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Home My WebLink AboutBld-20-004066 /4q/024,14.) ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department • of tqa 1146 Route 28,South Yarmouth,MA 02664 1 492 t. 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 �� y� This Section For Official Use Only Building Permit Numb��-/�r 2Q— )64, Date Applied: I ]" 50(.5 ✓ 1- C'V1k1 �-- Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property A dress: 1.2 Assessors Map&Parcel Numbers c109 (?eS+ dno.e�'�t 4 Y ywc+ 1.l a Is this an accepted street?yes I 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 I 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 0 Private Cl Municipal_ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Recor : Name(Print) City State,Z CI09 We- YcOl t re(# 118-6oq-13C No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction 0 Existing Building 0 ( Owner-Occupied 0 1 Repairs(s) ❑ Alteration(s)X, Addition 0 Demolition Cl Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Pro os d Wo k2: (E'{e L.ho,ack: SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: t .y1 Item Official Use (Labor and Materials) - - - 1.Building $ (4,560 1. Building Permit Fee:$1%c lad cite how fee is determined: 2.Electrical $ Pit Standard City/Town Application Fee El Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ -C)O0 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire S - Suppression) Total All Fees:$ Check No. Check Amount Cash Amo 6.Total Project Cost: $ 65 0 0 Cl Paid in Full sra Outstanding Balance Due: 115 A' . ` SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) C5^to 72 5? /O/01S/4 I iltoha5 HC44Ae. License Number Expiration date Name of CSL Holder J 1 CuWe Hil I Q_ a (O List CSL Type(see below) U. No.and Street 'w Type Description &Yc rMo$L mit 1 got 6 6/.1 1 U 1 Unrestricted(Buildingup to 35,000 cu.ft.) City/Town,State,ZIP I R Restricted 1&2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding ec 11 ( � - 1 SF Solid Fuel Burning Appliances •y / 7y'�X 1— S Htlye tr°+U f o/1�;( V l/4y,,` I Insulation Telephone Email address D ! Demolition 5.2 Registered Home Improvement�y Contractor(HIC) C$ p,g s e j due. Col `, '`0A HIC Reegistration Number ira ?Date 7 Co()Awe .ry- e Name P4 C 1 ., tr t Name 6 N Streetu Hill ('�j(rA�� f 4. [ ,( "4i I'Un ® _ �r Street (Pitt( "Wt+t�4 �y'j),1`001‹ 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 ❑ 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 -r0Nl j--ict v e to act on my behalf,in all matters relative to work auth ' by thi g permit application. //7/40)° Print Owner's Name(Electronic signature) Date SECTION /1• 7b:O 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 be of ray kno vied erstanding. ' tv.ie) OV Print Owner's or Authorized Agent's Name( nic Sigma e) 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.aovIota 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 -= _ l Department of IndustrialAccidetzts ,E91ltl= .54 1 Congress Street,Suite 100 Boston,MA 02114-2017 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): H043,,te_ (, ,Ac p� Address: 7 C'eve ( i I k rk J City/State/Zip: S,y rMcui 1 MA-1 04.401 Phone#: 7-N-Sd 1 —O095 Are you an employer!Check the appropriate box: Type of project(required): 1.0 1 am a employer with employees(full and/or part-time)." 7. 0 New construction ix.am a sole proprietor or partnership and have no employees working for me in any capacity.(No workers'comp.insurance required.] 8• El Remodeling 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. 1 will 1 ❑ Building addition ensure that ail contractors either have workers'compensation insurance or are sole MO 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 13.0 Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14•Q Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] 'Any applicant that checks box el must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 3Contractors 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: 7/ Date: / /7 / 0 Phone#: Y Ill" cock Official use only. Do not write in this area,to be completed by city or town officiaL ' City or Town: Permit/License Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext.-1261 Fox 508-398-0836 Office of the Building Commissioner BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G.L. Ch. 40, §54 and 780 CMR- Section 105.3.1. #4. I hereby certify that the debris resulting from the proposed work/demolition to be conducted at " e5-k- Yccmo,A+14 Yr/4 poV Work Address Is to be disposed of oat the following location: Ya1MoA 'RM 9 cAlf]E/) Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. rivn44,4' /7 a-o Signature of Appli ation Date Permit No. A —____._.. Gs � ness Office HOME IMPROVEMiENT Crs& ONTRACTOR on jIndividuat R • aii It.i► 09/11/2021Fxoi ..- f$ , THOMAS HA , a 1= / DB/A HAGUE •''" 0{ 1 - m THOMAS HAGU 7, :- ' /, 7 CURVE HILL RD`'<t°%-,,1taty re—. SO.YARMOUTH,MA 02664 Under sec (11— . Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Consitru4t'rSIA'apprvisor 'i . CS-107853 i 1 spires: 10/28/2021 THOMAS HAOUE '1 y f r 7 CURVE HILL ROAR )., i SOUTH YARM9UTH MMI,re64 t' `',Ot ,t,►LI Commissioner /.404-•"-A----__ 90 (,les1-- c3trM 4 r '"C(CMo,\ P G r li( .0 Iv T W OF ' ti7.1, :dr.TiL '" I CODE COMPLI- ANCE.REVIEWED FOP,!�, ,�Gir;,,AND�.,1:,",� r ERRORS Ok C:,;.iISSIONS DO NOT RELIEVE THE (� J\ (- APPLICANT FROM THE RESPONSIBILITY OF'AS BUILT' COMPLIANCE, DATE: / '4-8''-643 BUILDING OFF IAL ME' COP? / . / .�LIkli (2.4 1 G el rods -- No1--c-it °J - &A.ctin e,