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HomeMy WebLinkAboutBLD-19-3822 ,. 0/ i /4/lf• • ONE & TWO FAMILY ONLY—BUILDING PERMIT Town of Yarmouth Building Department or v 1146 Route 28,South Yarmouth,MA 02664-4492 ,�►�" 508-398-2231 ext. 1261 Fax 508-398-0836 F ' Massachusetts State Building Code,780 CMR Building Permit Application To Construct,Repair, Renovate Or Demolish ' a One-or Two-Family Dwelling This Section For Official Use y ! R F C F Ill ED �� Building Permit Number: . ,' �G" ,no Date Appli : , r' M rs I -1.:Iq . .. 29 20'8 Building Official(Print Name) Signature' - [ DEC__.__Date_ GUi'�L`: � ?: 1 110IMENT SECTION 1:SITE INFORMATION or S t�. 1.1 P�opuly,A\dAdre;s; 1.2 Assessors; ;. &Parcel Nugi e7 1.1a Is this an accepted stre a no Map Number Parcel-NGmber 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District - Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Aw i f Sj_ t/foPb p;Trost-ff.) 42.l e. . Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public f9 Private 0 Zone: _ Outside Flood Zory+? Municipal 0 On site disposal system [e'' Check if yes fi]/ SECTION 2: PROPERTY OWNERSHIP' 2.1 r' A Record,: W j Q(L�O 3'MPOZSF4/6^ KOSS Name(Print) 55e5 - - hass CAA 321-7 ,5k- 1 vi L ►- ;a_ can 1.1 No.and S Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building V Owner-Occupied ❑ Repairs(s) 0 Alteration(s) Fri Addition 0 Demolition 0 Accessory Bldg.0 Number of Units Other ❑ Specify: Brief Description of Proposed Work2:-- as • !_ %v... 4.. • P.M.Late ' ''" • I 3 r-_ — • . — SECTION 4:ESTIMATED CONSTRUCTION COSTS C (.4-€1 I= '� Item Estimated Costs: Official Use Onl (Labor and Materials) 37JAN 3 ?(i 9 1.Building $ 26-c9 302%) :1..Building Peim t Fee:$1 50.. Indicate how fee is determined: 1 2.Electrical $ /c/JD _ lil Standard City/Town Application Pee `5.1. ❑Total Project Costs Item 6)x multiplier - ---- ---- 3.Plumbing 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire ' Suppression) $ `�_ Total All Fees $ Checkit. Check Amount Cash Amount - ' 6.Total Project Cost: $ elbi 0 Paid in Full al Outstanding Balance Due: IIS SECTION 5:.CONSTRUCTION SERVICES 5.11 Construction Supervisor License(CSL) �5 07 9/n 7 5/2-9/20 • V C µti,(Q License Number 1717 Exion te Name of CSL Holder 16' C__ _cc. n P e List CSL Type(see below) No.and Street Type . .. Description it—VICS. O 2-bo U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted l&2 Family Dwelling Iit. M Masonry _ City wn,State,ZIP - RC Roofing Covering WS Window and Siding _ ter- SF Solid Fuel Burning Appliances —LHo -$Z66 Irmcsmiti hster0 I Insulation Telephone Email address gNA t ).CtrM D Demolition 5.2 Registered Home Improvement Contractor(IIIC) /36oe13 / 3G 003 ' tr/zy ?.� {�>�6 C.t= 1"�t r 1 c HIC Registration Number E:CPuatio Date HIC Company Name or HIC Registrant Name (4 re/X.12 ren4a,,(M khru_ts>_Ms O5 Gq)qMcta coils No.and Street . Email address (-Ey ttt4t a MN 5613-Zee -RZ66 Citytiown,State,ZIP Telephone SECTION 6:WORKERS' COMPENSATION INSURANCE AllIDAVIT(M.G.L.c.152.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this a plication. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. 4$% Signed Affidavit Attached? Yes 0 No 0 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 authorized)CZ. MILLS to act on my behaliy in all matters relative to work authorized by this building permit application. 13kccc MILES N-7245[11?-, Print Owner's Name(Electronic Signature) [D'ante • • SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under 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. µassA{A Ross 14 to J(a Print Owner's or Authorized Agent's Name(Electronic Signature) - Date • NOTES: I. 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 MC Program can be found at www.mass.zov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) F4'/4_ (including garage,finished basemen attics •ecks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces $74 Number of bedrooms /. Number of bathrooms Number of half/baths , —. ez Type of heating system t ` 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 Department oflndustrialAccidents =111r11= 1 Congress Street,Suite 100 • • : INE= Boston, M4 02114-2017 www.mass.gov/dia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): 'f cJGE ((_(r c' Address: 16 Croa-ka.c.9- pc,,,A City/State/Zip: -Nya -ab� Phone#: 5-'39 2L7 —e zicre Are you an employer?Check the appropriate box: Type of project(required): 1.❑I ployer with employees(full and/or part-time).* 7. ❑New construction 2 am aam a sole proprietor or partnership and have no employees working for me in 8. i—tdeling . any capacity.[No workers'comp.insurance required.] �,[ 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. l�liemolition 4.0 I 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. _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? 13.0 Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§I(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: Va Policy#or Self-ins.Lic.#: W 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify tinder the p and enalties of perjury that the information provided above Ls true and correct r Signature Date: if 't-efai(s Phone#: eZ (7 Ulm —lee — (o6 Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# • Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: of YaR TOWN OF YARMOUTH BUILDING DEPARTMENT x ;7= 9< ... 1146 Route 28, South Yarmouth,MA 02664 508-398-2231 ext. 1261 HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DATE: • JOB LOCATION:MAETS rekuJNI RD YARmovra NAME ; SSTT$,EE�RDR,SS,+0 SECTION OF TOWN "HOMEOWNER" MP�Sgrs. RoSs 3o/L �Z22—J1J3 S4ato•t tc NAME HOME PHONE WORK PHONE PRESENT MAILING ADDRESS 22_7 jA--51—lb► frrf—MA02-639 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 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 APPROVAL OF BUILDING OFFICIAL INSURANCE COVERAGE: I have a curre. 'ability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch.142. I po No If you have_cher -• es, please indicate the type coverage by checking the appropriate box. • lability insuran - •e '- • Other type of indemnity Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by apter f the Mass. General Laws and that my signature on this permit application waives this requirement. C one: Signature of Owner or Owner's Agent Owner Agent h:homeownrucexemp •YA • o TOWN OF YARMOUTH • a yg y BULLDING DEPARTMENT • • — 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 1115, I hereby certify that the debris resulting from the proposed work/demolition to be conducted at S PAcntti - kou"TR{ Work Address Is to be disposed of at the following location: 15 RA- Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. Iv Ito Signature of Application Date Permit No. . • • • • • ®I Commonwealth of Massachusetts • • Division of Professional Licensure Board of Building Regulations and Standards . i Constrge�hfrl%apervisor • CS-078587 E Tres;05/29/2016 • • BRUCE PMilY llS ik.++ "_ • • 16 CROOKEDPOND ROAD ,i' HYANNIS MA 02601'.'•:;" • �`^• _• r.t 'r,,;, L61 't��1SS1:3 ' ... ... • • • • Commissioner • l • �CFi-t g ^t-6L • • ' ...91; rmmevrreveldg!raaauao4.$e4A Office of Consume Affairs&Business Regulation • HOME IMPROVEMENT CONTRACTOR TYPE:Individual EeaLatratioq g roiratloq 1360Q3. . 09/242020 BRUCE MILLS1 Ir- "' ca • F H BRUCE P MILLSk I*f 1. \2t ,�- 16 CROOKED PONDRO. T3Qr U _ Y HYANNIS,MA 02601't?y-`" Undersecretary • • . > xlsne, . r M fess • r - ►.` ' -6;1E- { (is' -. 1 A �._ k._._...• $ ,_✓ �.P1... '.....-... ' ✓Tr .. . Y1T� 3'64' t - - - ,pos.s N,FibM‘ t I.AYo (stcr 3 . f1EW `. 2X�f- iiA�S IARo�N�,1 r .. Naw Sias To c&wcR ,!'v_„ ' _ . 0,r �. . .. 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