HomeMy WebLinkAboutbld-23-005080 -\
�— The Commonwealth of Massachusetts
►=4Department of Industrial Accidents
1gelm a 1 Congress Street, Suite 100
,` _ Boston, MA 02114-2017
NIP •'� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
• TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information
lck ca. Please Print Legibly
j`
Name (Business/Organization/Individual): 1(�11
((le-
`/ Address: 7 ye Lan
t.
City/State/Zip: es-4MP tag f Phone #:(5-OS)237- 13o
Are you an employer?Check the appropriate box:
Type of project(required):
I.❑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 7. ReW Jelin construction
any capacity.[No workers'comp. insurance required.] 8. Remodeling
3.❑I m a homeowner doing all work myself. [No workers'comp. insurance required.]t
9. El Demolition
4. 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.❑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.* 13.0 Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. I 4•❑Other
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 cer ify and r the pains and penalties of perjury that the information provided above is true and correct.
Js inature: ...„,i9a.litz____ Date: 3/J /02 3
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):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
Rat TOWN OF YARMOUTH
of -° BUILDING DEPARTMENT
Ate ~wa^°~t,:E=''"°9 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DA'1'h:
JOB LOCATION: 34.( 7 la() Ii Va(416041
NAM STREE AD
wet SECTION OF TOWN
"HOMEOWNER""HOROWNER" Ml t�¢.l ��J J3 7i? 3 D
NAMEHOME PHONE WWI(PlIONE
PRESENT MAILING ADDRESS 7 y (,Q1n.Q LU05t 6 (} f` 6 7 3
CITY OR TOWN STA 1'h 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 t 1./
APPROVAL OF BUILDING OFFICIAL
li 1SURANCE 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:homeownrticexemp
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 7 e(.J l-4AL it) es-I-VQ� �,/io 14/L✓
Work Address d 1 3
Is to be disposed of at the following location: 7 �elti �tKes
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
*ifeeilWiee— J
,/i3
Signature of Applicant Date
Permit No.
u�t Y^k TOWN OF YARMOUTH
cr
HEALTH DEPARTMENT
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To he completed by Applicant:
Building Site Location: ` \AL) I[V)L WeSt I4t irfri-0 '� �'� . 0.2C 7 3
Proposed Improvement: Di Y}‘ c-06`(\ o ?Nce.„-e U I!11 c'J dec
Applicant: tido t f O Tel. No.: (cOc) 73/—t o 30
Address: 7 Yu) f: eS ri •0)6 7 3 Date Filed:
**ifyou would like e-mail noJifrcalion of sign off,please provide e-mail address: /p.
30 ‘,1 L{f1/1lx t I ( I(1/j
Owner Name: 11)114“, _ 'Dit.( t
Owner Address: 7 Y lit V1 Q W �� YG I/t1'10 41"\ 1,4 6)-6 2 131wner Tel. No.• 0) 2 5 - (0 3 6
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:
--X-(1.) Site Plan showing existing buildings, water line location,
,) and septic system location;
G31�<<.�L t~.�M�J
(2.) • Floor plan labeling ALL rooms within building
MAR 1 5 2023 (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:,-�/ rft. DATE: 3 - 3
PLEASE NOTE
COMMENTS/CONDITIONS:
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MAR 15 2023
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HEALTH DEPT
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•01.•Yi'vt TC)11\ OF AR kin. Ti
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c 'o WATER DEPARTMENT
071_x 99 Buck Island Road
. --z 1V -r larmouth, MA 026"i
tf.,0me! 608 '-1-7921 • fax: i5{18' '_I-..')Jfi
BUILDING PERMIT APPLICATION FOR
WATER DEPARTMENT SIGN OFF
TRANSMITTAL FORM
BUILDING SITE LOCATION: 7 Yew LA kg.,
_
PROPOSED WORK: _l1ttsi +tjp g4mbK decK •
APPLICANT: l V_____Zicio..12...
ADDRESS: 7 k(4,,/l) Lai (i_ 5 �yvk J d0+11_ J . 02473
-1 El PHONE: (' o ) 7. _7-1 b3 a
Rl•SIDl:N1 IAL AND 'OR COMMERCIAL BUILDING
Water I)cpanment• Determine,Compliance of\\ater '1%aiIahiht) and or existing location
Engineering Department: Determines Compliance for Parking and Drainage
Consenatton Commission: Determine.,Compliance to Wetlands Act: i e If lots)border any type of
%%etlands. ,trcains. ponds. riNers.ocean. boas. boys. marshland, ETC..,
!leak!) Department Determines Compliance to Stale and I o%s n Regulations. i.e.
requirements Ibr Septage Disposal and other Public Health Activues
Fire Department: Determines Compliance to State and Town Requirements for Personal
Safety. Property Protections, i.e. Smoke Detectors, Sprinkler Systems,etc
et-to),
AP L CANT SIGNATURE 1OA
t)
OFFICE USE: COMMENTS N PERMIT APPROVAL.OR DENIAL
fr
ilk'
R}:�'tF:��'F: BY WATER DIVISION 5,r/21023
(SIGNATURE) DATE:
3/21/23,3:47 PM Mail-Sears,Tim-Outlook
7 Yew Ln
Sears, Tim <tsears@yarmouth.ma.us>
Tue 3/21/2023 3:46 PM
To: mikedalpe3036@gmail.com <mikedalpe3036@gmail.com>
Michael,
I have reviewed your application and there are some items needed.
Nt(Health Department sign off(under review)
�2. Updated plot plan stamped by a Land Surveyor showing location of existing deck.
Please submit these items for review
This email is considered a written denial of your permit application per Section 105.3.1 of the
Massachusetts State Building Code. Section 105.3.2 states in part that "an application fora permit for
any proposed work shall be deemed to have been abandoned 180 days after the date of filing, unless
such application has been pursued in good fairh"
You may appeal this denial to the Building Code Appeals Board in accordance with M.G.L. c. 143 §100,
within 45 days of this notice.
Timothy Sears CBO
Deputy Building Commissioner
Town of Yarmouth
508-398-2231 Ext. 1259
mailto:tsearssyarmouth.ma.us
https://outlook.office.com/mail/sentitems/id/AAQkADE3MDQ5NWZmLTkOYzItNDIwNi1 iMDQxLWNkMGQyNmE4NzE5NAAQAOx2000DTo1 LmYgWbv... 1/1
Fallon, Rosa
From: •
Fallon, Dolores
Sent: Tuesday, March 14, 2023 2:58 PM
To: Fallon, Rosa
Subject: 7 Yew Lane, West Yarmouth - Meeting Notes
Hi, Rosa.
Here are my notes from the meeting with the 7 Yew Lane property owner and Mark.
Met with Mark; does NOT need to go to ZBA.
R-40.
Bought the house in 2014.
Deck was built in 1994 without a permit.
Wants to raze/replace deck with a dining room.
The structure to support this room uses"Big Feet" (24 inches wide)which might conflict with septic system.
Mike Dalpe
508-737-1030
Mikedalpe3036@gmail.com
Dolores Fallon
Office Administrator-Zoning Board of Appeals
Town of Yarmouth
508-398-2231 x1285
dfallon@yarmouth.ma.us
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