HomeMy WebLinkAboutBld-20-000645 ' Z F_YAR Office Use Only ,1
�r0 14Permit#
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O . - -,�/Hy[�' 1Amount oZ £
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Itla�`°'°'°"`°"p E� 3Permit expires 180 days from
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i issue date
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 E�xt. 1261 /' /
CONSTRUCTION ADDRESS: it/ / �it d
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ASSESSOR'S INFORMATION: Map: Parcel: LI IS G 3-G 3 b .&) a
OWNER: L am e 13 •S�,ea.fz R�� ADD l Ce _�n o lcy_on91TEL , W q
et v A
NAME
CONTRACTOR: Ti enYVe-4 V'Q 'Le S a",\I ifir-Kaivsitrtr
NAME MAILING ADDRESS TEL.#
Residential ❑Commercial Est.Cost of Construction$ 3Sa7• c50
Home Improvement Contractor Lic.# Construction Supervisor Lie.#
Workman's Compensation Insurance: (check one)
0 I am the homeowner ❑ I am the sole proprietor 0 I have Worker's Compensation Insurance
Insurance Company Name: Worker's Comp.Policy#
WORK TO BE PERFORMED F- L_ - Er&vt
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares Replacement windows:# Replacement doors: #
Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
*The debris will be disposed of at:
Location of Facility
I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s)
will be just cause for denial or r- ocation of my li -nse anE or prosecution under M.G.L.Ch.268,Section 1. E
Applicant's Signatu : ___!�,_ _ „,' — ' C 1 / �e Date: 1 /r `�
Owners Signa ,re(or attaSi�. t_�,( _ ._'� L Date:I
I I C7
Approved By: �� .�/� >- 1/I
-f®� Date:
E.
Building 4 icial or"1,71 EMAIL ADDRESS:
Zoning District: Cs E D
Historical District: ❑ Yes No Flood Plain Zone: ❑ Yes ❑ No
Water Resource Protection District: Within 100 ft.of Wetlands: AUG 02. 2019
Yes ❑ No ❑ Yes ❑ No
BLI,,,C3ipG DEPRTMENT
•
r The Commonwealth of Massachusetts
Department oflndustrialAccidents
n 1 Congress Street, Suite 100
" 47
� 1� Boston, MA 02114-2017
^M 5�•`'' www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information PIease Print Legibly
Name
Address: ( (.P TC 'n ' woo c -
City/State/Zip: L(),L arrnal_th Phone #: L--
Are you an employer?Check tPt¢appropriate box: Type of project(required):
1. I am a employer with employees(full and/or part-time).* 7. New construction
2.—_I am a sole proprietor or partnership and have no employees working for me in
8. ❑ Remodeling
any capacity. [No workers'comp.insurance required.]
3._I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. E Demolition
4.Z I am a homeowner and will be hiring contractors to conduct all work on mY property. I will I O [ 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.EI I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.C Roof repairs
These sub-contractors have employees and have workers'comp. insurance.=
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Otherc�
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:
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 abov is true and correct.
Signature: ./t/ktir `j - 51r.19--)MAA--(2.j,. Date: I 1
Phone#: I ( 3 ) t 3(Q - 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#:
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nixIltfl 113gBs U1 RECISTEAK!) LAND
D>mf 0002ca2.42 PAcial S
4 RNE -__MIE flTLE SERVICES. INC. e9411123 PLAN DOOM AO PJIiGEs 39 an -
LIIMM7. FlfsT tASTERN MO TQAQE CORPORATION IRAN ItU101110hop 1288
OIf11 M DORIA TRUST •_ Etta
h
JA* T B. UCI At.D $J 5 N PEARACL RE D M A D
DATA: InhV/ S soil _L.4lZ SEGUYSEAifc:t MOM pip DATA:
RRTIFIC LTS OF!matt
FLOOD HAZARD INFORMATION FNAN NUNIONL LanS):
FLOW M&P C010LI11I1'ry NO.. 25G016 ZONE AS _ ASSESSORS MAP
Pomme_gOO5D DATED; O7L02 92 MAP: BLOCX: Pams
MORTGAGE INSPTs CTION PLAN
1 G 7`ANGLEWOOD DRIVE, YARAfOUTt , MA
LOT 30 LOT S1
160.34
I
LOT 29
13.234 S.F.
' �,
�, ." _ LOT 42
Me 41S107107.1
.. .- 6: ..a _.t IROX Pm
DRIVE 1
E
MORTGAGE LENDER
USE ONLY
- I
IIS IS THE RESULT OF TAPE MEASUREMENT. NOT THE RESULT VAr
SURANCETRUMENT COMP NYURVEY AND ABOVEIFIED LISTED TOS TITLEE
LENDER. . PAEisorAILIAEA8.
c
40 KENW000 CIRCLE. SUITE 8, FRANKLIN. MA 02038 t"
'ERE ARE NO DEEDED EASEMENTS IN THE ABOVE REFERENCED TEL.:(800)287-8800 FAX:(58)628-4011
!ED OR ENCROACHMENTS WITH RESPECT TO BUILDINGS SITUATED 7-
I THIS LOT EXCEPT AS SHOWN. i.
IE LOCATION OF THE DWELLING SHOWN DES. FALL WITHIN L f-
SPECIAL FLOCS HAZARD ZONE. MAtslo ‘\ F.
IE LOCATION OF THE DWELLING AS SHOWN HEREON EITHER ROD NIC01 13
AtANpANt
1S IN COMPLIANCE WITH THE LOCAL ZONING BY—LAWS IN No. 18841 J l
'FECT WHEN CONSTRUCTED (WITH RESPECT TO STRUCTURAL - �
:TSACK REQUIREMENTS ONLY). OR IS EXEMPT FROM VIOLATION�
_
IFORCEMENT ACTION UNDER MASS. GI. TITLE VII. CHAPTER 40A. - - - _
CTION 7, L
ENERAL NOTES; (1) The declarations mode above ars on the basis of my knowledge. information. and belief as the result of
mortgage Inspection tape survey made to the normal standard of core of registered land =Trowes practicing is Masseehusette.
2) Declarations era made to the above named client only es of thie data (3) This plmn woe not made for recording pu mom.
x wee in preparing deed descriptions or for constructions. (4) Verifications of property This dimensions. Wining offsets. fences.
r lot configuration may be aaeompl'whsd only by an accurate Instrument survey.
1
•TEE SIZES: 3/4" TO 1 1}
INLET DEPTH = 1Q„
OUTLET DEPTH = 14"
FOUNDATION— 12.5' SEPTIC TANK 74 D' BOX 9'
STOCKADE --___, / NOTE: POSSIBLE FLO DIFFUSOR LEACH FIELD
FENCE IN THIS AREA
25 (143'
25- LOT 42
LOT 31 is,
-- " - 147.'1;
110 '� TEl
� �, N RISER
/ \ `IND, 44/4/i
�,'EP / INV OUT
436k73.
�O /'O ELEV = 22.4' ,i
/' P•
.UITABLE t /• Q LOT 29
V •reo = 13.234
A
/
UND / /,/��`� 0.30 Acres �o /'
EM EXISTING
LAYER. / uv.cr 7
N MED. TF v �24.10' \ \ /
,�a
T r 3 / I
AL
#11‘ GARAGE SLAB r
to 4
1‘*40' 29
ITY ,
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4 #7,4 1#4 op A i i ii. . !,4,„ ,
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f�l
1 �� PAVED / /
'E S ,OF
40ip, ,/
• 4r. 1);\ -----, /4-)16C)
4 ._/. 0. 'N'NC3N/
.`�pG /\
�/' 92.84' �,9
rLO A
---- --- EDGE OF PAVE oo BENCHMARK \�..
iAuII1 \j
'
UTILITY
POLE r
SEI-3I 1C TANK: JJU GPD ( 2 ) = bbU 4. UE5R.N LUAUINU FUR ALL PRECAST UNITS TO BE AASHO H-
1500 5. PIPE JOINTS TO BE MADE WATERTIGHT.
USE A ____ GALLON SEPTIC TANK 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS.
LEACHING: ENVIRONMENTAL CODE TITLE V.
N/A 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE
SIDES: USED FOR LOT LINE STAKING.
[(24 x 20) — (8 x 4)] (.74) = 331
BOTTOM: 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC.
TOTAL: 448 S.F. 331 GPD 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITH
USE FIELD CONFIGURATION OF 5 CULTEC C4 INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAIP
FROM BOARD OF HEALTH.
FIELD DRAIN PANELS WITH 4' OF STONE ALL AROUND 10. PUMP & REMOVE (OR FILL W/CLEAN SAND) EXISTING CESSF
(SEE DETAIL) 4040s ABANDON EXISTING FAILED LEACH FACILITY (FILL WITH SAND
OR REMOVE AS NECESSARY)
11 . WATER TEST D'BOX FOR LEVELNESS
#2
LEGEND SITE AND SEWAGE PLAN
#3 100.0 PROPOSED SPOT ELEVATION OF 16 TA N G E W 0 0 D DIVE
100x0 EXISTING SPOT ELEVATION IN THE TOWN OF:tool PROPOSED CONTOUR (WEST) YAI OUTH
PREPARED FOR: ESTATE OF WM. DORIA
100 EXISTING CONTOUR
20 0 20 40 60 Feet
I— t I I
BOARD OF HEALTH
�� APPROVED DATE
MA SCALE: 1" = 20' DATE: NOVEMBER 17, 1998
REv: 12/2/98 (ADD'L VARIANCE ADDED)
a° off 508-362-4541
fox 508 362-9880
down cape engineering, inc. Of
CIVIL ENGINEERS o'�'� AgNEH, � nHNE ~'`, `,
LAND SURVEYORS at O.IALA 3 OJALP . 1
CIVIL
y .o No 26',0,
No. 30792 91. q "\,
939 main st. yarmouth, ma 02675 �o� pe . o Q ___ `sa ,f`-'s ` ____
3's;'►f r��1.\ OJALA, P.L.S. DATE
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