HomeMy WebLinkAboutBld-20-002548 ,�- "/A
ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department r
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
This Section For Official Use 0
Building Permit Numtir - 04,2.2.5 7 Date Appli
1")fr c prf ��—' 1 - 1� W
Building Official(Print Name) Signature ` E et '1 "
SECTION 1:SITE INFORMATION
1.1 Property Addr s : 1.2 Assessors Map&Parcel Numbers l,jt`1 / U 1
1.1 a Is this an accepted street?yes V no Map Number Parcel Numbed _D N E-
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:
Zone: _ Outside Flood Zone? J
Public Private❑ Check if yes❑ Municipal 0 On site disposal system Il
SECTION 2: PROPERTY OWNERSHIP' -
2.1 Ow er'of Reco d:
LAKA4 n ar60 12tdAlvtc mA oicii - 13bq
Name(Print) City,State,ZIP J f
42 CoJoa. t4l Dr "G 6t1 . 13 Sell t-dhcrbotdonicas.F, Nc
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) g Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work2: re,ctei im& 4-, r ow h c i-q 1 Y4 bk..44 roo h.
OV f(Dy�r j t. d�A t.f b A j Lra4' .l}'.*4 �' A 1�'4 (vt S I-A 1 9 ' v►, et t
y 0 r, h5 rtw Lr004 IOCIr N. bas�k.G.•
SECTION 4: ESTIMATED CONSTRUCTION COSTS.
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 1. Building Permit Fee:$ 5-0 Indicate how fee is determined:
2.Electrical $ it Standard City/Town Application Fee
0 Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ i-
4.Mechanical
(HVAC) $ List:
5.Mechanical (Fire
Suppression) $ Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ (j b OO.nC 0 Paid in Full EV Outstanding Balance Due: II 6
SECTION 5: CONSTRUCTION SERVICES II
5.1Consc��n Supervisor Li se(CSL) C5-001 3 7 L f `12 1 D
fL(,lk l ,. License Number ExpiLion ate
Name of CSL Holder
PO I;OX 7 List CSL Type(see below) V
No.and Street Type Description
OLA n`s O 4(0 U Unrestricted(Buildings up to 35,000 Cu.ft.)
1�1 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
nn SF Solid Fuel Burning Appliances
co If Z7�(p b s S S 0,44)24 C COM LAS t ot Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
f,� IQ1LlgyJXj7-01.0
k ha V" HIC Registration Number n Date
HI Company Nam or C egistrant Name Ll
N PdStreet (O'X� .s1 t 'f 4' 26e eatuefs),t�e.V
I
tuN. S AA- 021034 (of:, Email address
Ciy/Town, State,LIP 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 I 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 �j L•(. Q' IkaC Le Lei
1' L T
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) 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.
0 3 1y
Owner's r$, 4-
rinthorized Agent's Name(Electronic Signature) _ D e
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms "
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
•
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
_, Boston, MA 02114-2017
us"• www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH T$E PERMITTING AUTHORITY.
Applicant Information /�* Please Print Legibly
Name (Business/Organization/Individual): IJ S 14 0,1 I�l v.))
Address: P p ,60g
1 �-
City/State/Zip: CAP' S ‘41� 6263 Phone #: 5'06 t,(2 7 - (, 6
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. E New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in
capacity. 8. Remodeling •
any
p 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 Yproperty. I will 10 [] Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5.XI 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 13.0 Roof repairs
6.❑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$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby ce y un r the pains and pe alties of perjury that the information provided above is true and correct.
Signature: ail Date: / U 2 3 ) 1
l
Phone#: co 'f 'f 2 3 . 6 f r!J
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
•
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
0 TOWN OF YARMOUTH
BUILDING DEPARTMENT
1146 Route 28, South Yarmouth, MA 02664
508-398-2231 ext. 1261 Fax 508-398-0836
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
Pursuant to M.G.L Chapter 40, Section 54 and 780 CMR, Chapter 1, Section 1113,
[hereby certify that the debris resulting from the proposed work/demolition to be
conducted at 2 4 ,TO N h 14 Ct I t e a Y A
Work Address
Is to be disposed of at the following location: VG Vwt o V JI— I 1�
� W� V140
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 1 II, Section 150A.
Ignatare of pptication " Dlte
f y
Permit No.
�t=_ TOWN OF YARMOUTH
s(, - c HEALTH DEPARTMENT
Akt; 1
• ' PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant: 11ó
Building Site Location: 2_'j Jo h✓i . It CU,it h'W
I 1 '
Proposed Improvement: (Li .� C v�„cts ,t- it 6o �Ow i S11-a t Y's (��,,Y1_YooW
iM ow C kV r A, J v►-kti Vies"—.).k 4 vrs TAN s I l`f w a l \ w 1.t,
3'() d 4-0 rv14 vti A. v"Qvva-
Applicant: A ott\ Tel. No.: c06 tf e 3--(r F� 5
Address: e O t3,), t Vt olvg Date Filed: l O/ j l t
**If you would like e-mail notification of sign off please provide e-mail address:
Owner Name: Llvtdet '1$G W D
Owner Address: Q L Co 1o& a ( Q�ive fi-ZiA 3 YK A, Owner Tel. No.: 07 `1j1.3 7bc
pt✓b7
RESIDENTIAL AND/OR COMMERCIAL BUILDING
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
Please submit three (3) copies of plans, to include:
(1.) Site Plan showing existing buildings, water line location,
and septic system location;
(2.) Floor plan labeling ALL rooms within building
(all existing and proposed) —
Note:Floor plans not required for decks,sheds, windows, roofing;
(3.) If necessary, Title 5 application signed by licensed installer
with fee.
REVIEWED BY: DATE: /G e l
9
PLEASE NOTE
COMMENTS/CONDITIONS:
RANDY SMITH BUILDING
Randy Smith 508-385-5125
PO Box 76 fax 508-385-5851
Dennis,MA 02638
October 23, 2019
SUB-CONTRACTORS
Trademark Lighting LLC electrical work WE158512A
Adian Bloomer plastering UB-99721467-18
The Hokum Rock Corp
Dba Olsen Plumbing and Heating plumbing and heating HOWC986624
Charles Mauro tile work WCC-500-5012848-2018
Central Cape Glass shower doors 08WECCK8506
Dennis Murphy painting DEWC554148
Vhe (poam7noorwea it cy vi/tamaciucaeeta
Office of Consumer Affairs&Business Regulation Division of Professional Licensure
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
TYPE:Individual ConstRiCtibn ItUpervisor
•
Registration Expiration
101449 07/29/2020 CS-007437 E Aires: 04/16/2020
RANDY SMITH
RANDALL H SMITH �;� 401 1-
PO BOX 76
RANDALL H.SMITH ' • DENNIS MA 02646
15 BISMARK WAY 1() ��1'`
DENNIS,MA 02638 1ST i.l
Undersecretary
Commissioner
Linda D. Barbo
29 John Hall Cartway
Yarrnouthport, MA 02675
Linda D. Barbo,as owner of 29 John Hall Cartway in Yarmouthport, MA 02675, hereby
authorize Randy Smith to act on my behalf, in all matters relative to work authorized by this
building application.
Signature: .0-4'"""
Date: /0/?•01-/
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TOWN OF YARMOUTH
I
I REVIEWED FOr BI l!LCING AND ZONING CODE COMPLI-
ANCE. ERRORS OR A: ....1SSIONS DO NOT RELIEVE THE
,f,' i si' " ' • -
APPLICANT FROM THE RESPONSIBI OF'AS BUILT'
COMPLIANCE.
DATE:11—% —I
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BUILDIN FFICIAL
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