HomeMy WebLinkAboutBLD-19-3815 ONE & TWO FAMILY ONLY-BUILDING PERMIT
Town of Yarmouth Building Department of e
1146 Route 28,South Yarmouth,MA 02664-4492 f"
508-398-2231 ext. 1261 Fax 508-398-0836 `a� t:E
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 Onl -
Building PermitNtmtber./'j t'.DY/9-6b5$/5.- Date Applied: •
-
�m rs
Building Official(Print Name) Sign Date.
SECTION 1:SITE INFORMATION •
1.1 Property Address:'p L /� 2 Assessors Map�8 Pareel Numbers
^F ' 441/el Wte
1.1a Is this an accepted street?yes ✓ noMap Number Parcel.Num ¢ L t,w r: 4
1.3 Zoning Information: 1.4 Property Dimensions: 1
JAN 03 19 ; '
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft) r u I i DING o e PR ;i}, r a r
Front Yard -.Side Yards Rear air) ---- —"---"-
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L e.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public La— Private❑ Zone: _ Outside Flood Zone?Check yes]] Municipal El On site disposal system
if
SECTION 2: PROPERTY OWNERSHIP',
2.1 Owner'of Record: iR(re &ll( Atte, C (�9k,'n c.�T"�ft
Name rint) City.State,ZIP
47eR( ,{€ s-tv- 34, 6/k
No.and Street Telephone • Email Address
• SECTION 3:.DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building U Owner-Occupied ❑ Repairs(s) oH Alteration(s) ❑ Addition O
Demolition 6- Accessory Bldg.0 Number of Units I. Other ❑ Specify:
Brief Description of Proposed Workt: eRgettrA c C f if C4•I / n(Q-t.T VC(V L`1
CON11-P21 G '9t & /ATlO $e 75 g-efO✓y
SECIION:4 ESTIMATED CONSTRUCTION COSTS. ,
Item Estimated Costs: OfSclal Use Onl
(Labor and Materials Y
1.Building $ /zi ) :1.. Building Petit Feet$:.ISO. Indicate haw fee is determined:
2.Electrical 'lbstaudard CityfiownAlipficationFoe `: . :•
.
r ❑Total Project Costa temm 611 x multiplier x
3-Plumbing $ �v, i; Other Fees: $ V
4.Mechanical (HVAC) $ - tit ?CD List '
5.Mechanical (Fire -
$
Suppression) Total AllFees:$ . . .
6.Total Project Cost $ Check/46. -Check Amount Cash Amo t-- -
r LI Paid in Full Otm(andip8 Balance Dtf I$
GEE'�[C�2O 2616
8
Obit a JtPARTMENT
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) o r_p at/
cf
r License Number Expiration Date
• Name 'cc' * t T-pu f / /�V/�
List CSL Type(see below)
No.and Street (� �( ^ - Type Description
3 ,yin U K J r(� "/K` u _ U Unrestricted(Buildings up to 35,000 cu.R)
City/Town,State,ZIP _ R Restricted I8c2 Family Dwelling
M Mafnryro + pmP(Tki ( RC Roofing
Covering •
WS Window and Siding
SF -`Solid Fuel Burning Appliances
Insulation
Telephone Email address D Demolition •
5.2 Re isterred Home Imprrovement Contractor(HIC) /f® ?35 • ' /f Q
- tc
'-" N
rAic4W,RVetbN HIC Registration Number /V7
4.
HIC Company Name arHIC D LA Registrant Name
No.and Street fC(3 `'
�-. 4 I o.4 r in a �'��.�/�-'r0 J� I C{i(IEmail address S .
City/Town,State,State,ZIP Telephone Cttc PmP/7i• 14
pmc T • NeT
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 Issuance of the building permit.
Signed Affidavit Attached? Yes 413' No . ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject pr..erty,hereby authorize 0 3aley? (3�
to act o. my :-half;in all ilirelative to work thorized by this buildin permit application.
Print 0 .- e(Electronic Signature) __ 1111�� / Da ee '
• 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.
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(HEC)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.eov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) /g pvr ,TO FT (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces /4 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"
• L w`
. SECTION 5:.CONSTRUCTION SERVICES .
5.1 Construction Supervisor License(CSL) O`F'9 p`f
•
/p,�' ,p •,--pip /n�,j/j� . License Number f gEx`piration Date
• NametP n. $a //��/�'.�
List CSL Type(see below)
No.and Street �j Type . .. Description
3 4'4vP t/K fir r i- RG U . Unrestricted(Buildings up m 35,000 Cu.R)
City/Town,State,ZIP R } Restricted 1&2 Family Dwelling
rO 46 b4ft�p _( j/�JI 4/ A
M / Masonry
/•j RC Roofing Covering •
WS Window and Siding
1g7-11F-0i SF Solid Fuel Burning Appliances
I )Insulation
Telephone Email address D Demolition _
5.2 Re'�i'sjteer�eedd�Home Improvement Contractor(IIIc) /70 73 c . 4 //it
/I ,7
�t/I�I�C A N � D HIC Registration Number FFF/xxxpuation Date
BIC Company Registiant Name
• a riteidRJR , /GLIts$
1
No.and Street mit/rioter-A, zt-up- jj 7)((af Email address
Cny�S.SM ..-Telephone ad Q*Comc c&r .e/N T
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 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 pr...4 ,hereby authorize QQ Iacz f T' e+)1/44 la
to act .. my :-halt;in all ... . relative to work authorized by this buildm permit application. d
'\ ) fr' LO_ J'L/' 9 /2
Prim pw� ...e(Electronic Signature)
• - -.SECTION 7b_: OWNER':OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains end penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
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(EC)Program),will not have access to the arbitration
program or guaranty find 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.eov/dns
2. When substantial work is planned,provide the information below:
Total floor area(sq.It) /yap ifQ F-7-, (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft) Habitable room count
Number of fireplaces N/A Number of bedrooms
Number of bathrooms Number of halfbaths
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
"L 33/4
_ ` _ Department oflndustrialAccidents
g =;'1111- • 1 Congress Street, Suite 100
ne:
•
._
•• r,—'� Boston, MA 02114-2017
%gime-� www.mass.gov/dia
\Yorkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information L Q Please Print Legibly
G�
Name (Business/Organization/Individual): 1i tail Ai ('p pi�?R/rc�On
,3 /( t' I'
Address: c4 ez- /g /
City/State/Zip:fl &P(t'yll 12)4 Phone#` 77[.-1(Ere?IF I
Are•
SS you an employer?Check the appropriate box:
Type of project(required):
1,6 am a employer with V\ employees(full and/or part-time).* 7. 0 New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. s-Remodeling
any capacity.[No workers'comp.insurance required.]
3. I am a homeowner doingall work r 9. ❑ Demolition
❑ myself.[No workers'comp.insurance required.]
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property.ro 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.g-Pt-umbing 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.eRoof 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.
LContractors 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. ���y r 0 P/�
Insurance Company Name: t'7V¢lis---�t p'(Akaw csa„ �+
Policy#or Self-ins.Lic.#: 64 9 ^, J f(0 493? Y/p Expiration Date: 0 9//
QDJ tq A a a
Job Site Address: al %(7\4//�C -L �- " N j`\ 'ity/State/Zip:Wit ay1iRApe.44
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.
Ido hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature: ` Aevt. L Date:
Phone#: p"r/ 9) /
Official use only. Do not write in_I 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#:
$ �o TOWN OF YARMOUTH
• g c BUILDING DEPARTMENT
• Tr `�'-`i $ 1146 Route 28, South Yarmouth, MA 02664
C_n s 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 p)-1 7 itePr•VG Cd\/
Work Address
Is to be disposed of at the following location: ' I( 7 7c o
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
Siy.a reo / ��
f App(icatlo Date
Permit No.
•
•
=yk=
NOTICE NOTICE
TO ( *1_i= TO
EMPLOYEES t t= < EMPLOYEES
7 •4
O1M 54%
The Commonwealth of Massachusetts
-DEPARTMENT OF INDUSTRIAL ACCIDENTS
1 Congress Street, Suite 100, Boston,Massachusetts 02114 — 2017
617-727-4900.— http://www.state.ma.us/dia
As required by Massachusetts General Law,Chapter 152,Sections 21,22&30,this will give you notice that
I(we) have provided for payment to our injured employees under the above mentioned chapter by
insuring with:
THE TRAVELERS INSURANCE COMPANIES
NAME OF INSURANCE COMPANY •
P.O. BOX 1450
MIDDLEBORO. MA 02344-1450
ADDRESS OF INSURANCE COMPANY
(6HUB-1K63222-5-18) 09-29-18 TO 09-29-19
POLICY NUMBER EFFECTIVE DATES
JOHN J LAMB INS AGCY INC 24 NORTH STREET
HINGHAM MA 02043
NAME OF INSURANCE AGENT ADDRESS PHONE#
Ea DUBLIN CONSTRUCTION INC 2 HERSEY STREET
SO YARMOUTH
MA 02664
EMPLOYER ADDRESS
EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
= provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the
E. injured employee. The employee may select his or her own physician. The reasonable cost-of the,services
provided by the treating physician will be paid by the insurer, if the treatment is necessary and cea'sonably
connected to the work related injuy_ In cases requiring hospital attention, employees are hereby notified
that the insurer has arranged for such attention at the
•
NAME OF HOSPITAL ADDRESS
TO RE POSTED RV EMPLOYER
•
°` TOWN OF YARMOUTH
• A c HEALTH DEPARTMENT
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site Location: a 7 -74kr r45 LA
N 4 , 1(1
'R Ri1O vt-h
Proposed Improvement: V L' C e i L t . ,� A i i 41
�` ct�J `r h'e t t , -e-pi .'rte, lir-f-ch. n!
rN/ ry m Q . ���h
C46rhl - ' • ,Tt Mid ya /�i lAi mB�T•elE?�edjZerr/m
Applicant: �r i 061-Prf ,�P ��g£ Tel. No.: 3 6A 4
n
711— 7/ —
Address: /S F�U `L A K /7c, �', �,ARf?i d (111-, Date Filed: Q 7t'1/17
**/fyou would like e-mail notification of sign off please provide e-mail address: ,O ,n
Owner Name: Jc"JRr �eRPQNe r �.� FR UL 4N V e7
Owner Address: !T O q M 191R moot-h ten /9 • Owner Tel. No.:"'"cat ^
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: C 2Q DATE: /2.--)-e elf
PLEASE NOTE
CO ENTS/CONDITIONS•
.. !rk% .a• lit 4 i/ g • A ttr ' !'..t/`/
cxist Door rah TOWN OF YARMOUTH
REVIEWED FOR BUILDING ANC ZONING CODE COMPLI-
•
oZ 7 HI sot,y RI_ ANCE. ERRORS OR OM IISSIONS DO NOT RE -VE THE
APPLICANT FROM NE RESPONSIBILITY OF • •UILP
• ow COMPLIANCE.
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•
®Beia.Caacade Triple 1-3/4" x 11-7/8" VERSA-LAM 2.0 3100 SP Roof Beam1Kitchen
Dry i 1 span j No cantilevers j 0/12 slope November 28,2018 10:20:09
BC CALC®Design Report
Build 6538 File Name: BC CALC Project
Job Name: Richard Serpone Description:Designs\Kitchen
Address: 27 Harding Lane Specifier.
City,State,Zip:West Yarmouth, MA Designer.
Customer. Company: •
Code reports: ESR-1040 Misc:
Connection Diagram Disclosure
a a beCompveifedbys anyo ewowracy ofinput on verified by anyone who would rely must
output as evidence of suitability for
particular application.Output here based
• • • on building code-accepted design
• sis methods.
• i• • - Installation of Boisrties and e Cascade engineered
• wood products must be in accordance with
current Installation Guide and applicable
• building codes.To obtain installation Guide
or ask questions,please call
a minimum= 1-1/2"c=8-7/8" (800)232-0788 before Installation.
b minimum=6" d=24" BC CALC®,BC FRAMER®,AJSTM
e minimum= 1" ALWOIST®,BC RIM BOARD'TM,BCI®,
Install Screws with screw heads in the loaded ply. BOISE GLULAMTM SIMPLE FRAMINGSYSTEMS
Member has no side loads. PLUS® VERSA R M®M®,VERSA RIM
Connectors are:SDW22500 VERSASTRAND®,VERSASTUD®are
trademarks of Boise Cascade Wood
Products L.L.C.