HomeMy WebLinkAboutBLD-23-001478 ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department
1146 Route 28, South Yarmouth,MA 02664-4492 (r. (NI
508-398-2231 ext. 1261 Fax 508-398-0836
Massachusetts State Building Code, 780 CMR o.. e
Building Permit Application To Construct, Repair, Renovate Or Demolish
a One-or Two-Family Dwelling
This Section For Official Use Only R E C E I V E D
3�23- 4'.
Building Permit Number: (�� Date Applied:.:
�)( \ S��cS .�' �: 9--A 7- SEA 1 b 2022 j
Building Official(Print Name) ture
suit DINE-fJEPARTMENT
SECTION 1:SITE INFORMATION er: --
1.1 Property wd esssT KD INJ`� 1.2 Assessors Map&Parcel Numbers
Sci 1.1 a Is this an accepted street?yes no Map Number Parcel Number
r
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use c 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?
Check if yes❑ Municipal 0 On site disposal system El
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Re ord:
ifLu ot te9 (NALs ff ?1Q- 4 ttu TKE c A-M- C)Z 18''-/
Name(Print) City,State,ZIP
-7s R►+a (4 0 -236a35,7 7c- i
'` ..vivitt'No.and Street
Telephone Emai • 7.r=. r .. 'ti i
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that a•.ly' 7n
New Construction 0 Existing Building ll� Owner-Occupied 4Repairs(s) 0 Alteratio i(s) ,J�$Ed2cS 4�2
1 1
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: ------ - -
a�':[ ENT
Brief Description of Proposed Work2: R�""- V —
SEC
TION 4. ESTIMATED CONSTRUCTION COSTS 3\)c
Item Estimated Costs: Official Use Only
(Labor and Materials) •
1. Building $ 3 Ct) , 1. Building Permit Fee:$1 CO Indicate how fee is determined:
2.Electrical $ 0 Standard City/Town Application Fee
01)
0 Total Project Costa(Item 6)x multiplier x
3.Plumbing � $ 2. Other Fees: $ 3 5:W
4.Mechanical (HVAC) , $ List: ev -ate(
5.Mechanical (Fire - l
Suppression) $ Total All Fees:$ -
Check No. Check Amount: Cash unt: f-
6.Total Project Cost: $ 35 a , CR) 0 Paid in Full I(Outstanding Balance D e: 1
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.) _
City/Town,State,ZIP R Restricted l&2 Family Dwelling
Itil Masonry
• RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name HIC Registration Number Expiration Date
No.and Street
Email address
City/Town, State,ZIP Telephone
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 ❑
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 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 I p.e d ac• ate th est of my knowledge and understanding.
20 w4j4S / /6 2Z
Print Owner's or Authorized Agent's Name(Electronic Signature)) ate
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.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"
Q
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 508-398-0836M.l°�'�
Massachusetts State Building Code, 780 CMR
o.o a
Building Permit Application To Construct, Repair, Renovate Or Demolish
a One-or Two-Family Dwelling
This Section For Official Use Only R E C E I V E D 1
Building Permit Number: J Q(� n �'�`__._3 I 23-..(�Q�l� / Date Applied:.
SP 7 SEP 161U22 ,
re‘ ttcs -7 % -1 j
Building Official(Print Name) -$tgnature
SECTION 1:SITE INFORMATION SIP'_ SIN EPAR—MENT
1.1 Property W sn
it.
.541 Kt)
VJ`A 1.2 Assessors Map&Parcel Numbers
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 6 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?
—
Check if yes❑ Municipal 0 On site disposal system 0
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Regord:
156114 r4 R9 I N V Ls ii ?I tN 1i--& AM—— 02 1144
Name(Print) City,State,ZIP
-S R till (4 61 - 3oc:7 35,7 1
a44.,
No.and Street Telephone Emai r ( `' !
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that a ly; o
New Construction 0 Existing Buildings Owner Occupied Repairs(s) 0 Alteratiot(s) tS d Z22
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: --- —--I
Brief Description of Proposed Work2: R UlLdiw6 D` TVIENT
2 - 3 & kda•t-(
SECTION 4: ESTIMATED CONSTRUCTION COSTS a4P
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 3 W . ere) 1. Building Permit Fee:$'c J Indicate how fee is determined:
2.Electrical $ 0 Standard City/Town Application Fee
CV ❑Total Project Cost;(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ 3 5,60
4.Mechanical (HVAC) $ List: e 'al (
5.Mechanical (Fire —
Suppression) $ Total All Fees: $
Check No. Check Amount: Cash • ':.tint: 1-
6.
Total Project Cost: $ ?J5(S ,Ce) 0 Paid in Full Oil Outstanding Balance D e: /i
�_ The Commonwealth of Massachusetts
4I— Department of Industrial Accidents
1e1'= ,
_ _ 1 Congress Street, Suite 100
Boston, MA 02114-2017�jf
..,�• 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): &AA! ti-i.C. /f t/+LS ff
Address: c9 WEZ3-ruz.
City/State/Zip: w i4 ie-rN(d 1 ff MA a Phone : 6(7 337 /
Are you an employer?Check the appropriate box:
Type of project(required):
L❑I am a employer with employees(full and/or part-time).'
2.0 I am a sole proprietor or partnership and have no employees working for me in 8.7. ❑Rem delinruction
any capacity.[No workers'comp. insurance required.] ❑ eoeling
3Ri l am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9 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
proprietors with no employees. 11.❑ Electrical repairs or additions
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.: 13.❑Roof repairs
6.111 We are a corporation and its officers have exercised their right of exemption per NfGL c. 14.❑Other
152,§I(4),and we have no employees. [No workers'comp. insurance required.]
*Any applicant that checks box 41 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. 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 cert' tiler th p 'ns and penalties of perjury that the information provided above is true and correct.
Signature: V w441
Date: i// /2
Phone#: 6I-7 366 3S c
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#:
o� YAR�E TOWN OF YARMOUTH
BUILDING DEPARTMENT
49)
'a 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE: Cl/11(e 12-2--
JOB LOCATION: Vv E 5I Ei j) AI
NAZIE
EN OF OWN
"HOMEOWNER" C iZ /r4 �� STREET`s'1.1 4 i 1S3cr 35 '
NAME OME PHO E WORK PHONE
PRESENT MAILING ADDRESS 75- f F-D
AINTK- - (1 Z /g4f
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 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
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of t ass.
General Laws and that my signature on this permit application waives this requirement.
WV/(. Check one:
Signature of Owner or Owner's Agent •wne 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 5-CA VA/ e es7_x_ f2,p
Work Address
Is to be disposed of at the following location: FvO 1. €A116 AJ2 F i2Ei
D1Q ( o'ne 1w1L6--
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
'/(1A t/6/4 V/ , 2 2
Signature of Applicant Date
Permit No.
TOWN OF YARMOUTH
.;44HEALTH DEPARTMENT
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To he completed by Applicant:
A � 5.,TE D ail ,
Building Site Location: �J I /V L
Proposed Improvement: P O ititk6c `D _ N
Applicant: L S Tel. No.: 6' 17 6 3 59
Address: ,-- i( r P /ac t) lZ toTR O z l S L( Date Filed:
**If you would like e-mail notification of sign off,please provide e-mail address:
Owner Name: Atii
Owner Address: Owner Tel. No.:
RESIDENTIAL AND/OR COMMERCIAL BUILDING
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
Please submit three (3) copies of plans, to include:
(1.) Site Plan showing existing buildings, water line location,
and septic system location;
(2.) Floor plan labeling ALL rooms within building
(all existing and proposed) —
Note: Floor plans not required for decks, sheds, windows, roofing;
(3.) If necessary, Title 5 application signed by licensed installer
with fee.
REVIEWED BY: DATE: Cr / -- !
PLEASE NOTE
COMMENTS NDITIONS:
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