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HomeMy WebLinkAboutBLD-23-003741 pf'YgR TOWN OF \AR\ti)I'TH WATER DEPARTMENT 0.-.44 ` Nist lj 99) Buck Island Road \Vest Yarmouth. MA 0267 i t le ;�tu>nr: +ititil --1-792I • Fay: i >t)ti, 77I--998 BUILDING PERMIT APPLICATION FOR WATER DEPARTMENT SIGN OFF TRANSMITTAL FORM B[ILDING SITE LOCATION: 3 r 11 PROPOSED WORK: .4a- /7- 1 APPLICANT: 121.&. 24 J ADDRESS: 34f614/rili TELPI IONE: _e:V„gle,iiiqlskei41,if./ -274 RESIDENTIAL AND OR ( O\1\ll•:R('I:\f- BLILDING Water Department: I)':lcrluine ('ontpClattec(-'f\\-ater \'ailahihl and ul existing location I:I1gllteerung I)epartrncn1: I)eterlllltte. Compliance for Parkilit!and I)raIIIatc (•onser tIiun C•onu»i„ion: I)etcrntineN Compliance to Wetland; \ct: i e. II Iou;I border any type of- u etlam's. .Ireams. ponds. rig crs. ocean. hogs. hogs. marshland. ETC'... IIr; Iiii I)cp IL Itlent: I)cterntine.Compliance to State and Tow Regulation;- i.e. requirement; for Septave Disposal and other Public I lealth Actin ite, Fire Department: Determine;(-ompliance to State and 1-own Requirements for Personal Safety. Properly Protections. i.e. Smoke Detectors. Sprinkler Systems.etc S . .‘t111%.7- DATE OFFICE USE: COMI\IFN I-S ON PF:RMI"I AI'PROV:Al OR DENIAL I fit'►,Sr IN' ea (la f R_ Se-a-V t L.0 IS. t 7 UJ l y O P i1.- pr'orv -co Arc , ) A-6 pi/167/,) ow w r' Is fQ eSe .tic i g rue VC._ or-e_ e-O ;02 3 RFVIE\\ .D BY RATE DIVISION (SIGNATURE) DATE 0Ny4 it A TOWN OF YARMOUTH ;, tzt�.• °; HEALTH DEPARTMENT '�• ` PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET To be completed by Applicant: , > f� Building Site Location: ''. 'J(1�1l.--?, -.�1 ''`U(X --.C� ,.1 11) ' �I )6y1\lc\ I �'\� Proposed Improvement: , /../r�if •er-1 f rfr l ! `� --- j (-'I (ie,(1()0 rI > ')V/ 4 ,7 (7r r. Applicant: ' V i` \--/-, ,,,..---,t, 'r ,,2 Tel irtV `i) 1 ) )r. Tel. No.'�J J. Address: 1` ,' ' 1 % _I /'4-- ! f ` ,•11i 2,lJ ` Date Filed: ! ' ' >j **If you would like e-mail notification of sign off,please provide e-mail address: 1- '- �� ;'..`".I.'� �r 4't )c ) t 'L ' ( Owner Name: =?'t � ���(, t , v ,%, '' 1 ,-'-,--" Owner Address: ? Owner Tel. No.: i 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; JAN 0 6 2023 (2.) Floor plan labeling ALL rooms within building (all existing and proposed) — HEALTH DEPT. Note: Floor plans not required for decks, sheds, windows, roofing; (3.) If necessary, Title 5 application signed by licensed installer with fee. REVIEWED BY: /3_,.. ,,,,77 -- DATE: 1 /6/0 3 l PLEASE NOTE COMMENTS/CONDITI S: �? +ILL L,) ( ( ( !)e 3 f e,J,0 0`'4 ►4 t ( cis► ,,"`t r--(o,,`Z ��- ''� CONSERVATION p( + j OFFICE {�` bdirienzo@yarmouth.ma.us Yarmouth Conservation Commission Administrative Review Applicant Information: Name: C. 1 \<, pb n ( .1Aik 54)� IjS y/r 1 , -.) ?7 ' if7 . V J 47 Mailing Address: 2-, 8Ie,N k-vooc - -\ ' Phone: (GJ-r? r J2 ` 1 6 _Email: yv)(10f Gh 3 513 c ,1 Q)! , (cm I hereby authorize the individual members of the Yarmouth Conservation Co issidn af�d its agent s) e Le on thee p o al i;rty list below for the purpose of gathering information regarding this Administrative Review form. Property/Location of Work: 1 ✓ 8re k Street Name and amber c...4e5.744.7 g Si nature: •✓ F Detailed Descr n an e n for Proposed Work: # iv/ rniT'-' 'e. - 01(1 G 7*U 7 ( ?7. E t/r24 r.Vgg11-1/t L.-) Ale 'aeA-:- hot7-2-( ( Freo, 60\ror e2o4- [ .0 l or') Closest Distance to Resource Area: lit e Proposed Start Date: �! z Company to do Work: }-� Name: ne,n 1 -e 7(/ /gyp Address: 6v =y'l�C i T) Phone: 1/ 11 ���/��'`�' Email: bCl --t--y106Pi Oa . 6 ugher , c04, Administrative Approval: Qf0.skcJn Cc)N cO\ *C1 kA led an - Ie,.SoJr < NA Rid v•-cCi P l i 6 /23 This approval is valid for one year. This Approval does not grant any property rights or any exclusive privileges; it does not authorize any injury to private property or invasion of property. Yarmouth Conservation Commission• 1146 Route 28,South Yarmouth,MA 02664•(508)398-2231• Ext 1288 JOB .--0sQ..•A9 3/t4eXTSiarilL Quc�moo, SHEET NO. ( ___._ ._ Q¢ flt-N TAYLOR DESIGN, LLC CALCULATED BY Q� DATE {1 OF •�(• t7 . 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Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system Check if yes6( SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner"of Record: Mack ,c--«n N\1Ls- \/exc!h0,A1,) (Y\-f\ Ora-G- 13 Name(Print) City,State,ZIP 1 D3 G--t.,„_n,,.,cca s , (}-)S'I VA fOoCesil- ---i3gi ' „I ,ca:( \ No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 M Existing Building❑ Owner-Occupied Repairs(s) 0 Alteration(s) 0 , Addition t1 Demolition ❑ I Accessory Bldg.0 Number of Units 0 er 0 Specify: Brief Description of Proposed Work2: ! 'o &VA5-e, SECTION 4:ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 3 . 6--, 1. Building Permit Fee:$1k /5 Indicate how fee is determined: 2.Electrical $ .Standard City/Town Application Fee 5 ❑Total Projectosta( CI 6)x multiplier x v \ 3.Plumbing $ 2. Other Fees: $ (�(', lie (a0,00 \� 4_Mechanical (HVAC) $ List \ 5.Mechanical (Fire S V - 1 Suppression) Total All Fees:S S ` Check No. Check Amount Cash is.unt: 6.Total Project Cost: $ 3 S a-r r' p Paid in Full Outstanding Balance Due 3 g • \ \� ��° \ Y -��Li - L4 EC7 b3C3c C� -f- Sb c.. e Mc-'--Q- . c,171 SECTION 5: CONSTRUCTION SERVICES 5.1�Construction Supervisor Lice CSL)) CS tp s S8 • Z� Z g '� at)(•1 et I— KO Number E on�� •tto Date Name of CSL Hold m 7 b rtl ce. 5--k- List CST Type(see ow) (/ No, trees Type /- Description t/\, O 'Fr . U / Unrestricted(Buildings up to 3 u.ft.) R Restricted 1&2 Fami oiling City/Town,State, M Amy M41%. RC Roo vering WS widow and Siding 7gf_5 7`a72 N t SF Solid Fuelo Burning Appliances �l.�t'i CC)r�5 a,`7��0o I Insulation Telephone Email address •Cob. , D ' Demolition . 5? Registered Home Improvement Contractor(HIC) %?l 8 i., 213, zJ Registrant Name MC Regis ' n Number Expiration Date MC Company Name or MC No.and Street —V City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) Woike,a 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 AITTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize_ 4!I6 to act on my behalf in all matters relative to work b building permit application. Print wtier's Name `lectronic Sign ) 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 true and accurate to the best of my knowledge and understanding. 'MeV V' M/4 i J �r r�iVl Print Owner's or Authorized ��Agent' N (Electr is Signature) 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 MC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is p ed, ovide tt information below: Total floor area(sq.ft.) 4- (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) u 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" §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. 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 � ``-AZ Work Address Is to be disposed of oat the following location: " M x\ (Q-SS Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. Signature of Application Date Permit No. TOWN OF YARMOUTH BUILDING DEPARTMENT s .• 1146 Route 28,South Yarmouth,MA 02664 508-398-2231 ext. 1261 HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DATE: TT JOB LOCATION: M CI t.n c0` 5r11,,;c (/) C-1- \JC ,"MvLi''I_ \ NAME STREET ADDRESS SECTION OF TOWN "HOMEOWNER" (r-le- Do 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 assessor)/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 •X 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 yes,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:homeownriicexemp The Commonwealth of Massachusetts }4 ft Department of IndustrialAccidents 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 M � c 'b Name(Business/Organization/Individual): / '\ r, G Address: , GVt_r\ sz) \k1 y0-.:\-..o \ c - b'IL� City/State/Zip: \,J at Mo v tt('A i1 r.L13Phone#: k ) 51 a Coekg Are you an employer?Check the appropriate box: t Type of project(required): l.❑i am a employer with employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no io � Y�working for`�`n 8. Remodeling • any capacity.[No workers'comp.insurance required.] ❑ $ 3.01 am a homeowner doing all work myself.(No workers'comp.insurance required.]t 9. Demolition 4.( I am a homeowner and will be hiring contractors to conduct all work onI will 1 Q Building addition �"'jmy PmI�Y- ensure that all contractors either have workers'compensation insurance or are sole I in]Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.0 I 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 I •❑Roof repairs t 6_0 We are a corporation and its officers have exercised their right of exemption per MGL c, 14.0 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. Homeowners who submit this affidavit indicating they are doing all wale and then hire outside contractors must submit a new affidavit indicating such IComractors 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.Lie.#: 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,g25A 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 S250.00 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 cy under the pa ns and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: 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.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: