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Bld-20-001363
, e.)./c,c.vL VA 4 ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department "oF "r' __ 1146 Route 28, South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508-398-0836 '�i'�■ R `�`Massachusetts State Building Code, 780 CM Building Permit Application To Construct, Repair, Renovate Or Demolish :.,, ". g ) t a One-or Two-Family Dwelling 1 k, —,:-...--1 This Section For Official Use Only 1 % SEp -- ;3 ►ql G Building Permit Number:$ - 0 lJ ),/36 Date Applie • r i ,cD1NC if-r FTt nr 1 Building Official(Print Name) Signature Date /-r „,v P.e- eikfrsi. Lave SECTION 1:SITE INFORMATION , �Property ddre : 1.2 Assessors Map&Parcel Numbers /i09 er w. Litpd e- 59 L o f- .1 7 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: jr. 12- 4o Res;deAhal 47,04c 1° 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 3o-4• plo4f . ao-Ft 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Public% Private 0 Municipal 0 On site disposal system ,Ig( Check if yeses SECTION 2: PROPERTY OWNERSHIP' 2.1 O er'of Record: Ar4cw $ Coffee* 6r/u cc �'ia- s 144-7, hi / 0 5 6 Z Name(Print) City,State,ZIP 424 Darnels Rd2. Foa-3641 051 accar4tcc;yya�av• No.and Street Telephone Email Address/ SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction❑ Existing Building g Owner-Occupied fil Repairs(s) 0 Alteration(s) IS Addition ❑ Demolition 0 Accessory Bldg. 0 Number of Units / Other 18( Specify:POirdk oo f Brief Description of Proposed Work2 Bt4 1 a r oo f ` 1*44 tf46le roof) 0✓.ele . ,t ��s�A,g 4-0A/ -�.-r . U SECTION 4:ESTIMATED CONSTRUCTION COSTS. j ,f { n Item Estimated Costs: Official Use Only G D IL5 (Labor and Materials) 1.Building $ Soo, ' 1 Building Permit Fee:$.7 Indicate how fee is determined: 2.Electrical $ -21 Standard City/Town A lication Fee 0 Total Project ost3(Item 6) u 'plier. . x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List 5.Mechanical (Fire Suppression) $ Total All Fees: Check No:. Check Amount: Cash ••..i ount: 6.Total Project Cost: $ �Q� 0 Paid in Full 41 Outstanding Balance sue: L1/40 r , SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL Type(see below) No.and Street Type Description 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(HIC) HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name No.and Street Email address City/Town,State,ZIP 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 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 authorize to act on my behalf,in all matters relative to work authorized by this building permit application. 9/2/i 9, c OG✓ ie- 'iA.ri Print Owner's Name ectronic Signature) Date • SECTION 7b: OWNER1 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's true and accura e to the best of my knowledge and understanding. A+alitCC arm ?Ali9 Print Owner's or Authoriz 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 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.eov/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.) 4,7 Dt .i Habitable room count 7 Number of fireplaces / Number of bedrooms 5 Number of bathrooms 2 Number of half/baths Type of heating system o i/ .6se4 Number of decks/porches 3 3 Type of cooling system //on/E Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" . The Commonwealth of Massachusetts -- liM itil I Department oflndustrialAccidents -_ _ 1 Congress Street, Suite 100 �f'�__ Boston, MA 02114-2017 • um s'' `� • 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): 4/1- C/:Q/^/K CC 1. Address: 4014 AO ,eis lj• City/State/Zip: .SAj 6w' If• p.So26 Phone#: O � —391— O 1 5' / Are you an employer?Check the appropria c box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. 0 New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ixi Remodeling ' any capacity.[No workers'comp. insurance required.] 3.®I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑ Demolition sotke 10 E] Building addition 4.X I am a homeowner and will be hiring contractors to conduct 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.❑I 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.* 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. *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: 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: `�iG" e/4/G,4s��w Date: 9/// 9 Phone#: 'Oil—3,-It - Q i •s i 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#: TOWN OF YARMOUTH u BUILDING DEPARTMENT MWa;�� p E, 1146 Route 28, South Yarmouth,MA 02664 508-398-2231 ext. 1261 HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DATE,: I/42%/I JOB LOCATION: /c qhf er /llwl L.(,j�Je 5 01.cfh ) csioL1 & NAME STREET ADDRESS SECTION OF TOWN "HOMEOWNER"/PI"NAM. "1-4¢ --01kd7 6POA-369--0 IS/ ce//) NAME HOME PHONE WORK PHONE PRESENT MAILING ADDRESS dM4 ,Oa,,�el s Hai . Slta .5ba-y �/f, o sot foa CITY OR TOWN STATE li N 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 peinuut. (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. w HOMEOWNER"S SIGNATURE ai ebtLeegi 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 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. ayed4L4.,€ Check one: Signature of Owner or Owner's Agent ,ii Owner Agent h:homeownrlicexemp °x Y� U TOWN OF YARMOTH :yg C BUILDING DEPARTMRNT • Y =`st = y 1146 Route 28,South Yarmouth,MA 02664 tea.... 5 508-398-2231 ext. 1261 Fax 508-398-0836 BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.GI. Chapter 40,Section 54 and 780 CMR, Chapter 1, Section 111.5, I hereby certify that the debris resulting from the proposed work/demolition to be conducted at l5 41/aer- Pl�lti7 L4, , X1r u14 • Work'Address Is to be disposed of at the following location:irma 1-41 ,t2/f Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. 9/2/// 9 Signature of Application Date Permit No. 9/02//4? 1(/Aaln /T 7cowcee'.vj 1'4A/ ov 6;=•yeK' 'Logi 4.t.e__ 1 ermir ge.ae, z— I/ e • C412 JktcGc 641("ele iIrl" (o I I e en) CaiZ 1 to c.c i �°r°'= ��,) AA- £/eu ©,�v 15 6i,o of Pion Lase _ ,' oc A /�✓ 'ON i of ILr 1111111_ ..6.1111111111 TOWN OF YARMOUTH :din REVIEWED FOE'gl IILDI�lG AND ZONING CODE COP�IPLI- Nevi) propoaeS) goo- .i,i.. ANCE. ERROIS OR UndrIISS:ONS DO NOT RELIEVE THE • e 1 APPLICANT FROM THE RESPONSIBILITY OF"AS BUILT' 0 U ex 1 JT'0.0g -cro off for dt, - COMPLIANCE. /DATE:9 -id, -r9 __ BUILQIIIG O _Pfi IAL _ _ ' r / . 11L-IIl I(i ...,- 1 ___ __.__ _�._ . . i I 1 II ir 3_ 'A 1 I �1 , i I ' - .--,-.. .1 F.1.-ILIYIL . .....).../..±:u...._.,_ ,L ,.,,, ..), 0 . ii , --r---�- a r- I : - ' i � [ F i'Stil'i u_. L � �0� - L' 'n „ >~ p ee 7`I 7 r t 1 a . ,.r gai k ta • ®r; ; I MIN I• MIN' { • I Er I , i • { .. !�Sts o ., , ! ,, , ......___.................... , . • i,_. „..! ! : •• . 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