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HomeMy WebLinkAboutBLD-23-001653 ONE & TWO FAMILY ONLY. BUILDING PERMIT Town of Yarmouth Building Department ap.....r 1146 Route 28, South Yarmouth,MA 02664-4492 i. �' "-i it 508-398-2231 ext. 1261 Fax 508-398-0836 • ....,jt Massachusetts State Building Code,780 CMR Building Permit Application To Construct, Repair, Renovate Or Demolish _ a One-or Two-Family Dwelling This Section For Official Use Onlyf ...! e-ElVED Building Permit Number: H( 3 61.053 Date Applied: _ /' el SEP 4 6 2022 Building Official(Print Name) Sig{lature B LMIR N G 1 L PA R TM E N SECTION 1:SITE INFORMATION Hy -_.__ T 1.1 Property Address: .4 1.2 Assessors Map&Parcel Numbers 11)1912 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 Supply: (M.G.L c.40,i 54) 1.7 Flood-Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0Zane: _ Outside Flood Zone? Municipal 0l On site disposal system E l Check if yesE1 SECTION 2: PROPERTY OWNERSHIP' Ac2.1 Owner'of Record: r Name Print) City,State,ZIP V 2-0 �,JoC., t•, . i D.C— 1T) 0 _ ‘-‘Lvb rG c,,, A o - vt Li ✓ ..f- No.and Street Telephone Email Adcess SECTION 3:DESCRIPTION` � OF PROPOSED WORK"(check all that apply) New Construction E Existing Buildingll:] Owner-Occupied U 1 Repairs(s) 0 Alteration(s) Addition El _ Demolition El Accessory Bldg. El Number of Units i Other E1 Specify: lt 4}K viN Brief Desch ti oa of Proposed W rk2:,!1I785,_ rile------ 1 f/l l!1 ��4- r\IAi e C c'7/i, /E O''A5` . R E--i SECTION 4:ESTIMATED CONSTRUCTION COSTS. Estimated Costs: OCT 04 2022 Item Official Use Only (Labor and Materials) , I.Building $ // Od I. Building Permit Fee:$ I t t', Indicate how fee is tietelg wined:E PA R T M E N T Ufa ✓ M Standard City/Towu Application Fee ,—" _ 2.Electrical $ El Total Project Cost(Item 6 x multiplier x 3.Plumbing $ q ,i fi 2. Other Fees: $ 3 LW 4.Mechanical (HVAC) $ ! ddd List: C o/"7 "__ 5.Mechanical (Fire / Suppression) Total All Ries:$ Check No. Check Amount: Cash ount:,.. 6.Total Project Cost: $ 2��Qv IDPaid in Full i Outstanding Balance tie: I j> L) rn I o13W-- i ._. • • • SSOS OO T30 • • • , SECTIONS: CONSTRUCTION SERVICES 5.1 Constructio Su ervisor,License(CSL) (1---' J 'd�i�0 ' —C ��U7�� /fz/2 3 License Number Expiration pate Name of CSL Holder � List CSL Type(see below) i No. Streetil) Type Description �� e inV , I,o- 0� / ( u� Ucirestncted(Buildings up to 33,000 cu.ft)_ R Restricted 1&2 Family Dwelling CitylTown,State,ZTP Iv1 Masonry RC Roofing Covering • WS Window and Siding _ - ) 7�j 7— Gj 7 ,-0 y� SF Solid Fuel Burning Appliances ,.,, , (/i `(�` icivrizi c4/0 4/��� I Insulation _Telephone Email address Demolition (65,2 Registered Home provement ontractor CHIC) f' • ... f'ir/37\1 r�rin 1 3 C Co pan•Name or HIC Registrant Name HIC Registration Number Expiration Date , Q 197,190/C"` 10 ©6 J / .50,—f l 7-907 Email address City/Town,State,ZIP Telephone SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M,G,L, c,152.§ 25C(6)) ai Workers Compensation Insurance affidavit must be ompleted and submitted with this application. Failure to provide this affidavit will result in the denial of the Issue e of the building permit. Signed Affidavit Attached? Yes No . SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLES FOR B ING PERMIT I,as Owner of the subject property,hereby authorize 4 - 1f` '' vJ �'�'�� to act on my behalf,in all matters relative to work autho bylhis building permit application. ri t 1-f' 0-1 /1\ Print Owner's Name(Electronic Signature) D to SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION i _. By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contar+ + s a scat' is true and accurate to the best of my knowledge and understanding. 1 772-1Z.7' ( `tint Owner's o, uthorized Agent's Name(Electronic Signature) Date 1 1 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(WC)Program),will riot 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/oc4 Information on the Construction Supervisor License can be found at www,mass,gov/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 Common wealth of Massachusetts = , / Department of Industrial.Accldents 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 Infor ation e s tint L Q'bl Name (Business/Organization/Individual): — Address:- id 6o, a �- City/State/Zip: rlemdfA I ' b Phone#:_ 90— d' 7 Are you an employer?Check the appropriate box: - - Type of project(required): m 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 ma in any capacity,[No workers'comp. insurance required.] $' emodeling 3.0 I am a homeowner doing all work myself(No workers'comp.insurance required.)r 9. Demol itjon 41: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 11.0 Electrical repairs or additions proprietors with no employees. 5.0 I 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 13. Roof repairs d 6.0 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. 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$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$?50,00 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 certify under the ins and per hies of per' that the information provided above is true and correct, Si mature: /z �� Z C Date: _ Phone#: ) .-'7 - 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): I.Board of Health 2.Building Department 3.Cityffown Clerk 4, Electrical Inspector 5. Plumbing Inspector 6.Other 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 % 1 Work Address Is to be disposed of oat the following location: ti 74 v Ma k4 '/ 1 /0 Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. 771' 3 /2 Sign re A ication Date Permit No. Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constw:tt lipry i sar Expires:01;0212023 C S-060795 EVAN K POUNDER THE COMMONWEALTH OF MASSACHUSETTS Po BOX 642 I. FALMOUTH MA 02641 1E1 , . Office of Consumer Affairs and Business Regulation h�rr, /Sti l 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 � r• g Home Improvement Contractor Registration Commissioner r Type: Individual Registration 170163 EVAN POUNDER ` ' i `,� , � Expiration: 12/05/2023 PO BOX 642 FALMOUTH, MA 02541 x.,�1a Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE:lndividual Office of Consumer Affairs and Business Regulation Regil;iratlon ExDlftlltlon 1000 Washington Street -Suite 710 170163 12/05/2023 Boston,MA 02118 EVAN POUNDER S ' y "VAN POUNDER t43 ACAPESKET RD r i; ' =AST FALMOUTH. MA 02536 "� 4Qa, l i '-' '`' 9.-/ IV/ ,/l to M ___.____ _______ _____ __(." -{',(' ,� _ I �'0 / s1/A pit 0 If Z J N 7 _ CST • 4--ye/Y (2:1