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Home My WebLink AboutBLD-23-005107 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 MA .un e Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: , l-Z3-00 5/0 2 Date Applied: •Z 3-0 e/p 7 Building Official(Print Name) Signa re Date SECTION 1:SITE INFORMATION 1.1 Pro erty Address: 1.2 Assessors Map&Parcel Numbers 1-ee4v'l Cock C cc-e 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 Rear Yard Required Provided Required Provided Required Provided _____-- 1.6 Water upply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Privatfilli* Zone: _ Outside Flood Zone" Check if yes❑ Municipal 0 On site disposal system SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Name( nt) / City,State,ZIP rj Ps4 e45.4-NT eO vk C(rtc,• c ._ ,' i 17 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 Existing Building❑ Owner-Occupied 0 l Repairs(s) 0 Alteration(s) Br Addition ❑ Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work-: �Q rv.o v..4. '['v la-, -�lAc� ta�r'N- 1-1t� w.2 Npt a-- viJ ei,av�`.r ) (T _ / SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Q E D E I V C D (Labor and Materials) Y 1. Building , $ to oo.B c 1. Building Permit Fee:S ,fO Indicate how f is determined: 'c. 'Standard City/Town Application Fee MAR 2 2 2.Electrical $ 023 5-0m_ T 0 Total Project Costa(Ite 1 x) multiplier x . J1Y� 3.Plumbing $ �..5,7c._�• 2. Other Fees: $ ��v v BUILDING DEPARTMENT sy: ,L P4ettchani AC) $ ---- List: R E D5Em9ckidni Suppress ni on) $ Total All Fees:$ - MAR6.h6tDPojFet Cost: $ ��DoQ o� Check No. Check Amount: Cash Am t: V 1 ` / 0 Paid in Full Outstanding Balance Du : \\tj fYry v' DEPA� �/ A a/ Y � SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) a�� A.r,�e,uat0 e.L Ol ? 4 LicenseNumber Expiration Date Name of CSL Holder < 5'44 List CSL Type(see below) (l No.and Street Type Description C/i riel— p-ri m 24�� 1 Unrestricted(Buildings up to 35,000 cu. ft.) City/Town,State,ZIP Restricted 1&2 Family Dwelling M Masonry • RC Roofing Covering _ WS Window and Siding �0_ Z,Ccy. D/14 C Zlc#Ws_/ i InsSoluldation Fuel Burning Appliances 7 V I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) COI D,1102.44 HIC Company Name or HIC Registrant Name HIC Registration Number Expiration Date ' e— ,t µ tt&SgsaMSMt '•AT No.and Street y/$64, f .0f-042 G� Email address City/Town, State,ZIP // Telephone N q W as 01\5 ,La Irk SECTION 6: WORKERS' COMPENSA A URANCE AF I!AVIT(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 oft 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 VP,...) to act on my behalf, in all atters relative to work authorized by this building permit application. 3/Print Owner's Name(E ec onic Signature) ��' Z� D to SECTION 7b: OWNER1 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 fAuthorized Q ame(Electronic Signature) /23 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 + L Department oflndustrialAccidents 1 Congress Street, Suite 100 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): Da'JD 44) 1.-\Al2!.40 /Z-- Address: rp t/ -.d 'V 5.-14 2.G? �y City/State/Zip: V 6+-.1-. "l'mo Phone #: ":::;ePS • ;, ';' Are you an employer?Check the appropriate box: Type of project(required): l.❑lam mployer with employees(full and/or part-time).* 2 am a sole proprietor or partnership and have no employees working for me in 7. New construction 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. El 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.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.0 Roofr Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance.t 1 0Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.flier 'atatrAi- 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 certi under the pain andpenalt"es of perjury that the information provided above is true and correct. Signature: 1(e Date: Phone#: 2`L►—�j {�tU 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#: Rat o TOWN OF YARMOUTH . - BUILDING DEPARTMENT 1146 Route 28, South Yarmouth, MA 0266E 508-398-2231 ext. 1261 HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DATE: JOB LOCATION: NAME STREET ADDRESS SECTION OF TOWN "HOMEOWNER" NAME HOME PHONE WORK PHONE PRESENT MAILING ADDRESS CITY OR TOWN STALE 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 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 Y 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 57 DCL.tii5A4/7 Work Address Is to be disposed of at the following location: 12c, .i7?,,! 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. ^orpmvi Y ?ivp Jauo!ss1ww03 9L9Z0 VW 12IOd H111OWNVA IS N33113 OZ 13018N3N211(H r 01VN00 tiZOZ/Z1/S0:saaid 9L61710-S0 JOS!A UULO4SU00 •spJepuetg pue suoltejnbe bugpim8 to pteo8 ainsuaoii leuoltednooO to uoisiAia �a suasnLaesseW to titleaMuounuo0 THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE: Individual Registration Expiration 100909 06/23/2024 DONALD HARKENRIDER D/B/A DONALD J.HARKENRIDER DONALD J.HARKENRIDER 20 EILEEN STREET YARMOUTH,MA 02675 Undersecretary Registration valid for individual use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 1000 Washington Street -Suite 710 Boston,MA 02118 Not valid without signature