HomeMy WebLinkAboutBld-20-003338 4.
ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department 1146 Route 28, South Yarmouth,MA 02664-4492508-398-2231 ext. 1261 Fax 508-398-0836 ',15.............444
Massachusetts State Building Code, 780 CMR
Building Permit Application To Construct, Repair, Renovate Or Demolish
a One-or Two-Family Dwelling v
p.
This Section For Official Use Only I)
Building PermitNumber:C A / e1 _ cc , Date Applie - DPC t)Z019]
DING �
Building Official(Print Name) Signature C3' f,, k riv NT
SECTION 1:SITE INFORMATION -- --
1.1 Property Addres : 1.2 Assessors Map&Parcel Numbers
a -'trove. I- (' Ave. .c9 - iY ,
1.1 a Is this an accepted street?yes X no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
II IIGI
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
30 3 2- Zo a9 E® Z1 SO
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public K Private 0 Zone: Outside Flood Zone?Check if yes❑ Municipal 0 On site disposal system 0
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
TA W ri 'I vvi II u jLoo4 01 6 D-D 1 C7
Name(Plitt) City,State,ZIP
►is" Groat Si- Ail-- . 7q1 ciA 54411 rn 66 )1-1qa`1 a covtet J ► coM
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction 0 Existing Building Owner-Occupied 0 Repairs(s) 0 Alteration(s)W Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other ❑ Specify:
Brief Desciiption of Proposed Work2:
prOVIdm41 Ct new s4-ep ' C4CIL 40 Ake_ Slcle C101r
SECTION 4: ESTIMATED CONSTRUCTION COSTS. cv + 'tol
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 2,000, 00 1. Building Permit Fee:S ft 7 S Indicate how fee is determined:
2.Electrical $ In Standard City/Town Application Fee
0 Total Project Cost3(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 ount:
6.Total Project Cost: $ 2 000 0 Paid in Full al Outstanding Balance ue: 40
5DS— 7L1
C-(114€0 a 9 —
t 4d/kiA
v SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)tid . t5f4 dS/Yvj/ 3—a—2a20
/tPr e / /#k e) License Number Expiration Date
Name of CSL older
,23 i List CSL Type(see below)
No.and Stree 4r Type Description
fisel1/1u /44 air U Unrestricted(Buildings up to 35,000 Cu.ft.)
R Restricted I&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding _
SF Solid Fuel Burning Appliances
561-6 CH, tS x3 C Crm1.ajT a. ,- I Insulation _
Telephone Email address D Demolition
5.2 R eisterell�Home Improvement Contractor(HIC)
,-I A l75/Y9 7 1-0-1->
HIC Registration Number Expiration Date .
HIC Company N e or HIC Registrant Name
a � '-lG
No.and S t
nn�� Email address
(jcCity/Town, State,LIP Telephone Co,-4 E' s -tJt:::T
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 Elk 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
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: 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
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.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
I =54.� 1 Department of Industrial Accidents
_f.:M11= 1 Congress Street, Suite 100
-4 N1t_ Boston, MA 02114-2017
.me,�•- 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): iafffrl s-ef
Address: )) t 61
City/State/Zip: -4•7 i /' 0 X31 Phone #: 5O? Z EiY
Are you an employer?Check the appropriate box: Type of project(required):
I.E I am a employer with employees(full and/or part-time).* 7. ❑New construction
2.�—M t I am a sole proprietor or partnership and have no employees working for me in 8. ' Remodeling '
any capacity.[No workers'comp. insurance required.]
3.0 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 my property. I will 10 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.E Electrical repairs or additions
proprietors with no employees.
12.[1]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.El Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other � e clt'C IL
152,§1(4),and we have no employees. [No workers'comp.insurance required.] j
*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.
1Contractors 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 he pains and penalties of perjury that the information provided above is true and correct.
Signature: 41 Date: /Z —1/-1/
Phone#:
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
o y BUILDING DEPARTMENT
* ` 1146 Route 28, South Yarmouth,MA 02664
• !LB' 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 debris resulting from the proposed work/demolition to be
conducted at (2C1 Tow.. 11 A-c1r
Work Address
Is to be disposed of at the following location: 'fr r41 a 'L
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
Signature of Application Date
Permit No,
Commonwealth of Massachusetts
�r Division of Professional Licensure
Board of Building Regulations and Standards
Construction Supervisor 1 & 2 Family
CSFA-081484 Expires: 03/11/2020
KITTREDGE P HOLMES'
PO BOX 32
DENNIS MA 02638
Commissioner
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
TYPE Incividual
174497 01/17/2021
KITTREDGE P.HOLMES
KITTREDGE HOLMES
23 APPLE LANE
DENNIS,MA 02638 Undersecretary
YARMOUTH WATER DIVISION
99 BUCK ISLAND ROAD
WEST YARMOUTH, MA 02673
PH.: 508.771.7921
FAX: 508-771-7998
BUILDING PERMIT APPLICATION
DEPARTMENTAL SIGN OFF TRANSMITTAL SHEET
Bldg. Site Location 099 /p1dr, /4// 4-1/6- Map #: 59 Lot #: 11-(,0
Proposed Improvement: /lew /p� ck- cm 4 0 /lou
S(
Applicant: I L j/n/tS
Address a3 it_ In !' to/5 Tel. #: r‘.9e6 yg Date Filed: /Z-//-/j
RESIDENTIAL AND / OR COMMERCIAL BUILDING
Water Department: Determines Compliance of Water Availability and or Existing Location
Engineering Department: Determines Compliance for Parking and Drainage
Conservation Commission: Determines Compliance to Wetlands Acts; i.e. If Lot(s) Border any Type of
Wetlands, Streams, Ponds, Rivers, Ocean, Bogs, Bays, Marshland, Etc...
Health Department: Determines Compliance to State and Town Regulations, i.e., Requirements
for Septage Disposal and other Public Health Activities
Fire Department: Determines Compliance to State and Town Requirements for Personal,
Safety, Property Protection;, i.e. Smoke Detectors, Sprinkler Systems, Etc...
/z--1/-/2
Signature of app nt Date
PLEASE NOTE:
COMMENTS:
/Reviewed by: Water Division
Date
e
!?-4 ti',;° , I AMMO
MwP:59 TEST HOLE,LOGS
11,41,01°- PAACEI: l0� 0 TIEOISTAWUIOIIMUSTItM91ASTAMW.COIVUANCEvan;
�ISOIL EVALUATOR: Fi CS•E. TNS PIAH. ,191 MASLlOS1SETiS TUib v t TOMN a, ° �r FLOOD TONE:) WITNESS: ,0 AYAe/NI OOARDOFNEALTNRECAMnONS
'1 aEFEAENCE:�� SATE: ;)DE aStAUEa SHALL vim nE mow OF Ula,mas,
1/4''- ,t. PEACOLATI RAT• b iJ MEINITAIuM AND sum CCAPOWITS NUM TO
WO +,.._ �'1'• N ° 7)TI05 MN MALL BE MO FM SEPTIC SYSTEM IKTAIUTNIN
Y ` 1' DEEP AND slue NOT EE USED Pa PROEM ua:
Ir.) .7 f h • �y Fill 45° q All POND to OE r sCIimB«®,A 1 FOOF. QAIFSS
.I ECM 01111111
1f �Yf�l� 15.43
LOCATION 11APC111S� b 10A+" ,IefR416 n A IIEMOOFTi6 SYSTEM MS NOT ALLOW FOR TFELEENA
3TUSAGE DISPOSAL
�Eolu� r 131Z O R K MUST C 4AIWCP RIi ki1siaxAletJIEF ,
— C 5419 2 �na5 T LAWS ittrOR MI
Piro eP
SO woo YARMOUTH WAT R+E+D T .. D ....
" __. SEPTIC SYSTEM DESIGN
10 .,9 ghu1 ofr i
Z F — , i 47.4tios.Pl1hl 1501,E flit ,
_rJ FLOW ESTIVATE 1 Witis IJIEE/ *A1 VILE 1(6Y- 'AN If'
I610' 4 MOONS AT 110 8LL/W/10000.440 GAL/DAY -pU.A,I V II-'Poitao(UM'.1E45 _
_
rhs c 1 n„ SEPTIC TAMS —.__
S9 FJf, ti sv f L 6I 40 GALYDAY°2 SAYS•i'l OAL
pN�Jj `-mil IpE J GALLON SEPTIC TANa_N 1 Yarmouth T__ t
Ib. (14 1 ` Health DeCpa
SOIL AIRRIPTION SYSTEM
n,_/ O(3)SOo r;AtI J Pot.tir taco•c H6as / ,.;� PP' ! VE
4.
i 4g,„Treod Rw510E5 (33.SIL,LISIw(719
to a '�" SIOEAAFA1�33.5)2+((1)2]FZ > 0.7(:1316¢ �// �•/ 2*
j S•,lib .170 7+2 t
aoTTOR AREA: ,5e s3 a 0.74.9.2.27 a®(' Date
'ro►1 w 451.94PD
me,
R''� rA Pr I AN i ;. SEPTIC SYSTEM SECTION 799O6 PIL
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SITE AND SEWAGE PLAN
ow,
fewnl E, T r\ LOCATION:II TOW#41.4 �i f1uE
TT
Sow)kg.mouni me
fI x: Pa IS PREPARED FOR: VEARI}-
I ' vA ;' ISy1 ��
I ;; DARREN M.MEYER,RS. KALE;1 4)i
1 y w .t ��_/Q� P.O.BOX 981 DATE:(� r
/( EAST SANDWICH'MA 02531
DATE IN AGENT Ph:(508)362.2922
i
RECEIVED
. DEC 112019
Commonwealth of Massachusetts
.- Title 5 Official Inspection Form HEALTH DEPT.
E 101 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
!► y o2 9 Town / d/ w�
Property Address
e14GN
Owner Owner's Name
information is so H 0,4 f� 4 D y a �S' i
required for every �/
page. City/Town State Zip Code Date of In do
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view �jw
at least two rmanent reference landmarks or be�LWi� ell=d Off tttateo
where is water supply enters the building.Cher it% -;f =nix i REGULATIONS
hand-sketch in the area below # 07 /0/f//-I,
0 drawing attached separately ARMOUTH WATER DEPT DATE
„...N._ -.A.t.
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CDY'G� GAIIah see-h. m1.1
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Tide 5 Official Inspecllon Pone:Subsurface Sewage Disposal System•Page 15 of 17
151ns.doc•rev.6/16
*--0 4k,1 TOWN OF YARMOUTH
r_
HEALTH DEPARTMENT
" - PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To he completed by Applicant:
Building Site Location: cQy / iu, hit"
Proposed Improvement: lied 471-61er lecic
Applicant: 41/ICI"'45 Tel. No.:,S 2l'8/51
, Address: 0 /! Ze7 £2'ulni:) Date Filed: /2-//-/9
**/f you would like e-mail notification of sign off please
provide e-mail address:
Owner Name: i& ^ 4//
Owner Address:/ 5 rave s/ 41 6 Owner Tel. No.: -217 g2`1�.5Yl 9
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 Iabeling 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: P\--"\i/-
DATE: (01 / I( 1 9'
PLEASE NOTE
COMMENTS/CONDITIONS: