HomeMy WebLinkAboutBLD-23-003915 pu21Jz3
R E C E I V E ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Departmenti
JAN 18 2023 i
1146 Route 28, South Yarmouth,MA 02664-4492
508-398-2231 ext. 1261 Fax 508-398-0836 , 4<P
Massachusetts State Building Code, 780 CMR
BUILDING DEPARTMENT.
1 '
Bv. iszulciing Permit Application To Construct, Repair, Renovate Or Demolish ..
a One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: f5/,D-- -i2,439/51 Date Applied:
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORiMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
-11)e.1 so _i(D l
1.1a Is this an accepted street?yes %-ono Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
SF Ca-- CCSOC CI 5
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 sO4 i i 30 4 Z0 2:64-
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public l Private 0 Zone: _ Outside Flood Zone?
Check if yes® Municipal 0 On site disposal system At
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: �
i.n a,... vr"U`1 s i \k d s w►o Li. 1 A. 0 2...40 3 t/
Name(Print) City,State,ZI�p
.3 u/'f1se, r -17-- j °?6-igsti s C ?
No. and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 I Existing Building 0 Owner-Occupied 0 l Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: 14 K/(s 'Oet(c
Brief Description of Proposed Work': fAC 1 %--knC I lo -'1) t, c k- ci 4 t tcW" i} \- cuc.
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
1. Building $ 1. Building Permit Fee:$ Ji Indicate how fee is determined:
2.Electrical $ [19 Standard City/Town Application Fee
0 Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ -()0 OP(
4.Mechanical (HVAC) $ List: 0il
5.Mechanical (Fire _
Suppression) $ 53 0-0 Total All Fees:$
Check No. Check Amount: Cash ount: -
6.Total Project Cost: $
0 Paid in Full Outstanding Balance ue: ��
• SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
0 44 tF 3 et 7 (i/L q
Ke'Vr i r\ �C.l A ,f' License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
l c7c F\0 e,v5 ,v c�'L `G el
Type Description
No.and Street yp
��q Unrestricted(Buildings up to 35,000 Cu.ft.)
dC Wit tA-Vv.
b✓ U"L Ix 0 1 7 R Restricted 1&2 Family Dwelling
Cit Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
(----�O SF Solid Fuel Burning Appliances
3 7 S i C�l li I'EhArt 1'=
t0,—e C n W\CP S 4 .✓ I Insulation
Telephone Email address D Demolition
5.2 Registered HenitImprovement Contractor(HIC)// i53iarc << 151 �1
1‘._e,...)‘,'%., `�` HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
<-,cA.t,--T 5(AAA- r
No.and Street
v C� Set—.�,C Email address
City/Town, State,ZIP Telephone
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(MVI.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 a' 0 No . 0
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 ��,v c,C
to act on my behalf, in all matters relative to work authorized by this building permit application.
�0I6 . . 1 2L" 7 3
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.
(C� %. ri \--44Lt f l 1 I 2 0 2 I
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"
'� The Commonwealth of Massachusetts
I n 1, Department ofIndustrial Accidents
. fil*Mr
1 Congress Street, Suite 100
' Boston, MA 02114-2017
‘4,,, ,•`, 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): K. -,r);,• v.•'../ C�. �c.. '-tc )v
Address: 1 o O 40 vv.@,✓'�g �a,� 1
City/State/Zip: ' A-- Ac. (9 L� 7 5 Phone #: co 3 2 5� C ?2.
:c9
Are you an employer? heck the appropriate box:
Type of project(required):
L❑I am a employer with employees(full and/or part-time).* 7. E New construction
2.�I am a sole proprietor or partnership and have no employees working for me in .
�` 8.
any capacity. (No workers'comp. insurance required.] Remodeling
3.E I am a homeowner doing all work myself [No workers'comp. insurance required.]t 9 C Demolition
4.]I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 C Building addition
ensure that all contractors either have workers'compensation insurance or are sole • 11. Electrical repairs or additions
proprietors with no employees.
12.—Plumbing repairs or additions
5.❑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. 14.0 Other C
152,§1(4),and we have no employees. [No workers'comp. insurance required.]
*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: �E0O.-)A T rL. .1
Policy#or Self-ins.Lic.#: Expiration Date: S b I b./Z. 3
Job Site Address: A,5 be\ 1-.-.., City/State/Zip:Vo t t a fills...t 1 el&3,1
Attach a copy of the workers' compensation policy declaration page(showing the policy number a d .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 pains and penalties of perjury that the information provided above is true and correct.
Sienature: Date: i 1 ZV
Phone#: (e rP) ?Sci 0 7 Z-0
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 YARMOeUTH
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. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section 111/5
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at S3 ISen \ LAS �4 ` 0 i,en t. �"t,
Work Address
Is to be disposed of at the following location: i.
di' r'rt d t,.. �‘
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
t
, ____ _,L. I itrinrz- )
Signature of Applicant Date
Permit No.
Commonwealth of Massachusetts
IPDivision of Occupational`Unsure
Board of Buiiding R ulations and Standards
Cons tgwi� isor
CS-094639 r E d,pires:07/01/2024
KEVIN J FAI d '`
100 HOMER $•
7
YARMOUTHIVtOR
b�'QI.Lt+di��
Co:nh:iss:or= ;i;.
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Aff &Business Regulation
HOME IMPROV ONTRACTOR
y1 A tHY t'"I e�
Re•
, a,, , ti.n
KEVIN FAIR
KEVIN J.FAIR a
100 HOMERSDOCK Rs c !
YARMOUTHPORT,MA e UndersecretaN
6�: o TOWN OF YARMOUTH
ittior,
A ,c HEALTH DEPARTMENT
``' '� PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site Location: ,c-5 G t ` 6 t"? Cc_
Proposed
Improvement: I `4 K < <G OC, k
Applicant: ' ( k v �
E.�-% \"ck. t 4 Tei. No.: (o 0) X5ct Oil> Z._C
Address: ,/L O 4-:1s ix-1G rip o`.',� \. a Date Filed: i f t / L)2- 3
**Ifyou would like e-mail notification of sign off,please provide e-mail address:
Owner Name:~1 t t`\ \ .2 k ZX v
Owner Address: _ 'J LA..9 +\ S 0{1 \d Owner Tel. No.: 7 6-1 9q CX)L_
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,
G3LILL1U / and septic system location;
(2.) Floor plan labeling ALL rooms within building
JAN 18 2023 (all existing and proposed) —
HEALTH DEPT. Note: Floor plans not required for decks,sheds, windows, roofing;
(3.) If necessary, Title 5 application signed by licensed installer
\with fee. ii
REVIEWED BY: Ai .1 A. DATE: � 7 U /al:3 '
e
. EASE NOTE
COMMENTS/CONDITIONS:
, .
-I-
1.--- „ c , e, ...,,,.. c i, 4, - .
. ..
TOWN OF YARMOVII i
•••df""!( --•
- `04• ' .c 'C''' WATER DEPARTMENT
Buck t6ianj Road
We::-!;t Yarmouth. ,k1A.0267 I
W '7 i l • I a k: i)08 7 7 1-7996
BUILDING PERMIT APPLICATION FOR
WATER DEPARTMENT SIGN OFF
TRANSMITTAL FORM
BUILDING SITE LOCATK)N: —:.1- 3 1..../Ci t II ECW\ ..c.‘
=‘,1,.
PROPOSE[) 4 WORK: ) 4 -.'i.., 1 L., 1...,)Ece,,..,_ d .4''. 0. d1,7,.. i.„.,, \...,1,01.1 S,c,
k....,
\ .
APPLICANT: ;' Q‘ LA \— ‘'''t k l'''
,... . .
ADDRESS: IQ c t7.-k.o.:LAA(2-..,..o. <Dc. \<,_
„ , ,---,
1 FE,PI IONE: 4, C;)) --?. )-(1 o v„,i (.--(,,,,)
RFSIDENTIAL AND OR COVINIFRULAI, BUILDING
Water Department: Determtnes Colnplutnec of-Water.1%atlahainy and or I..*\IStini! li,CaliOn
Engineering. Department: I-Mei-mines Compliance for Parking and Drainage
Conservation(ommission i),...!tvrininc,t.`ompliance to wetlands Act: i c If hn(0 harder any type of
\s et lands.sitcoms.ponds,rivers.ocean. hoes,boys. marshland.ETC...
I leolth Department: 1)etermines Compliance to State and'I ow.n Replation.s. i.c.
reqUiremems for Septave Disposal and other Public Ito:1th Acti‘nes
Inc Delman-lent: I ktcrintues Compliance to State and Town Requirements for Personal
Safety. Property Protections, i.e. Smoke Detectors.Sprinkler Systems,e1c
,..1,w_____,.
.,..
APPL 'ANT SIGNATURE DATE
OFFICE USE:COMMENTS ON PERMIT APPROVAL OR DENIAL
ft
414
REVIE‘1'VV.WATER DIVISION(SIGNATURE)
tizsluzs
DATE
‘110
4111PS1