HomeMy WebLinkAboutBld-20-002818 IV
ONE & TWO FAMILY ONLY-BUILDING PERMIT
Town of Yarmouth Building Department or
1146 Route 28,South Yarmouth,MA 02664-4492 `
508-398-2231 ext. 1261 Fax 508-398-0836 r
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 Num Date Applied:
Seitrs
Building Official(Print Name) Signature• Date
SECTION 1:S.w?INFORMATION
1.1 Property Address: j 1.2 Assessors Map&Parcel Numbers
_scR"",
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 0 Private❑ Zone: O►rtside Flood Zone? Municipal 0 On site disposal system in
Check if yes❑
SECTION 2: PROPERTY OWNERSI P'2.1 Awper'of RecBrd: I.AJ - YrirM GA 4 MN N (L CCy
Name(Print) City,State,ZIP
C- ro4i'+ 141or , ii N tio 016
No.and Street Telephone Email Address
SECTION3:_DESCRIP'TION OF PROPOSED WORIK2(check all that apply)
New Construction❑ Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition CI
Demolition 0 Accessory BIdg.0 Number of Units Other 0 Specify:
Brief Description of Proposed Work?:
y'
of
- SECTION_4£ESTIMATED C•ONS 1 RUCTION COSTS . a 1)1,
Item Estimated Costs: "OfficialTse Only �J
(Labor and Materials)
1.Building $ 13 l S ir 0 :-1 Building Permit Fee:$1 5.0 Indicate how feels deterrainalt
2.Electrical $ 17 Standard Citytrown Application Fee: '•: `
❑TotalProject Costa tem.6)x multiplier x
3.Plumbing $ 15 0 C 2: Other Fees: $ '. •
4.Mechanical (HVAC) $
5.Mechanical (Fire
Suppression) Total All Fees:$
Check NO. Check Amount Cash-Amours/ -
6.Total Project Cost: $ 0 0 O p Paid inFull 13 Outstanding Balance Due:11-
SECTION 5: CONSTRUCTION SERVICES
• ' 5.1 Construction Supervisorpf License(CSL) C c — /07453 /o/�Q I 1 i
O,4aS HcL L a License) Number Exph ionODAtev"
Name of CSL Holder •-1
C. Tye 1_ I/l I (.,� List CSL Type(see below) (.A.No.and Street
('! 1 Type Description
So+ , I OIi*Alowk /44 66)661/ U Unrestricted(Buildings up to 35,000 cu.ft) .
Cijy/Town,State,ZIP ' R Restricted l&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
.�/ f e J r j SF Solid Fuel Burning Appliances
t-1'7 7 4-1 00 Have COAA C °nd-C�r I Insulation
Telephone Email address J :'4:44 D Demolition
5.2 Registered Home Improvement Contractor(HIC) f pE, $S 9 l j
N, C" 1 artBICRegistrationNumber F4uati&Date
HIC� ��any Name or I�C,�Rpgist�ttName
No.and S &Awe •{ (f (� 1-ict ,t,C e-onzm'tAci-i I CC&JMcri ,(o,
So, YutMvu-1h t M/4 ed6 C4 i ry Sd 10v fc V Email address �I ,
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 PERMfl
I,as Owner of the subject property,hereby authorize 1, M
to act on my behalf;in all matters relative to work authorized by this building it application.
c: •t. C
Print Owner's Name(Electronic ignature) 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.
VC,L o
Print Owner's or Autholii Agent's Name(Electronic Si ) 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.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 Indus&ial Accidents
_:Ail: 1 Congress Street,Suite 100
• Boston,MA 02114-2017
• www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/EIectricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Nave
Please Print Lei lbly
Name (Business/Organization/Individual): (iM, N
a5 ave
ffrr �
Address: 1 ()AtV . n l't I f
City/State/Zip: S. r t t--/A0A 1 6 hone#: 17 y rj c� I O(q
.5
Are you an employer?Check the appropriate box:
Type of project(required):
1.0 I am a employer with employees(full and/or part-time).*
7. El New construction
2111 I am a sole proprietor or partnership and have no employees working for me in
any capacity.[No workers'comp.insurance required.] 8. Remodeling
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]* 9. Demolition
4.0 I am a homeowner and will be hiring contractors to conduct all work onI will 10{�Building addition
ensure that all contractorsmy�°�•either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
I2. 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. 14.0 Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Arty 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_ 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 it 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 pai and penalties of perjury that the information provided above is true and correct.
Signature: Date: /f/7/11
Phone#: 1741 Si.I oqc
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#:
3 . . °�-Yf o TOWN OF YARMOUTH
o � y BUILDING DEPAR'I11-TF'NT
- �• -t�• 1146 Route 28,South Yarmouth,&IA 02664
508-39&2231 ext. 1261 Fax 508-398-0836
BUI.DING DEPARThEN'I'
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 N0 r4IJ1 , (A/e54- YCcoMa.t.4 4
Work Address
Is to be disposed of at the following location: Ktnvick4 44 ff5 fer . 41:g
Said disposal site shall be a licensed solid waste facility as defined by M.G.!.
Chapter III, Section 150A.
Signature of A 6 a lication Date
Permit No.
Division of Professional Licensure 7� �a�z�u�°f✓a�aa�zaouvPi�s
Board of Building Regulations and Standards Office of Consumer Affairs&Business Regulation
Constr,VCtMri tStlpFrvisor HOME IMPROV MENT CONTRACTOR
a , TX E lndividual
CS-107853 i r Aires: 10/28/2009 — Expiration
09/11/2021
27710,
1 1, r • THOMAS HAG ' (
THOMAS HAGUE 4 • D/B/A HAGUE N
7 CURVE HILLROAD y
SOUTH YARM6 TH MA � X` - x' - �/ ,;J
() ��1�1 THOMAS HAGUL1`7 u' sk
ICX-.1-1 7 CURVE HILL RD ,, f'i ✓w�o�' t
SO.YARMOUTH,MA 02664 Undersecretary
Commissioner CAL
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