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I
ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department ""0r _
1146 Route 28, South Yarmouth,MA 02664-4492
508 398-2231 ext. 1261 Fax 508-398-0836 .41%, -
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 Number i ,a.' ' .I_ Date Applied:
I w` f\ S Date
Building Official(Print Name)
Signature
SECTION 1:SITE INFORMATION '
1.1 Property Address: 7 1.2 Assessors Map&Parcel Numb'
g S 04.4 Parcel Number
a 1
1.1 a Is this an accepted street?ye umber
no p
1.3 Zoning Information:
1.4 Property Dimensions:
Zoning District Proposed Use
Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft) Rear Yard
Front Yard Side Yards
Required Provided Required
Provided Required Provided
IIIIIIIIIII
1.6 Water Supply:1 (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
_ Outside Flood Zone?
Zone: Municipal 0 On site disposal system
Public Private 0 Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ow er'of Record /V��
� l�t'1 � ,d'� V City,State
`�
Name(Print) n ,
i i Y' t iftg• / (J Telephone Email Address
No.and Street
(check-
SECTION 3:DESCRIPTION OF PROPOSED WORKs all that apply)
0 Addition 0
New Construction❑ Existing Building 11 Owner-Occupied ❑ Repairs(s) 0 Alteration(s)
Bld ❑ Number of Units Other ❑ Specify:
Demolition 0 Accessory g•
0-._ •-_ . .n' 'posed Work2: i Air., , i
SECTION 4:ESTIMATED CONSTRUCTION COSTS
j stunated Costs: Official Use Only
.'. ��' l Indicate how fee is determined:
f �,,,,, �t abor and Materials) i r -
- ] Building Permit Fee:$T_
'y $ od licationFee
1.Building ❑Standard City/Town APP.
2.Electrical 0 Total Project Costa(Item 6)x multiplier.______x--
01111111111111111 2. Other Fees: $
3.Plumbing List:
4.Mechanical (HVAC)
Total All Fees•$
SCash Amount:
Mechanical (Fire k Amount__
Su■■ression) CheckNo• ChecDutstand g Balance Due:_____6.Total Project Cost: $ 3 co0 0 Paid n Pull
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Superv' or License(CSL)
t 7c 2JJ 0/4 /wi License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) u
/7T SALLOtik.-. Aver
No.and Street �T Description
) S• O x� 0 C % Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
Mil- RC Roofing Covering
WS Window and Siding
�
SF Solid Fuel Burning Appliances
5°$ j�o 3�� /`(i®i,t5Aitrt/Q1 7 tieri I Insulation _
Telephone Email address • N'4-r D Demolition
. 5.2 Registered Home Improve ent Contractor(HIC)
1_ O 1/170 23 -202JD914) HIC Registration Number Expiration Date
HIC Company e or HIC Re i trant N e •
(2 &DJ Fys G2 cn lurti-
No.an eet
..)40 l3 mil- G2�P o Sc't gL q 3/1g Email address
City own, State,LIP 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
0 R'S AGENT OR CONTRACTOR APPLIES FOR B DING PERMIT
Owner th subject prop ,hereby authorize Pit
to` b alf,in al a rs relative to work authorized by this building permit application.
1.
Z-4_...-"" C-1 /(-----LO —/f
wn s ame(Ele onic Signature) Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
By entering y e belov I hereby atte tTl e and penalties of perjury that all of the information
couta' ' applica ' is accurate to the best of my knowledge and understanding.
Print Owne or Auth ized 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.eov/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.) , 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
�111 1 Congress Street, Suite 100
= t•F- Boston, MA 02114-2017
. . ,$).• wwww.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): 614/P V 0U kii,A4
Address: /)C Sets 4rt ,di Gk 0140.
•
City/State/Zip: ..S. ilei,".ts lit. 6 Goa Phone#: ,j 1 v 36 r 3'1 °
Are you an employer?Check the appropriate box:
Type of project(required):
LEI 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. 11 Remodeling
•
any capacity.[No workers'comp.insurance required.]
3. I am a homeowner doingall work myself. t 9. RDemolition
❑ y [No workers'comp.insurance required.]
4.❑I am a homeowner and will be hiring contractors to conduct all work on mYP roPrtY•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 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet.
A
These sub-contractors have employees and have workers'comp.insurance.: 13.❑Roof repairs
6.ElWe are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
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. 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
I do hereby cer fy tin
the pain nd Pno/ties of perjury that the information provided above is true and correct
Signature: C/J Date: /-2_O - r 1
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
6. Other
Contact Person: Phone#:
• .4 t TOWN OF YARMOUTH
BUILDING DEPARTMENT
Ma=p, 1146 Route 28, South Yarmouth,MA 02664 508-398-2231 ext. 1261
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE:
JOB LOCATION:
NAME STREET ADDRESS SECTION OF TOWN
"HOMEOWNER"
NAME HOME PHONE WORK PHONE
PRESENT MAILING ADDRESS
CITY OR TOWN STATE VIP 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 BUTT DING 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.
Check one:
Signature of Owner or Owner's Agent Owner Agent
h:homeownrlicexemp
TOWN OF YARMOUTH
B TJIILDING D EPA.RTMF.NT
1 1146 Route 28, South Yarmouth,MA 02664
�--.• 5 508-398-2231 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 111.5,
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at 0& 41- l vl/.S/Q ) lt' 1
4-e
Work Address
Is to be disposed of at the following location: a,/oft --LA E,
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter Section 150A.
ignature of Application /l' Dat ee` 9
Permit No,
4 .° -
ANIMMIIIIIIMIE
TOWN OF ''f^rc F 7 C•'W, � i ps 7
• REVIEWED For 911ILCING AND ZC,'N''I;;3 CODE COMPLI-
ANCE. ERROicS 0;1,',,,:,,ISSh :S DO NOT RELIEVE THE
APPLICANT FROM THE RESPONSIBILII Y OF"AS BUILT"
FILE Copy DATE: I I/1 '19 _
Buda OFFICIAL
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egolse Cascade
Single 3-1/2" x 5-1/4" VERSA-LAM®2.0 3100 SP PASSED
CL01
BC CALC®Member Report Dry 112-00-00 November 25, 2019 11:25:10
Build 7480
Job name: Andy's Folder File name: Hatch Gable Headers
Address: Description:
City, State,Zip: Specifier:
Customer: Designer: J Andrew Shakliks
Code reports: ESR-1040 Company: Mid-Cape Home Centers
Load Summary Live Dead Snow Wind Roof --- 3.5"
Live
Tag Description Load Type Start End 100% 90% 115% 160% 125%
1 point load Conc. Pt. (Ibs) n\a n\a 1219 1800 5.25"
from ridge
Bracing Elevation Sheathing
Top 12-00-00 1
Base 00-00-00
Top r---
12-00-00
Controls Summary Value %Allowable Duration Case 111
Axial Compression 3083 lbs 33.2% 115% 1
Slenderness Ratio 41.14 82.3% n\a 0
Bearing Supports Dim.(LxW) Value %Allowable Duration Material
Wall 3-1/2"x 5-1/4" 3083 lbs nla 115% Unspecified
Notes
A generic column cap was used in the analysis of the column. Make sure to install and size the cap.
BC Calc does not perform shear wall or connection design for in-plane load transfer.
BC CALC®analysis is based on IBC 2009.
Disclosure
Use of the Boise Cascade Software is subject to the terms of the End User License Agreement (EULA).
Completeness and accuracy of input must be reviewed and verified by a qualified engineer or other appropriate
expert to assure its adequacy, prior to anyone relying on such output as evidence of suitability for a particular
application. The output here is based on building code-accepted design properties and analysis methods.
Installation of Boise Cascade engineered wood products must be in accordance with current Installation Guide and
applicable building codes. To obtain Installation Guide or ask questions, please call (800)232-0788 before
installation.
BC CALC®,BC FRAMER®,AJSTM,ALLJOIST®,BC RIM BOARDT"',BCI®,BOISE GLULAMTN,BC FloorValue®
,VERSA-LAM®,VERSA-RIM PLUS®,VERSA-RIM®,VERSA-STRAND®,VERSA-STUD®are trademarks of
Boise Cascade Wood Products L.L.C. �---
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