HomeMy WebLinkAboutBLD-23-004352 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 1....,,i,S
Massachusetts State Building Code,780 Chill.
Building Permit Application To Construct Repair, Renovate Or Demolish
a One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: I? Z�1 Date Applied:
Building Official(Print Name) Si Lure catEIVED
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers FEB 02 2123
,2 .S/ti/THg-e-!a V4110140vT#1 1DEPARTMENT
_
1.1 a Is this an accepted street?yes no Map Number Parcel Numb aU I L D I N G D E PA R T M E N T-
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:
Zone: Outside Flood Zone?
_ Municipal❑ On site disposal system 0
Public 0 Private 0 Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Ee/A 4GAO S•/A/tau°u.-e,, ,41,4. o 02 64.4'
Name(Print) City,State,ZIP
2 SdiT/f Ra4-17 866-.2/.2-Sa18 C'i'6 5FA«ET0 6AV 1d. "J
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK"(check all that apply)
New Construction 0 Existing Building Owner-Occupied % Repairs(s) 0 Alteration(s)X I Addition 0
Demolition 0 1 Accessory Bldg. 0 Number of Units , Other ❑ Specify:
Brief Description of Proposed Work: /QE vc_ ex Si?4N(r,l aUM(4D d dDR/ "1E4.4 .Si-Awe ZKf
//t) S4-wt F foal /t/.v r AJ6 l/N T/4 vv �•tlss')ii-cf ArcT.f1t,0#2
/AV e G vuf — G-
O Sa ?of la A;'.NO Ali /94 Gli,1 7 s . 7 lJf —LL- n. psis s.)f£-cc. .
SECTION 4:ESTIMATED CONSTRUCTION COSTS.
Estimated Costs: Official Use Only
Item (Labor and Materials)
1.Building $ zv DV?) ---- 1. Btulding Permit Fee:S OO Indicate how fee is determined:
-El Standard City/Town Application Fee
2.Electrical $ 4 a'c' p Total Project Cost3(Item 6)x multiplier x .
3.Plumbing $ 2. Other Fees: $____c�_,.d_Mechanical (HVAC) $ List e /C q4.
5.Mechanical (Fire $ Total All Fees:$
Suppression) Check No. Check Amount Cash ( J ►Y I,
6.Total Project Cost: $ 2S, ' 0 Paid in Full -ell Outstanding Balance ne:
,'i 27G l�t
` e
C 6 iti J'
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 0 77 9 Co8 ,S'ljo/Z ej/
/ �
__daft l� fvel License Number Expiration Date
Name of CSL Holder '
Z 6f ete List CSL Type(see below) Li
No.and Street Gy Type I Desc.iption
[.' . Unrestricted(Buildings up to 35,000 cu.ft.)
/�5'�.ea/!C� /e� Qp2(O , R Restricted 18t2 Family Dwelling
City/Town,State,ZIP ' M Masonry
RC Roofing Covering
1 WS Window and Siding
SF Solid Fuel Burning Appliances
5 cis-VII--c/336 /50,.,ry 3 e 6-.04<il, ('e07 I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
H:C Registration Number Expiration Date
HIC Company Name or HIC Registrant Name ! /77 1(60 1740 Y.
2.6S CoAktc, — ,41Xele4 '3 (6I'uIee.00rti
No,and Street Email address
City/Town,State, 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 a building permit.
Signed Affidavit Attached? Yes I 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 dv+e f /SS42-K7
to act on my behalf,in all matters relative to work authorized by this building permit application.
elto 6 4,64c.v /Vol 2 7--
Print Owner's Name(Electronic Signature) Date
• SECTION 7b:OWNERr 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.
E(..,10 AG-ftD tl ( iS / 2-7--
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. 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. I42A.Other important information on the HIC Program can be found at
www.mass.govlace Information on the Construction Supervisor License can be found at www.mass.zov/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
I Number of fireplaces__ Number of bedrooms
Number of bathrooms Number of half/bathe
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" 1
ad ..ill h(lhg
0
9
THE COMMONWEALTH OP MAIMACHUUTTE
Office of Consumer S Ethiblami ReetiWon
HOME iMP NTRAC1OR
ADAM G.HART Ill
ADAM HART III •
2!M CHURCH ST. ►,4,40(ei••/ a
E HARWICH,MA 02845 • .T. urxietseaty
Commonwealth of Massachusetts
Division of Occupational Licensure
Board of Building R u rations and Standards
ConstciMi t 1isor
CS-077968 ti t empires.05/10/2024
ADAM G HAflf
266 CHURCH,ST • , L
HARWICH Mit, ; •
Commissioner r
§TOWN OF YARMOUTII
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 S M
Work Address
Is to be disposed of oat the following location: T° ,tJ y -"4 0`'1-14
T✓Z-'tJ S r-fir - s'N3 i t 0+v
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. Ill, §150A. ///i`/tL
�r /1/2/ zz
Date
Signature of Appli , on
Permit No.
The Commonwealth of Massachusetts
1, Department oflndustrialAccidents
!►� 1 Congress Street, Suite 100
- h Boston,MA 02114-2017
"t�t`� www.mass.gov/dirt
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibl'
Name (Business/Organization/Individual); /90 t9wr !( 16te9
Address: Z//S C 471 5S'�%
City/State/Zip: ,124 wl , 419 d&GY6hone#: (5-Oft, -34'/— Y33�
Are you an employer?Check the appropriate box: Type of project(required):
►.E 1 am a employer with employees(full and/or part-time),' 7. 0 New construction
2.71i am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t
9. ❑ Demolition
Q Building addition
4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will
10
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5.0I am a general contractor and I have hired the sub-contractors listed on the attached sheet, 13.0 Roof repairs
These sub-contractors have employees and have workers'comp.insurance.
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 1 0 Other
152,§1(4),and we have no employees.(No workers'comp.insurance required.)
'Any applicant that checks box t1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing ail work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached art 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 t or Self-ins.Lic,0: 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 ivIGL 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 DR for insurance
coverage verification.
I do hereby certify wider the pains and penalties of perjury that the information provided above is true and correct.
,Signature: /1 4 Date: / Z 3
Phone#: 5 00— 34. ''3S.
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 :
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