HomeMy WebLinkAboutBld-20-004063 : ` ` Al/T
• ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department ......-4—-); --
1146 Route 28, South Yarmouth, MA 02664-4492
508-398-2231 ext. 1261 Fax 508-398-0836 •''''':"'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:SU) 00 906.3 Date Applied.
Building Official(Print Name) SignatureDate
SECTION 1:SITE INFORMATION
1/.1 Property Address: //�� 1.2 Assessors Map&Parcel Numbers
/0 d 06 r,�r�4V 3 R..KOL[/ 'f 7 &
1.1 a Is this an accepted street?yes ✓° no Map Number Parcel Number
1. Zoning Information: 1.4 Property Dimensions:
es Q-yo u► �- /6i 1155%d "7. i i
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
S0 3 1.. fa 01D ° a..1 c19O 1)0V1 4a•41
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flops Zone Information: 1.8 Sewage Disposal System:
PublicZone: M Outside Flood Z ne?
Private 0 Check if yes Municipal 0 On site disposal system EL,
SECTION 2: PROPERTY OWNERSHIP'
Val-0( IA ReN��tlo( 1 TR SUaf ma oa16 V
Namea (Print) City,`5fate,ZIP
Oa spocoiorwis-�� ow 6j&�3�5=a/o3 [b/riuol�ccti//o h 1 &
o.and treet Telephone Email Address I/ 1 CJ /, , /�
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction 0 1 Existing Building 0 Owner-Occupied VI Repairs(s) V Alteration(s) 0 Addition IV
Demolition ! Accessory Bldg. 0 Number of Units ' Other 0 Specify:
Brief Descrizion of Proposed Work2: ` 1 .ace. oor s d (a l i o> 5i /d�‘15�'� f e4 d.e Cd1 d �l;.d i 1 _ (!.-
SECTION 4: ESTIMATED CONSTRUCTION COSTS 1 r
Item Estimated Costs: Official Use Onl C 1''
(Labor and Materials) >
1.Building $ 5b6o 00 1. Building Permit Fee:$ l)Sindicat h® t iktIR rU ::::76 _
ea Standard City/Town Application Fee BM ----. --.--__: __ a
2.Electrical $ f 0 Total Project Costa(I em 6)x multiplier x
3.Plumbing $ ,, 2. Other Fees: $— 3
4.Mechanical (HVAC) $ , List:
5.Mechanical (Fire $
Suppression) , Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 0 Paid in Full ®Outstanding Balance Due: 40_
SECTION 5: CONSTRUCTION SERVICES
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5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
j R Restricted I&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
f WS Window and Siding
/ SF Solid Fuel Burning Appliances
f/ I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name IC Registration Number Expiration Date
No. and Street I Email address
City/Town, State,ZIP Telephone
SECTION 6:WORKERS' COMPENS TION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit m t 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 ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOA APPLIES FOR BUILDING PERMIT
I i
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: ►%WNER'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.
Pa/ri aa m cCul 1/31)
Print Owner's or Authorized Agent's N e(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
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"
N The Commonwealth of Massachusetts
Department of Industrial Accidents
�_ 1. I Congress Street, Suite 100
Boston, MA 02114-2017
1.5 www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
aisle (Business/Organization/Individual): Pair c,u, i(-6,LA bl y, r)
Address: 1 to �► ll �..te'.,r` uS, Z, �0�� I
City/State/Zip: S yis tru\kibil ( t Oa( t/ Phone #: Spy 3 j-1 -1b
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.❑I a a sole proprietor or partnership and have no employees working for me in
capacity. S. Remodeling •
y p ty.[No workers'comp. insurance required.]
3. 1 am a homeowner doing all work myself. [No workers'comp. insurance re ired.]r 9. ❑ Demolition
4.]I am a homeowner and will be hiring contractors to conduct all work on property. I will 10 0 Building addition
ensure that all contractors either have workers'compensation insurance are sole 11.0 Electrical repairs or additions
proprietors with no employees.
12.El Plumbine repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed o the attached sheet.
These sub-contractors have employees and have workers'comp. ins ance.t I •El Roof repairs
6.0 We are a corporation and its officers have exercised their right ofe)hmption per MGL c. 14. Other
152,§I(4),and we have no employees. [No workers'comp. insurance required.]
*Any applicant that checks box 411 must also fill out the section below sh wing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all w rk and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet sho mg the name of the sub-contractors and state whether or not those entities have
employees. lithe sub-contractors have employees,they must provide eir workers'comp.policy number.
I am an employer that is providing workers'compens,tion insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy's or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation .olicy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under GL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment, as well as ci tl 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 stat,ment may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
do hereby certify-fy under the pains and,renalties of perjury that the information provided above is true and correct.
Signature:Q. J, A `rn n i /I
Date: f Li Ian
Phone#: 6-08- 3?y5 -67p
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License r
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#:
•
o� YARD TOWN OF YARMOUTH
o -).:;1
BUILDING DEPARTMENT
M*TT C G(E CsFf ?� 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE,:JOB LOCATION: /0Q()U4047/NOn , 2 LOW S niol 1 0c2c V
AME STREE ADDRESS SECTIOP bF TOWN
"HOMEOWNER" �� JCi.A m�1 di Los.. Lo8' 3.3 5 Ai
NAME O Ell PHONE Q WORK PHONE
PRESENT MAILING ADDRESS ea a uarie /?f 5>k OWyetrim.z.th 2:24o(p y
r
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 peiiiut. (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 requirements and that he / she will comply with said procedures and
requirements.
HOMEOWNER"S SIGNATURE _ var)
cadite
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.
C - k one:
Signature of Owner or Owner s Agent • Agent
h:homeownrlicexemp
§TOWN OF YARMOUTH
1146 Route 28, South Yarmouth, MA 02664
508-398-223'1 ext. 1261 Fax 508-398-0836
Office of the Building Commissioner
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
Pursuant to M.G.L. Ch. 40, §54 and 780 CMR - Section 105.3.1. #4.
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at /0c9 oua JJu' 2s 162.ROL1) 0� u
Work Address
Is to be disposed of oat the following location: halt, dkinP d-Crno1 b'i1
ConshLr ni 5-Cade.
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. 111, §150A.
/13 05
Signature of Application Date
Permit No.
11,3lzv
�. lug isvROuJ 5c\.0 cwn Jw i &_
01 5340 6t,d.a.ck_
Q31
•
011•Y4k TOWN OF YARMOUTH
, ° HEALTH DEPARTMENT ti
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To he completed by Applicant:
Building Site Location: /Oc:, 6 U a r' h9V7 '` o 5 4(, 0 s4
Proposed Improvement: ; `7 ,� }�
Applicant: P)-1 f i 0 Pi) \6' --) Tel. No.:
Address: /1 Or? J )(1')fd 5 'rrc.,Ajj 1 Date Filed: /9/3 f) fi`7
**/f you would like e-mail notification of sign off,please provide e-mail address: rail-1 'l(;)r)) la!/6t.0 3 h 1.
jj Veil -&r . 4
Owner Name: ct, C ( G ) (,( t tAi tt
Owner Address: /bc:9 u( 4,171( 2#A go( ' Owner Tel. No.: , ^ -
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.
1 REVIEWED BY: �?/ /7
DATE: /0 ` a//?
PLEASE NOTE
COMMENTS/CONDITIONS:
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 /Q uardi.'J2 Map #: Lot #:
Proposed Improvement: Cy 2 ��,� 1/ ._ 'c2 �� a fir,
Applicant: �(� !`
LAddress Mc-90L4 t -//1GSirl,Tel. #: ,5 8-33S--8- /�
/03 Date Filed: 36l/
60
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...
ignature of applicant Date
PLEASE NOTE:
COMMENTS:
Reviewed y: Water Division l
ate
no.00'
3.2•
rsNEo/%
to
LOT 102 c
15.455.2 th SF.
of
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RECEIVED ' 16.0 Vii
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Dew
1� ��
DEC 302019 ± " °fQ'`
a 6u� -
HEALTH D /
ry
ERT. �` z9�9• 7
EX/SANG D14EZUNC
4 22.2'
d1
a
__� k
t�n ;���-1 OF C/;��
t f '1.42.81 TER RO" ,. i Rr niN \ 'l
Mx�J $
QUARTER ,\ w t
#102 t 1 O. 31.,l �j
G ,4: ,v ,
TO THE BEST OF MY INFORMATION, "PROPOSED" PLOT PLAN
KNOWLEDGE, AND BELIEF THE SOUTH YARMOUTH, MASS.
STRUCTURES SHOWN ON THIS PLAN LOT 21, PL.BK. 222, PG. 21
HAS BEEN LOCATED ON THE GROUND DATE 11/21/19 SCALE 1" = 30'
AS INDICATED JOB 8279-00 CLIENT McCULLOUGH
11/21/19 SWEETSER ENGINEERING
203 SETUCKET ROAD
DATE PROFESSIONAL LAND SURVEYOR PO BOX 713 SOUTH DENNIS, MA 02660
OFF. 508-385-6900 FAX. 508-385-6991
C: 1 S8 1 PROD 18279-00 I dwg 18279-cppdeck.DWG 0 2019 SWEETSER ENGINEERING
. f
110.00'
3.2'
,SNE0
u , /ii
LOT 102
15,455.2 1- S.F.
IN
O
i w
RECEIVED N
'
DEC 3 01019Ilia DECK 7EALTH DEPT. :t 16.0
29.9
EX/S77N0 0V£LUNG
i
/
4 22.2'
w
Oh
at
Ail all'
�_ yn° ;Y1 Or rd,-
ROW � 7
WORK M C LL TER p°,.., R ' r
1' 2c� / .
TOWNUA S �..
424 02 Q °`'` 3 3. 1
YARMOUT . WATER DEPT D AT' \ `'� �� `,.`'
c1
TO THE BEST OF MY INFORMATION, "PROPOSED" PLOT PLAN
KNOWLEDGE, AND BELIEF THE SOUTH YARMOUTH, MASS.
STRUCTURES SHOWN ON THIS PLAN LOT 21, PL.BK. 222, PG. 21
HAS BEEN LOCATED ON THE GROUND DATE 11/21/19 SCALE 1" = 30'
AS INDICATED. JOB 8279-00 CLIENT McCULLOUGH
11 /21/1 9 SWEETSER ENGINEERING
203 SETUCKET ROAD
DATE PROFESSIONAL LAND SURVEYOR PO BOX 713 SOUTH DENNIS, MA 02660
OFF. 508-385-6900 FAX. 508-385-6991
C: 1 S8 I PROJ 18279-00 I dwg 18279-cppdeck.DWG 0 2019 SWEETSER ENGINEERING
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