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Home My WebLink AboutBLD-20-121 -, 71/19 ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department : "'oF.....r 1146 Route 28, South Yarmouth,MA 02664-4492 ( t 508-398 2231 ext. 1261 Fax 508-398-0836i' -,ti 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 Only Building Permit Number Lb J e' &vi Date Applied: I ) Cenrs e 7- 1� ��ti Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers / I a� 2 - / Ymr w et- 1.1 a Is this an accepted street?yes no Map Number 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: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public ElPrivate 0 Zone: _ Outside Flood Zone? Municipal❑ On site disposal system 0 -- Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2. 1C�'of eco�l� ' lv`f t^'lv, v t T 1 /"L A' C�2( � ame(Print) (( Y City,State,ZIP I 46. Cu ft --y clr j-cis--Si3-3i :C No.and Street I Telephone Email Address SECTION 3:.DESCRIPTION OF PROPOSED WORD'(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) g Addition ❑ Demolition 1:1 Accessory Bldg. 0 Number of Units Other ❑ Specify: Brief Description of Propose Work':_`t,,.A.vc ,Z crii\' �c�%y c L Se r Qj,c„`ri 100,.., s c,,,,.,),. In c to 1 .•.r,�,. I",o.11L, r....vv/�." A CJ ' 4. r.►,n A CV i-,r�.frt ,v,5-c.1 (Ad...1 r recAr t•• 5W es-IrrGct� cm" 4L..CS SECTION 4:ESTIMATED CONSTRUCTION COSTS- Item Estimated Costs: Official Use Only (Labor and Materials) • 1.Building $ 100 1. Building Permit'Fee $ .l cV Indicate ho ' de rmine 2.Electrical $ 000 13 Standard City/Town Application Fee 0 Total Project Co 3(Ite 6)x multiplier 3.Plumbing $ 2. Other.Fees: $ .S List: 4.Mechanical (HVAC) $ ... 5.Mechanical (Fire Suppression) $ Total All Fees:$ Check No. Check Amount: Cash Amount: ki 6. Total Project Cost: $ 0 Paid in Full 4 Outstanding Balance Due: h SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) Cc 0\.v ` v 1. C ,"`);S y License Number Expiration Date Name of CSL Holder cAra C List CSL Type(see below) No.and Street Type Description n A A ' 0 ` 3\ Unrestricted(Buildings up to 35,000 Cu.ft.) '�(C-V /"\ ► 1 R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding t Solid Fuel Burring Appliances 79-4 —563 GLi1-6 CRC I uittlyM nCu lto 0 1"`u014sfii tTtn Telephone Email addres D Demolition 5.2 Registered Home improvewent Contr for(HIC) HI o HIC Registration Number Expiration Date mpanName or HIC Reg strant Name � Ac.�a..; c {1cic ' k1iv..3fe.,, ,,lclt‘n,ol l� +K►n.nw¢ et)'^, No.apd Streetrt o O247' qv)4 56 3 Email address City/Town, State,LIP 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 Issuance of the building permit. Signed Affidavit Attached? Yes (g[ No ❑ . 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 0L- ad lett 5 Sr to act on my behalf,in all matters relative to work authorized by this building permit application. Nt-rI tS 5 M c-C-r 4i (, --016--,0 -0I 1 Print Owner's Name(Electronic Signature) Date • 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 Nafne(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(RIC)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 www.mass.aov/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" The Commonwealth of Massachusetts Department of Industrial Accidents :l>111 1 Congress Street, Suite 100 _41 Boston, MA 02114-2017 www.mass.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): -Gk.-• C'L y �.(A CH I- (> oCCt Itr. Address: I z O{ilt- C.frctc 6t'ct,.ISVCcr lil O.2.0 3 I City/State/Zip: ,u>s}cr, M 0?631 Phone #: -513 -v4 24 Are you an employer?Check the appropriate box: Type of project(required): 1.N I am a employer with a employees(full and/or part-time).* 7. ❑New construction 2.21 I am a sole proprietor or partnership and have no employees working for me in 8. g Remodeling any capacity.[No workers'comp. insurance required.] 9. ❑ Demolition 3.❑I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 10 ❑ Building addition 4.❑I 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.❑ Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We area corporation and its officers 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 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. 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-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: 455oc ` J { lu1 "51,•( u. cyv.-1 c-✓`7 _ Policy#or Self-ins. Lic.#: Lj( C— 500 _ co 2O 369_ ZUi i A Expiration Date: 4-42--C Job Site Address: 18— Cicn vs) Wr 16 City/State/Zip: Yerr,^^ut—ki- rr4 t/ 0.ZC1S 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 u r the pai d penalties of ped at formation provided above is true and correct Si nature: Date: G ".2 C - Zo(`1 Phone#: (71 5-6 3 G 4-( -6 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#: • Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, 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, §25C(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, §25C(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 requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking 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 Accidents. 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"Job 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 bum 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 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia "� Y TOWN OF YARMOUTH .1._ `. �� . •V41 c BUII.DING DEPARI11IENT °, I ,x 11=�6 Route 28, South Yarmouth,MA 02664 5-� 508-398-2231 ext. 1261 Fax 508-398-0836 BUILDING DEPARTMENT 1/ 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 workldemolition to be conducted at ( ir � (Z L^), 0(• ')A. bef i Al A Work Address 0 Is to be disposed of at the following location: 1/46-6-.ur^1-t-x )1/4-k---r Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. C —�G — 20 I€1 ignature of Appti on Date Permit No. &��elfi(0- Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor ntractor Registration Type: Individual 7,1 sI Registration: 195393 JOHN CLOHESSY t Expiration: 04/25/2021 D/B/A CHC BUILDING AND REMODELING a 12 ORIOLE CIRCLE l BREWSTER, MA 02631 .. € SFr Update Address and Return Card. SCA 1 0 20M-05/17 Forn,na/zwead o1✓I�aJJa641JeffJ Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. If found return to: Reaistation Expiration Office of Consumer Affairs and Business Regulation 19533 04/25/2021 1000 Washington Street -Suite 710 JOHN CLOHE$S �:$ Boston,MA 02118 D/B/A CHC BUILD N ANDA4MODELING -77 JOHN M.CLOHESSY 12 ORIOLE CIRCLE ��4 . BREWSTER,MA 026 1 Undersecretary Not valid without signature C1 � jt♦ 1"milmmilemillr" //NNW" r () z. oc g E'er' r• 9--- •