HomeMy WebLinkAboutBLD-23-001936 O IcH
, r
ONE & TWO FAMILY ONLY-BUILDING PERMIT
Town of Yarmouth Building Department r
1146 Route 28, South Yarmouth,MA 02664-4492 or
508-398-2231 ext. 1261 Fax 508-398-0836 4.;
Massachusetts State Building Code,780 CMR %.,,2,..e,:iBuilding Permit Application To Construct, Repair, Renovate Or Demolish
a One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: L C��..-a3--(U A(. C E Q �✓ E D
I Date Applied:
BuildingI i r• SeAc 5 / i to-0-4,,)___ OCT 11 2022
Official(Print Name)
i re _Date
SECTION 1:SITE INFORMATION BUILDING DCFARTMENT
II Property Address: "Y
1.2 Assessors Map&Parcel Numbers - -
9 /owLe.1 L.1. Y totel.Pow
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information ) J 1.4 Property Dimensions:
,,,/ i
Zoning District Proposed Ose Lot Area
(sq ft) Frontage(ft)
-1.5 Building Setbacks(ft)
Front Yard Side Yards
Rear Yard
Required I Provided Required Provided
Required Provided
I J
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public' Private❑ Zone: Outside Floo ne?
Check if yes Municipal 0 On site disposal system
SECTION 2: PROPERTY OWNERSHIP'
2.11pwnpr' f Record:
n1 a Ya.ryt.6i k PoriiI .Nl s¢ a -49 7 —
Name(Print) City,State,ZIP S
9 &NI(e Lvi.. - 777— oa'to
No.and Street ( Telephone
Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 I Existing Buildin ' Owner-Occupied ❑ I Repairs(s) I Alteration(s) D I Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units 1 Other 0 Specify:
Brief Description of Proposed Work2: el.ef(act_ f- b -fib gyp.,
r
SECTION 4:ESTIMATED CONSTRUCTION COSTS.
Item Estimated Costs: •
(Labor and Materials) Official Use Only
1.Building S 7s `= 1. Building Permit Fee:$1C) Indicate how fee is determined:
2.Electrical $ 3 S c 0 Standard City/i'own Application Fee
3.Plumbing $ f , v- 0 Total Project Costa(It 6)x multiplier x
3 2. Other Fees: $ ' 3
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) $ Total All Fees:$
6.Total Project Cost: $ �. Check No. Check Amount Cash t:
U�S� ` 0 Paid in Full Outstanding Balanc Due: 1-
pp
..sus..
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
acob • CS-681040 y
Name of CSL Holder License Number Exp lion Date
p D. gO X 3 y y List CSL Type(see below) U
No.and Street Type
Description
Porgy tM�9 0 7S U Unrestricted(Buildin s up to 35,000 cu.ft.)City/Town,State,ZIPSifA R Restricted 1&2 Famil Dwellin
NI Ivlaso
RC Roofing Coverin
WS Window and Sidi❑
7 74-353-(� 3 S ol ng.- actL,S 7 r' �A k od c o SF Solid Fuel Burning Appliances
I insulation
Tele'hone EmatI add ss
D Demolition
5.2 Registered Home Improvement Contractor(HIC)
PA Mobs _____ ____-,5(688
HIC Company Name or HIC Registrant Name HIC Registration !Y ao3
P O. ( ox 3c( piration Date
I�Jo.and Stree t Lerc ObS 7f�na yak 00 • Co rLl
`� �i' p 71��S � Email ad ress
Ci /Town,State,ZIP
Tele.hone
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 0
No .0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of e subje• .-rty,hereby authorize Pa+rfe-k Iia. S
to act o ehalf, ',,, .. hers relative to work authorized by this building e/ permit application.
Print Owner's lame lectronic Signature) /f 24 2.-
Date
• SECTION 7b: OWNERI 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 t ' app • ati •s true and accurate to the best of my knowledge and understanding.
Print Ovmer Name
s or Au orized Agent's (ElectronicSignature) /O
3 �o�
ate
NOTES:
1• An Owner who obtains a building
(not re g Permit to do his/her own work,or an owner who hires an unregistered contractor
,istered in the Home Improvement Contractor
(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142
www.mass.e.ov/oca Information on the Construction Supervisor License ant ncan be found ation on the at www.mass.eov/d s
IC Program can be found at
2. When substantial work is planned,provide the information below: o Total floor area(sq.ft.)
Gross living (sq,ft.} (including garage,finished basement/attics,decks or porch)
Number of fuepfaces Habitable room count
Number of bedrooms
Number of bathrooms
Type of heating system----___________ Number of decks/
Type of cooling systemNumber 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
1 Congress Street, Suite I00
=f� Boston,MA 02114-2017
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
0 der/Contractorsctricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY'.A [leant Information
Name (Business/Organization/Individual): Please Print Leoihl
S
Address: P 0. 6 ox '{ (
City/State/Zip: ou Pr- y(4 p,7S- Phone#: 77q—
Are you an employer?Check the appropriate box: 3S"3 S Sa
l am a employer with Type of project(required):
t.❑
employees(full and/or part-time).* t—[
2X 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. 0Remodeling •
3.0 1 a a homeowner doing all work myself.[No workers'comp.insurance required.]t
9. ❑Demolition
m
4.01 am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10 ❑
ensure that all contractors either have workers'compensation insurance or are sole Building addition
proprietors with no employees. 1 I•❑Electrical repairs or additions
12.❑Plumbing repairs or additions
5•❑1 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.[
13.❑Roof repairs
6•❑We are a corporation and its officers have exercised their right of exemption per NIGL c. ❑
152,§1(4),and we have no employees.[No workers'comp.insurance required.] 14' Other
*Any applicant that checks box Al 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.
tContractors 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. !f 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 t4 or Self-ins.Lic.k:
Expiration Date;
Job Site Address:
Attach a copy of the workers' compensation policy declaration page(showingtthe policy number and ex iration da
Failure to secure coverage as required under MGL c. 152 p te).
and/or one-year imprisonment,as well as civil penalties in the form of STOP We ORK ORDER nal violation punishab1 and a fine of upby a fine upo o$250.00
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insura0.00
ce a
coverage verification.
nee
I do hereby certify u r th air and penalties o,f perjury that then formation provided above is true and correc Sienature: t
Phone#: 77 Date: �—
Official use only. Do not write in this area,to be completed by city or town official
City or Town:
Issuing Authori Permit/License r
ty(circle one):
I.Boar of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Ins
6. Other
pecto r
Contact Person:
Phone :
§TOWN OF YARMOUTH
1146 Route 28, South Yarmouth, MA 02664
508-398-22311 ext. 1261 Fax 508-398-0836
Office of the Building Commissioner
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
Pursuant to M.G.L. Ch. 40, §54 and 780 CMR - Section 105.3.1. #4.
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at 9 h p (A„
W rk Address
Is to be disposed oat . e following location: ?i n,(k
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. 111, §150A.
OjicSignature o Application to
Permit No.
IFDivision of Occupational Licensure
Board of Building R lations and Standards
Cons i nu$ visor
r� f
CS-081040 S r= s Aires:04/04/2024
PATRICK H JACOBS,, s
28 WHITTIER,DRIVE i a 4
DENNIS MA b 638 i .
4Vril.L fV 3-1
Commissioner do.ia K. DCvnn>!ra,
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
TYPE:Individual
Regfi t5 Ex r i n
1PATRICK JACOBS 05114l2024
D/B/A P.JACOBS CUSTOM CARPENTRY AND REMODELING
PATRICK JACOBS r
. Vi
28 WHITTER DR.
DENNIS,MA 02638 r a
Undersecretary
•
TOWN OF YARMOUTH
Nofz 1146 ROUTE 28,SOUTH YARMOUTH, MA 02664-4451
OCT 1 4 20z, Telephone(508)398-2231 Ext. 1292-Fax(508)398-0836
"YAkiviQUi h OLD KING'S HIGHWAY HISTORIC DISTRICT COMMITTEE
0 D KINGS
APPLICATION FOR
CERTIFICATE OF EXEMPTION
Application is hereby made for the issuance of a Certificate of Exemption under Sections 6 and 7 of Chapter 470 of
Acts of 1973, as amended, for the proposed work as described below and on plans,drawings,or photographs
accompanying this application.
Type or print legibly:
Address of proposed work % /27 0 0) L . Map/Lot# 1145
Owner(s): •Si=k Phone/I. 5206-737-0,9410
All applications must be submitted by owner or accompanied by letter from owner approving submittal of application.
Mailing address. 9 Roc,)/A Year built; 80 S
Email Preferred notification method. k- Phone Email
Agent/Contractor, 11447141 cJa cJ Phone# 7?5/.-3 S13 /„_13s--,D_
Malting Address p 0. 1 _YetrriA 0.j-A
Email a ca,s 7e) ti no Preferred notification method: '<,Phone D<Email
Desoription of Proposed Work(Additional pages may be attached if necessary):
— "14.4 tia--ft.__ Ler/ 69- 60,ifiliVek#1,5- 51‘<kot,..) S \401 VLS r-‘%4(AN,t- d-IL
ovs-e.,„•
Aft_
Signed(Owner or agent). Date. /0/247 077
X, Owner/contractor/agent rs aware that a ermit may be required from the Stealing Department.(Check other departments,also,)
X• This certificate is good for one year from approval date or upon date of expiration of Building Permit,whichever date shall be later
for Committee use only:
Date._ 10i/t432 ,AL Approved Approved with chang.:a
Amount W Reason for denial. r
`11 •
A P
Cash/CIS#: ,S12 OC r 1 4 ?O
Rd by
H
1NG HiHWA
Date Signed:Aqii10 Signed: 5efe AZt'Ve OM )
APPLICATION
.02017
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REVIEWED FOR BUILDING AND ZONING CODE COMPLI-
,�_ ANCE. ERRORS OR OMMISSIONS DO NOT RELIEVE THE
2-'�'L I Pi, r APPLICANT FROM THE RESPONSIBILITY OF"AS BUILT'
COMPLIANCE.
DATE: 1U-17- ) .
B f OFFICIAL
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