BLD-23-001305 0 & TWO FAMILY ONLY- BUILDING PERMIT
Q Town of Yarmouth Building Department
1146 Route 28, South Yarmouth,MA 02664-4492
( �� Co-
,. 508-398-2231 ext. 1261 Fax 508-398-0836 ,.
9�0v2 Massachusetts State Building Code, 780 CMR ,4
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Se BacileNf ermitApplication To Construct, Repair, Renovate Or Demolish .....;...•
oP P f�M a One or Two Family Dwelling
so` This Section For Official Use Only
ey utlding Permit Number: 6-1)-23-OD(, Date Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
y�� 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers •
tt,\
3v 'R-k v-cv s.4- . 0 4 z,(pq co2-7 .__
1.1 a Is this an accepted street?yes < no Map Number Parcel Nu ep E I E D
1.3 Zoning Information: 1.4 Property Dimensions: f C
Zoning District Proposed Use Lot Area(sq ft) Frontage(fto SEP 20 2 22
1.5 Building Setbacks(ft) _
BUILDING DEM TMENT
Front Yard Side Yards Rear Yavd
Required Provided Required Provided Required Provided I C4 riV
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: L
Public 0 Private 0 i Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
libihovn SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
le-GL-k-h e S a�.e_., C3 ass vw (act . v 2-c oco Li
Name(Print) City,State,ZIP
. 2wvc . '10 O 33(-1 g--W 1 a tot t.d Ca -�►�r<C.l c1 o i.�Gt ,cc.)rv-1
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction 0 1 Existing Building IRK Owner-Occupied El" Repairs(s) 21 Alteration(s) l ' Addition 0
Demolition Ell Accessory Bldg. 0 Number of Units I Other 0 Specify:
Brief Description of Proposed Work2: P,0,...i-h v[j o evN r e.m o de I t op e✓1 u_p S¢-cu rs
�t rt am oyi✓ .of Gl0 Sew Y o�/P �lr�c L� S-FCLt✓S t.uat it
P•An l'9-e; t 1 v1 n rOO rn t Y e v e. op rS ct-v1 a .erl 1 Qh-Od e. O p e %t no
(crl+1"1 uJ e-ti s) -In e x is-f-t✓16 rC)0 rr S
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 1. Building Permit Fee:$A,SCG Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List: 3 S;pQ 0 401
5.Mechanical (Fire
Suppression) $ Total All Fees:$ .
Check No. Check Amount: Cash Am c .1-,
6.Total Project Cost: S o2a I Go(J a) '1 0 Paid in Full 0 Outstanding Balance Du :` c —
rip A�Z1' Lcc.,-‘,�'' :I
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7 *. ' 211t: 76-%
TOWN OF YARMOUTH
k _ BUILDING DEPARTMENT
���w; =E% '�a 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261
��
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE: C't-(.,- Z Z_
JOB LOCATION: .J' V2—1€Y )+ ) . 96.3/w W ti
NAME S T ADDRESS SECTION OF TOWN
"HOMEOWNER" L -91U2 Q 60o3c1 Ti g
NAME I'IOME PHONE WORK PHONE
PRESENT MAIL[ TG ADDRESS
CITY OR TOWN STA'1'h 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 SIGNATU
APPROVAL OF BUILDING OFFICIAL
NSURANCE COVERAGE:
I have a current liability insurance 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'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner Agent
h:homeownrlicexemp
II\\aims
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. 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 3 12\Y( i/ S-F
Work Address
Is to be disposed of at the following location:
C Malt s-e+ ( -100Su.i )
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
Signature of Applicant Date
Permit No.
\III.11/
•
•
_* a The Commonwealth of Massachusetts
} =v , Department of Industrial Accidents
=g;;;;�� _ 1 Congress Street, Suite 100
='ai`-f • Boston, MA 02114-2017
www.mass.gov/dia
,1'MM11.
sV ,.
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information ���� ������ Please Print Legibly
Name (Business/Organization/Individual): �t i.v7 LE i L Sa_ e
Address:S ' /2 t vL.-- S-f- , ( -Jc fr 3 ce t.v•ev SI )
City/State/Zip:s•LI&r✓IW 1'12ck- Phone #: ?@D 33y W-7 Pi
Are you an employer?Check the appropriate box:
Type of project(required):
i.❑I 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
ca aci 8. Remodeling
an •
Y P tY�(No workers'comp. insurance required.]
3 ❑I am a homeowner doing all work myself [No workers'comp. insurance required.]r 9. ❑Demolition
ri I am a homeowner and will be hiring contractors to conduct all work on my10 ❑ Building addition
� property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp. insurance.[ 13.El Roof repairs
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14•El Other
152,§I(4),and we have no employees. [No workers'comp. insurance required.]
*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.
$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 verific ion.
I do hereby cer i y under the pains and Ities of perjury that the information provided above is true and correct.
Signature: Date: e(
Phone#: g ` 3t J g 7 e
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 4:
r A" •
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 l&2 Family Dwelling
M Masonry
RC Roofing Covering
• WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email addres D Demolition
5. Registered Ho
Ho �)Improovement Contr. or(HIC) '- ,
-1�S C fl (�"HOC `��"�"`�) HIC Re • tration Number Expiration Date
HIC Co .any i < e or HIC Registrant N. e
2. 1 ' () St - i2 ny)scaveti l+ eg Mai
No.
t et
trt U U.4-(�t I(Ylu 0 Z(o?3 y of-a��'�1 a 1 mail addre
CO
.an/
City .wn, State,ZIP Telephone
SECTION 6:WO' 'I RS'COMPENSATION NSURAN E 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 Issua a of the building permit.
Signed Affidavit Attached? Yes 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 name below,I hereby attest under the pains and penalties of perjtuy that all of the information
conta. d in this application is true and ccurate to the best of my knowledge and understanding.
69,L-es,,&
P t Owner's or Authorized Agent's Name lectronic 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 1 Number of half/baths
Type of heating system FP f c A't✓ Number of decks/porches
Type of cooling system $ Enclosed Open •
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
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FLOOR 1 ;E `'
L.
BUILT"
BRICK11 X13
Bedroom 1
2 x 4
CLOSET
12X8
Bedroom 2
11x12.5
CLOSET KITCHEN
12X15
PARLOR 3x3s
LAUNDRY
_ 8X10.5
7-- BATH
AY
FLOOR 1 BEDROOM 1
Remove closet and door, create entryway
BEDROOM 2 /4fk
Remove closet and surrounding walls
(Create open floor plan between BEDROOM 2 and PARLOR )
Electrical panel here to be updated and moved from*to**
E
.r 11X13 _
Bedroom 1
E4
,, ,
,,v,
,,
.....
, 2 2x4
, CLOSET
-'s
mmomm
* KITCHEN
12 X 8 Remove door
Bedroom 2 Create entryway/wall opening
center to kitchen opening w/sidewall
11 x 12.5 Replace countertop,
2 X 4 sik,hardware,etc.
CLOSET KITCHEN
New Lighting
Remove washer/dryer(W/D)
closet door,make solid wall
12 X 15 � • y BATH
PARLOR Open wall for W/D behind door
�� 3X35`
LAUNDRY .E— Replace tub with tiled shower
Half wall between shower&toilet
. = (bottom solid/top glass)
8X10.5
" BATH _
Replace vanity&sink
ri /4.5X6
ENTRYWAY i '
p oRcH
PARLOR
Remove door, create entryway
New or Replacement windows in the Spring
FLOOR 1
I 1
11 X 13 _
Bedroom 1
12X8
Bedroom 2
11x12.5
KITCHEN --,-_
12 X 15
PARLOR 3x35
LAUNDRY
8 X 10.50 _
BATH
4.5 X 60
ENTRYWAY
PORCH
FLOOR 2
•
r 1
CLOSET
c-:,:iiii_„,,,,,,„,„,,,„..,
,,,--N.6wktia
17X23
Bedroom 3
W
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)
I r--
FLOOR 2
I
Remove closet,including door and walls surrounding
Build out closet/Storage Space entire Inegth of wall
(recycle doors from 1st floor to create barn doors for closet)
CLOSET
--,
„,‘„.
,„„„.,„„ffk•
Make existing wall a 1/2 wall(42")
",,
17X23
Bedroom 3
44 Create"eve"storage space along entire wall
no higher than 5'slope
w with doors on either end
v'r ,.
O,
V New or replacement windows/new trim throughout
J I
0i4(kur i Y)
FLOOR 2
17 X 23 UPSTAIRS
Bedroom 3
w