HomeMy WebLinkAboutBLD-23-001184 4
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RECEI VogiPsi TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department of --_
SEP 19 2022 1146 Route 28, South Yarmouth,MA 02664-4492 /(.3e. Istil
508-398-2231 ext. 1261 Fax 508-398-0836 '�
BUILIDING DEPARTMENT Massachusetts State Building Code, 780 CMR
By: liz,tikii/vg,'ermitApplication To Construct, Repair, Renovate Or Demolish
a One-or Two-Family Dwelling
This Sect!In For Official Use Only
—
Building Permit Number: 8 L D-2.3-t D I I al Date Applied:
1rm <PAf5 _77
_ c\-1644-- RECEIVED -
Building Official(Print Name) i ature paw_—
SECTION 1:SITE INFORMATION LSEP 0 2 2022
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers a
/I14 VeJe54H cv, .7y
Rity1'�N T
1.1 a Is this an accepted street?yes no Map Number Parcel Number 1 1__
By _
1.3 Zoning Information: 1.4 Property Dimensions: ,
K-,r5" /D,975- a‘,.??
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 IVPrivate 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system Er
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP' 1 e mekr-C-�
2. wner'o Record:
f, ,1 /V ‘� i v,1G25
Name(Print) City,State,ZIP
2, cr/xicl sl CI SaP-a9y-Ua,' Liolexc,(o...A. �J• ' , cep
No.and Street Telephone Email Address/
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building lEK Owner-Occupied Vr Repairs(s) 0 Alteration(s) it Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units / Other 0 Specify:
Brief Description of Proposed Work2: _._- _ ., z_____ a__C_- , /
SECTION 4: ESTIMATED CONSTRUCTION COSTS.
Item Estimated Costs:
Official Use Only
(Labor and Materials)
1.Building $ 1 p®O, ' 1. Building Permit Fee:$ ISO Indicate how fee is determined: GV-
❑ Standard City/Town Application Fee
2.Electrical $
3moo' 0 Total Project Cost3(Item 6)x multiplier . x ��
3.Plumbing $ pips. 2. Other Fees: $ 3 S
4.Mechanical (HVAC) $ w/j9 List:
5.Mechanical (Fire
Suppression) $ 'in Total All Fees:$
Check No. Check Amount: Cash t:
6.Total Project Cost: $ A 30O 0 Paid in Full 0 Outstanding Balance D e:
`1G*
F�- a
r
SECTION 5: CONSTRUCTION SERVICES
�.1 Construction Supervisor License(CSL)
gA,A 0Z3
License Number Expiration Date
Name of CSL older
9 PVit,,c4s ,` C-I List CSL Type(see below) tJ
No.and Street Type Description
WS-
��j��,y��� �� �)�73 Unrestricted(Buildings up to 35,000 Cu.ft.)
City/Town,State,ZIP Restricted 1�Yc2 Family Dwelling
M Masonry R•
C 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) yya !/ I
7)&0/ '& ;7n.eJ (kYuo���'� 1Ke HIC Registration Number Expiration Date
HIC Company
Company,Narpe or HIC Registrant Name
� w/ CI �Y
No. and S reetJANA*da/ � r Email addres
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 [" 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
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 perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
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.eov/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 Commonwealth of Massachusetts
Department of Industrial Acciderzts
;7P
Eak— 1 Congress Street, Suite 100
E `_ Boston, MA 02114-2017
www.mass.s ov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): �sfiJ/ U ' '
Address: g ea,.✓e 1t'. ,,'``'' C of e,/xiefe,..H, ✓sti9 a>&73 .
City/State/Zip: Phone#: 5 -..)52q1--)?`"-G0FY
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 a sole proprietor or partnership and have no employees working for me in
y capacity.(No workers'comp. insurance required.] 8• Remodeling
3. I 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
6. ✓e are a corporation and its officer's have exercised their right of exemption per MGL c. 1 4•❑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 verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Sienature: � sc -- Date: i//atea
Phone#:
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#:
7 Y TOWN OF YARMOUTH
BUILDING DEPARTMENT
1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DA'1'h:
JOB LOCATION: Gi�/14,4"4,.. C-74Xific.rroci/L!
NAME STREET ADDRESS SECTION OF TOWN
"HOMEOWNER" ?",/ De quo 59F-a9Y-1.7.F`{
NAME HOMEP ONE WORK PHONE
PRESENT MAILING ADDRESS 2 �/fr- u/. yyq Q,W 73
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 ./-'afi,
APPROVAL OF BUILDING OFFICIAL
INSURANCE COVERAGE:
I have a curre. 'ability insurance policy or its substantial equivalent, which meets the requirements of MGL
Ch.142. No
If you have checked yes, 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
•
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 2. Gv; h��,kk el
Work Address
Is to be disposed of at the following location: X .)..I7 �.5 � 64
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.
FORM 153 The Commonwealth of Massachusetts 4ED
Department of Industrial Accidents
Ti— Office of Investigations-Dept. 153 �f Y 2 g t ••
` — 1 Congress Street,Suite 100,Boston,Massachusetts 02114-2017 • i
_ `__•• http://www.mass.gov/dia Inv �� Snvesli ;ons
' s
AFFIDAVIT OF EXEMPTION FOR CERTAIN CORPORA
OFFICERS OR DIRECTORS
Chapter 169 of the Acts of 2002 amended M.G.L. c. 152, §1(4) by adding the following paragraph:
"This chapter shall be elective for an officer or director of a corporation who owns at least 25 percent of
the issued and outstanding stock of the corporation.Notwithstanding section 46, these provisions shall
apply only if the corporate officer provides the commissioner of industrial accidents with a written
waiver of his rights under this chapter. Said commissioner shall promulgate regulations to carry out the
purpose of this paragraph.Violations of this paragraph shall subject the corporation to the penalties set
forth in section 25C."
Pursuant to M.G.L. c. 152, §1(4) as amended, I/We the undersigned officers of:
DeMarco Contracting, Inc., 361 Hudson Road, Sudbury, MA 01776
(Name of Corporation and Address)
each holding at least 25%of the issued and outstanding stock in said corporation, do hereby invoke the
right to be exempt from the provisions of M.G.L. c. 152, §25A and therefore are not required to carry a
workers' compensation policy covering the undersigned corporate officer(s) or director(s). I/We the
undersigned do also waive any and all rights to make claims for benefits as defined in M.G.L. c. 152 for
any injuries that may be sustained while in the employ of the above-named corporation.
Further, I/we the undersigned do understand that, should the above-named corporation hire or have in
its employ any employee(s) in addition to the undersigned corporate officer(s) or director(s), said
corporation is required to obtain workers' compensation coverage for the employee(s) as prescribed by
M.G.L. c. 152, §25A.
UWe the undersigned have read and understand the statements and obligations as delineated above and
I/we have checked the appropriate box below my/our name(s)indicating my/our desire to be exempt or
not to be exempt from the provisions of M.G.L. c. 152.
Signed under the pains and penalties of perjury:
- Paui-DeMarcn._. — 04/29/2021
•
Signature Print Name&Title Date(mm/dd/yyyy)
❑✓ I wish to exercise my right of exemption or ❑ I wish NOT to exercise my right of exemption
Signature Print Name&Title Date(mm/dd/yyyy)
❑ I wish to exercise my right of exemption or C I wish NOT to exercise my right of exemption
Signature Print Name&Title Date(mm/dd/yyyy)
❑ I wish to exercise my right of exemption or ❑ I wish NOT to exercise my right of exemption
Signature Print Name&Title Date(mm/dd/yyyy)
❑ I wish to exercise my right of exemption or ❑ I.wish NOT to exercise my right of exemption
Note:ALL ELIGIBLE CORPORATE OFFICERS MUST SIGN. THERE CAN BE NO MORE THAN 4 SIGNATURES. Instructions
on back. Form 153—7/2010
Commonwealth of Massachusetts
Division of Professional Licensure ✓/e Konu iae¢/%%t/. /6/44„r.,44e//•
Office of Consumer Affairs&Business Regulation
Board of Building Regulations and Standards
Cons li%)frvisor HOME IMPROVEMENT CONTRACTOR
j. • TYPE:Corporation
CS-053325 r Registration E piration
#-i Ocpires: 08/22/2023 • 114418 10/06/2023
PAUL P DEMARCO DEMARCO CONTRACTING,INC.
361 HUDSON ROAD _
SUDBURY MA�01776oik,
,,o
AO PAUL P.DEMARCO ,
>5ti13U 361 HUDSON RD.
{r, ,. ;%Cd•
SUDBURY,MA 01775 Undersecretary
Commissioner la. a /; tr ,,, �
TOWN OF YARMOUTH
cc, DEPARTMENT
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To he completed by Applicant:
Building Site Location: e7 ti"''k n Ca '
Proposed Improvement: "iCry 1�� T ;- � �N c1=1 et l� 4✓
�N r v avv'C -re.„ ti u4 v-e ce C-re LA —to, ✓ / (r,4
Applicant: /Gyv/� C '�f2�-� Tel. No.: -5—b5"; `•ef- cp) y
Address: (icii '`)4i1 Date Filed:
**lfyou would like e-mail notification of sign off,please provide e-mail address: : pp7pnzc rt,-,v—stc75 g g 6l4'L) ,Co"?
Owner Name: 'a:.. ""e1,,1i'rt
Owner Address: 4'1v'C"1,5 4-A. Owner Tel. No.: 4-6J"c).4/-C�?ry
RESIDENTIAL AND/OR COMMERCIAL BUILDING
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e'.,ketituntrlsV E D
For Septage Disposal and other Public Health Activities.
Please submit three (3) copies of plans, to incluG e: SEP 16 2022
(1.) Site Plan showing existing buildings, water] ;{$ TMENT
and septic system location; By:(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.
REVIEWED BY: DATE: 7-16—'a
)'
PLEASE NOTE
COMMENTS/CONDITIONS: `
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