 5'0-f he cC,lweel,/ 14e ACIelke, as-1 A .41q0_/i✓i n.3- mart -, ,n> . .SECTRON4LESTJMATEDCONSTIITICrIgN COSTS Item (Labor and Materials) a 7 ,: .Ofcia1[J'se Only „C.i 1.Building $ �OZ p O O o d `1s Butldmg PeziitFee $$(ca Indicate how fee is deteimmeth 7 NStahidaid CitytVownApphcatioil ee > <.. ,ri t"•'"" 2.Electrical $ SDO, o O ClTotalProjecECostTtT b)xmultiphe.r • x 3.Plumbing $ a 500.00 2 Othet`Fees $ 3 14K � 4.Mechanical (HVAC) $ ,^, Listr,... M ;,', F i 5.Mechanical (Fire Suppression) $ 1 otat All Fees $ +; e Check No' Che`ckAmount.-'-_Cash AmounF, 6.Total Project Cost: $ /CO 0 0 ho d Paid 1nFuU .'" 6b' Outstanding llafaiite Due 115 • • • a. . - - SECTIONS:.CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) cc 0,7/87 Z 20 1 CrDIIv\ k.oneGicp to License Number irati Date Name of CSL Holder T. 4List CSL Type(see below) eik No.and Street ��,��A/' Sn� // U Unrestricted(Buildings up to 35,000 cu.ft) S. ‘ 0,,,,,,c, , -%] `�P'6 R Restricted l82 Family Dwelling City/lbvro,State, M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances Tom'77yajaoyfJ jal;nce elephone Email address. we* DI Insulation Demolition 5.2 Registered Home Improvement Contractor(HIC) X00 39 -- • O Urf7'�t0()61{Ir)N1JifX. HIC Registration Number Exp nDate TUC Company blt or HIC Registrant Name aHardzi 5I 10ci0CaertZ0 )4VIof- ? treet /lwlCif eft /W MY 97 342 1/2/ya Email address ...- City/Town,State,ZIP j 34116 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 Is ce of the braiding permit. Signed Affidavit Attached? Yes No ❑ . -SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT 011 CONTRACTOR APPLIES FOR BUILDING PERMIT l I,as Owner of the subjecthereby 'J L loriuSet e) COJt i I/1 L. J property, authorize � h to act on my behalf in all matters relative to work authorized by this building permit applicad R491, a- f c "64.-9— ,11 nf/r Print Owner's Name(Electronic Signature) Date • • . . SECTION 7b:OWNERi OR AUTHORIZED AGENT DECLARATION . By entering my name below,I here. attest under the pains and penalties of perjury that all of the information contained in this application' 1 .d.er i %to to the best of my knowledge and understanding. // 5).ti lerte/ -u.. Jr ttInJl- Print Owner's or zed ea'!" ame D - . .nic Signature) ! // Date 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 yvww.mass.gov/dos 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/batbs 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 —:M1r p Department of Industrial Accidents • _i 1/= 6 1 Congress Street,Suite 100 __�l " Boston,MA 02114-2017 -.,.a , www.mass.gov/dia wwmass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant information Please Print Legibly Name(Business/Organization/Individual):J.O'Loughlin, Inc. Address:2 Harold Street City/State/Zip:Harwich Port,MA 02646 Phone#:5084624942 Are you an employer?Check the appropriate box: Type of project(required): ICI I am a employer with 6 employees(full and/or part-time).• 7. 0 New construction 2.0 l am a sole proprietor or partnership and have no employees working for me in 8. ❑� Remodeling any capacity.[No workers'comp.insurance required.] 3.0t am a homeowner doing all work myself.[No workers'comp.insurance required]: 9. 0 Demolition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. 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. 12.0 Plumbing repairs or additions 5.0 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.DRoof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.0 We aa corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other ate 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. tContractors 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:Acadia Policy#or Self-ins.Lic.#:MAARP300998 Expiration Date:12/24/18 Job Site Address:9 Helen's Way, Dennisport, MA City/State/Zip:02639 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 spy of t r' tatement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 441 do hereby cert'' r the tains and penalties of perjury that the information provided above is true and correct Signature: 4/ �S Date: IN Ila lg. Phone#:508' :.2k Official use only. Do n r .fit, 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#: .l4 r� n,•od la, ' - 4 Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home ImprovemeYnt Contractor Registration ) Type: Corporation J.O'LOUGHLIN,INC. ' It Registration: 100398 2 HAROLD ST J Expiration: 06/15/2020 HARWICHPORT, MA 02646 =11 _ E qty 111 Update Address end Return Card. SCA 1 0 20M-05/17 .'assachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-074187 Construction Supervisor JOHN C LONERGAN t EAST DENNIS MA 02641 -_ �" I , Z/1;:f 60 Dina --- Expiration Commisslo er . 02/20/2019 f oF'YgRs. TOWN OF YARMOUTH r. .� c:93 BUILDING DEPARTMENT F i '- 1146 Route 28,South Yarmouth,MA 02664 Cs3 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 it i /'G]( a-se Work Address Is to be disposed of at the following location: Sea— Exco, in;S, Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 11,ection 150A. AV /Wig- or: : :Lure o Application Date Permit No.