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Home My WebLink AboutBLD-23-000015 . f6k Vid4 ONE & TWO FAMILY ONLY- BUILDING PERMIT (;� tlwd b Town of Yarmouth Building Department t ri- .— 1146 Route 28, South Yarmouth,MA 02664-4492 I [ J UL O 1 g 508-398-2231 ext. 1261 Fax 508-398-0836i ••, . 2022 Massachusetts State Buildin Code, 780 CMR `�' _BUILDING DEPARTMENT Buildi g I ermit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number W Z3--cbt j (S [Date Applied: Tr—, k. s �1 BuildingOfficial F )—\c�1^, (Print Name) Signature Date SECTION 1:SITE INFORiMATION 1.1 Property ACddress: �/ / � ��K 1.2 Assessors Map&Parcel Numbers �j 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 l 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' Private 0 Zone: — Outside Flood Zone? Check if yes❑ Municipal ElOn site disposal system 0 SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: ,( C Name(Print) ��i/�Z7-J�My ,S%ZI 12014 /1 City, S ate,ZIP Z3 CA OM/ ) I /tcv/P e �-f,-Z d 6 No.and Street Telephone p Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK''(check all that apply) New Construction 0 I Existing Building 0 Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) 0 Addition ❑ Demolition ❑ Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work' /j?p % e r c f /..r-p_ 45 Cx 66.04-->-- SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and Materials) Official Use Only 1. Building $ ,'y 600,- I. Building Permit Fee:$t O Indicate how fee is determined: 2.Electrical $ Od . ?Standard City/Town Application Fee ,o , 3.Plumbing 0 Total Project Costa(Item 6)x multiplier x b' " $A Dd� 2. Other Fees: $ 3S pp C, /ZU 4.Mechanical (HVAC) $ .-- List: � ' 5.Mechanical (Fire Suppression) $ Total All Fees:$ Check No. Check Amount: Total Project Cost: $ 70� Cash Amount:c� ❑Paid in Full lifl Outstanding Balance Due: X S______ 00 Nv SECTION 5: CONSTRUCTION SERVICES 5.1 nstruction Supervisor License(CSL) 14 Name of CSL Holder /` License Number ExpiraEion Dag f0 05p Uc e 1-4 43 .SZ List CSL Type(see below) No.and Str Ft f Type Description ,rT1. 66/20 A/f- OZW3 U I Unrestricted(Buildings up to 35,000 cu.ft. City/Town,State,ZIP R Restricted 1&2 Family Dwelling ) M Masonry • RC Roofing Covering WS Window and Siding y pl &3(a CpsSF Solid Fuel Burning Appliances Telephone 1 I Insulation Email address D I Demolition 5.2 Re istered Home Improvement Contractor(HIC) I".—Z/* 04 HIC Company Name or HIC Re istrant Dame HIC Registration Number Expiration p ion Date AI 4 e4,�� . " 1�e�vse'04r`r: No. and Stet aP 6 �,,yj�,��-��rn /09` fi eb0770 014 Gas 1' Email address City/Town, State,ZIP Telephone .1 en frA IG}C-11' ,, , Q Cb ill SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. C. 152.§ 25C(6))�mu-A--e‘ ��'�"'` 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 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 beh. , in all matters relative to work authorized by this building permit application. Print 0'. -.s Nam--Ironic Signature) "///Z-" Date • SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of peijury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. rFfrYirf Zili'f re v 1 Z.Print Owner's or Authorized Agent's Name(Electronic Signature) Ate 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.cov/d s 2. When substantial work is planned,provide the information below: Total floor area(sq. ft.) Gross living (including garage, finished basement/attics,decks or porch) b area(sq.ft.) Habitable room count Number of fireplaces Number of bathrooms Number of bedrooms Type of heating system Number of half/baths Type of cooling system Number of decks/porches Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" The Commonwealth of Massachusetts Department of Industrial Accidents i 1 Congress Street, Suite 100 z1 1"l;`' � Boston, MA 02114-2017 www.ma ss Q.a o v/d[a Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant Information Name (Business/Organization/Individual): Please Print Leaibl Address: /bW City/State/Zip: -4 G,,eG` � _ • Phone #: e)/+ 7 Z, Are you an employer?Check the appropriate b J �*� box: LE I am a employer with C' employees(full and/or part-time).* Type of project(required): 2 T am a sole proprietor or partnership and have no employees working for me in 7. ❑ReW delinrllCtlori any capacity.[No workers'comp. insurance required.] 8. Remodeling 3.0 I am a homeowner doing all work myself [No workers'comp. insurance required.]t 9. Demolition 4.11 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 10 E Building addition proprietors with no employees. IA Electrical repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 17r®Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance.[ 13. Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. [1]152,§1(4),and we have no employees. [No workers'comp. insurance required.] 1�' Other *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: Attach a copy of the workers' compensation policy declaration page(showing thetpolicy 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 S1,500.00) 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. 1 do hereby certi y under tl pain and enalties of perjury that the information provided above is true and correct. Signature: Phone#: ,/-ap)U� Date: 7 / •P 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#: �� TOWN OF YARMOUTH " - l BUILDING DEPARTMENT �� ^GCE 41 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261 HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DA LE: JOB LOCATION: iee R 03 OP/7 # c) /A/C NAME STREET ADDRESS SECTION OF TOWN "HOMFOWNER" NAME HOME PHONE WORK PHONE PRESENT MAILING ADDRESS 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 fouiii acceptable to the building official,that he/she shall be responsible for all such work perfoiuied 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 '47 APPROVAL OF BUILDING OFFICIAL INSURANCE 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 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 VAW/71 e/Z 6 1-7. LU/LJ 2 e'f,OM1/•(J &J P1/q1C Work Address Is to be disposed of at the following location: y/AX/'�l�7l� l = " 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. Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constr,u t Mt*rvisor CS-064503 . 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