HomeMy WebLinkAboutBld-20-002471 1 „,7`f
ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department ,.."of• v-_-__
1146 Route 28, South Yarmouth,MA 02664-4492
508-398-2231 ext. 1261 Fax 508-398-0836 '14' �'
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: j, D-02V- `791 Date Appli Ytil-s'
) Ir, cS �T \\ - 6- 1S
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION.
1.1 Property Address: 1.2 Assessors,Map&Parcel Numbers
fli Cau l hCT,ct ��. � /35 / yy
1.1 a Is this an accepted street?yes V 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 OWNERSHIP'.
2.1 Own r'of Record:
0 Vic .. (3‘Carlo
atyg _____________
Name(Print) City,Stat ,ZIP
No.and Street Telephone Email Address 04.5d/
SECTION 3 DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building Cl Owner-Occupied 0 Repairs(s), ii Alteration(s) / Addition ❑
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work2: R.LCINA1 b Q,tk tract Dmt‘3 o`L
fro
to , �;� Y uJl '' C Ill L� � e
E ON 4:'ESTIMATED CONSTRUCTION COSTS �t�e
Estimated Costs:
0 Item Official Use Onl k
(Labor and Materials) Y •
,_
1.Building $ ic , p GD 1.. Building Permit Fee:$1,00 Indicate hOw eiptoRined:
2.Electrical $ 1 **Standard City/Town Application Fee !0.3
"�,, ' 0 Total Project Costa(Ite ^6)x multiplier x
3.Plumbing $ 0) V, 2. Other Fees: $ ?jJ
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) $ Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ \j5 L .(1)
t 0 Paid in Full el Outstanding Balance Due:,()S-
SECTION 5: CONSTRUCTION SERVICES
• 5.1 Construction Supervisor License(CSL)
6'641/41o }v CS-ttg —►a—Z►
License Number Expiration Date
Name of CSL Holder
a u n , List CSL Type(see below)
No.and Street Type Description
S ,(j W\ f p_LI® Unrestricted(Buildings up to 35,000 cu.ft:)
Restricted l&.2 Family Dwelling
City/Town,State,ZIP Vl�1t R
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Insulation
Telephone Email address D Demolition
Registered5.2 '_ w ��Ho everpgntContractor(HIC)
br. okVS
HIC Registration Number Expiration Date
HI C mpany NNarAe; HIC Registrant Name
t•‘tLA‘C.D cod gCrAOdel -
No S eet n , 11Aft `ic mail address
City/Town, State,LLP Telephone
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(1VI.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
n ,,, Qu
I,as Owner of the subject property,hereby authorize PCI Qc, , ,
to act on my behalf,in all matters relative to work authorized by this building permit application.
1V Cam.+ (AM 1,0-3—t1
Print Owner's Name(Electronic Signature) Date
• SECTION 7b: OWNER1 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.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 .3
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
nN11= 1 Congress Street, Suite 100
•••11L Boston,MA 02114-2017
•
tot,.•�'•�� 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): birbtohe &MMAMI 6_, AAA)
Address: 7.--7,-
City/State/Zip: S ` 6Ary aw,, Phone #: ii4 Ltai ( ,ly
Are you an employer?Check the appropriate box: Type of project(required):
1. am a employer with ` employees(full and/or part-time).* 7. 0 New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. giRemodeling
any capacity.[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 YP 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.
12.0 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.Q 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.
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: tg wt k\-ctiAtk(iji
Policy#or Self-ins.Lic.#: NrCvXCtin3ga Expiration Date: t �1'tq
Job Site Address: (-51 ant long CANIAL City/State/Zip: leelp - 1`4 O2-42'11'
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 certi y under the pains and penalties of perjury that the information provided above is true and correct.
Signature: C
Date: O—
Phone#: ,°"U15''1313tocD.3
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#:
'YA,4 . TOWN OF YARMOUTH
•
u • BUILDING DEPARTMENT
N nAnAcn __�:�4 11.46 Route 28, South Yarmouth,MA 02664 508-398-2231 ext. 1261`y'arc.nmx
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
JOB LOCATION: e e-CIAOS1A �� ►Cx�+ moaNixecNk
1 STREET ADDRESS SECTION OF TOWN
"HOMEOWNER" 1T C t CAAD Tc 88,111201
NAME • I P .O A � WORK. PHONE
PRESENT MAILING ADDRESS M"'J� `r'%r �,.�I� -• i , ''\ FI`nass oisrbi
CITY OR TOWN STATE ZIP 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 requirement n that he / she will comply with said procedures and
requirements.
HOMEOWNER"S SIGNATURE /\OLS
APPROVAL OF BUILDING 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
• Y.g\ TOWN OF YARIYIOUTH
t _ y o
;yg y BUILDING D EPARTMENT
MENT
1146 Route 28, South Yarmouth,MA 02664
�, ...4:2? 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 1115,
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at 0 Gvecsl\1& A (YCl
Work Address
Is to be disposed of at the following location: ' CL✓MULPI\ (1S9661
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter III, Section 150A.
diAz1 ii0-3-t
Signature of Application q
Date
Permit No.
„.�t .'"&' ark 0 ”. + ``c a ;,"9,;. �� .>'.t. ' a ,x '' , �; �' _ y, a
r ..'i� �: , era ro ° : e, .
,• v. �. ;u ,.-t 3°�W 8�6�Wax,�ti,
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/ Bill To:
NICOLE OLIVEIRA
Al; Berkshire Hathaway 22 Carter Rd
1741 G U A R D Insurance
Companies South Yarmouth, MA 02664-4406
Workers' Compensation Insurance Premium Bill
For Policy Number NIWC015800 as of 9/26/2019
Policy Cost: $ 4,078.00 Policy Period: 11/01/2019 - 11/01/2020
Billing Fees: $ 0.00 Carrier: NorGUARD Insurance Company
Total Payments: $ 0.00 Agent: SCHLEGEL& SCHLEGEL INSUR
Account Balance: $ 4,078.00 508-771-8381
Policy Premium - Down Payment $ 815.60
AMOUNT DUE 10/31/2019 $ 815.60
The down payment for your renewal policy is required by the due date shown for uninterrupted coverage to continue.
If not received, this policy will be canceled in accordance with state law.
Payment Terms: 20% Down Payment, 9 Monthly Installment(s)
► Please see Important Messages on the back of this bill. 4
Make your check payable to WestGUARD Insurance Company and remit with the coupon below.
Due Date: 10/31/2019
Account Number: 14092303015800
w Berkshire Hathaway Current Amount Due $ 815.60
Total Amount Due: $ 815.60
GUARD Insurance Companies
Amount Enclosed
NICOLE OLIVEIRA IIIWlilliiull"itlllllhlhllliihlllll,llllilllidllllilhtil
22 Carter Rd WestGUARD Insurance Company
South Yarmouth, MA 02664-4406 PO BOX 785570
PHILADELPHIA, PA 19178-5570
Policy Number NIWC015800'
10312019 1409'23030158007 000815600 000815600 5
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/oir(- ',--,if?1J1(I1r(f'(4'f//a� 7- "4.
Office of Consumer Affairs & Business Regulation
iM
HOME IMPROVEMENT CONTRACTOR
�LL TYPE: Corporation
Registration Expiration
196891 10/03/2021
BROTHERS RENOVATIONS I C.
PEDRO A. DEOLI I
22 CARTER ROAD :::.
- f t ' �
SOUTH YARMOUTH,- A 0 64
Unde�rs l � M.
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Sears, Tim
From: Sears, Tim
Sent: Monday, November 4, 2019 4:23 PM
To: 'nicole@capecodremodel.co'
Subject: 28 Greenland Circle
Braulio,
I have reviewed your application for 28 Greenland Circle, and there are some items that need to be addressed;
Old Kings Highway approval is needed for doors and windows
The floor plan needs to have the smoke detectors marked—adding a bedroom requires upgrading the entire
house to code
Please submit the above items for review
Thank you
Timothy Sears CBO
Building Inspector
Town of Yarmouth
508-398-2231 Ext. 1259
mailto:tsears@varmouth.ma.us
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TOWN OF YARMOUTH OCT 09 2019
s' ,c HEALTH DEPARTMENT
0 "3 Hc^-''_.TH n PT•
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant: _ _ AA n�
Building Site Location: c g e,..\, �►�[ N'1(71 1
Aaps
Proposed Improvement: is \ v1��.414 m.
n uw& — 110
Applicant: 1Sk(he_ UUv0,1 Tel. Noo.: ` ()��1��,¢,),?
Address: 22, Co v ICE?oik S • . 6291U►'w: Date Filed: 1 q
**/fyou would like e-mail notification of sign off please provide e-mail address:
Owner Name: t 1 lk- 1D L&,A i
Owner Address: 1-VM- ���•t•�� ►�' Jr_ AiX(\ &AS Owner Tel. No.: St7 s$11oO14
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: ed /16/0
?\)1K-.
PLEASE NOTE
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