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HomeMy WebLinkAboutBld-20-003898 L M ///'6/TOV ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department ...-.4 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 Fermit Number 3 ' 7 Date Ap lied: af-'1,°44; /—16 --ND Building Official(Print Name) tgnature Date SECTION 1:SITE INFORMATION 1.1 Pro erty Address: 1.2 Assessorsjap Parcel Numbe s a piktwoo Q� tr./No-A 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: r"-- Zone: ) Outside Flood Zone? Public❑ Private 0 Check if yes❑ Municipal 0 On site disposal system SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: f ; `� ieOviG.,•clo j,1a;rrcie, V' r4iovj4 444 02C13 Name(Print) City,State,ZIP ` 1 q Pule woad 69 �i3ge 1qs V No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 Existing Building IS Owner-Occupied ❑ Repairs(s) E1 Alteration(s) 0 Addition ❑ Demolition ❑ Accessory Bldg. 0 Number of Units Other ❑ Specify: Brief Description of Proposed Work2: L ego ii. e $e co I gC/ o ' Al /-IOdle (to free "1.....,, ce.--C-4 ... , i ...z c A,o #6633 3 SECTION 4:ESTIMATED CONSTRUCTION COSTS I Estimated Costs: Item Official Use Onlye__ (Labor and Materials) c 1. Building $ 3003 1. Building Permit Fee:Ti, .49�Indicate how fee is determined: 2.Electrical $ 0 Standard City/Town Application Fee WO 0 Total Project Costa(Item 6 x multiplier . x 1 3.Plumbing $ 1000 2. Other Fees: $ S 4. Mechanical (HVAC) $ List: 'SD pv .�-v `; ,:f1/4'v 5.Mechanical (Fire Suppression) $ Total All Fees:$ 9t' Check No. Check At: Cash Amount: 6.Total Project Cost: $ 5 000 ❑Paid in Full La•Outstanding Balance Due/34. ) SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) caul I. LJi^1 License N r) umber Expiration Date Name of CSL Holder 25 aid 4 +�N��J� List CSL Type(see below) No.and Street t `,{ Type Description S O o benniS �t I{� 0 !Irk O U Unrestricted(Buildings up to 35,000 Cu.ft.) J"! R Restricted I&2 Family Dwelling City/Town,State,ZIP Iv' Masonry RC Roofing Covering WS Window and Siding 71 r, j(� h /° J ) SF Solid Fuel Burning Appliances t 26 OZO tbraut o'IUri to'& V) (.A.I .(�"Jhq I Insulation Telephone Email addre4 D Demolition 5.2 Registered Home Improvement Contractor(HIC) • (�ib 4^i �o S�^u;t�� 12 cal O(4/ /lZ( HIC Registration Number Expiration Date HIC Company Name or C Registrant Name �$ VA c,k t4h It No.and Street SD Jt be note PiI O2(( 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 0 No .0 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 8 rcv/l'O 0 to act on my behalf, in all matters relative to work authorized by this building permit application. i�e.q,‘,...,•to 4.11(-11 cJ 01imiZo 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. C,r� 9//26' '` i.J Print Owner's or Atrrliorized 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.aov/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 Nnmber 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, 1 Congress Street, Suite 100 Boston, MA 02114-2017 �Workers' �j orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization//Individual): /,6 i d0 S.t.,()°(-U Address: zs al t,�.e .tan hy • City/State/Zip: .00IIrk DMA 1.J. MA 02660 Phone #: 71'1 —26 6-- 0 e496 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.N 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.[I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. ❑ Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on m Y property. 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.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[I]Other 152,§I(4),and we have no employees. [No workers'comp. insurance required.] *Any applicant that checks box 41 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: 'Q P.it 61)00 g City/State/Zip: �2ctmo 4 /4 c p2Lj3 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. Siunature: apet,t, E?..4 Date: /he C 0 Phone 4: 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 TOWN OF YARMOUTH �' •erg c BUILDING D EPARTNIENT • °, - of •Z• 3 114-6 Route 28, South Yarmouth, MA 02664 75a, s- 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 q Pi:'1 wood Icicm.c)L-(4 Work Address Is to be disposed of at the following location: t1v'tvtouI4 Di`J,,o)441 Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. 74/ o1/04ea Signature of Application Date Permit No. TOWN OF YARMOUTH c, HEALTH DEPARTMENT '�•`` PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET To he completed by Applicant: Building Site Location: Pi rie Woo _ Wi A Y rol o.t4 /414 Proposed Improvement: (j r'i fi Stcnri ( (Q o r 60 build/is COd e. R W►ouLd lt;�- c t..,J?..^ - FLr1 Applicant: a (`ceo l i L2 D i D Tel. No.: Address: 25 Uri It S an iej (Ali S. iS M a Date Filed: Q//Q4/49 **/fyou would like e-mail notification of sign off please provide/e-mail address: Owner Name: L e ©i ia+^do dot pi Czl Owner Address: ci pi he,Wood Rec. kiQ.r✓novg Owner Tel. No.: 50 - i 3N S' 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: / /7 'a0c)) d PLEASE NOTE COMMENTS/CONDITIONS: J -e.. / i,vv r r'1 hies ( f(G(i& Sere. J /6-A / C <r • - • •• . ' ' .. :'•-,-• . ' .-.,• -,,,, ' , lig-. . , it •' 4 - , ,0 • • .....,...* III 1 I p1.1 ,, ..,.. ., .... ,, .3,c. a a e , ... t ... 01 is I . . . .. III 1 i .3.,,, , % * ......*. - -4,i'Mt: 'ti,,- ''.-.-‘" ' '• ' It .0 • ,. . 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Details Page 1 of 1 Licensee Details Demographic Information Full Name: BRAULIO BRITO Owner Name: License Address Information City: South Dennis State: MA Zipcode: 02660 Country: United States License Information License No: CS-110548 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: Issue Date: Expiration Date: 5/23/2020 License Status: Active Today's Date: 2/27/2019 Secondary License Type: Doing Business As: Status Change Reason: License Issuance Prerequisite Information No Prerequisite Information http://elicense.chs.state.ma.us/Verification/Details.aspx?agency_id=1&license id=854161& 2/27/2019 ,s ` ONE or TWO FAMILY— BULDING PERMIT APPLICATION REGULATORY APPROVALS NOTICE Address of Proposed Work: 9 Piet toad Rd. Uk)4 &from-it / (A 026 13 Scope of Proposed Work: L;j�li L.rt. Sec ,d (/ooc O/ l e AooP Date: 0 i 10 412,0 Based on the scope of work described above, the applicant is required to obtain approval sign- offs from the following departments as checked-of below: /Health Dept. —508-398-2231 ext. 1241 Conservation —508-398-2231 ext. 1288 Water Dept. —99 Buck Island Road, 508-771-7921 Old Kings HWY. Hist. Comm. —508-398-22631 ext. 1292 Engineering Dept. —508-398-2231 ext. 1250 _Fire Dept. — Kevin Huck/Scott Smith, 96 Old Main Street, SY Note: Please call Fire Department for an appointment. 508-398-2212 Other Appropriate plans and/or application shall be provided to each departments checked-off above. Each of these regulatory authorities has their own requirements outside the jurisdiction of the Building Department. All applicable approvals shall be obtained prior to submitting a building permit application to the Building Dept. Thank you for your cooperation. Receipt A cknowle�ent: ' t41'tJ l9//UG ed Applicant's Signature Date Rev. 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