HomeMy WebLinkAboutBld-20-000999 e,,,„..„1: ?x-L 919
4
ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department --
1146 Route 28, South Yarmouth,MA 02664-4492 ��
508 398 2231 ext. 1261 Fax 508-398-0836 ;,_`' ■
Massachusetts State Building Code,780 CMRk.
Building Permit Application To Construct, Repair, Renovate Or Demolish
a One-or Two-Family Dwelling
This Section For Official Use 0
Building Permit Number: RWji:21/2'a22 Date Applie
r^ S2A(S D-A-15
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address:3 ba,
�j� locit,OC\ 1.2 Assessoffp&Parcel NumberslhUU //
1.1 a Is this an accepted street?yes k 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 upply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Private❑ Zone: — Outside Flood Zone? Municipal 0 On site disposal system
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'. --v-'-' f
2.1 Owner'o;M
r ___A r I
rtk bl(Nt _
Pll , , 65J
erne rint) + 1 f
C ,State,ZIP ;
VIA • 3f V/ S AUG i 4 201d, a
itv
No.and Street Telephone Emai A
SECTION 3:.DESCRIPT OF PROPOSED WORK2(check all that apli ---- _--- _ — 1
New Construction 0 Existing Building Owner-Occupied 0 Repairs(s) 0 Alteration(s) e Addition ❑
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed World: � iieiltr � �� 1/ �� I r(, '�� &NI'_._.-
SECTION 4:ESTIMATED CONSTRUCTION COSTS.
Item Estimated Costs: Official Use Only
(Labor and Materials) Y.
1.Building $ /��� 1. Building Permit Fee.$ I cn Indicate hoer fee- . r 10 i.id
2.Electrical $ a Standard City/Town Application Fee 1 � _ i _
' 0 Total Project Cost3(Item 6)x multiplier ' x e
3.Plumbing $ i 2 —
Other:Fees: $ SS f 1 Al,j 6 t 2U l '
4.Mechanical (HVAC) $ List i i
5.Mechanical (Fire < -011 a. _4.
Suppression) $ Total All Fees:$ - _. __ I! --- _.. -
Check No: Check Amount: C.:• Amount: �'
6.Total Project Cost: $ 3o
w .Paid in Full M Outstanding Bahl ce Due: it S
T T
' SECTION 5: CONSTRUCTION SERVICES
5.1 ConsVuction Su rvr Licensec (CSL) e C c C�3 C� ( 13
fil`, 6 itl% License Number Ex iration Date
Name of CSL Holder
/c Pdib ; List CSL Type(see below) y���5R�y
No and Street ('/l f,qIL
J oloief / Description
/d t, , `1111 01673 U Unrestricted(Buildings up to 35,000 cu.ft.)
(, ti R Restricted 1&2 Family Dwelling
City/T wn,State,ZIP M Masonry
.2 —3 — Wi' RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
(Oa' il((�"JC%/1 4)qe(�Ll�" 6 i1 ` ``(�� I Insulation _
Telephone Email address D Demolition
5.2 ,legistered nom cnis ement Contractor(HIC) /5-7Y[-) 7
/y J /`L tirn / � ` f` HIC RegistrationlNumber/ pirat on Date
HI g or e trant Name
Em '1 ad ss
o.Lan j. ) 3qi f i 16T1e L -' t Ci own,State,LIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation Insurance affidavit must be co u leted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuanc= •f the building permit.
Signed Affidavit Attached? Yes T% No 0
SECTION 7a: OWNER AUTHORIZATION TO BE CO LETED WHEN
OWNER'S AGENT OR CONTRACT R APPLIES F DING PERMIT
- ....
I,as Owner of the subject property,hereby authorize ' R
t act on ehalf, ' all matters relative to authorized by this buildingpermit application.
( � PP gl
I�'G(J /l
Print er's Name(Electronic Signature) to
SECTION 7b: OWNER1 OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest and the pains and penalties of perjury that all of the information
()fl ained' 's pplication is true d acc e to the best of my knowledge and understan
1 / /7
rint ers 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.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"
• The Commonwealth of Massachusetts
Department oflndustrialAccidents
1 Congress Street, Suite 100
e=i—E1 Boston, MA 02114-2017
..s-,•'). www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information PII�] �Q 1JLICPleaas//e�Pr�int Legibly
Name (Business/Oranization/Individual): . -t � 1 (iLo G ent( ��`""
p
r�P�Address: C� ys pi
___
City/State/Zip: W iKiU 1�'k /7l t Phone #:_y g 3 6-- /t7/1
Are you an empl r?Che the appropriate box:
Type of pro' t(required):
1.❑I employer with employees(full and/or part-time).* 7. ❑ construction
•
2 I am a sole proprietor or partnership and have no employees working for me in
8. Remodeling
anycapacity. g
ap ty.[No workers'comp.insurance required.]
3.0 I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. ❑ Demolition
4.0 I am a homeowner and will be hiring contractors to conduct all work on m YP roPnY�
e 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.❑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.t 13. Roof repairs
6.❑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' compensati. •olicy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required • a er GL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment, as w= as ' vil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy o'this : atement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under th•paid'/ , al 'es of perjury that the information provided above is rue and correct.
Signature: /� �� C
Date: x
Phone#: 5-6r 37 U Z 2 t 0
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#:
61.'+4. TOWN OF YARMOUTH
\ BUILDING DEPARTMENT
1146 Route 28, South Yarmouth,MA 02664 508-398-2231 ext. 1261
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DA'1'h:
JOB LOCATION:
NAME STREET ADDRESS SECTION OF TOWN
"HOMEOWNER"
NAME HOME PHONE WORK PHONE
PRESENT MAILING ADDRESS
CITY OR TOWN STATE /I P 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�es, 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.
Check one:
Signature of Owner or Owner's Agent Owner Agent
h:homeownrlicexemp
o''_-Y-9-Ae TOWN OF YARMO UTH
- ,1' :vi c BUILDING DEPARTMENT
` _1 — y 1146 Route 28,South Yarmouth,MA 02664
cL�� 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,
I hereby certify that thee- brig resulting from the propAsed workldemolition to be
conducted at 3(05tiNdOd& ((I it ) 8011061/k,__
Work Adress
Is to be disposed of at the following location: I4/101(0nJ -
Said dispos site - all be a licensed solid waste facility as defined by M.G.L.
Chapter 1 1, Se .on 150A.
Si are of Application /
� PP�cah°II Date
Permit No.
•
•
il
/
''" `MASTER'.
r--' 1.• C
1 ••• BATH Mall
U !Te
Stu war* r, ,
Sun to'I
,�:';'�'e"( ` \ I r, MASTER BDRM �,
BEDROOM _ �'� _ /\, Ills IT
,•No... I It a tt71 HALL r+-- a
inn rs / il KITCHEN/
4 DINING/
__, IVING
nix 2r
CLOSET t HALL \ 11
s•t.tsi
ii 5.112 101
BEDROOM
tl'bi„•s LAUNIDRY�� BATH
TSItr1 1 test �`.
CLOSET 1 r ''(—) i
ss.got -�� r, ; .--._.._.': ---i.
t
-••�••�+'^' ............00SWO • COVERED PORCH HIKE
reiity SHED
I re lc r
1 WIWI AREA •
12E@20M D tits s4 t< '--- • - t-
APR 04 2018
Pitcar.. .) • HEALTH DEPT.
60.60irt b./0 i
a/o%€TS .
f �.S
KirekiL likeoL6 s a i 1 41 Rort -
1/4s.. ,601 oNkeold a 117-41ALL.... .
3 Y 6uc.k Gi oe.)d- S.
y
and winicy, . — — \
•--, move window • iGT.I.'. .7in ov;
_ — — I- —4'9— 1, 7'8 1 _
I-- I .1 A. I
- -1 0 0 /
winnow , / — \
/ 1
_
ruct) OatilL En 0 ' 0 015Viti /1)1(' 41' —' ! .•
— .....---- iii:-11-1 ( ------
-..i. 4'9 T 2'4 1, 3'4—,.. 1 -'"".>'''--- 4------ 0 (
bp
BEDROOM , -----, Ti \, A \
.,
v -\- \07 .
156 sq ft zn .
\ / \ // \ '.x" 1 ,
\
— _•—, L MASTER BDRM J \
/
....--
I
156 sq ft _ 1
/ I
HALL
.•/ KITC
1--- 4C) sq iT / 1 DINI
---1 L 1-1- _---
1-1-1 LIVIt
\, I 55e
i HALL
- WALK-IN ., \ UP
OfT BEDROOM........._j 62 sq it •
..,
_,
\ ft 139 sq11
1 1
yiq 1
1 .__.
0 ' ,
LAUNDR. . ' ' ' : BATH ---
co sq ft 1 63 sq ft 1
_II
C 'N / !i
VVA K-IN
CL SET _, (_._. ( L
.
64 sq ft .. . [ 0 _
___-- . -------1 ---4 t I 1 o , , 6'
,----bay winnow berrit,i.,,irigic,
0 TOWN OF YX7LUTH
,4; UV'
REVIEWED FC''''''I".r IN::AND 20NII,',3.-:DDE COMPLI-
i LIVING AREA
NOT RELIEVE IRE 1532 sq ft I-
APPLICLI4T PROM THE REGrOri•)IBILI 1`r.OF AS BUILT" - _ _
COMPLICE.
DATE: 6fr a --/I ,
,...97...4,-,
•
BUILDING OFFIL, L
•
l
add window > move window OO
---> move window k —4'9_ 7'8 y _
BATH - O o
L ,I`O i .
window MA) O ]n�J
�� iA BATH �Jil
v 4'9 N--2'4 3'4 %
bo -
f 1 \ 1 \
g : ,
BEDROOM o o cio,,t -
156sgft \ / \ / \ ��
MASTER BDRM
;% 156 sq ft KITC
7
HALL
i ) 1 DINT
endow i
40sgft . `
I r
,__, ,
HALL — I 556
.\
ALK-IN 62 sq ft
indow L ET BEDROOM �` � �
64 ft 139 sq ft _ - 1
n I _--.
LAUNDR "'� ' BATH 0�'
60 sq ft ' ' 63sgft1
N
L IN
LOST I
64sgft - [ O
r, ` ° _ 6' -1
I1 I I
I
<--bay window becomes single
TOWN OF YA GU ; H I I
REVIEWED FC"''''7I+, ANC:CN;;I . C^DE COMPLI- LIVING AREA
ANCE. ERPf . ,;;Sf^!S nc,NOT RELIEVE THE 1532 sq ft
APPLICANT'S COPY APPLICI;,T,'<OM THE IESr'OiNN iBILII Y 'F'AS BUILT" `
COMPLIANCE,
DATE: p-;.\�'15
�INGM.
B ILD OFF! L