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HomeMy WebLinkAboutBLD-23-001306 , i -1, F'C E I V O TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department SEP 212022 1146 Route 28, South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508-398-0836 'g i 1 - . Massachusetts State Building Code, 780 CMR ' BUILDING DEPAR__Dui M T o�;e:: ,`/� � ng ermit Application To Construct, Repair, Renovate Or Demolish Ely'— a One-or Two-Family Dwelling This Section For Official Use Only rr----- Building Permit Number: 13L)— 1p23-� � Date Applie • 1 -R c. �. E (V E D ci,1,0,4,11. t_ _ _o_6 1 Building Official(Print Name) Signature 4 + a e 2U21 __ SECTION 1:SITE INFORMATION PlUILDI1vG DEP f, 1.1Proper� w: 1.2 Assessors Map&Parcel Numbers --�� //77�� 0�3 6 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: /�� �/ i Zoning District Proposed Use Lot Area(s!�ft) Frontage(ft)`!�1 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Waterer Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public q Private 0 Zone: _ Outside Flood ZDne? Check if yes 1 Mlmicipal 0 On site disposal system SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Recor •ei.,S 1-ZA 4+ &,,7-,,,, „-. --712,/ ..EE.. isommfryili lYfrL 44 Name( rint) 4,,,1 / City,State,ZIP �U71 and Street , i/ NV 403-M-MAP if eee /tt5 Se 1�1�•�1.i Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'-(checkJa l that apply) New Construction 0 I Existing Building Owner-Occupied�Repairs(s) 1 ' Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units / Other 0 Specify: - Brief escription of P os d Work2: j / iftM 31 — /.— 411 cS/ /A) . — SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ /0 ODD 1. Building Permit Fee: $' OO Indicate how fee is determined: 2.Electrical $ El Standard City/Town Application Fee 0 Total Project Cost3 Item 6)x multipli r x 3.Plumbing $ 0.-- 2. Other Fees: $ Lit) CIS 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Suppression) $ - Total All Fees:$ - Check No. Check Amount: Cashru:t: ) 5 . 6.Total Project Cost: $ /.) t)OO 0 Paid in Full Outstanding Balance De \ \iJLi "� D - * � fid if rtidepV /1 /Ar'e z�� �.oT r ' SECTION 5: CONSTRUCTION SERVICES 5.1 C nstructii/own,,Supervisor License(CSL) /� ,iiif 40 A {l Pinta). License Numi7er Expiration Date N e 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 I&c2 Family Dwelling M Masonry RC Roofing Covering • WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Register•d Home Improvement intractor(HIC) i iG Li- 1 i / idL" /.:7/ HIC Re stration Number Expiration Date IC Company Name or HIC Regis • t i ame No.and Street I 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 i�' No ❑ 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 /1/fr to act on my behalf,in all matters relative to work author.zed by thia;uilding permit application. / I. v 94722, Print Owners Name(Electronic Signature) �/ Da • SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and pen. 'es of perjury that all of the information contained in this application is true and acc .te to the .=.t of.,. . •ledge and understanding. V / - '• � ^t •wner's or •ut orize. •gent's Name ctronic S b ature) 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(RIC)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, rovide the information below: Total floor area(sq.ft.) /03 (including garage, finished basement/atti ,,decks or porch) Gross living area(sq.ft.) Habitable room count •t7 Number of fireplaces / Number of bedrooms Number of bathrooms Number of half/baths Type of heating system J Number of decks/porches Type of cooling system Pm)) Enclosed Open 3. "Total Project Square Footage"may be su stituted for"Total Project Cost" /087#z#fikjit /he s_ PC'#zvj/ote 2VD # 6Ale- ( /n. fi) The Commonwealth of Massachusetts �Ilj�►= Department of Industrial Accidents ��1= 1 Congress Street, Suite 100 C�_' �-_ Boston, MA 02114-2017 • ;._.,• www.mass.go v/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le ibl Name (Business/Organization/Individual): 11/,/Ai iefi, ,- e".T'4 0614,0_ Address: 70494 j ,,1 //--Zip r i1� City/State/Zip: i'' 4,y c _ Phone 4: Are you an employer?Check the appropriate box: Type of project(required): I.❑1 am a employer with employees(full and/or part-time).' 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp. insurance required.] 8. remodeling 3.2<am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. ❑ 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 contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions proprietors with no employees. 5.0 I 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.: 13•❑Roof repairs 1 MUNtir 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other ��/�,(�/ �j 152,§l(4),and we have no employees.[No workers'comp.insurance required.] ��, ��"`"` *Any applicant that checks box ill 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: /1'/k 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. 1 do hereby certify titter the ains and enalties of perjury that the information provided above is true and correct. Signature: Date: Phone Y: e3--p9-Oicta 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.Y44--,-, TOWN OF YARMOUTH o —�si�..;, BUILDING DEPARTMENT MATTAGh Ct(�,10' \� ,-,� 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261 HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DATE: JOB LOCATION: �. i:717ra /11 •' }j. in tAL D�7 j NAME S ' (f2/i2 ADDR SS' SECTION OFIOWN "HOMEOWNER" 6*a /i te-1�0 ��3' '�7/p NAME 0 HONE WORK PHONE PRESENT MAILING ADDRESS CITY OR TOWN STATE 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_elg/ APPROVAL OF BUILDING OFFICIAL INSURANCE COVERAGE: I have a current liability is • ce policy or its substantial equivalent, which meets the requirements of MGL Ch.142. Yes No If you have checked yes, p ease indicate the type coverage by checking the appropriate box. A liability insurance policy Other type of indemnity Bond OWNER'S I SURANC WAIVER: I am aware that the licensee does not have the insurance coverage required by Ch--iter 14/of the ► . sr eneral Laws and that my signature on this permit application waives this requirement. A RP., � . AN,- I Check one: atur- of Owne,�Owner's Agent Owne Agent h:homeownrlicexemp ,oF''''AR,� TOWN OF YARMOUTH o BUILDING DEPARTMENT .I''�_kg 1146 Route 28, South Yarmouth,MA 02664 4e,..,..«.3'GCd 508-398-2231 ext. 1261 Fax 508-398-0836 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 0/411i) )j1t .Vci V #64 ork Address Is to be disposed of at the following location: /ñviDSL s f(rC-- 3, 404 i Said disposal site shall be a licensed solid waste facility as defined by M.G.L. 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