HomeMy WebLinkAboutbld-23-001827 ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department of r-
1146 Route 28, South Yarmouth,MA 02664-4492
508-398-2231 ext. 1261 Fax 508-398-0836
Massachusetts State Building Code,780 CMR o� e
Building Permit Application To Construct, Repair, Renovate Or Demolish
a One-or Two-Family Dwelling 1 R
...�g, .‘.., E-I V E D
y,Thhiis�Secction For Official Use Only "t. CT
03 2022
ee
Building Permit Number: 1.1)--2 3-a 71t Date Applied•
l
BU
E C
Building Official(Print Name) Signature late
SECTION.1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
,,) Ct-a-bela. ST,
1.1 a Is this an accepted street?02 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,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private❑ Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
!Cel 0 At ICIO 6- 0,J S .y140. i-tP . o >66(f
Name(Print) City,State,ZIP
61 Cebn --1--. mod'- 790 - g6 s?
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)9 Addition 0
Demolition 01 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work'`: UX`/4`r . $(7. 1ZDor-S, , 'S E 0'1 flaPfrl
/2G M.°bC:k t't c7-te.-IJ C Gt' 11 Po I 1GtAiS
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 000 1. Building Permit Fee:$3 0 _Indicate how fee is determined:
t Ill Standard City/Town Application Fee
2.Electrical $
� Qd+ t� 0 Total Project Costa(Item 6)x multiplier x
3.Plumbing $ )a/000 2. Other Fees: $ c r ')L /
4.Mechanical (HVAC) $ List: 4?( '
I
5.Mechanical (Fire � i
Suppression) Total All Fees:$ - C.-k
$ ' 1U°
Check No. Check Amount: Cash ount: , 1
6.Total Project Cost: $ J, 0 000 0 Paid in Full fli Outstanding Balance ue: ) ,
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
boilIL "T20j j.fjOt.4tS License Number Expiration CSC �81�t8� 3t Date
Name of CSL Holder
D 3 '-pIt 6 L,'wJ List CSL Type(see below)
No.and Street Type Description
!.6 P 1"I IC• t i.ti`, (j a d 3 } U Unrestricted(Buildings up to 35,000 Cu.ft.)
City/Town,State,ZIP R Restricted I&2 Family Dwelling
a M Masonry
S cog• a po . 8019 •
RC Roofing Covering
WS Window and Siding
I‘
/ + O`MC& a 3 6 ev C I Sod Fuel Burning Appliances
C, t� '� 1 .i� I I Insulation
Telephone Email address D Demolition
5.2 Registered_ Home Improvement�o'n�tr r(HIC) ''7 N�q7 '
II aebb-6 i4 l R��3
HIC om an N e o C i tr t Name HIC Registration Number Expi RI
Date
p &lam� ^ V a O D30 CON
No.and trqet �AS��C ii
�eN N I S . 0x36 s 4 ) .8r 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 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 12(. Acf/
to act on my behalf, in a atters relative to work authorized by this building permit application.
Print Owner's ame(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.Qov/oca Information on the Construction Supervisor License can be found at www.mass.2ov/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.)
Number of fireplaces Habitable room count
Number of bathrooms Number of bedrooms
Type of heating system Number of half/baths
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
_,te= L
Department of IndustrialAcc/dents
1=
=vim= 1 Congress Street, Suite 100
C�=' d= Boston, MA 02114-2017
www.mass.;ov/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): ' "t T(Z—( b6-b P. f 0 L r(
Address: a-1 6�}�(, e rL lieNi C
City/State/Zip: 'PE i J 0- I S MA *-4. 36 Phone g: 5.° ' 9O. 8 14i
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. ❑New construction
am a sole proprietor or partnership and have no employees working for me in
any capacity.[No workers'comp. insurance required.] 8. emodeling •
3. I am a homeowner doing all work myself. [No workers' 9. lJ Demolition
se
Y rs comp. insurance required.]t
4.❑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
11.0 Electrical repairs or additions
proprietors with no employees.
Plum5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.0 Roof r ng repairs or additions
These sub-contractors have employees and have workers'comp. insurance.t 13.0 repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 1 [I]Other
152,§I(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.
*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 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 Junder the pains and penalties of perjury that the information provided above is true and correct.
Signature: ��=,-'�►V Date: 6 'abg 3.?-
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#:
01' Y� � TOWN OF YARMOUTH
o _' BUILDING DEPARTMENT
,�;=E;- �°� 1146 Route 28, South Yarmouth,MA 02664 S08-398-2231 ext. 1261
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:'
DALE:
JOB LOCATION:
NAME STREET ADDRESS SECTION OF TOWN
"HOMFOWNER"
NAME HOME PHONE WORK PHONE
PRESENT MAILING ADDRESS
CITY OR TOWN STA IF, 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 permit. (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
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.
Check one:
Signature of Owner or Owner's Agent Owner Agent
h:homeownrlicexemp
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. 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 C 1 C E:Det (2 Si,, • yftl2. M A • >E6�f
Work Address
Is to be disposed of at the following location: ('+ ' L 5S , C
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
/ 31t/4
Signature of Applicant Date
Permit No.
Yai0..weAwrerfl o/l iriiiir iiie/%
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
TYPE:Individual
Registration Expiration
174497 01/17/2023
KITTREDGE P.HOLMES
KITTREDGE HOLMES
23 APPLE LANE
DENNIS,MA 02638 Undersecretary
Commonwealth of Massachusetts
Division of Occupational Licensure
• Board of Building Regulations and Standards
Consiructios ►tlefui1 & 2 Family
CSFA-081484 spires:03/11/2024
KITTREDGE HOLMES
23 APPLE LNJE
PO BOX 32
DENNIS MA 02638
ti .I,W.'t
Commissioner jira I;. tiCvn�a.
TOWN OF YARMOUTH
�. � HEALTH DEPARTMENT
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To he completed by Applicant:
Building Site Location: 6 C ‹.(=- Of' r:� i.
Proposed Improvement: t` ' f `t t (L tA_L-Gr,1 J(& C 3
F' Y,k)cCk."(S w , 124.1 (`fit i1 Qjfi.
Applicant: ir t l2tt 3t - f PL'IL-ST Tel. No.:S66. d ' °Iti /
Address: D3 v1 r-� t E_ 1 iCL. ==�/�I� '"t't� . Date Filed: 5 t �G,• -a?—
**Ifyou would like e-mail notification of sign off,please provide e-mail address:
Owner Name: �- � v `, E (G.,J
Owner Address: (; Owner Tel. No.: Tr-B
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,
PICEZitiED and septic system location;
(2.) Floor plan labeling ALL rooms within building
AUG 2G 2022 (all existing and proposed) —
Note: Floor plans not required for decks, sheds, windows, roofing;
HEALTH DEPT. (3.) If necessary, Title 5 application signed by licensed installer
with fee.
REVIEWED BY: DATE:
PLEASE NOTE
COMMENTS/CONDITIONS:
�/a c-rr `c ) C of y S_ ' !z. f".: /e Rev/'.^.Aitc c(f — -
„,`of''Rk`'- TOWN OF YARMOUTH
_27A
BUILDING DEPARTMENT
T
7 '" �_� 1146 Route 28, South Yarmouth, i\1A 02664
i.`•� Telephone 508-398-2231 ext. 1261 Fax 508-398-0836
Contractor's Affidavit: Substantial Improvement or Repair of Substantial Damage
Property Address: V ( CE b ';. S .yii 11 Mo..) `11-1-
Parcel ID Number:
Owner's Name: JA JkJ Qv t 0 l.j2 LI jJ?C/O(}tf tC! J
Contractor: 1-71-0, Fes- • -HOL otAe
Contractor's License Number: CSF/4 - DS I t( &!
Date of Contractor's Estimate: 6 - ' ,)' -
I hereby attest that I have personally inspected the building located at the above-referenced address by the
nature and extent of the work requested by the owner, including all improvements, rehabilitation,
remodeling, repairs, additions, and any other form of improvement.
At the request of the owner, I have prepared a cost estimate for all of the improvement work requested by
the owner and the cost estimate includes, at a minimum, the cost elements identified by the Town of
Yarmouth that are appropriate for the nature of the work. If the work is repair of damage, I have prepared a
cost estimate to repair the building to its pre-damage condition. I acknowledge that if, during the course of
construction, the owner requests more work or modification of the work described in the application, that a
revised cost estimate must be provided to the Town of Yarmouth, which will re-evaluate its comparison of the
cost of work to the market value of the building to determine if the work is substantial improvement. Such re-
evaluation may require revision of the permit and may require revision of the permit and may subject the
property to additional requirements.
I also understand that I am subject to enforcement action and/or fines if inspection of the property reveals
that I have made or authorized repairs or improvements that if inspection of the property reveals that I have
made or authorized repairs or improvements that were not included in the description of work and the cost
estimate for that work that were basis for issuance of a permit.
Contractor's Signature 1 l6D
Date: .;,b • eo -
Notarized: JENNY DEUTSCH
•
Notary Public
�� COMMONWEALTH OF MASSACHUSETTS
�� My Commission Expires On
March 18,2027
TOWN_N OF YARMO TH
•
1146 Route 28 South Yarmouth, MA 02664
508-98 31 ext. 1261 Fax 508-98- 836
Office of the Building Commissioner
FINAL COST AFFIDVIT FOR WORK IN FEMA FLOOD ZONE
To the Building Commissioner.
In accordance with 780 CMR Section 109 of the Massachusetts State Building Code, the total estimated cost of
construction, including all related costs* of the building at 6 ( C& b O- S~i'> S•vehe•AAtu t-f4 .
and constructed, reconstructed, altered, repaired, or extended under building permit no.
amounts to $ 60, 000
I, K tTt ri-E- 4.-totWIes , being referredtto as the owner/agent identified below,do solemnly
swear that the statements made herein are strictly true, correct and made in good faith
*Related construction costs include all work done with or concurrently with the work contemplated by the building
permit including construction, reconstruction, repairs, demolition, HVAC work. etc. Furnishings and portable
equipment are not part of the total construction costs.
lip (,( eAzs
Signature of owner/agent
• a, A
totary Public Signature air 16
My Commission ExP ires
Notary Seal:
JENNY DEUTSiCH
Notary Public
COMMONWEALTH OF:MASSACHUSETTS
4j My Commission Expires On
Mire.io,2027
•
.°o��R _ TOWN OF YARMOUTH
TH
- ''. , c BL ILDLNG DEPARTMENT
;:.; '� :ri 1146 Route 28, South Yarmouth. MA 02664
Telephone 508-398-2231 ext. 1261 Fax 508-398-0836
Owner's Affidavit: Substantial Improvement or Repair of Substantial Damage
Property Address: C ( (a ►(Z T. ,3•I 604..., 1J:1.Ji-"(-f- 6.4A
Parcel ID Number:
Owner's Name: IA---- N"' L 0 tl 2l l_ J,} AO G-}kl(Yt J
Owner's Address/Phone: 61 Ce-Dni2 Ste. q)et
Contractor: ! 1T i at: 1(yt , '4 ., f40 L vt/lL
Contractor's License Number: CS r—r — Ibi LiO`/
Date of contractor's Estimate: �' • )1,
I hereby attest that the description included in the permit application for work on the existing building all
improvements, rehabilitation, remodeling, repairs, additions, and other forms of improvement. I further
attest that I requested the above-identified contractor to prepare a cost estimate for all of the work, including
the contractor's overhead and profit. I acknowledge that if, during the course of construction, I decided to add
more work or to modify the work described, that the Town of Yarmouth will re-evaluate its comparison of the
cost of work to the market value of the building to determine if the work is substantial improvement. Such re-
evaluation may require revision of the permit and may subject the property to additional requirements.
I also understand that I am subject to enforcement action and/or fines if inspection of the property reveals
that I have or authorized repairs or improvements that were not included in the description of work, and the
cost estimate for that work that were basis for issuance of a permit.
Owner's Signature: KezLYK-1-. Y,') ( c\AQ_,,,,,:, .4,)9 '
Date: --Da0. C) -
Timothy Costa
Notarized: .� NOTARY PUBLIC
_ Commonwealth of
Massachusetts
Z`i+i ` My Commission Expires
. v.`' 12/1/2028