HomeMy WebLinkAboutBLD-23-002202 2(f ////e/62_
RECEIVED
O4E & TWO FAMILY ONLY- BUILDING PERMIT
OCT 2 4 2022 + Town of Yarmouth Building Department :''oF....r. _.
1146 Route 28, South Yarmouth,MA 02664-4492
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BUILDING DEPARTMENT 508-398-2231 ext. 1261 Fax 508-398-0836
w _ Massachusetts State Building Code, 780 CMR t **.at,e
Building Permit Application To Construct, Repair, Renovate Or Demolish
a One-or Two-Family Dwelling
This� Section For Official Use Only
13 Building Permit Number: (J)-3-� tiZ Date Applied: /aojo7d...faZ
�ir-, ASS - \\-S'�---
Building Official(Print Name) Sign ture Date
SECTION 1: SITE INFORiMATION
1.1 Property i�dds�s ���� Lre� 1.2 Assessors Map&Parcel Numbers
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
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private 0 Zone: Outside Flood Zone?
—
Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP`
2.1 Owner'of Record:
�oei',s MalZal e. WetTYhh,s r1Il o a 670
Name(Print) City,State,ZIP
G7 14n le_6(trneys 2( 76r mq,Gveci /014,2vhevi/ceyiie
No.and Street Telephone Email Address • Coot ,
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 [Owner-Occupied 0 Repairs(s) i Alteration(s) 0 Addition 0
Demolition E/ Accessory Bldg. 0 Number of Units ( Other_� 0 Specify:
Brief Description of Proposed Work �
: P,� 6 ' -V a 0.. bec(cOOwt
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $.2 rol71. Building Permit Fee: $ tk()) Indicate how fee is determined:
2. Electrical $ Aar) 0 Standard City/Town Application Fee
0 Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ 3 C - - 1109
4.Mechanical (HVAC) $ de/ List:
5.Mechanical (Fire $ .
Suppression) Total All Fees:$
Check No. Check Amount: Cash ount:
6.Total Project Cost: $ �I �� ❑paid in Full 0 Outstanding Balance ue: 3(p<
i \4e-
C [(p7`(
- . __ ' 'The Commonwealth of Massachusetts
it -,► I. Department of Industrial Accidents
=e= 1 Congress Street, Suite 100
" ,° 1_ Boston, MA 02114-2017
� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectriciansfPlumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): L✓ ,cC y)/4 iv( U ry
Address: 3 i C 'V' ' 1—
City/State/Zip: W' Nti.,< in(I 0„i7o Phone #: o —3 6 7 -rill
Are you an employer?Check the ap box: Type of project(required):
I.1I 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 8. 0 Remodeling '
any capacity.[No workers'comp. insurance required.]
...„*A9. ❑ Demolition
,,z I am a homeowner doing all work myself. [No workers'comp. insurance required.]t
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
10 0 Building addition
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
5.0[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.t
6.❑We are a corporation and its officers have exercised their right of exemption per,MMGL c. 14. Other`i t�, T i~D i�
152,§1(4),and we have no employees. [No workers'comp.insurance required.] 't i S rt i Ad p - . Oc
*Any applicant that checks box:1 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.
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.
Cb_Insurance Company Name: i )vt I i\ L f cl Al
Policy g or Self-ins.Lic.#: G I I t.-7 3 Expiration Date: 99 ) /, ',.)
Job Site Address: f 1 Ac V. `,v C in) City/State/Zip: f a1. •/aY 1v►G v-7-ii 0,D Z 73
Attach a copy of the workers' compensation policy declaration page(showing the policy numb 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$250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereb ertify un e ains and penalties of perjury that the information provided above is true and correct.
Signature: --��
Date: /IS .3 d)..D D
Phone#: -rd — 3 tv '7 — .5--- -CI
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
. SECTION 5: CONSTRUCTION SERVICES
5.1 Construction ervisor License(CSL) d-7 4;.)C- ------ l:,2 2-3 i/-.) D
el.-., G • /1 L`YK <'y"-) License Number Expiration Date
Name of CSL Holder vim? R
S List CSL Type(see below) !t.
-I -3 t t-
No.and Street Type Description
S`T �� '`� /� ��� 7G7 U Unrestricted(Buildings up to 35,000 cu.ft.)
',. . c159 Restricted l&2 Family Dwelling
City/Town,State,ZIP f Masonry
RC Roofing Covering
• WS Window and Siding
_ �'� �p4)i 1 ..---CD A,A v-� SF I Solid Fuel Burning Appliances
4. _- -3`7 -Sa rv' G )Y►,,-,( cow I 1 Insulation
Telephone Email address D Demolition
r5. Registers Ho Improvement Contractor(HIC)�
n� Ayr�uJ /02 �' �718` di,a71� :2
HIC Registration Number Expiration Date .
HIC Cony Nanke or HIC registrant Name
No.and Stre i Email address
Lc;'..-S r,cJ ; (yamn 3 d k...3vl 7 J F$
City/Town,State,Z1P 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.
v Signed Affidavit Attached? Yes 0 No iffi-
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERT
I,as Owner of the subject property,hereby authorize j}t1 .) )>4j) M t'! t4 I\l
to act on,my behalf 1n all matters relative to work authorized by this building permit application.
/el/2-0 bie2c2--
Ptsat�Owners Name(Electronic ignature) Date
• SECTION 7b: OWNER' 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 plication is true and accurate to the best of my knowledge and understanding.
1 t Owner's or Authorized Age '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.eov/oca Information on the Construction Supervisor License can be found at www.mass.2ov/dos
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"
TowN OF VAR MOUTII
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
conducted at II 0ack_ �JftCk Lam E. Mit yet(-met.t *I 01-4 "13
Work Address
Is to be disposed of at the following location: 4 04'mo 2)t.4fritp ,kcwS'elr 5
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
De folt� /0 /0/1/ AO 2
Signature of Applica Date
Permit No.
•
Commonwealth of Massachusetts
irtDivision of Professional Licensure
Board of Building Regulations and Standards
CSFA-074205 Expires. 12/31i2022
DAVID L DADMUN
43 POND STREET
WEST DENNIS MA 02670
Commissioner
r, •cf
, 4 'Coitstotle:Af:::Ts&BUS:11,,SS riZAiLitiALICk.1
170;117 IMPROVEWEN f CON1 OR Regibt4ation ilid ioi ltidvdt Is:.0,71y
before the expiration ciato. If found return to:
11'41.1istiation Expiration OrWco of Coununor Affn!is nnd Businesz-,ficEiLf!atiorf
28716 OP'2(-1i023 rioff.irc;:t 710
t!Tri
1).'SIA DL.DiDN C:i- 1() I.91)!:.DERS
L. DALinliti _
43 POND Si UN11 7
nENNis.°.:4 02670
Not valid withoul ciionaittre
Uncierticc.,nia+y
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TOWN OF YARMOUTH
1444, HEALTH DEPARTMENT
a;
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To he completed by Applicant.
Building Site Location: /7•Biet c.k )Lir k 1s e
Proposed Improvement: � (mar cif �t p� roa Ht
C( — ak•
Applicant: iL CHO F /1/(1 12c h t'_. Tel. No.: f 7g'J -% I V,- yff
Address: L 7 C /f11`&I rvi ey 15 fir€)' . 11/1 �Piirtis (��� Date Filed: /0/)(00.22
v1&76
**/fyou would like e-mail notification of sign off please provide e-mail address: /',Flit; I Zc o f tl y tt yef Leo,rt1 t-t
Owner Name: /.0 if/5 r fi /zo
Owner Address: lc 7 till IF I r201 ey 5 12 it‘ if::eivi/5/ r//Awner Tel. No.: /b'1-9�(7-‘q8/
ea( 7o
RESIDENTIAL AND/OR COMMERCIAL BUILDING
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
Please submit three (3) copies of plans, to include:
(1.) Site Plan showing existing buildings, water line location,
and septic system location;
(2.) Floor plan labeling ALL rooms within building
(all existing and proposed) —
Note: Floor plans not required for decks, sheds, windows, roofing;
(3.) If necessary, Title 5 application signed by licensed installer
with fee.
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REVIEWED BY: '` DATE: /%'& d�
l
PLEASE NOTE
COMMENTS/CONDI IONS:
rst-ULd rsc/.1/1 a — 111°. 13eCifC)
v'T-h / oc=t e, -3 Li s
t �
/ 7 13Lac k uc k 1--cu e_ Wes+ ya. W ttl a1 jvi4 o_26 73
C KITCHEN
BEDROOM ,'I
BEDROO
HALL VP'
DINING ROOM
LIVING ROOM �%'
PRIMARY BEDROOM rid 41
FIOPlan
OCT 2 0 2022
HEALTH DEPT.
Property Location: 17 BLACK DUCK LN MAP ID:49/184/// Bldg Name: State Use:1010
Vision ID:7408 _Account#7408 Bldg#: 1 of 1 Sec#: 1 of 1 Card 1 of 1 Print Date:08/05/2016 17:18
CONSTRUCTION DETAIL I CONSTRUCTION DETAIL(CONTINUED)
Element Cd. Ch. Description Element Cd. Ch. Description
Style 01 /SF nch Cit
Model DI roResidential
Grade 03 . %verage PTO 20
Stories 1 ....(Story 0
Occupancy 1 MIXED USE 10 10
Exterior Wall 1 14 �ood Shingle Code Description Percentage
Exterior Wall 2 / 1010 SINGLE FAM MDL-01 100 20
Roof Structure 03 Gable/Hip BAS 36 SAS FGR 12
Roof Cover 03 /Asph/FGls/Cmp UBM
Interior Wall 1 05 Drywall/Sheet
Interior Wall 2 COST/MARKET VALUATION
Interior Fir I 12 Hardwood Adj.Base Rate: 110.68
Interior Fir 2 06 Inlaid Sht Gds 156,840
Heat Fuel 1/3 fGas Net Other Adj: 0.00 24 24 2222 22
Heat Type 04 Forced Air-Duc Replace Cost 197
AYB 1975
AC Type 01 �TPone
Total Bedrooms 02 2 Bedrooms Dep Code G
Total Bthrms 1 Remodel Rating 12/ J2
Total Half Baths II Remodeled 3�'= / /
Total Xtra Fixtrs Dep% 15 �'
Total Rooms Functional Obslnc D
Bath Style 02 Average External Obsinc D
Kitchen Style 02 Modern Cost Trend Factor
Condition
%Complete
Overall%Cond 85 _ '
Apprais Val 133,300 '. t _ ,....s •,r , ,fig "' i
Dep%Ovr D -'� ' '- ° .`r , T al=".
:.
Dep Ovr Comment _ W0, •
Misc Imp Ovr ) fry f
Misshnp Ovr Comment :* . lip '
Cost to Cure Ovr D �f: '14 „ srar+
Cost to Cure Ovr Comment ,{. ?1t i ' ',
TA
OB-OUTBUILDING&YA ITEMS(L)IXF-BUILDING EXTRA FEATURES(B) '�' "
• Code I Description ISub Sub Descr. t IL/BI Units(Unit Price` Yr IGde I Dp Rt I Cnd I%Cnd I A.r Value .„ 1'— ' o.+` r,' a . a► _ OF
FPL1 FIREPLACE 1in, B 1 2,200.00 '2000 1 200 1,900 - a }-
. , Hof
iira
, ► ,-'
BUILDING SUB-AREA SUMMARYSECTION
Code Description Living Area Gross Area Eff Area Unit Cost Undeprec. Value
BAS First Floor 1,128 1,128 1,128 110.68 124,852 _,
FGR Garage 0 264 106 44.44 11,733 • ,
PTO Patio 0 200 10 5.53 1,107
UBM Basement,Unfinished 0 864 173 22.16 19,148
..T_tL Gross Liv/Lease Area: 1,128 2,456 1,417 156 840
Property Location:17 BLACK DUCK LN MAP ID:49/184/// Bldg Name: State Use:1010
Vision ID:7408 Account#7408 Bldg#: 1 of 1 Sec#: 1 of 1 Card 1 of 1 Print Date:08/05/2016 17:18
CURRENT OWNER I TOPO. UTIL _STRTJROAD LOCATION. C/ZRRENTASSES,SMENT
MALZONE LOUIS F TRS 1 Level 2 Public W er 1 Paved 2 Suburban Description Code Appraised Value Assessed Value
MALZONE JEANNINE I TRS 6 Se tic RESIDNTL 1010 135,200 135,200 815
67 UNCLE BARNEYS RD p
14 RES LAND 1010 96,300 96,300 YARMOUTH,MA
WEST DENNIS,MA 02670 SUPPLEMENTAL DATA
Additional Owners: Other ID: 43/C042/// VOTE V
MISC 220 VOTE DATE 10/18/2004
CHANGES ADD PP FY 16 MG PRIVATE R(BLACK DUCK LN-WY
BETTERMENT VISION
PLAN NUMBEI697A
ZIP CODE 2673
GIS ID: M_307252_824447 ASSOC PID# Total 231,500 231,500
RECORD OF OWNERSHIP .BR VOL/PAGE SALE DATE''q/u of_SALE PRICE VC. PREVIOUS ASSESSMENTS(HISTORY)'
MALZONE LOUIS F TRS 29298/180 11/27/2015 U I 100 1F Yr. Code Assessed Value Yr. Code Assessed Value Yr. Code Assessed Value
MALZONELOUISF 28523/175 11/21/2014 U I 100 1F 2017 1010 135,2002016 1010 135,2002015 1010 114,600
BURLINGAME MICHAEL 28322/231 08/14/2014 U I 200,000 IS 2017 1010 96,3002016 1010 87,5002015 1010 87,500
FEDERAL NAT'L MORTGAGE ASSOC 28212/118 06/19/2014 U I 199,742 IL
KOENEN CASSANDRA 14223/ 41 09/11/2001 Q I 175,900 00
DYER HELEN I EST OF 14223/ 38 09/11/2001 U I 0 1F
Total: 231,500 Total: 222,700 Total: 202,100
EXEMPTIONS OTHER ASSESSMENTS This signature acknowledges a visit by a Data Collector or Assessor
Year Type Description Amount Code Description Number Amount Comm.Int_
APPRAISED VALUE SUMMARY
Total Appraised Bldg.Value(Card) 133,300
ASSESSING NEIGHBORHOOD Appraised XF(B)Value(Bldg) 1,900
NBHD/SUB NBHD Name Street Index Name Tracing Batch Appraised OB(L)Value(Bldg) 0
0044/A Appraised Land Value(Bldg) 96,300
NOTES Special Land Value 0
WEATHERED IA
,..4.... Total Appraised Parcel Value 231,500
Valuation Method: C
Adjustment: 0
Net Total Appraised Parcel Value 231,500
BUILDING PERMIT RECORD VISIT/CHANGE HISTORY
Permit ID , Issue Date 1}pe Description Amount Insp.Date %C mp. Dat Comp. _Comments Date Type . IS ID Cd. Purpose/Result
15-002069 10/23/2014 INSL Install Insula 3,659 /� (508-778-0111)install ins 07/17/2015 RF 54 Field Review
. 15-001025 09/09/2014 RI Reside 2,000 j,i° Siding-4 sqs. 01/01/2014 01/ 1 BH CY CYCLICAL 2014
15-001026 09/09/2014 WIN Windows 1,500 2 Replacement Windows 05/21/2012 WP 07 Measur/Inf/Dr Info taken
05/03/2004 GM 02 Measur+2Visit-Info Caro
05/03/2004 GM 01 Measur+lVisit
lrill&(ll t C 614 l.C,
LAND LINE VALUATION SECTION
B z Use Use Unit L Acre C. ST. Special Pricing S Adj
# iCode Description Zone D Front Depth Units Price Factor S.A. Disc Factor Idx Adj. Notes-Ad) Spec Use Spec Cale Fact Adj. Unit Price Land Value
1 1010 SINGLE FAM MDL-01 C 10,019 SF 8.73 1.0000 4 1.0000 1.000044 1.10 1.00 9.61 96,300
Total Card Land Units: 0.23 AC Parcel Total Land Area:0.23 AC j Total Land Value: 96,300
l 7 El-ack I e{Ck L Wes+ •f1410 Oki, Nig 0,2673
� � ,. -- 1
REVIEWED FOR PUILDING AND. an-c, -tS e q?..,s s
ANCE. ERRORS OR OMMISSIONS DO N .i_KLLIEVE THE l NS
APPLICANT FROM THE RESPONSIBILITY OF"AS BUILT
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OCT 20 2022
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