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HomeMy WebLinkAboutBld-20-004071 w //eVi 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 1' � A� 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:II)-;AO ebYR/ Date Ap ' d: t c-.s \ 1.5-4so C I C". Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION isProzirty Ad re 1.2 Assessors a Parcel Numbersc �G %l�P�i�j� ��` G� 1.1a 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: Public❑ Private❑ Zone: Outside Flood Zone? — Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1.•�O r�,ero /Record: ov m s0� //7/J ie�©ar / C//L if'I Nae(P(ri`nt)) City,State,ZIP No.and S Street G Telephone y Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK"(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied 0 Repairs(s) ❑ Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. ❑ Number of Units Other 0 Specify: Brief sc ' 'on of Proposed Work': SECTION 4: ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ C 00 1. Building Permit Fee:$ l SO Indicate how fee is determined: 2.Electrical $ 1 Standard City/Town Application Fee 0 Total Project Costa(Item 6)x multiplier - x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 6'O 0 Paid in Full Outstanding Balance Due: � SECTION 5: CONSTRUCTION SERVICES 5.1 Constructionr� Supervisor License(CSL) es-ft z`J-32 ©/ ©�7 2c2e G6433IPI Z 1 4/ , /.71-- License Number Expiration Date Name of CSL Holder fr62 V, eE 19� 1��/ List CSL Type(see below) (.1No.and Street K` Type Description ,9JQ !;�/�� f— U Unrestricted(Buildings up to 35,000 Cu. ft.) ✓✓ ZIP R Restricted l&2 Family Dwelling City/Town,State,/(Z vI'P (I/ M Masonry RC Roofing Covering WS Window and Siding > qq e SF Solid Fuel Burning Appliances .6-6// a-oP2J 9A�A�TE-Gy, 4frov I Insulation Telephone Email addre D Demolition 5.2 RegisterRI HAme Improvement Contractor(HIC) _ G ilotAE i�( Ro a-►7e i Date HIC Registration Number Expiration Date FNmpany Na me ame or HIC e i tr t o. reextiiC�+ M� „cI , 82S% � G HAIL 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 to act on my behalf,in all matters relative to work authorized by this building permit application. 4/. /(.JO)20 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 conta din this application is true accurate he best of my knowledge and understanding. 0, 11 2o20 Pr' t Owner' o Authorized Agent's Name(El tonic ignature) 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.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 r z� L Department of Industrial Accidents lac 1 Congress Street, Suite 100 Boston, MA 02114-2017 y www.mass oov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information p� Lease Print Legibly Name (Business/Organization/Individual): G /w - ,//R Address: P��` Qc' , /njc ,& City/State/Zip: YOttiCti 114 Phone #: v6-67 °C6 8250 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.g 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 4.0 I am a homeowner and will be hiring contractors to conduct ail work on my 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._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. Roof repairs 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152,§l(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 certify un ze pains a�nalties of perjury that the information provided above is true and correct. Signature: _ Date: 0 r, ©2 0 Phone#: 5 / 306 52 &N, 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#: TOWN OF YARMOUTH cBUILDING DEPARTMENT YorD x 1146 Route 28, South Yarmouth, rvlA 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 1115, I hereby certify thatQ the debris resulting from the proposed work/demolition to be conducted at oG,S l� 7092 4, Ylie/ 7// Oie Work Address Is to be disposed of at the following location: S? J L2 Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. Si ature of Application Date Permit No, F Office of Consumer Affairs and Business Regulation 1000 Washington Street-Suite 710 Boston, Massachusetts 02118 Home Improvement,Contractor Registration = Type: Inrinridual Registration: 192964 GABRIEL PANAITE Expiration: 08/3012020 D/B/A G&R HOME IMPROVEMENT 862 QUEEN ANNE RD HARWICH,MA 02645 _ -'' Update Ms s and Return Card. SCA 1 0 2014-05/17 -&;reirevre"*z( -:1-',./IferzAtezaiere,seeff; Office of Consumer Affaks&Business Regulation HOME DAPROYEINENT CONTRACTOR Registration valid for individual use only TYPE hidividuaI before the expiration date. If found return to: 8/1114114A211-, gaRifillbS1 Office of Consumer Affairs and Business ReguMtion - 0813or2020 1000 Washington Street-Suite 710 GABRIEL PANAlit Boston,MA D/BIA G&R HOMF4141144400ENT T-F-a GABRIEL PANAIW, . 862'QUEEN ANNER00:5; ' • HARWICH,MA 02645 Undersecretary PA valid ut signature Commonwealth of Massachusetts V.; Division of Professional Licensure • Board of Building Reglitations and Standards Constr44"titni'StIp!rvisor CS-112592 anires: 01/05/2022 ,F. • GABRIEL I PANAITE 862 QUEEN ANNE ROAD HARWICH MA 112646 .• Commissioner aiL • oF.Y.yp RECEIVE L- TOWN OF YARMOUTH . diiit.:1,:. 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451 JAN 21 2020 Telephone(508)398-2231 Ext. 1292-Fax(508) 398-0836 i YARMOUTH 0 D KING'S HIGHWAY OLD KING'S HIGHWAY HISTORIC DISTRICT COMMITTEE APPLICATION FOR CERTIFICATE OF EXEMPTION Application is hereby made for the issuance of a Certificate of Exemption under Sections 6 and 7 of Chapter 470 of Acts of 1973, as amended, for the proposed work as described below and on plans, drawings, or photographs accompanying this application. Type or print legibly: ,� .2g Lh� P�� "se % 1��T' Address of proposed work: Map/Lot# !� / �/ .o / Owner s): 4 el��jL �DIT iI�N Phone#: �f �y ,2/?0.51j� All applica ions must be submitt b o er or accompanied by letter fromfr owne prrooving submittal ofapplication. Mailing address: 5 ///G�t � Ap �`l //©l/, ��ar built: AST �i Email: Preferred notification method: Phone Email Agent/Contractor: G�J IQ)EL ?9, /T Phone#: 5C/ 3 6V282 3 Mailing Address: 8612 ( u 5/5/ //N/Vi 02 /1•'17 w/coi-/ //T/ 62.2 Email: gig/ 5 n/3P/5/! 0/(4//L, (70� Preferred notification method: V Phone er Email Description of Proposed Work(Additional pages may be attached if necessary): l e-ry-v vL GI co r, -�—r,6-I-c� i I 3 -P. (AA P a....-,e- g l a SS S a '�-'�v v,cL r7 Signed(Owner or agent): T- Date: 01/ 2/'())0D > Owner/contractor/agent is aware that a permit may be required from the Building Department.(Check other departments,also.) > This certificate is good for one year from approval date or upon date of expiration of Building Permit,whichever date shall be later. For Committee use only: Date: /'a?/4Q72) ✓ Approved Approved with changes Denied Amount ab Reason for denial: APPROVED RECEIVED Cash/CK#: \dam\ �•/M JAN 21 2020 JAN 11 2020 Rcvd by: YARMOUTH TOWN CLERK OLD KING'S I IIGHWAY SOUTH YARMOUTH, MA Date Signed: fAi/ZO L 0 Signed: �..JC• V � APPLICATION#: 20 l- 603 V5.2017