HomeMy WebLinkAboutBld-20-002819 ,
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ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department .. "oF. 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 Only
Building Permit Numbf,� • 2Q� of• k/, Date Applie
17
-. n S- .A(5 .� \\ -\5-►`1
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Proper�J'Address: JCO h 1.2 Assessors Ma &Parcel Numbers
�7 /'tic„ Jet. ' 3
1.1 a Is this an accepted street?yes )0 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 tY1' Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system .
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'o Rhcord: J �^
./.(,,, ,A G/Ie/1 &ice., fir.t! J r,-1 `4-,,_'� . 0i Ga(V
Name(Print City,State,ZIP
Ll7 4etc.-. los 7.37-611/y
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) Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units : ,Other ❑ Specify:
Brief Descript�i,Qn of roposed Work2: �chi.-ia '•ep'r ` 1 r tJor- 54'r� ,L cot., J ru-ze,,,t/
4 4/N1, grid✓ t •
0``1 J -
SECTION 4: EST1MATED'CONSTRUCTION COSTS ;4 iv
Estimated Costs: ZN
Item Official Use Only-t3'/ 3c
(Labor and Materials) Y
1.Building $ /D GOO 1. Building Permit Fee:$15 O Indicate how fee is determined:
IIStandard City/Town Application Fee
2.Electrical $
3 coo 0 Total Project Cost3(Item )x multiplier x
3.Plumbing $ ,),v o 0 2. Other Fees: $ au
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amoun•
6.Total Project Cost: $ 0 Paid in Full la Outstanding Balance Due: \\`
SECTION 5: CONSTRUCTION SERVICES
5.1`"'Coonstruction Supervisor License(CSL) /6 72 r 1�� /l�
J C5C-' IL a tri� License1 Number Expiration Date
Name of CSL Holdpr
/a / / List CSL Type(see below)
No.and Street Type Description
o.16 ?r U Unrestricted(Buildings up to 35,000 Cu.ft.)
R Restricted l&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
P y_36 o_0/we err/
y •
SF
e Solid Fuel Burning Appliances
j ® (.r^70i/� r,tt.cv'1 I Insulation
Telephone Email address D Demolition
5.2' Registered Home Improvement Contractor(HIC) / 3 Vie
Jci6i" en,-, HIC Registration Number Expiration Date
HIC Companyame or Registrant Name //
v Sr` rJ C.�c(t 'i F/�`loc 4 � �
Cc .
N . d Streetcos_ ( Email address
City/Town, State,ZIP 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 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 ch e,,t/✓'7
to act on my behalf,in all matters relative to work authorized by this building permit application.
FYiAnilr
Print Owner's Name(Electro is Signature) Date
• SECTION 7b: OWNER5 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 acc ate to the best of my knowledge and understanding.
Print wners or Authorized Agent's e(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 Information on the Construction Supervisor License can be found at www.mass.2ov/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
cwL_ I
_ Department of Industrial Accidents
=_ai 1 Congress Street, Suite 100
1•f- " Boston, MA 02114-2017
;; 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/Organizationn/Individual): " L Job fiC/7
Address: GAS Si; - C!-€
City/State/Zip: Y,r /t 4,./ ii (J1C7f Phone #: ,,�d b(-3 6 U -)%'y"
Are you an employer?Check the appropriate box:
Type of project(required):
l.❑I am a employer with employees(full and/or part-time).*
7. ❑New construction
2.!.OP am a sole proprietor or partnership and have no employees working for me in .
any capacity.[No workers'comp.insurance required.] 8• Remodeling
3.❑I am a homeowner doing all work myself. [No workers'comp. insurance required.]r 9. ❑ Demolition
4.0 I am a homeowner and will be hiring contractors to conduct all work on m property.Y
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.❑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.: 13.Li Roof repairs
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,s§I(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.
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 above is true and correct.
Signature: j
Date: l G/.14
Phone#: � 3 4 40 ".l`'e/cr
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#:
CDT:Y 4_ TOWN OF YARMOUTH
o y BUILDING DEPARTMENT
1146 Route 28, South Yarmouth,MA 02664
5-v 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 S,
I hereby certify that there debris resulting from the
proposed work/demolition to be
conducted at 1 7 /GC 6Gv, �,I, -'•t
Work Address
Is to be disposed of at the following location: 7 fin6ci
Said disposal site shall be a licensed solid waste facility as defined by IA.G.L.
Chapter 1 I I, Section 150A.
/e/?A
ignature of Application Date
Permit No,
•
se Y/tk TOWN OF YARMOUTH �``'� J
76 HEALTH DEPARTMENT NOV 0 4 2019
�Loc PERMIT APPLICATION SIGN OFF TRANSMITTAL _ - �r LTH DEpT,
To be completed by Applicant:
Building Site Location: 7 7 ����•� 5���� (�in��
Propoip Improvement: coi tier. ‘_ex . _ ab 0.4„1-, 7 0,14 .
16 `cruel c -� '
Applicant:jC„f 8e/7 Tel. No.:
Address: ( d fa,/,-1 ( I( l 'msti4 /G/ .J'- Date Filed: 11114
**lfyou would like e-mail notification of/sign off please provide e-mail address:
Owner Name: fl/�,.. �`r,� y
Owner Address: II 7 De cc, S,� J c 14. Iv o,-/h Owner Tel. No.: SDJ 3 7- t 1 y Y
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: 1/// 3 i
PLEASE NOTE
COMMENTS/CONDITIONS: n � ` � �a ��
U�� 1`�vvx
1 f
.7/le U'o"mosee& g�✓�G�meze.X.4.1e/4- Division of Professional Licensure
• Office of Consumer Affairs&Business Regulation ' Board of Building Regulations and Standards
• HOME IMPROVEMENT CONTRACTOR Construction„S14:000r�1 & 2 Family
augZukatiIndMdual
Expiration lCSFA-105477 k' 6X Tres: 12/09/2019
03/16/2020 a
i JASON BERRIj<.} l e �
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E1 JASON BERRY 117,1
a 1 YARMOUTH PORT MA 676 '�
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' 105 SISTERS CIR �M ' , % 1' ' •1-1�i-I
YARMOUTHPORT,MA t72675
Undersecretary
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TOWN OF YARMOUTH
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REVIEWED FOR BUILDING AND:ONINJ CODE COMPLI- r`
ANCE. ERRORS OR C,::.ASSIGNS DO NOT RELIEVE THE ---
APPLICANT FROM THE RESPONSIBILIT "AS BUILT
COMPLIANCE.
DATE: II-1'y'�5 NOV 13 2019
BUILDING I IAL HEALTH DEPT.
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