HomeMy WebLinkAboutBLD-23-003945 . _. ... : PU MIz''))
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 508-398-0836
Massachusetts State Building Code, 780 CMR o,e
Building Permit Application To Construct, Repair, Renovate Or Demolish
a One-or Two-Family Dwelling
This Section For Official Use Only C i� I V E
Building Permit Number: 84,,23-tb39 Ls Date Appli . [ ' j
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�, 810
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Building Official(Print Name) Signature BLOWING DEPARTMENT
SECTION 1: SITE INFORMATION
11..1 Property t Address: �� O 1.2 Assessors Map&Parcel Numbers
=i . a. PJS to a
1.1 a Is this an accepted street?yes , no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
F£S.
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❑ Zone: Outside Flood Zone?
— Municipal❑ On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: Q� ,{,� A ._ l/ �J
Name(Print)� � 1�C� -444 tA &sc llgit.3 ic)t me),-) 1
( ) City,State,ZIP
•
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check.all that apply)
New Construction 0 1 Existing Building/Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units i Other 0 Specify:
Brief Description of Propo ed Work2: �-h)rf1 € A - -c
as a dcb�aradL (iv it c l code. car'r p ,it* ,u y_ a-t;o 8
walk and ,
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $250 Q 1. Building Permit Fee:$t 50 Indicate how fee is determined:
ill Standard City/Town Application Fee
2.Electrical $ i TO
❑Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 0 2. Other Fees: $
4.Mechanical (HVAC) $ 0List: 3 Jam.oD attk 9�
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash
6.Total Project Cost: $ .3,tp°, ❑Paid in Full IA Outstanding Balance e:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
CS -On(0332 g 5 23
Ke v tr\ M _Totrr License Number Expiration ate
Name of CSL Holder
PA .'BOx 2 List CSL Type(see below) U
No.and Street Type Description
W. Barnsfiable Mn�1 02c0456 U Unrestricted(Buildings up to 35,000 cu. ft.)
City/Town,State,ZIP R Restricted I&2 Family Dwelling
M Masonry
•
RC Roofing Covering
WS Window and Siding
�M� 1.357
SF Solid Fuel Burning Appliances
,
y'( ql i:eccd ea) I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
Q$t GUSIOM �,u►�C O S 1(02150 1 25 c
HIC Comp Name or HIC Registrant Name HIC Registration Number Expiratio Date •c
�-O• �vx ZI ,
`_No an Street "SVIn " •�� •��
Y • arMiaUe , MA oa.( -)qc4 1357 Email address
City/Town, State,ZIP Telephone
fi
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 <jE'� A-triercettO
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 Accidents
milrywes,t'' 1 Congress Street, Suite 100
=f Boston, MA 02114-2017
_ S�• www.mass.gov/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): la,g,t fricrn 13 tJ Lung
Address: P 0 . BOIL. Z
City/State/Zip:W, 624.0(D8 Phone #: ^17'4 - 6144 - 135-7
Are you an employer?Check the appropriate box:
Type of project(required):
1.❑lam a employer with employees(full and/or part-time),*
7. ❑New construction
2.❑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.❑I am a homeowner doing all work myself. (No workers'comp. insurance required.]t 9. Demolition
4.❑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
I 1. Electrical repairs or additions
proprietors with no employees.
CKI 12.❑Plumbing repairs or additions
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.t 1 •El Roof repairs
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14 Other
152,§1(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.
r 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: n i
Policy r or Self:ins.Lic.#: Expiration Date:
Job Site Address: AfelrnSOJ� E y � ��
•
City/State/Zip: A
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 certif under the pains and penalties of perjury that the information provided above is true and correct.
Sienatu e: q Date: l tin(ZZ.
Phone#: `7'11{- (/t - 13s"7 .
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#:
I.
. - 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 44 rnftvNN PR)E. .
Work Address
Is to be disposed of at the following location: \jIl5c bUTC PS E .. 7D LicE,43Sa
D 1POsA-t- Iup
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
l_'I III (-71zz
Signature of Ap 'cant Date
Permit No.
5
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Kevin M. Boyar
•
/? Getteral Contractor
.
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Cornfivmoyann Of Ressar-iniarti,
Divi-itorl of Professional L=s .irr-
Briard of Slidcfraa Regulations mat Steritfards
CS-016332 • Expires, OBirOS?2023
KEVIN BOYAR ØtIIIiII
PO sox 21
WEST BARNSTABLE IBA 020AS ',7fir-•
• 4;41,
Commissioner
iliCt Of Cow**t ikflOirg&arkftii11.35 Reguietiori
HOME lIAPROVEMENT CONTRACTOR Registration Sor Vidividr.tat use only
TYPE.Cave:rasa- before aptretron date, if founo return to
FiggitttiltiOri gaPitattcht of Consumer Affairs and Business Fiegulation
162:50 OT,25,75;:-',i 000 Washington Street -Butte 710
BAD CUSTOM EU/IDEAS,INC Boston,MA 0211S
Bov4q
MAIN SBEET
WES I BAi4NSIABLE.MA r- Not valittiovithout signature
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Home Owner Authorization
I,S , as Owner of the subject property, hereby
authorize B&D Custom Builders., Inc. (and their agents) to act on my behalf in
all matters relative to work authorized by this building permit application for:
44 Madison Ave,Yarmouth, MA
Signature of Owner Date
s.
l'e-Irket • vl i V
-(F)--Lh
Print Name.
Home Owner Authorization
I,S , as Owner of the subject property, hereby
• r- Odat—
authorize B&D Custom Builders, Inc. (and their agents) to act on my behalf in
all matters relative to work authorized by this building permit application for:
44 Madison Ave, Yarmouth, MA
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gukcik;)bakci .
Signature of Owner Date I
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E'�7SYketlktS,_
Print Name•
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ilLE COPY
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REVIEWED FOR 9I_1!I_DNG AND Ru, COMPLI
ANE. ERRORS OR(MISSIONS DO NOT RELIEVE THE
APPLICANT FROM THE RESPONSIBILITY OF"AS BUILT'
COMPLIANCE.
DATE:
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