HomeMy WebLinkAboutBLD-23-003943 .,,sizo.- ' /a M k3
ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department
1146 Route 28, South Yarmouth,MA 02664-4492
41%.‘
508-398-2231 ext. 1261 Fax 508-398-0836 f
Massachusetts State Building Code,780 CMR '. e
Building Permit Application To Construct, Repair, Renovate Or Demolish
a One-or Two-Family Dwelling
This Section For Official Use O y
Building Permit Number: 61.0-23-003_Ie43 Date A15I.:7R E C ETV E D
\Iry IAic 1., r -�/ \- 30-�,3 Fltaie 18 2023Building Official(Print Name) Signature
SECTION 1:SITE INFORMATION BUILDING DEPARTMENT
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers BY
'12 M .
a cs Yet to-1 11y .e-1
1.1 a Is this an acce ed street?yes j no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Res Res. nla
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 yes0
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Ree rd:
Maihetl a�ka��c Lex1 nb , M A o2421
Name(Print) City,State,Zl
3, Cle.11anj Rd . (211 ,tom -3118 2hin)_clark a y a1po. can()
No.and Street Telephone Ede Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building i Owner-Occupied le Repairs(s) C] Alteration(s) °` I Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
trief Description of Proposed Work2: 7, ,,. _ - =f _AAA
i-emu ra, • ►* 11.• "WI . . 116:,..1 •,,
4
SECTION 4:ESTIMATED CONSTRUCTION COSTS.
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 34 I. Building Permit Fee:$ I'S 0 Indicate how fee is determined:
2.Electrical $ Standard City/Town Application Fee
---- 500 ❑Total Project Cost3(Item 6)x multiplier_ x
3.Plumbing $ (01 TOO 2. Other Fees: $
4.Mechanical (1WAC) $ 0 List: .3S.00 6.,4-# 114,44 1
5.Mechanical (Fire .. ��
Suppression) $ Total All Fees:$
Check No. Check Amount: Cash Am t: 5 rr
6.Total Project Cost: $ 11 i OOO• 0 Paid in Full Ng Outstanding Balance Du :
I )3q'17
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) r
j( -v CS-014P 32 6_122
- � 1
`� �• tI ar License Number Expiration Date
Name of CSL Holder J
'Po , �,�I 21 List CSL Type(see below) Li
No.and Street-�'7� Type Description
Yv`• I5D MSible, rn6 0 eib U Unrestricted(Buildings up to 35,000 cu.ft.)
City/Town,State,ZIP -- R , Restricted 1&&.2 Family Dwelling
N1 Masonry
RC Roofing Covering
WS Window and Siding
(�� -J SF Solid Fuel Burning Appliances
114_q rl—135/ key ing a4 feted• 1 Insulation
Telephone Email address COM D Demolition
5.2 Registered Home Improvement Contractor(HIC) 1(02. `5-O
13t3
) l l) IC Registration Number irat' n Date
rJ l l� inc-J.!1� p
HIC Company Name or HIC Registrant Name
/� ;/}D
No.and Street C Email addr.,s
14- rn5-1a i MA 0206v corn
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COIYIPENSATION 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 1117- 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 acS�e_el
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.
Vey,r-> 1 Botor ill-7122
Print Owner's or Authorized Agent' ame(Electronic Signature) to
NOTES:
I. 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.sov/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"
Home Owner Authorization
I, Matthew Clark , 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:
72 Mayflower Terrace, South Yarmouth, MA
Z-
Signature of Owner Date
CI,9kr<
Print Name
== The Common ruI ealth of Massachusetts
i�= Department of-Industrial Accidents
"v�$_ 1 Congress Street, Suite 100
ar
=`:1?= Boston,MA 02114-2017
' . 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): Bg..� C541 B0116613.. dl[
Address: PO , Bek 21
City/State/Zip , `BarnSt . MA a2466Phone#: 77-4 -ii4 -1a7
Are you an employer?Check the appropriate box:
Type of project(required):
1.0 I am a employer with _employees(full and/or part-time).*
7. 0 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
3.0 I am a homeowner doing all work myself.(No workers'comp.insurance required.]I" g• El Demolition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property_ I will 10 El Building addition
ensure that all contractors either have workers'compensation insurance or are sole
11.❑Electrical repairs or additions
pr ictors with no employees.
5. 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.t 1' •Q Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL C. l El Other
152,§1(4),and we have no employees.(No workers'comp.insurance required.]
*Any applicant that checks box M I 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: ' Z 1_1 ,,ieC " � , City/Statep:''a(M
Attach a copy of the workers' mpensation policy declaration page(showing the policy number and expiration date).
�2�b�
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.
.l do hereby certify ider the pains and penalties of perjury that the information provided above is true and correct.
if
Sienature: _I / crl Date: k?12.:3
Phone#: "-r7A- q9A—/ 1'S5- 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
Kevin . Boyar
/ Goner Contrat tor
Corranonwesith of Massannusetts
Division of Professional L€censurr
Board of Burt-Mpg-Regulations And Strosiaro.s
S-0"76.332 ores 09W5/2023
KEVIN BOYAN.
€o aox2t
WEST BARNSTABLE MA 92440
Corn missi r
°Rite of Consvr»tv Maim it alosinoss€Rtidvia€ion
HOME IMPROVEMENT CONTRACT istration vetid to,individual use only
TYPE e -rsaet °fors the er siref>on date, if found return to
Registraffon Lgfitation Office of Consumer Affairs and Business Regtwietiu
1821 0 ,2 2C 1000 Washington Stu -Suite 710
fl ) tJS orK SOLDERS,it3C Boston MA 02118
KLVI N BOYAR :,<r '1
ILSI BARNS1A 0 nfiers Not valid. ifthout signature
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§TOWN OF YARMOIUTH
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. Ch. 40, §54 and 780 CMR - Section 105.3.1. #4.
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at '72. 4 toulef Tetca cam.- - M00 61
woria Address
Is to be disposed of oat th fo low4n locatie x. an.?
Ccothec (cmta;.)ef `�121V lC�s -fir a ilcenses1
tA3 s4e .c��,.}�,,�
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. 111, §150A.
Sig ture of Applic n ate
Permit No.
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