HomeMy WebLinkAboutBld-20-001965 ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department of r -
Town
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 Only
Building Permit Number&D"-A-0-OZ) / 6 Date Applied:
Building Official(Print Name) Si ature Date
SECTION 1:SITE INFORMATION.
1.1 Property Address:d 1.2 Assessors Map&Parcel Numbers
-� \\L�tC Lux2 VD d.) ._._
1.1 a Is this an accepted street?yes �/ no Map Number Parcel Number C -- t t. `>
1.3 Zoning Information: 1.4 Property Dimensions:
NOV ' t `ii il-i
Zoning District Proposed Use Lot Area(sq ft) Frontage(ftt
`
1.5 Building Setbacks(ft) tX430
Front Yard Side Yards Rear Yard ��
Required 1 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 CI On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owper'of Rec rd:
Lac`st‘N..e. \e ornb\y `\us u,% \c► Dn.V13
Name(Print) City,State,ZIP
'To FVkci&ec Lcti\e SOS-Yty--Il 11
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) X Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
rief Description of Proposed Work2: �eQ�Qt_t rt tik k stXkLY\ CCO iSS k_G�d.l\135-S�Ci
t\GU `\ W �n� O4\Sk c L 1% VS,:�.o1J5- \1\-K:
't \G.LL S\. tf la.'.0.e. `tn-\C:ncl
. 1
tt.LC W\'' t CeIc.0 S\ .l‘t tS.- �.k\\� CiC` \e.t."
SECTION 4:ESTIMATED CONSTRUCTION COSTS et T i 1 t) - 1`1
Estimated Costs: yi 9
Item (Labor and Materials) Official Use Onl C 1
1.Building $ 13�5U 0 1 BuildingPermit Fee $ `Z Indicate ho fee is determined: .
.: .
0 Standard City/Town Application Fee:
2.Electrical $ %.y(0 s
0 Total Project Cost' 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ S
4.Mechanical (HVAC) $
5.Mechanical (Fire
Suppression) $ Total All Fees:$
Check No.. Check Amount: Cash Amount:
6.Total Project Cost: $ ,5%"0 1 0 Paid in Full El Outstanding Balance Due: 1 lkO
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) �1 y ,; `S_1q
Lrc .S License\Number Expiration Date
Name of CSL Holder
C• List CSL Type(see below)
�cL\t
No,
and Street -� Type Description
rU C1 t\��S \0 1L O U Unrestricted(Buildings up to 35,000 cu.ft.)
Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
50nA10 SSSS o,c..Cl►5 tt u, d.essecos c.04, I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
CC��.5kLc tt.\ A ke.(5 1 O`�q`1l
HIC company �e 4r xr�Re is t Name HIC Registration Number Expiration Date
"a5� CSC tat W e Ve v d c(Uo' ev..%\c�tcj@ Cflfc*c ire\
o. d Street‘ Email address
SNo S \G Li\AIO 501339y 141'1
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(1VLG.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 J e_e *O C()Le e
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.
\t.A\k Lr uk\5-caci5\ `b\it'14.L k U- `\-\`‘
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.gov/oca Tnformation 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"
Harwich Ecumenical Council for the Homeless, Inc. (HECH)
Housing Emergency Loan Program
General Contractor and Owner Agreement
Attachment A
NOTICE TO PROCEED
To: Glenn Crafts, GC Custom Builders, Inc.:
You are hereby given authorization to proceed with the renovations at 28 Flicker Lane,
Yarmouth, MA 02673 in accordance with the General Contractor and Owner Agreement dated
October 3, 2019.
The work is scheduled to begin on October 3, 2019 and to be completed on or before December
31, 2019.
CS)— -.\/`
CO" .o 17
Owner: Christine Trombly Date
itness: : Kimberly B g , HECH Program Manager Date
' °� " TOWN OF YARMOUTH
; yg c BUILDING DEPARTMENT
' ,` � �. "-`� ,`'' 11�t 6 Route 28, South Yarmouth,MA 02664
� ��-•� s'a' 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 � C
% \ \\L\&tc \fin#
Work Address
Is to be disposed of at the following location: fob (._\1\.qs
Said disposal site shall be a licensed solid waste facility as defined by M.C.L.
Chapter 1 1 1, Section 150A.
qr `-` °
Signature of Application Date
Permit No.
Commonwealth of Massa:.iiusetts
II-f Division of Professional L;censure
• Board of Building Regulations and Standards
Constctior�l$bperuisor
CS-006646 ,I Noires: 11/15/2019
i et
GLENN W CRAFTS ,, �5 rr4.-;
72 COUNTRY]RCLEf :..
SOUTH DENNI l�j/41 026(0 5 ''
•
y:��/S t_i0��
cam_
Commissioner /---
•
. 4 Fommoneveccra/ig¢.w,r/PuJeas
Office of Consumer Affairs 8 Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TY Corporation before the expiration date. If found return to:
Expiration Office(If Consumer Affairs and Business Regulation
0 07/02/2020 s 1000 Washington Street-Suite 710
I(
G.C.INC.CU` , g`; r. ,/ Bost. ,M• 12118
.. =-_,-,-....--„._. ,....,==11 7,_:€1:.f---- -------
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A ------=.75:..--=="-- L'• 4.,„, if
GLENN W.CRA: =' v \ �`--' A ��1 �-
. 21
259 GT WESTER ' (�S.DENNIS,MA 0266• Not valid without si9
nat-
Undersecretary
:,
•
n.-
Y:a
The Commonwealth of Massachusetts
Department of Industrial Accidents
j, -- 1 Congress Street, Suite 100
= Boston, MA 02114-2017
wwwmass.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): G.C. Inc
Address: 259 Great Western Road
City/State/Zip: South Dennis Ma 02660 Phone #: 508-394-1612
Are you an employer?Check the appropriate box:
Type of project(required):
1.�✓ I am a employer with 3 employees(full and/or part-time).* 7. ❑New construction
2.1=1 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.]
9. El Demolition
10 ❑Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or arc sole 11.0 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. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.:
6.0 We arc a corporation and its officers have exercised their right of exemption per MGL c. 14.El 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 arc 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: Travelers
Policy#or Self-ins.Lic.#: 7PJUB-9904L51-4-19 Expiration Date: 1-1-20
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 unde t and penalties of r jrjury th' the_lpformation provided above is true and correct.
Signature: �, ', � Date:
Phone#: 508-394-1612 /
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#:
V VAS.
TRAVELERS J WORKERS COMPENSATION
AND .
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (7PJUB-9904L51-4-19)
RENEWAL OF (7PJUB-9904L51 -4-18)
INSURER: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA
NCCI CO CODE: 13579
1.
INSURED: PRODUCER:
G. C. CUSTOM BUILDERS, INC. THE INSURANCE AGCY CAPE
259 GREAT WESTERN ROAD PO BOX 960
SOUTH DENNIS MA 02660 EAST SANDWICH MA 02537
Insured is A CORPORATION
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 01-01-19 to 01-01 -20 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
• MA
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work In each state listed in
Item 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident: $ 100000 Each Accident
Bodily Injury by Disease: $ 500000 Policy Limit
Bodily Injury by Disease: $ 100000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B
c S
=
D. This policy Includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
MMEN
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required Information is subject to verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: 12-17-18 WC ST ASSIGN: MA
OFFICE: DIRECT ASSIGNMENT 701 29BJH
PRODUCER: THE INSURANCE AGCY CAPE
002251
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YARMOUTH WATER DIVISION
99 BUCK ISLAND ROAD
WEST YARMOUTH, MA 02673
PH.: 508.771.7921
FAX: 508-771-7998
BUILDING PERMIT APPLICATION
DEPARTMENTAL SIGN OFF TRANSMITTAL SHEET
BldSite Location
9• �`b F\��kcc Laic Map #: Lot #:
Proposed Improvement: {{Romr -r f}ctL STEW
Applicant:
Address '15Q (nt.'s ,I3dcio Tel. #: SOS 3y -\t\). Date Filed:
So" Ot 1,0
RESIDENTIAL AND / OR COMMERCIAL BUILDING
Water Department: Determines Compliance of Water Availability and or Existing Location
Engineering Department: Determines Compliance for Parking and Drainage
Conservation Commission: Determines Compliance to Wetlands Acts; i.e. If Lot(s) Border any Type of
Wetlands, Streams, Ponds, Rivers, Ocean, Bogs, Bays, Marshland, Etc...
Health Department: Determines Compliance to State and Town Regulations, i.e., Requirements
for Septage Disposal and other Public Health Activities
Fire Department: Determines Compliance to State and Town Requirements for Personal,
Safety, Property Protection;, i.e. Smoke Detectors, Sprinkler Systems, Etc...
`Signature pplicant Date
PLEASE NOTE:
COMMENTS:
Rev we y: a er n ate
o`=Y44. TOWN OF YARMOUTH RECEIVED
HEALTH DEPARTMENT
is y OCT 082019
PERMIT APPLICATION SIGN OFF TRANSMITTAL
R DEPT.
To be completed by Applicant:
Building Site Location: �.(6 Lcktv
ti 43
Proposed Improvement: \'�t �c,,« 4\A \- t.;1/41\S e.QskeSS `s,s \s\ - 5
HAR`t ANt) Czft ;
Applicant: CC( sl,;\ %kAktc� l\rc Tel. No.:Sl��l
Address: `aS\ C3 t kck \),\tc, qc ) \\a U/.IAU Date Filed: \(1 1
**If you would like e-mail notification of sign off,please provide e-mail address:
Owner Name: C.\\C t v I\\)\„1
Owner Address:.): \\\L\(tr \--(kAt Owner Tel. No.SOS •S`\V-1\'‘\
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: IC— `�� ( CI'
PLEASE NOTE
COMMENTS/CONDITIONS. ,
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