HomeMy WebLinkAboutBLD-23-002538 •
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* �II& TWO FAMILY ONLY- BUILDING PERMIT
NOV 0 3 2022 Town of Yarmouth Building Department
1146 Route 28, South Yarmouth,MA 02664-4492 _
_ 508-398-2231 ext. 1261 Fax 508-398-0836 •, . •`
EPARTMENT .—;
BUILDING D Massachusetts State Building Code, 780 CMR
By. --- *1clangPernzitApplication To Construct, Repair, Renovate Or Demolish fil _
a One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: L b Z —�)Z Date Applied:
Building Official(Print Name) Signature"- Date
SECTION 1:SITE INFORMATION
1.1 Property Address: elza14 lit/ 1.2 A ses ors Map&Parcel Numb s
10,
1.1 a Is this an accepted street?yes " no Map Number Parcel Number
1.3 Zoning Information: 1.4 Pro er imensions:
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
39' 3g4.2Y _ Alt gq
1.6 Water/ Supply: (M.G.L C.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
PublicH Private 0 Zone: Outside Flood one? /
Check if yeses Municipal 0 On site disposal system �1
SECTION 2: PROPERTY OWNERSHIP'
2.1 Zner1ofecor.. . frer,ieJsfci1
r /` Pewaid ,14
Name(Print) City,State,ZIP
6 t' gh2,46e L -
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) ❑ Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other Q Specify:
Brief es iptio of P posed Work2:T S `�`2'-lei If Nam/ 1,
odd- lip�$rati
SECTION 4: ESTIMATED CONSTRUCTION COSTS.
Item Estimated Costs:
(Labor and Materials) Official Use Only
1. Building $ C7C 1. Building Permit Fee:$ C Indicate how fee is determined:
2.Electrical $ f7 Standard City/Town Application Fee
0 Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ ?A--- C KW 3/�/
4.Mechanical (HVAC) $ ——' List: v�
5.Mechanical (Fire Y
Suppression) $ Total All Fees:$ �\
Check No. Check Amount: Cash runt: \ '(
6.Total Project Cost: $ ay
am'
0 Paid in Full CI Outstanding Balance D e: LAO 1 ,� ' /
4`�
1� CJ�
p
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Su ervisor icense(CSL)
r �y CS-14 0 f L3
�/K J � / License Number Expiratio Date
Name of CW Hol er
c2 ( aped r List CSL Type(see below)
No.and Street f T e Description
sit Y o� � G'OC 4L c _ Unrestricted(Buildings up to 35,000 cu. ft.)
�/ Restricted I&2 Family Dwelling
City/Town,State,ZIP M Masonry y
RC Roofing Covering
WS Window and Siding
2 4/p7-1753 " C c SF Solid Fuel Burning Appliances
+`+:•YY „�i/t G ` /s�� I Insulation
Telephone Email address D Demolition
/
5.2 red5ociti to
Imp lr
rovement Contractor(HIC) G 1 l u 'Z l l/15/00
HIC/�C (.p N e or HIC Registrant Name HIC Registration// Number bberr Expiration Date
dal
o nnA Street
N1,7cj})''�AJf�'. 'bet 0 7/I 7®('� 75, Email agg d sd s w1
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 Issu nce of the building permit.
Signed Affidavit Attached? Yes 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 , 41MI/61ex)
to act on my behalf, in all matters relative to work authorized by this building permit application.
. bile kerll ei t/,5 N 1 1/ )0
Print Owner's Name(Electronic Signature) Date
• SECTION 7b: OWNERI 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.
5"ji tie lerie4t i( 1 �.
.Print Owner's or Authorized Agent's Name(Electronic Signature) f 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"
t
The Commonwealth of Massachusetts
_ d. Department of Industrial Accidents
(Y � 1 Congress Street, Suite 100
S. Boston, MA 02114-2017
pt,, —,,.•> www.mass.gov/dia
\Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information ,,�ryy Please Print Legibly
Name (Business/Organization/Individual): %/a:9 V.4iI7's�
Address: dO e�j Or
City/State/Zip: S. Ar� 1 Y Phone #: 77(i'lieS7-1 -J
Are you an employer?Check the appropriate box:
Type of project (required):
1.0 I am a employer with employees(full and/or part-time).*
7. El New construction
2.'1/4./f am a sole proprietor or partnership and have no employees working for me in .
8. Remodeling
any capacity.[No workers'comp. insurance required.] �
3.E I am a homeowner doing all work myself [No workers'comp. insurance required.]t 9. ❑ Demolition
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.❑ 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. oof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other O�
152,§1(4),and we have no employees. [No workers'comp. insurance required.]
*Any applicant that checks box'41 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 certi under the pain at a ies of perjury that the information provided above is true and correct.
Signature: 441;i% Date: ///j/ �1
Phone#: t 175)
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#:
r
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
�/ ie L n
conducted at b = 4-
Work Address
Is to be disposed of at the following location: i '2' ? Thpie)
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
•
///i/0A2
Signature of Applicant Date
Permit No.
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Commonwealth at Massachusetts
Division of Professional Licensure
aoard of Building Regulations and Standards
Constratoithit'eop;Arvisor
CS-112255 , . Eijaires:06/12/21323
JASON PATRICK iNlifTFAEAD ;
20 E1UCKWOOD DR
SOUTH YAR1A9UTH MA;02664
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Commissioner
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4,1? ...."(t/1?/.1?ohyvi.6(.7e1A/ ,17,„,-,,q,),,,,,,,2-44),(4)..df,),
(f7:'
CY-fie() of Consurner Ivilairs and Buus oon
1000 V\frisilingtun Street- Suite-/10
Bosion, Massachunsitte 021-i0 •
iniproverneint Gorni-actor Rediso-aties
l'kg',:iftn.11.1 on: 101621
JASON W nrr EliF AD 041i 5:2023
0/BIA J:3 CONSTRUCT/OF
20 BUCKWOOD DO
SOUll I YARIVIOIJTH,MA 02664
t Address end Return Cad.
Scs C3 2,0fx,-05/17
A6, e^/,
()Mos or Consumer Affairs&Busiress Reguattion
HOME IMPROVEMENT sONTRACT011 RcgtrvtOfl valid for inclivicitte1 use onIy
TYPE:!rdialci.fai before the expiration clefs if found return to:
P.SPIratIe.11 Office or Censurner Affairs and Busirsse Ilegulstion
lt18,41 D4115/2023 1000 Weshingtorl Street -Suite-PIO
Basf...on.MA 02113
JASON WI--;riatEAD
a;sfA„s CONSTRUCTION
JASON WI,ITEHEAD
BUCKWOOD '"(;".'"/'
Not valid without signature
SO 'I'PRI,A0U711,MA 025r54 Undersecretary'
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 . E fAte
sk Map #: Lot #:
Proposed Improvement ti-cci sfrir .etsfry
Applicant: 17-q.5_ L &K/
Address oi,/046 tit Tel. #: .27"1 0/ 0-41Date Filed:
taitAe\pcic* ovtle glo-kcoN 'ow"
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...
Signature of applicant Date
PLEASE NOTE:
COMMENTS:
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