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ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department op
1146 Route 28,South Yarmouth,MA 02664-4492
508-398-2231 ext. 1261 Fax 508-398-0836 ;..* !?
Massachusetts State Building Code,780 CMR
Building Permit Application To Construct, Repair, Renovate Or Demolish
a One-or Two-Family Dwelling ' --__ _.._V" _..__,m_. _.,,......
This Section For Official Use Only _ �
Building Permit Number:75G0`aqD- /36/" .Date Appli-• G n i
Building Official(PrintName) ia, _.. Date _--_
SECTION 1:SUE INFORMATION -
1.1 Property Address: � � gA 1.2 Assessors Map 4 Parcel Number
aD. V1P :I- / a / gy
1.1a 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 0 Private CI Zone: _ Outside Flood Zone? Municipal 0 On site disposal system ❑
Check if yes❑
SECTION 1: PROPERTY OWNER.SI 1
2.1 Owner'of Record:
Tom(--t M e-)o f rnti a r-A.Q,.-F'1,. l M A- I
Name(Print) C' State,ZIP
2 a 3 G rttk j ki tbS -erN Qe4 $eS`d•520"AU A.Pieutt0M•r gZ0a.w.- Ae"".**---
No.and Street Telephone Email Address
SECTION3:.DESCRIPTION OF PROPOSEDWORKZ(check,all that apply)
/
Br-Owner-Occupied Construction 0 Existing Building �Owner-Occupied 1 Repairs(s) [l Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other ❑ Specify:
Brief Description of Proposed Work2:
eplac,s R®— -ki 7) eoK
SECTION:4:'ESTIMATED CONSTRUCTION COSTS. : -
Item Estimated Costs: `: OMCialV a OnI ',
•
(Labor and Materials) ... y,
1.Building $ o p :1.:Budding Peimit Fee:$ .4$.. Indicate how fee is determined:
2.Electrical l�Standard CitytTown Application.Fee
$ t ?. �° i
❑.TotaiProject Costa(Item6)x.multiplier
3.Plumbing $ 2. Other.Fees: $ `_v ` W 3'
4.Mechanical (HVAC) $ List: '' . - i SEE ? h 2e� ; i
5.Mechanical (Fire $
Suppression) Total All Fees:$ i ;3 •,,
CheckNo: Check Amount: .Cash Amour -- --
6.Total Project Cost: $ .4 v o o p Paid*Full ®Outstanding Balance Due: 63
TOWN OF YARMOUTH
( )) BUILDING DEPARTMENT
1146 Route 28, South Yarmouth,MA 02664 508-398-2231 ext. 1261
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE: 813oh0/9
JOB LOCATION: Meloomsoh ,443 Greai L eS4-eyn PA .
NAME STREET ADDRESS SECTION OF TOWN
"HOMEOWNER" ?a0.0.4- M rl at p^ r.. So P—s?i —at4s M8
NAME HOME PHONE WORK PHONE
PRESENT MAILING ADDRESS Mart,. 1 to H eiJ Vj �Rq+ a Pe.i+n
Frah yI /11 A, '741'
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 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.
•t Check one:
ature of Owner or Owner's Agent Owner/Agent
h:homeownrlicexemp
The Commonwealth of Massachusetts
°"_= —eft Department oflndustrialAccidents
?Mil. 1 Congress Street,Suite 100
1.1= 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): trek s.e tPk,Q tQ b SOA
Address: ) 3 G r f U3 e.I'f'rrti 2a
City/State/Zip: Yet f wk C Phone#: st a -s?o-80 6,o
Are you an employer?Check the appropriate box: Type of project(required):
i.0 I am a employer with- employees(full and/or part-time).* 7. ❑New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling
any capacity.[No workers'comp.insurance required.]
3.0am a homeowner doingall work myself. t • 9. ❑Demolition
y [No workers'comp.insurance required.)
4.0 I am a homeowner and will be hiring contractors to conduct all work on my 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.Q Plumbing repairs or additions
5.❑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.Q Other
152,§I(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also till 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. lithe 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.
1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
ature: Lie-, Date: /9
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 Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
5.Other
Contact Person: Phone#:
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 1&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 Company Name or HIC Registrant Name HIC Registration Number Expiration Date
No.and Street Email address
City/Town,State,7TP 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.
Gam[ �--� PIb o)c/9
rin� ame ectronic 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 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.IL) , 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"
1, . o� Y o TOWN OF YARMOUTH
'vt c BUILDING D EPARTIMMENT
• °. t = ,4 114 6 Route 28, South Yarmouth,MA 02664
t , 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 1113,
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at a o a at rat IJPs7441 /CJ
Work Address
Is to be disposed of at the following location: h Dy_
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
Si attire of Application Date
Permit No.
• ot:Y TOWN OF YARMOUTH
''' 0
A. c HEALTH DEPARTMENT
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site Location: a o 3 Grew - tJ estrrv, 4
Proposed Improvement: Pecvvs 't'- G s 1hl cl ea_. /e1' x/y
Applicant: Tsai, } Ak e.t a vti Mei Tel. No.: SOk— S70 --(406 Q
Address: J-3 6,,P,ze .1- A j ¢.rr-A ';,( Date Filed: Pig b/ o)9
**/f you would like e-mail notification of sign off;please provide e-mail address: 1'h e I etps tin.roc Cw s,.ems+, h Pl-
Owner Name: 2—cc n e'- )4& k e,yap,b.\
Owner Address: r,{ M k a*s of Owner Tel. No.: ,fie._3.?0 _eD4 0
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: rir DATE: a 3G 1 1 of
PLEASE NOTE
COMMENTS/CONDITIONS:
Town of Yarmouth
Subsurface Sewage Disposal System As-Built Information
Street Address: 202 &/2-Otr OJEST81144 R11). . Ma 1 O p� P rcel: �/O
Y
Owner Name: fYLAcNGS A140 3-f eT M e L- dvs.o t( Permit#: Bad TG (9 -0377
Date Installed: O - l Z ' / [ New: Repair: S _
Installer Name: cAeeweb.' el-cT42'Qise1//SBaCRY 8. 6 Installer Phone; R' 77 2 '7 7
installation of(list all components,both newly installed and existing to remain in use):
I &ri I NCw N20 D -so, w ./ + TA Pe0 -kr
Rtc 04.
Leach Capacity(gpd): Ground Water Depth(inches): Health Inspection by: t C -"'
68/A9-it?
As-built Diagram
(Print Clearly in Black/Blue Ink and Use Straight Edge—Label Risers and Zabel Filter)
RECEIVED
AUG 1` 2019
inCe
HEALTH DEPT. D6Lk
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RECEIVED r AUG -
3 02019
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LEGEND •
EXISTING SPOT ELEVATIONS 03cO
EXISTING CONTOUR---0 --- • -
FINISHED `SPOT ELEVATIONS MI
FINISHED CONTOUR-0 PROPOSED PLOT PLAN
APPROVED oAR E LT•A _ YARI7O1l.TA-,MASS.
DATE. • ��7 14GEN ..7 ::;Lor'P ', 'e.Szoso.Its ID.e.vF
I CERTIFY THAT THE PROPOSED R. ✓.• O'HEARN, INC., RLS, J?S
BUILDING SHOWN ON THIS PLAN 1348 ROUTE 134
CONFORMS TO THE ZONING LAWS EAST DENNIS, MASS.
OF V ,f L)7 / , MASS..EXcCPr .9) DATE' /G/ =
/voTI=0 73 _ SCALE: / '--�c "
JOB N0.79-4t3 CLIENT' Pe..•e.o
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SHOWN ',ON THIS PLAN HAS BEEN - 1348 ROUTE 134
LOCATED .ON�THE GROUND AS'.' INDICATED. EAST ;' DENNIS, MASS.
DATE: 1/2 ,/,9 SCALE: f '='��
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JOB NO. 79- 43s" CLIENT: .aic4,e.b
DATE •' EGIS • RED LAND SURVEYOR DR. BY: A'.A/.A SHEET--/—_ OF —2—
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TOWN OF Y•4 cT410,LITH
REVIEWED FOP P!"LDI":C ANC Z3 'I';3 CODE COMPLI-
ANCE. ERROIc;:uR C ;,..11SSV)NS DO NOT RELIEVE THE
APPLICANT FROM THE RESPL)NSiBILI)Y •-'AS BUILT'
COMPLIANCE.
DATE: C "11.'ly
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