HomeMy WebLinkAboutBLD-19-2732 L.► ONE & TWO FAMILY ONLY-BUILDING PERMIT
Town of Yarmouth Building Department or r
tti
1146 Route 28, South Yarmouth,MA 02664-4492
508-398-2231 ext. 1261 Fax 508-398-0836 l' '
Massachusetts State Building Code,780 CMR
Building Permit Application To Construct, Repair, Renovate Or Demolish
a One-or Two-Family Dwelling R C E ED
's Section For Official Use ('' I
Building PermitNumber. �/ ate Applie r4 .1
1 IQf 2019 J
/ \'1.. CS 'j-� ' .//-/r-is• eUILDINGGPEPA'RTMENT
Building Official(Print Name) . t/ Signatures . .. . . , . Y . _
SECTION 1:SITE INFORMATION
1.1 Pro erty Address: 1.2 Assessor/s M,ap&Parcel Numbers
74Zen L41/e. Seq//, gee
1.1a Is this an accepted street?yes !/ no Map Number Parcel timber
13 Zoning Information: 1.4 Property Dimensions: R E
C ,EI(V E ID
Zoning District Proposed Use Lot Area(sq ft) Frontage ) �-^' +`�JJJ'---7
NOV 19 2019 1
1.5 Building Setbacks(ft)
Front Yard Side Yards R} tf4,DING DEPARIiMENT
Required Provided Required Provided Required ` er ovided— �_
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: ' 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? lel
Public 0 Private 0 Check if yes❑ Municipal 0 On site disposal system 0
• i
SECTION 2 PROPERTY OWNERSIITPI.
2.1 Owner'of Record: NJ
MAC/.&t'cXLcN.o 0/24/CA/C-7/Pit Co rMCJ . ..),
Name(Print) City,State,ZIP��//79 )
4c
9, 'GBere A'n DG_/'7o
No.and Street Telephone Email Address fi
SECTION 3:.DESCRIPTION OF PRQPOSED WOR1C2(check all that apply) c---
New Construction 0 Existing Building Owner-Occupied 0 Repairs(s) ❑ Alteration(s) ❑ Addition ❑ ps
Demolition 0 Accessory Bldg. 0 Number of Units 1 Other 0 Specify: _ \\
Brief Description of Proposed Work-2: '"Q
.ZJ$24t1// /0[.b.OD00/52 A Prof>/ojii,J Pxtigcio/1( VI t
fltC&,afn 0 C/,/ee/-,Oc/c ,4#i e (h
.
SECTION4:ESTIMATED CONSTRUCTION COSTS II
Estimated Costs: •
Item Official Use Only
(Labor and Materials) ,,
1.Building $ 9700, 0 e 1 Building Permit Fee:$.4,0b Indicate how fee is determined:
2.Electrical $
4 Standard City/Town Application Fee
❑Total Project Cost;(Item 6)x multiplier x
3.Plumbing $
4.Mechanical (HVAC) $ List
5.Mechanical (Fire
Suppression) $ Total All Fees $ '-
Check N6; Check Amount Cash Amoun/t Q Y
6.Total Project Cost: $ O Paid in Full , irk Outstanding Balance Due: U q
M
SECTION 5:.CONSTRUCTION SERVICES
•
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder List CSL Type(see below)
• Type .. Description
No.and Street '
U Unrestricted(Buildings up to 35,000 cu.ft)
R Restricted I&2 Family Dwelling
City/Town,State,ZIP M Masonry
• RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HTC)
/72 7.5"3 HIC Registration Number Expiration Date
BIC Company Name or BIC Registrant Name
S'i"Lluif/ /,fie.rMA'D
No.and Street Email address
1 s /Sec,/,vy Rj/2 or tnA/e744-761,-.93:7s-
City/Town,
City/Town,State,Ziff 1.des yA/L/y/Othw Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE Al'FWAVIT(M.G.L.e.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...........la-
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 C7PAue/ gevog,vo
to act on my behalf;in all matters relative to work authorized by this building permit application.
fJAR1 &fcRh4v o //.3/a0/S-
Print Owne 's Name(Electronic Signature) Date
• SECTION 7b:OWNERI 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(HIC)Program),will not have access to the arbitration
program or guaranty find under M.G.L.c.142.A.Other important information on the BIC Program can be found at
www.mass.govlora Information on the Construction Supervisor License can be found at www.mass.gov/dps
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/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"
•
• r.YAR TOWN OF YARMOUTH
• . ° BUILDING DEPARTMENT
0 -ask
` 6A.-Wn,= ? 1146 Route 28, South Yarmouth,MA 02664 508-398-2231 ext. 1261
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE:
•
JOB LOCATION: /1fi}a 4vagC9j✓r✓ /3 papte g GN Sony/a2 e -r+
N STREET ADDRESS SECTION OF TOWN
"HOMEOWNER" m'9n/ 4i/rfl4cD flo-7a9--Ha91 NAME HOME PHONE WORK PHONE
PRESENT MAILING ADDRESS 9Fi/i6/IdeeRae
/WA/CAW 740,iL Cana/ e',44 oVO
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 be / she will comply with said procedures and
requirements.
HOMEOWNER"S SIGNATURE *t_,-y
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 o
es
If you have checked , p ease 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 required by
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 Swaer Agent
h:homeownrlicexemp
•
The Commonwealth of Massachusetts
• `t=� l Department ofindustrial Accidents
_niltl_ . 1 Congress Street,Suite 100
a Boston,MA 02114-2017
=Fad •
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMI i i INC AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): m/94/ea CA'1,efrogio
Address: 9 nje, &nW ,e,,
City/State/Zip:aA.ics/e,Sf ,. CO4/Al Phone#: 'e'-7029• 5/.3 PP
Are you an employer?Cheek the appropriate box:
• Type of project(required):
1.0 I am a employer with employees(full and/or part-time).• 7. 0 New construction
2.[J4tm a sole proprietor or partnership and have no employees working for me in 8. 0-12.:modeling
any capacity.[No workers'comp.insurance required.]
3.01 am a homeowner doing all work myself.(No workers'comp.insurance required.):
9. 0 Demolition
10 0 Building addition
4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will
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 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.1E-Roof repairs
These sub-contractors have employees and have workers'comp.insurance.:
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other
152,§I(4),and we have no employees.[No workers'comp.insurance required]
*Any applicant that checks box 111 must also fill out the section below showing their workers'compensation policy information.
:Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contactors 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:
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 certify under the pains and penalties of perjury that the Information provided above is true and correct
Signature: y i,a- C.-•"' Date: j%%Zv/..c
Phone#:
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 Departinent 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
•
Contact Person: Phone#:
`• : z°� rte° TOWN OF YARMOUTH
• a :vg y BUILDING DEPARTMENT
• e � $ 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,
[hereby certify that the debris resulting from the proposed work/demolition to be
conducted at_3/1 Z/Me/0 L6fl .Serf A ON
74/
Work Address
Is to be disposed of at the following location: 1A90dss6
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
/fr/...y. /1(.-.4—wC .49/3-076 ./...0
Signature of Application Date
Permit No.
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3 • o e TOWN OF YARMOUTH
r 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451 U07L�St
`'" Telephone(508)398-2231 Ext. 1292-Fax(508)398-083 I e\-h
CP t>•--
OoD KING S HIGHWAY HISTORIC DISTRICT COMIRECEIVED
OCT 3 7 ;Tit; APPLICATION FOROCT 3 0 2018
TOWN CLERK CERTIFICATE OF EXEMPTION YARMOUTH
SOUTH YARMOUTHn.,. O/LI KING'S HIGHWAY
Application is hereby made`fdr the issuance of a Certificate of Exemption under Sections 6 a o hapter-a
Acts of 1973, as amended, for the proposed work as described below and on plans, drawings, or photographs
accompanying this application.
Type or print legibly:
Address of proposed work: 3 ' 2f41€/? /suKe So t4 e , . .. , i ap/Lot#
Owner(s): "MY' • egCM..i.nN1) Phone#: :MO- 707,-41:41,97
All applications must be submitted by owner or accompanied by letter from owner approving submittal of application.
Mailing address: 9 Q , O / ciar S/PC7 enMrueie4r< Year built: /9,S-9
Email: /UOi✓e Preferred notification method: v Phone Email
Agent/Contractor. Sf/9ir/Gey /Po/s//9V0 ,/ 1 Phone it::: 77Q-26P- 99.555
a'
Mailing Address: c "roc/e a:G /empty 4,4„,,,, �e$T-x4c2b nov- #
Email: d� Preferred notification method: L-' Phone Email
Description of Proposed Work(Additional pages may be attached If necessary):
gcpM eal /a £xr/,d&,vy t4wn
O •7S, a-0/-2/ /ON?.adleieiOaeS ,9x. a1/0 S2x Anap
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/4yoe esenl/niece)area d e,QA,/sNrd..c'
�/il/W t ePxtown_ 1`5e/iv/ &robe/ Ano dao d. l�ep&cu9 ffF�&1t1
�t`R/p ft/J ''Bine,' b/ogre at/c/ALle-60�pq, -rerr R/?ehlht4e `y esi 5/-Iw eeS
ReJ°Ainf bode, f ;flisfir/Ley Goco,c 4Gee
Signed(Owner or agent): S / agile Date: /'O 30 -79----
>
"E> Owner/contractor/agent is aware that a permit may be required from the Building Department(Check other departments,also.)
> This certificate is good for one year from approval date or upon date of expiration of Building Permit,whichever date shall be later.
For Committee use only:
Date: /O-3o-7 Ss" V Approved Approved with changes_ _Denied
IAPP V I
Amount 'ty� Reasonfordenial:
. i
CK .
cas Ig7a
Lam ,
Rcvd by. i
C I OLD KING'S V'
HIGI^ IAY j
_
Date Signed: f0/3 ( Zo/-g" Signed: 2 .
APPLICATION#: J -L //9
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G7e''mironwea/tA nt@'Mina cAtue/a
Office of Consumer Affairs&Business Regulation {{II
iti F-_tt OME IMPROVEMENT CONTRACTOR
r �_ Registration: 178253 Type:
6 •!p
1.4441 " Expiration3!31/2018 Individual
STANLEY ROMANO . -
STANLEY ROMANO
25 MOCKING BIRD LANE \,c..crL••.
W.YARMOUTH,MA 02673 Undersecretary
•
Commonwealth of Massachusetts
Division of Professional Licensure
• Bi rd of Building Regulations and Standards
Construction'Supervisor
CS-045800 Expires: 05/20/2019
WILLIAM J KROUZEK,III' _fes
725 PLEASANT ST#511
NEW BEDFORD MA 02740
•
Commissioner CL
ot:4 4 TOWN OF YARMOUTH
,' • .c HEALTH DEPARTMENT
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site Location: /&'/ Z4Ze/1 L.9ye Soyer/g/z to
in-17 r/00
Proposed Improvement: cyop/-17oox gA/t t 5 L1LSP,4 1r1, /�,q/,✓�,� P/?/o/a
/,/4br !2//All�A/,S Dou/,v $Y4rnsf/,�Q/2.a/c '7n CR trealFort S7`nir49c
dwL V
Applicant: %404eisi (;PnyZei& Tel. No.:Si,P- .y/
Address: 7v7SjeP05/SdA•71'Sf A1�Aid eedteizvj /7142 Date Filed: /�j/�
•*Ifyou would like e-mail notification of sign off please provide e-mail address:
Owner Name: Mee/ evcM44
Owner Address: /1vGrtpvc fit, ,442,var/ec*n Owner Tel. No.:24oa
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: Pari---V/A DATE: l/f/ h a
PLEASE NOTE
COMMENT/CONDITIONS:
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(dip 74,X94 if b /./ RECEIVED
TOWN OF YARMOUTH ' }r �C // NOV U 1 2018
REVIEWED FOR BUILDING AND ZONING CODE COMPLI- 1
ANCE. ERRORS OR CMMISSIONS DO NOT RELIEVE THE /? /9 ZALP� Z-Mv rourf i/094,.,4!'&214 HEALTH DEPT.
APPLICANT FROM THE RESPONSIBILITY ' S BUILT'
COMPLIANCE. •
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