HomeMy WebLinkAboutBLD-23-002337 PJ /3I/ e
RECE VED
ONE & TWO FAMILY ONLY-BUILDING PERMIT _
Town of Yarmouth Building Department g - N 2 7 2022
1146 Route 28,South Yarmouth,MA 02664-4492 ,:
-n� c' TPA, ___
508-398-2231 ext. 1261 Fax 508-398-0836 . 4i DE'ARTMENT
Massachusetts State Building Code,780 CMR ='n:._;
Building Permit Application To Construct, Repair, Renovate Or Demolish
a One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: 13 u) I-AL/337 Date Applied:
Vii
Boil g fficial(P' tName) • Si afore r.
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
I 6 roast 14I+ Cm.
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
a
1.6 Water Supply:(M.G.L c.40,i54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public k Private❑ Zone: _ Outside Floo Zone? Municipal❑ On site disposal system AC
Check if ye
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Pr. 'u. growl W. `(anMalt-C•.t Mel- b 3 673
Name(Print) City,State,ZIP
1 (3c c r'f C,rt. 1 _751-1.8r.)-
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 I Repairs(s)1 Alteration(s) 0 Addition ❑
Demolition ❑ Accessory Bldg.0 Number of Units Other ❑ Specify:
Brief Description of Proposed Work2: ' # 'co,. 4 ,.1
SECTION 4:ESTIMATED CONSTRUCTION COSTS.
•
Item Estimated Costs: Official Use Only
(Labor and Materials)
I.Building $ 3 1. Building Permit Fee:$ � Indicate how fee is determined:
t ❑Standard City/Town Application Fee
2.Electrical $ 1 �' '•
❑Total Project Costa(Item 6)x multiplier
3.Plumbing $ 2. Other Fees: $ CL\
4.Mechanical (HVAC) $ List: /Z ' �" J
5.Mechanical (Fire
Suppression) $ Total All Fees:$ . • • -1-,
6.Total Project Cost: $ 7S- Check No. Check Amount Cash Amo
0 Paid in Full 0 Outstanding Balance D : /7rr
�, . .
•
a
5.5
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
RJ � � CS-661040 y
c G-3 cob." License Number Exp tion Date
Name of CSL Holder
P.O. 0 X 3 t{y List CSL Type(see below) U
No.and Street Type Description
yarrhQ I) j ✓vU9 (�c��07� U Unrestricted(Buildings up to 35,000 Cu.ft.)
City/Town,State,ZIP R Restricted 1&2 Family Dwelling
hrl Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
174-35'-613 Sol o V a.c ,c 7 valitoo• c o,�t I insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
dt,�acobs !ros888 — /t
HIC Company Name or HIC Registrant Name HIC Registration Number ira'on Data
P.O. SOX 3YY pa..". .tzcolos 78 ) yak oo• Covh no and Strept
et row D uTti Yori-1 D 't A O h'7 r '17`(-'3S7-lo$Sol 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 O No 13
. 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 T D414,c., ct t pb f
to act on my behalf,in all matters relative to work authorized by this building permit application.
a' k7_ !6 aS/ as
Print Owner's Name(Electronic Signature) / Dlte
SECTION 7b:OWNER'OR AU 1fORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in ' app' ati . true and accurate to the best of my knowledge and understanding.
'Li •
Print Owner's or Au orized Agent's Name(Electronic Signature) (O/; -
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 Corrzmo
nwealth of Massachusetts
Department of Industrial Accidents
" f� I Congress Street,Suite 100
` -= Boston,MA 02114 2017
www.massgov/dia
•
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH fl k,PERMITTING AUTHORITY.
Applicant Information
PIease Print Legibly
Name(Business/Organization/Individual): ea+6 ct.,Tawt,c
Address: P Q. 6 Ox 3 L(L f
City/State/Zip:Yue6tOC tC �orf t'v114 oak 7S- Phone#: S Sa
Are you an employer?Cheek the appropriate box:
Type of project(required):
1.0 t am a employer with employees(full and/or part-time).*
7i i[[am a sole proprietor or partnership and have no employees working for me in 8 ❑aRe construction
any capacity.[No workers'comp.insurance required.] . �� emodeIin�
3.0 I am a homeowner doing all work myself.(No workers'comp.insurance required.)t 9. Ll Demolition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition
ensure that all contactors either have workers'compensation insurance or are sole
proprietors with no employees. 1 I.[�Electrical repairs or additions
5.0[am a general contractor and I have hired the sub-contractors listed on the attached sheet 12. Plumbing repairs or additions
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 NICTE,c. 14•E3 Other
152,§I(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box ill must also fin 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.
tContractors 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 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 S250.00 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 a th ai and penalties of penury that the information provided above is true and correct
Signature:
Date:
Phone T: 77y-3 —(,g.—.z2.
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 0:
TOW '_ a OUTH
1, „.-----
1146 Route 28pb I f �` ��` th, MA 02664
508-398-223 .: 4108-398-0836
Office of ' , $ I,. missioner
y .
FINAL COST AFFIDVIT FOR WORK IN FEMA FLOOD ZONE
To the Building Commissioner,
In accordance with 780 CMR Section 109 of the Massachusetts State uilding Code, the total estimated cost of
construction, including all related costs* of the building at \ B a.St" L► t.
and constructed,reconstructed, altered,repaired,or extended under building permit no.
amounts to $ 3 5;o0Or
I, Pocxi Deft.°los ,being referred to 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.
c
Signatur of owner/agent
/423/7ç6
No Public Signature My Commission Expires
Notary Seal: gx GLENN A
;, LAN FlTZGfERALhD
� Notary Public.Comn onwealth of Massachusetts
My Commission Expires October 3,2025
•
•
Substantial Improvement Worksheet for Floodplain Construction
(for reconstruction,rehabilitation,addition,or other improvements,and repair of damage from any cause)
Property Owner: t'tVti G lK vwA
Address: I B coda cos t- Lr. L4/. Y&-M out.
Permit No.:
Location: I OrCAd.a).ts 4— L.".
Description of improvements: K elk a t c.-flour ;st' as A ecd 1 -hhhver art I LIzt. at oath iret a.tcl, repladc •�S
l sect t'e of tie Llt.�f
e, _ol r r ac aent, .r r
e+' 3
4 � $ Oct ln07
Coster ent :r
aofl 9 sl sr ea+�tQ s ude) $ YSOX)-
:+n.+i--:..�.r...... +.:..::P...- .... r c M:. N,r - {A''- 3. '� F Er+-4? .'• � }..
ff ratio is 50 percent or greater(Substantial Improvement),entire structure including the existing
building must be elevated to the base flood elevation(BFE)and all other aspects brought into compliance.
Important Notes:
1. Review cost estimates to ensure that all appropriate costs are included or excluded.
2. if a residential pre-FIRM building is determined to be substantially improved,it must be elevated to or above the BFE. If a
non-residential pre-FIRM building is substantially improved,it must be elevated or dry f oodproofed to the BFE.
3. Proposals to repair damage from any cause must be analyzed using the formula shown above.
4. Any proposed improvements or repairs to a post-FIRM building must be evaluated to ensure that the improvements or
repairs comply with floodplain management regulations and to ensure that the improvements or repairs do not alter any
aspect of the building that would make it non-compliant.
5. Alterations to and repairs of designated historic structures may be granted a variance or be exempt under the substantial
improvement definition)provided the work will not preclude continued designation as a°historic structure
5. Any costs associated with directly correcting health,sanitary,and safety code violations may be excluded from the cost of
improvement. The violation must have been officially cited prior to submission of the permit application.
Determination completed by: `(Okjrr€(.5C— aer$'
Date: Ioa-(o (a03�
S
TOWN OF YARMOUTH
( ' :; 1BUILDING DEPARTMENT
0
?' » l„ •�) 1146 Route 28, South Yarmouth, MA 02664
.9
' ten. ' Telephone 508-398-2231 ext. 1261 Fax 508-398-0836
Contractor's Affidavit: Substantial Improvement or Repair of Substantial Damage
Property Address: 1 E cOa.ClCa,S1- Lin .
Parcel ID Number: 0-G-7
Owner's Name: Aline- 6 rt7 oil
Contractor: PO 4 C ie_V , 1&co tO S'
Contractor's License Number: CS d P 1040
Date of Contractor's Estimate: l 0 1 a-s-1 aoa a
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 w• e b.si . issuance of a permit.
9� COM OF A�HUSE7TS
Contractor's Signature couNrY of
au. z0uer«�me.the undersigned
Date: /d fr-/7.07 2 or o�ome raPpeared.
hwere �pfid
preceding name is signed on the or attached document,and
Notarized:)) GLENN ALAN FITZGERALD stated (he)(she)signed it voluntarily for its
KcrcNotary Public,Commonwealth of Massachusetts
My Commission Expires October 3,2025
Notary 's Signature My Commission Expires 2.121130?sr—
Division of Occupational Licensire
Board of Building R ulations and Standards
Cons ion 5rvisor.
CS-081040 pires:04/04/2024
PATRICK H
28 WHITTIE
DENNIS MA'16c838
•
Commissioner d,i I„ tie.smih
THE COMIMO EqM TH OF M
i 4.
Oi ice of Business Regulation
HOME itil"
FACTOR
PATRICKJACOB3
DfefA P.JACK C s era
AND REMODELING
PATRICK JACOBS
28 WHITTER DR. 7.DENNIS.MA 02638 ✓ t'lG
Undersecretary
,.
10/22
I, Anne Brown,give my permission for Pat Jacobs to work on my property at 1 Broadcast Lane,
West Yarmouth, MA.
61(yvn, c(u.A..91
Anne Brown
Owner, 1 Broadcast Lane
§TOWN OF YARMOUTH
1146 Route 28, South Yarmouth, MA 02664
508-398-22311 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 \ Q ro&.0( S-- L
Work Address
Is to be disposed of oat the following location:
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. 111, §150A.
A04_46. -------- (
Signature of pplication D to
Permit No.
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