HomeMy WebLinkAboutBLD-19-003232 s4
ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department Ciii4).
1146 Route 28, South Yarmouth,MA 02664-4492
508-398-2231 ext. 1261 Fax 508-398-0836MassachusettsState Building Code,780 CMR -•BuildingPermitApplication To Construct, Repair, Renovate Or Demor,sliiZ f.}a One-or Two-Family Dwelling .�
- DEC ub 211R
This Section For Official Use Only -}�(C11 1
Building Permit Number. b -. /9"OV _. . ...
�✓ 32?i�„�DaieApplie • aui�uwcoevu:im:. 4r
lir. S2A(g • T •
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Blinding Official(PrintName) igoanse • Date
. SECTION 1: 511Li INFORMATION
- 1.1 Property Address: 1.2 Assessors"? &Parcel Nnmbert_
q Jcft. rs AI 1 �
1.1a Is this an accepted street?yes )( _ no Map Numbdr 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: (MGS:c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal D On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2. n
Owers of Record:
` &-
S S iSern) DDiZ,tf',4 A- t-) —Co c114 /4-Kmo ,l7 r vi-o164 Sc
Name(Print) City, State,ZIP
3c..(7--r we e 9 Ley' csvY 274 4759 Sot i-f;eta CDD''rc sIf e7
No. and Street Telephone Email Address
' SECTION 3:DESCRIPTION OF PROPOSED WORK'.(cheek all that apply) .
New Construction❑ Existing Building 0 Owner-Occupied 0 .Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units_ Other 0 Specify: -•
Brief Description of Proposed Worle: IiiEMOVF •hi f_ /SMAN ha?' Rilb afgni l: 4-# i .
NEW VAN r4Y 4A/6 jot LFA
"Iffi9_,:7 And
. : SECTION 4;.EST:MATED CONSTRIIGTI01�•CO T$u.tt.otKGo�? 1{tT.tn...f••r
Estimated Costs: :--
Item -0�ffici - seoa1 ..•'.,,.:-: .
(Labor and Materials) -. • •.Y- ,.:_.: , - .,. --. .
1. Building $ ii 600 :1. BmTr1ing2exmitFeet-$'/e4. 3ndicatehowfee:is?determmed:
2.Electrical $ .9 Standard C'sty/`T9wnA pfii_c..atiogee x.:-.:u_,;,es::•:-'
ilTetalPro]ectCisf3- j :z.mmltrplier - :'7436;:-•r-a'..
3. Plumbing $ :.-�a,:;3a .. .
��� •2::Otfiex Fees: $- ._.
4.MerhanicaI (HVAC) $ ?icf.'
- r.irc a•i•r`:.,.s^,'::_�:<:t.a=s-.:r:-..:•a• .>. .::.�.e .• K. _ •
5. Mechanical (Fire �`-
Supprossion) $ .'I'acal A111 cess$' :' . . - 7.7...,•—• . :. : .. .
04;c4.}16::=7"...: Clier cA oi�t • CashAmonnt
Cost S 525-00 /
6. Total Project Cos
it � �I;Otrtst�adingESalaace.Dne:: IIS '
a _
SE •
CTION 5: CONSTRUCTION SERVSCES .,
CIPSnala g-t ____
5.1 Construction Supervisor License(Ca) g no Date
S 1p� - 'INE License Number
a, .1. ' ‘1\
Name of CSL Holder List CSL Type(see below)
as ►7R�F&. —A ln/ Descrption
No.and Street U Unrestricted :uildina �,to 35,000 cu ft
SO `T4j R/ 4/1 -� - Restricted l&2Emil Dwellin:
M ••
City/Town,State,ZIP RC ,,,,_ , _
ws
SF CriZarrEES
3�� t?AWeBLbRCYAlIoo .(AM I
InErISSEMINI
,.,, bid Tel .hone Email address D Demolition
as • 6-a3 a/9
5.2 Registered Home Improvement Contractor(BIC) uationDate
4o E A'S E /EC Registration Number ERP
a ompanyName orBIC Rees' trantName PAI-Ag-.3a
„ ..� 3tl.-2S/6) Ya/1to, Com
•
. Company
�:•� Email address
No.and treet tut 21 e� 0� 1
� AQ ui b t - Aid Tel .hone
Ci /Town, State, ZIP AVTT(M G.L.c.152.§ 25C(6))
SECTION 6:WORKERS' COMPENSATION INSURANCE APTID
Workers Compensation Insurance affidavit must be completed and subavtted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the builainz permit
Signe
d Affidavit Attached? Yes £1 No ...........❑
SECTION'7a:OWNER AUTHORIZATION TO SE COMPLETED
RISEN •
• OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT _
1
i
\- itLas Owner of the subjectproperty,hereby authorize d b this loading,Permit application
to act on my behalf/� in/�all
,,matters relative to wor authorized /���C���� 2/12..7k-____
//27 ,
SosA-503,fM. e1 '” `g,) 4 . / 1. lD/ate
print Owner's Name(Electronic Siguature)
. SECTION lb: OWNER':OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest tinder 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.
•
.4
Date
Print Owner's or Authorized Agent's Name(Electronic Signature) . :
NOTES: . • stered contact:
1. An Owner who obtains a building permit to do hislher own oic, anowner who own hao��es an1 e teief oat
n
(not registered in the Rome Improvement Contactor(HI )Program), can be
program or guaranty fund under M.G.L.c. 142k Other imp ortint information on the HIC Program
wwwm_ aInformationontheConstructionSupervisorLicensecanbefoundatvivm.mJ_sal
2. When substantial work is planned,provide the information b Blow:
•
(j�lnrlinggarage,fm ishedbasementlattics,decks or porch)
Total floor area a(sq.
R) Habitable room count Grossumeying area ces .ftNaber of bedrooms
Number of fireplaces _ Number ofhalflbaths
N
Type of hooting systestem yof oebas Number of decks/porches�—
pe ng Enclosed _Open
Type of cooling system
T
..j"
V_�_ The Commonwealth ofMassachusetts
• �='471= Department ofIndustrial Accidents •
1 Congress Street, Suite 100
5- f= Boston, MA 02114-2017
www.mass.;ov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH TEE PERMITTING AUTHORITY.
Applicant Information A Please Print Legibly
Name (Business/Organization/Individual): /A
�LS PAnvr
Address: 9•2 R. (r F int D0a Liti
--
City/State/Zip:S6 `i)Amavin Phone#: 6/7 Bal 3 ti Lia
Are you an employer? Check the appropriate box:
Type of project(required):
1.0 I am a employer with employees(full and/or part-time).*
7. ❑New construction
3.R I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers'comp.insurance required.) $• Q Remodeling
3.0 I am a homeowner doing all work myself [No workers'comp.insurance required.]t 9• ❑ Demolition
4.❑I ani 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.❑ Electrical repairs or additions
proprietors with no employees.
Plum60 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 12.❑Roof r ng repairs or additions
These sub-contractors have employees and have workers'comp.insurances 13.❑ Aof epaln
6.0 We are a corporation and its afncers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no employees. [No workers'comp. insurance required.]
*Any applicant that checla box#1 must also fill out the section below showing their workers'compensation policy lulu(motion.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such•
t-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-contactors 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 the
information.
InsuranceCompany Name:
Policy#or Self-ins. Lic. if: Expiration Data:
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 51,500.00
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 c • under th ains and penalties of perjury that the information provided above is true and correct
Siena - �.-- Date:if/OV 27 a if'/
phone#:G/ 7 Qat 304a
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 it:
• Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for then employees. •
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of Eke,
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 a joint 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 construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§250(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirement of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checldng the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s), address(es) and phone number(s) along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(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 Department of Industrial
Accidents for confirmation 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
Industrial Accident. 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 listed below. Self-insured companies should enter 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 sure 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"lob 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 permits 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
Boston,MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or l-877-MASSAFE
Fax# 617-727-7749
Revised 02-23-15 www.mays.gov/dia
• .644)e.„. TOWN OF YARMOUTH
BUILDING DEPARTMENT
1146 Route 28,South Yarmouth MA 02664 S08-398-2231 ext. 1261
HOMEOWNER.LICENSE EACEMPTION
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:
Pers on(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 P5.1.3.1)
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 yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy .Other type of indemnity Bond
OWNER'S INSURANCEWAIVER 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
Ithomeovnarlicexerap
T i
n,r � TOWN OF YARMOiTTH.
o -'r '`t BUILDING DEPARTMENT
tib;-5, 1146 Route 28,South Yarmouth,MA.02664
• 'Ht:.oceex 508-398-2231 ezt 1261 Fat 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 certifythat the debris resulting from the proposed work/demolition to be
conducted at '1/ )72..1r'1y;t&JOOb }-JJ
Work Address
Is to be disposed of at the following location: f/?ianJS rite sJA 'b4
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
• C.7.2.2itiza."....- Nv d-t ao1g
nature of Application Date
Permit No.
TOWN OF YARMOUTH
RE" -NED FOR BUILDING AND ZONING CODE COMPLIet
-
1'tAAPPLICANT FROM THE RESPONS'B iw or s BUILD E
E ERRORS OR OWISSIONS DO NOT i
�01�Y COMPLIANCE.
DATE:1• - '1-1% .
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