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Home My WebLink AboutBLD-23-003653 ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department 1146 Route 28,South Yarmouth,MA 02664-4492 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 RECEIVED This Section For Official Use Only Building Permit Number: 15LD --,2�j-( Date Applied: JAN 05 2023 S2A Y j I i—/) Building OflciaI(Print Name) Signature BUIlJ UPJG DEPARTMENT SECTION 1:SITE INFORMATION may. 1.1 Property Address: po ,Ra,.` "�p 1.2 Assessors Map&Parcel Numbers 1.1 a 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,g 54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: Outside Flood Zone? — Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Neal Checka Name(Print) City,State,ZIP 617-708-5309 nealchecka@gmail.com 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 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition ❑ Accessory Bldg.0 Number of Units Other 0 Specify: rii)J Brief Description of Proposed Work: � V Gin \AA?,‘,442.3 L142 A's.4 (// C}1 SECTION 4:ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 1. Building Permit Fee:$I cC Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List 3 s-,di) 5.Mechanical (Fire Suppression) Total All Fees:$ /„�..,� Check No. Check Amount: Cash Amount: " 6.Total Project Cost: $ (�C/ El Paid in Full 0 Outstanding Balance Due: 1(tj �l 1 \\ SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) c1,A C C-1\+C°-A License Number ExpirittiodDate Name of CSL Holder r�� List CSL Type(see below) No.and Street �C T' e Description ,16611),1\ /V A /�Z� 73 �-lY Unrestricted(Buildings up to 35,000 cu.R) City/Town,State,ZIP / 11 Restricted 1c4c2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding \- _'•_ SF Solid Fuel Burning Appliances �bs 1,0 -,`fit Ct^ ° � gl4AC' I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) ef HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name t r& & L\�Aa CAM M No.ands et ^ � �v1 Email address 1J. c[h f1 n Iry City/Town,State, l 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 ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTORC APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authori•ze 15(✓ C tt to act on my behalf,in all matters relative to work authorized by this building permit application. Neal Checka \\S V7.) 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. Neal Checka di-123 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.gov/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 1— 1 Department ofIndustrialAccidents g iii = 1 Congress Street, Suite 100 C=' y�=_ 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 Legibly1 Name (Business/Organization/Individual) p i„, Ct-,.. &r, Address: ,/ R City/State/Zip:r''v ,y 6-lk Phone#: suF) 6 7 `(N 1 Are you an employer?Check the appropriate box: > Type of project(required): I.('I am a employer with -) employees(full and/or part-time).' 7. El New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in c aci8. El Remodeling an y ap ty.(No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. 0 Demolition 4.0 I am a homeowner znd will be hiring contractors to conduct all work on my property. I will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.0 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 1 •Q Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. IQ/Other \kA_LAja.+ 152,§I(4),and we have no employees.(No workers'comp.insurance required.] *Any applicant that checks box#I 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 ant 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.#: \ . CC'S6 p 5'O\7 i117 Expiration Date: I Z(13 Job Site Address: 60 = , \ �� City/State/Zip: vl' " " 4, ,fV1� 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 S1,500.00 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 certi t er the pains and penalties of perjury that the information provided above is true and correct. Signature: CS-°-i) e2Y Date: 'SIM Phone#: --"I l M- Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License A 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 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 13 0 <: Work Address Is to be disposed of oat the following location: lCCvV`O l _ Vc,j/ Sf eir Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. Ill, §150A. S �3 Signature of Application atbe Permit No. Commonwealth of Massachusetts Division of Professional Licensure Beard of Building Regulations and Standards Cons�i ^t t i yrvisor i1. CS-075281 ?' _ cpires:03/12/2023 TODD J CAN)7ARA 10 ECHO RDA WEST YARM531TH MA 02673 1 • Commissioner (144 K. bfvnc . v J ffice of THE COMMOConsumeNWEr AA 08,F MASSACHUSETTS O gffa� Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:'tndividual Regis___, tration F__Ex iration TODD CANTARA �592f 1Q¢[0 ,:91202,4 D/B/A CANTARA HOitiE ' TODD CANTA RA ` . n� s' 10 ECHO RD. W. YARMOUTH, `-= MA 02673 Undersecretary