HomeMy WebLinkAboutBLD-23-005143 f- ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department
1146 Route 28, South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508-398-0836MR CD
Massachusetts State Building Code,780 CjBuilding Permit Application To Construct, Repair, Renovate Or Demolisha One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: ; „ , - II) 51 3
Date Applied: /
1. i
Building Official(Print Name) ign ��d."tO
igna re D
SECTION 1:SITE INFORMATION
1.1 Property Address:
-..8._ �____ ,r aAi g__ ) 1.2 Assessors Map&Parcel Numbers
1.la 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 f0 Frontage ft
1.5 Building Setbacks(ft) )
Front Yard
Side Yards Rear Yard
Required Provided
Required Provided Required q Provided
1.6 Water Supply;(M.G.L c.40, 54
§ ) I.7 Flood Zone Information: 1.8 Sewage Public 0 Private 0 Zone: Outside Flood Zone? Disposal System:
Check if yes❑ Municipal❑ On site disposal system 0
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
l d>!r I
e
Name(Print) L/,�/r7"(/j�/ �Q OZ�/7
y �,,, s S City State ZIP
No.and Street 6./7-SJo-8/63 74E1... pAgeTC-�
Telephone �a'N'Atz Li�t�#t'rd•Rq�A. US
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that aEmpply)
l ddres
New Construction 0 Existingpp Y)
Building 0 Owner-Occupied 0 Repairs(s) 0 Alterations p
( ) Addition 0
Demolition ❑ Accessory Bldg. 0 Number of Units
Brief Description of Proposed Work2: Other 0 S eeify;P
SECTION 4:ESTIMATED CONSTRUCTION COSTS.
Estimated Costs:
� (Labor and Materials)I.Building Official Use Only O
$ co - 1. Building .��
Permit Fee:$ � � Indicate how fee is
'.'Standard City/Town Application Fee -
0 Total Project Costa(Item 6)x multiplier �� 013
2. Other Fees: $- 3 - x 1
laIIIIIII List: --� � . (MINT
M4'�
i. •
Total All Fees:$ r
IEIIIIIII
•- 0 �- `\
;t: $1� Odle— Check No. Check Amount:
CIPaid •in Full Cash ..: '
Outstanding Balance . r G 1
•
J
, '`Mhb.,.,,....iwii................._.
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No,and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
City/Town,State,ZIP R Restricted 1&2 Family Dwelling
NI Masonry
RC J Roofing Covering
•
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name HIC Registration Number Expiration Date
No.and Street 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 IX 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
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
•
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my n.•.- below,I hereby attest under the pains and penalties of perjury that all of the information
contained in th s applic.tion' true and accurate to e best of my knowledge and understanding.
��'V
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.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 Corrlmonwealth of Massachusetts
Department oflndustrialAccidetzts
1 Congress Street, Suite 100
Boston, MA 02114-2017
a �•` www.mass.aov/dia
im b
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): `��V/0 CiZt-17,A
Address: 25 i/ g--//) 46 S '
City/State/Zip: A2c,A1 c11/13 ot44 ozy?y Phone#: $/7- s/O -3/13
Are you an employer?Check the appropriate box:
-
Type of project(required):
Ill I am a employer with employees(full and/or part-time).*
7. Q New construction
•
2.Ei I am a sole proprietor or partnership and have no employees working for me in
ca aci8. Remodeling
an y p ty,[No workers'comp.insurance required.]
3.y1 am a homeowner doing all work myself.[No workers'comp.insurance required.]r 9. El Demolition
4.Q I am a homeowner and will be hiring contractors to conduct all work on my property. I will I Q ❑ Building addition
ensure that all contractors either have workers'compensation insurance or are sole
11.❑ Electrical repairs or additions
proprietors with no employees.
Plum5.0 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.Q Roof �pair5
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other
152,§1(4),and we have no employees.[No workers'comp. insurance required.]
*Any applicant that checks box:1 must also ill out the section below showing their workers'compensation policy information.
/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 r zder the p rain an ralties of er' ry that the information provided above is true and correct.j
Signature: �, ;�
'�/ 'vl v� Date:
Phone#: 6/7— 8/63
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 Cleric 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone It:
Licensee Details
Demographic Information_.___._..___..._.___._..._...__..._._._.._...._ __........______._.
Full Name: DAVID J GELDART - '�1
Owner Name:
License Address Information
City: Arlington
State: MA
•
Zipcode: 02474
Country: United States
License Information
License No: CS-049900 License Type: Construction Supervisor
Building Licenses Profession: n 212 0 2 2
Issue Date: 10/26/2010 ExpirationDateofLast DateRe: ewal: 9/1 10/26/2024
License Status: Active Today's Date: 3/19/2023
t, Secondary License Type: agencyl profOsecondarylicTypeO
Doing Business As:
Status Change Reason: License Renewal
Prerequisite information
_�✓— No Prere uisite Information
No Available Documents
Commonwealth of Massachusetts
ill Division of Occupational Licensure
C Board of Building Re utattons and Standards
^'°nweaft Building,,
bivisio^of h of Masafl
&fictic,n
Board of gui/afp9 Ref essio^alsLlcQusetts BO-2006 'oral InspectorP
Cons + Patio ^Sure �scp+res: 12/31/2024
Cg O499p0 ttfpRrr,isd Standards DAVID J GEI,dART ��
ar 354 RIDGE ST s
DAVID J G eo + s
NARLINGTON` A r
ti Af 354 NisrART , 10/26/2022 aro ARpN 0
--i Commissioner .
a �;` ra
Comrrtissioner , ,�/S8 !I4)2�`1
Licensee Details
Demographic Information
;Full Name: DAVID J GELDART
Owner Name:
License Address Information
City: Arlington
State: MA
Zipcode: 02474
iCountry: United States
License Information
License No: CS-049900 License Type: Construction Supervisor
Profession: Building Licenses Date of Last Renewal: 9/12/2022
Issue Date: 10/26/2010 Expiration Date: 10/26/2024
License Status: Active Today's Date: 2/24/2023
Secondary License Type: agencyl profOsecondaryLicType0
Doing Business As:
Status Change Reason: License Renewal
Prerequisite Information
No Prerequisite Information
No Available Documents
"r TOWN OFYARMOUTH
C E
q BUILDING DEPARTMENT
�` "tea^�r�,=�Al 1146 Route 28, South Yarmouth, MA 02664 S08-398-2231 ext. 1261
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE:
JOB LOCATION: g 4,74,1/24,v f64, S,, ,stryiJ ,,fie vUill
NAME STREET ADDRESS SECTION OF TOWN
"HOMEOWNER" 7 AVi/9 6e 04/2 i
NAME HOME PHONE WORK PHONE
PRESENT MAIL 1NG ADDRESS 3 5-/ /2-1✓94 E.57---Al/Z�.-/4_/%ir-n` /44 02-477 y
rr7 S✓o - E/6,3 _ .
CITY OR TOWN STALE 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 requir •miiks and that he / she will comply with said procedures and
requirements.HOMEOWNER"S SIGNATURE `40./
APPROVAL OF BUILDING OFFICIAL
INSURAN CE COVERAGE:
I have a current liabilit .nsurance policy or its substantial equivalent, which meets the requirements of MGL
Ch.142. Yes , No
If you have.checked ves,please indicate the type coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity Bond
OWNER' INSURANCE WAIVER: I aware that the licensee does not have the insurance coverage required by
Chapter 147�.of-tireZass. General Laws d that my signature on this permit application waives this requirement.
;//�� Check one:
Signature of Owner or Owner's Agent Owner/ Agent
h:homeownrlicexemp
ONE or TWO FAMILY— BULDING PERMIT
APPLICATION REGULATORY APPROVALS NOTICE
Address of Proposed Work: 8 khlovt PA^J 0'4l7 g 0
Scope of Proposed Work: `I,,rcu /v / s-cat a,.' /X174 7Z1 or- LA I(, A00 (-1441 /C1
Date:
Based on the scope of work described above,the applicant is required to obtain approval sign-
offs from the following departments as checked-of below:
Health Dept. —508-398-2231 ext. 1241
Conservation—508-398-2231 ext. 1288
Water Dept. —99 Buck Island Road, 508-771-7921
Old Kings HWY. Hist. Comm. —508-398-22631 ext. 1292
Engineering Dept.—508-398-2231 ext. 1250
Fire Dept.—Kevin Huck/Scott Smith, 96 Old Main Street, SY
Note: Please call Fire Department for an appointment. 508-398-2212
Other
Appropriate plans and/or application shall be provided to each departments checked-off above.
Each of these regulatory authorities has their own requirements outside the jurisdiction of the
Building Department. All applicable approvals shall be obtained prior to submitting a building
permit application to the Building Dept.
Thank you for your cooperation.
tc
Receipt Acknowledgement:
/
Applicant's Signature Date
Rev. Jan. 2019
§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. 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 65 k/4 A 19(.AJv A el )2 0
Work Address
yA/Z4-10 7774A./j TL s
Is to be disposed of oat the following location: wg. fJv).� 2e 1c1�-54
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. 111, §150A.
•
Signature of Application Date
Permit No.
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