HomeMy WebLinkAboutBld-20-002577 . . - _ 1,43ly
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 CMR
Building Permit Application To Construct, Repair, Renovate Or Demolish
a One-or Two-Family Dwelling FRECEIVED
is Section For Official Use yF...._..:.... ,_.....______
Building Permit Number,( ",0 5'7'7 Date App • I. U L T 3 0 n 19
i lr^ ]RAGS \\-la--1C1 BU LD 'L
f,Y
Building Official(Print Name) Signature - ate +_ — -
SECTION 1:SITE INFORMATION
11 Prlop ty Address: 1.2 Assessorsyu3&Parcel Numbers !J
_6(09 Fa.rm a soL4-t-ii
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 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIPI
2 O nerr of Record:
c..I—I 6 ioseAA,,,,e_ Leo yvcn:...5 `►/�rrti,�All Pow 1✓�a 6a -s
Name(Print) ` City,State,ZIP
3.2 Er t, Co.s-ram (0a.a Se wth &ors " 3 a,6 -'$s( PG,..k ,9 s P AOL . Co^,.
No. and Strbet) Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK''(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 8 Repairs(s) ,p' Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work2: , ., f } tot Q '-
t C r C,.Y ?)CSf LC'• 105 all SY 0 c 1 bQ• I airs,r cc.il • re,..)i1,+d-
‘':""rici
d( . ?la_cc' ,max-tdr,or AooC,, 9..c Q‘e...c, ft.. s� ., 4- we OS
SECTION 4:ESTIMATED CONSTRUCTION COSTS_ , v i,v •.
1 Estimated Costs:
Item (Labor and Materials) Official Use Only [,/ _ L//7 5
1.Building $ 1 U 01. Building Permit Fee:$I S 0 Indicate how fee is determined-.
2.Electrical $
1 ii Standard City/Town Application Fee
0 Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ 35---
4.Mechanical (HVAC) $
List
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Ca Amount:
6.Total Project Cost: $ `li ow 0 Paid in Full t9 Outstanding Balanc Due: 115
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
/p� � a 1/3/ao
t �(Gf� 1_ 'O�Y� 1 v16 License Number Expiration Date
Name of CSL Holder
McaCFiccj,
List CSL Type(see below) LQ
No.and Street Type Description
(b�� c. 3
U Unrestricted(Buildings up to 35,000 Cu.ft.)
L$ { i G O� R Restricted 1,k2 Family Dwelling
City/Town,State,ZIP � / M Masonry
RC Roofing Covering
WS Window and Siding
/ ,,`` SF Solid Fuel Burning Appliances
(y�,i-7)d7t,- 1c sw VEFtot-vl�ca ,I.c�n� I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) `C►G f 7/�boa}
' `-' ' r �`"�4 L lnC' HIC__llRegistration Number Expiration Date
HIC Company Name or C Registrant Name
�(4 MCX-P1r td S Ge'F bIA'lc�c(s ;►I. �.
N,o`and Street
LI �S� R 0\00 i M G. ba l J a (�{l)a 1 C, d$a6 Email addr s
City/Town, State,L Telephone
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(MYI.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 ❑ No ❑
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.
Print Owner's Name(Electronic S a ur 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.sov/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
:, — G Department of Industrial Accidents
_°L�1= 1 Congress Street, Suite 100
�K Boston, MA 02114-2017
,;,5�•`'�` 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): C, .E. --3,,,l t o(511CL
Address: 1"1 ? Mc T i,i,U sq-
City/State/Zip: � - rts. RDA, /t/LAa 132 Phone #: (cii) a -7 Co -agpc
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. ❑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.]
3.0 I am a homeowner doing all work myself [No workers'comp. insurance required.]r 9. Demolition
4.❑I am a homeowner and will be hiring contractors to conduct ail work on m YP property.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
5.0 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.Z We 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. 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$250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby c tify unde the p "ns a penalties of perjury that the information provided above is true and correct.
Signature:
Date: 10 4214/00)
Phone#: (C1n) of1 (a '4Q'JG
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License# •
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other_
Contact Person: Phone#:
. •°� Y -t_ TOWN OF YYARJvIOUTH
o BUILDING DEPARTMENT
�. 114-6
Route 28, South Yarmouth, MA 02664
�-•� 5=� 508-398-2231 ext. 1261 Fax 508-398-0836
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
Pursuant to M.G.L Chapter 40,Section 54 and 780 CMR, Chapter I, Section 111.5,
I hereby certify thatthe debris resfCO
ulting from the proposed work/demolition to be
conducted at 302 B Cc. cr , bvi 11
WorkTddress
Is to be disposed of at the following location: Nl/Ccny,nt j4
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
44.4/
/44/7k-
io/ t//D® t
Signature o Application Date
Permit No.
e.
Commoritvealth of 0(assechusetts_
.T S n rura'uoew41 97,rga�sac, ife/44 ��4 Division of Professional Licensure
Office of Consumer Affairs&Business Regulation Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Res7..TYP1LkCorporationicalian ".I0.
Con..,st .,r4-„..-1..1-_
t5pFrvisor,
_; 0 p C4-112390 .- •Uoires: 07/03/2C
G.E.F.BUILDER i i ,' r.
• GERARD EDMUND , • � �'
y 48 MAXFIELD$�T
GERARD FLORET n _ 7 • W ROXBURY Mkt13 02 -
48 MAXFIELD ST �G. '�, a 'l '« l:i:
WEST ROXBURY,MA 02132 Undersecretary
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TOWN OF YARMOUTH
REVIEWED FOR BUILDING AND ZONING CODE COMPLI-
_ ANCE. ERRORS OR C;,.,1ISS1ONS DO NOT RELIEVE THE FILE COPY
/ . T--T
C APPLICANT FROM THE RESPONSIBILITY 0 "AS BUILT"
COMPLIANCE.
DATE: 11 - l.-)9
T . Ct.
BUILDING OF CIAL
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