HomeMy WebLinkAboutBld-20-004360 r , ..__C;----nA.A..a - .../.../9 46.4.fi
ONE & TWO FAMII",Y 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 e
Building Permit Application To Construct, Repair, Renovate Or Demolish
a One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Bt.')a a"OZ) Y36 0 Date Applied:
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 P,ronerty Address: DA-A/iW 1.2 Aljss� s Map ZParcel Numbers
bi 1.1 a Is this an accepted street?yes "no Map NumlSer < Parcel Number
P
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 4 Private 0 Zone: Outside Flood Zone?
_ Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: c
To6A u A. v€JP/g 9 C. /or Z4/" ,e rJ .
Name(Print) City,State,ZIP
k t-Au-cFc> --1)06- 7 7e 99y aVv.3
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building 0 Owner-Occupied 0 Repairs(s) ir Alteration(s) 0 Addition 0
Demolition ❑ Accessory Bldg. 0 Num er of Units Other 0 Specify: F R i R C r m i.z 5
Brief Description of Proposed Work': AemO✓e-_ ��p/6ze P Alt A I-i i f 64- i Nsul ,e -34 zig,di--
PAIdl/ -i kegiliC2 OaeywAI (P.41')'/ lrAtwc i'il 61414C,eavvL kw irg'ezewx- ��,..aC. _
( J0,91 Or')Jt -fPon,L,.,�./ 1,v,-n j .evd,tc . 6-/aS i,us,eA lr 1,14 "247-g°x,Tl repF E D
/'Rl`frkr6 ,4eTy —AAs i er/ea"62,z se- a nieces
SECTION 4:ESTIIYIATED CONSTRUCTION COSTS02)
Item Estimated Costs:
FEB ► 2J2.0 "S
(Labor�/`and Materials) Official Use Only — .
1.Building $ TJ � -- g I1- _-• L lt�G QEePt. MENT
U 1. Building Permit Fee:$1 p Indicate ho`� is�etermmed:
2.Electrical $ vY PQ 5 Standard City/Town Application Fee
0 Total Project Cos tem 6 x multiplier - x
3.Plumbing S ' $ �71i�,C 5 2. Other Fees: $
4.Mechanica (HVAC) $ List
5.Mechanical (Fire
Suppression) $ Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ j - 0 Paid in Full l!,Outstanding Balance Due: k\E
i SECTION 5: CONSTRUCTION SERVICES
, 5.1 Construction Supervisor1 Lic nse(CSL) ^ 0 - t/Q Z c/ r _/O c2
(ilk( `( ii"r`' � Licensel Number T Expiration Date
Name of CSL Ho der
•
`2 -1._ rv+_'b 5r List CSL Type(see below) -/t'"�
No. and Street Type Description
`3(Le-4-6�1 X (U ) Unrestricted(Buildings up to 35,000 cu.ft.)
Restricted I&2 Family Dwelling
City/Town,State,ZIP M Masonry
itk* " 0 i-o Z , RC Roofing Covering
WS Window and Siding
J� 7 SF Solid Fuel Burning Appliances
1Y__Ali l7 I Insulation _
T lephone Email address D DemoIition
5.2 Registered Home Improvement Contractor(HIC)
0),1,10 tu <e_- /2-7 2-‘ y 7-1 f-l(
HIC Registration Number Expiration Date
EC Comp4n�y Name or HIC Registrant Name
144,.it .-'itec 10 ic,si n ow s re,cve t frS • tre3 le•re"wkeie.✓.ter and Street �t.Ft7iY'J_
No.
Sa and
- ao'xf Z 1_ ice1)�€+✓W ( 77'ly170y37 Email address •lowt
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 .0
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES, FOUR BUILDING PERMIT
I, as Owner of the subject property,hereby authorize 11- '��[� 0 i
!fL-
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: 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.
[A)dttikok ,
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.Eov/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"
°�'Y ,� TOWN OF YARIv1OUTH
�- ° BUILDING DEPARTMENT
g
.fit 1146 Route 28, South Yarmouth, MA 02664
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 111.3,
I hereby certify that the debt-is resulting from the proposed work/demolition to be
conducted at 8 Cl-/ `J ' \ ¶0,1*
•
Work Address
Is to be disposed of at the following location:
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
44, 7//1' (P *V-6
Signature of Application Date
Permit No.
The Commonwealth ofMassachasetds
- , tTr, Department of brdaal+rr°alAcctdenls
• =�n 1 Congress Street,Suite 100
=1 i— .Boston,MA 021144017
`� a4
wWMmassgov/dda
Workers'compensation insurance Affidavit:Builders/Conteactora/Electrieians/Plumbers.
TO BE FILED MITRE PERMITTING AUTHORITY.
Aoulicatat Information Please Print Lenihly
Name oksinessogenkationMdividualy Whalen Restoration Services
Address: 22 American Way
City/St e/Zip: South Dennis, MA 02660 phone it: 508 760 1911
Are you an employer?Check horn
Type of project(required):
- 1.®I em a employer with 2 5 employees(tbll andtorpart-time).* 7. ®New construction
2.01 am a solo promiemror partnership and have no employees worldng for me in S. ®Remodeling
any capacity.Utoworkers'comp.instance required.] .
3.DIama homeowner doing ell work myeelf.[No workers'comp.insuri erequirerl]tDemolition
- 4.0i am abomaownaraad wai be hieing oonua000moo conduct ell weak on my property. F w{i{ 10 Building addition
ensure thatell contractors either have workers'compensation hreutenoe mare sole 11.0 Electrical repairs or additions
proprietors with no employees. 12.®Plwnbing repairs or additions
S.E3 Ism a general ransartorand'have hired the sub-eontraotem listed on the attached sheet. 1I, Rdof re_ airs _
These sub�eorttisotors have employees and have workers'comp.insurance o -.
6 Wears aco 14._ e a,ef P E 1, FR.
corporation Wm:have exercised their right e.
1552,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicanethat checks honGl mustelmOaseethesectionbelowsltowingtheirworkers'compensation pot*inbnnation.
HeatiOngswhombmitthisetridsrltindicatingtheyaredoingallweakandthenhheoutridecondaoreramartsubmitanewatlidavjbathaidegsuch.
'Cont;actors duet&Aft Mount attached an additional sheet showing the name ofthe suboontmotom and ate whether Grantham entities have
employees.ifthesbsontraatare have elloyees,they must provldetheir workers'comp.policy number.
I am ate eutployer that Is pram ngworters'coiwjensafion ifsuraiwefopmy employees. Below is the policy audio&site
iojbrmatlon.
insueaneacompanyName: Ace American Insurance Company
Policy#or Self4ns.Lin.#: 5B89454219 Expiration Date: 4/1/20
lob Site Address; 8 C 14 M ( to 47> City/State/24;C ise0t C(._ at•t--
Meth.a copy of the workers'compensation policy declaration page(showing the policy number end aspiration date).
Failure to secure coverage as required under MOL a 1S2,§25A is a criminal violation punishable by a fine up to S1,500.00
and/or the near imprisonment,as well as civil penalties in the form(fa STOP WORK ORDER and a fine ofupto$250.00 a
day against the violator.A copy ofthis statement may be forwarded to the Office oflnvestigations ofthe DIA for insurance
coverage verification.
/do Barely eerie un =-the p ins and enalls ofpeuy hap the information true an d correct
Signattua: Date: Z t,
•
)?hones*: 7757 G) -7z
• Official use orris Do trot write in this area,to be completed by ale;or tow official
City or Town: Perrui iceuse#
Issuing Authority(circle one):
1.Board of Health 2.Bonding Department 3.City/Town Clerk
4.Electrical Inspector S.Plumbing Inspector
6.Other •
Contact Person: Phone#:
ikedeil47storation Services Inc.
Fire, Smoke,Soot,Water Damage&Mold Remediation Services
Cleaning • Deodorization • Reconstruction
Specializing in Fire Restoration - All Work Guaranteed
Access, Authorization and Direct Payment Request Form
I (we) authorize WHALEN RESTORATION SERVICES to perform work Pt 12 111'61-
at property located at 6 G M- "biAsiti k. .(
to repair damage caused by 1 1 P-E on d
--As owner(s) of this property, I (we) understand that I (we) must authorize this work. I (we) hereby
authorize WHALEN RESTORATION SERVICES to perform this work and accept responsibility for
payment upon completion.
I (we) authorize and direct my Insurance Company -DiaN�u2 \ ‘
Policy No. 14 Sz ZZ s zrei , to make payments directly to WHALEN RESTORATION
SERVICES, Insurance Claim Specialists, for doing this work and to that extent I (we) assign the benefits
applicable to this loss to WHALEN RESTORATION SERVICES.
I (we) acknowledge receipt of a copy hereof:
( OWNER
DATED 7 SSNED
24' OWNER
HAL N RESTORATION REP. SIGNED
22 American Way,South Dennis,MA 02660
Phone:(508)760-1911 • Fax: (508)760-9995 • 1-800-244-2598•E-Mail:restore@whalenrestorations.com
Web Page:http://www.whalenrestorations.com
OFFICE COPY=WHITE CUSTOMER COPY=YELLOW
___ ___ _ _ Commonwealth of Massachusetts
Division of Professional Licensure
•
-^"""e`/r« 411, /67.446,..,/,;i c/4 Board of Building Regulations and Standards
Office of Consumer Affairs 8 Business Regulation Construction`Supervisor
HOME IMPROVEMENT CONTRACTOR
TYPE:Corporation CS-074928 Expires Di3/10l2420
Registration Expiration € r r
129244 07/29/2021 1
WHALEN RESTORATION SERVICES INC.
WILLIAM WHALEN
122 POND STREET
BREWSTER MA.=02631
WILLIAM WHALEN
22 AMERICAN WAY 4:401'4
• SOUTH DENNIS,MA 02660 Undersecretary -
Commissioner
•
•
Registration valid for individual use only Construction Supervisor
before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation Unrestricted-Buildings of any use group which contain
10 Park Plaza-Suite 5170 less than 35,000 cubic feet(991 cubic meters)of enclosed
Boston,MA 02116 space.
Not valid without signature
Failure to possess a current edition of tb1Massachusetts
State Building Code is cause for revocation of this license_
For information about this license
Call(617)727-3200 or visit www.mass.gov/dp1