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HomeMy WebLinkAboutBLD-23-001829 ONE & TWO FAMILY ONLY-BUILDING PERMIT .....Y Town of Yarmouth Building 4492 ��� '�� 1146 Route 28, South Yarmouth, �� 508-398-2231 ext. 1261 Fax 508-398-0836 I Massachusetts State Building R pair 7RenovMR Or Demolish Building Permit Application To Construct, a One-or Two-Family Dwelling This Section For Official Use Only Date Applied: E Building Permit Number: / ' o CT 0 3 zo.2 _Date r 1 � [s -' _ Signature BUILDI -_ . "A' MENT Building Official(Print Name) INFORMATION SECTION 1:SITE INF &parcel Numbers 1.2 Assessors Map I 1.1 property Address: parcel Number •` L Map Number I Cann eno 1.1a Is this an aacccee ptedd s street?yes r/' 1.4 Property Dimensions: 1.3 Zoning Information: Frontage-- Lot Area(sq ft) District Proposed Use ZoningQ Rear Yard 1.5 Building Setbacks(ft) Side Yards provided Front Yard Provided RequiredRequired Provided Required Outside 1.8 Sewage Disposal System: (M.G.L c.40,§54) 1.7 Flood Zone uInformation: Flood Zone? Public Pr _ 1.6 Water Supply:rivate 0 Zone: Municipal 0 On site disposal system -Q— Check if yes SECTION Z: PROPERTY OWNERSHIP' es( MIA /J �Y 2.1 Owner'of Record:VILQ.L S. ZIP Nameet a VII. %:t City, r ��� (Print) v..� � Email Address o. �i 4�J es Telephone No.and Streetcheck all that apply) - ccu ied Repairs(s) 0 Alteration(s) $ Addition 0 SECTION 3:DESCRIPTION OF PROPOSEDO � WORK- New Construction 0 Existing Building� Owner p Other ❑ Specify: Bldg.0 Number of Units_ � --,. -I: b,:,. 0 Accessory .fid �• ►+- � a Demolitionvtt- gyp' t...7 ' �' Proposed -is Brief Description of�rop W F:. ii. � e s'GG Or V.." a SECTION 4:ESTIMATED CONSTRUCTION COSTSCIIMNIIIII Estimated Costs: Official Use Only (Labor and Materials) Q Pert Fee:$ Indicate how fee is determined: 1. Building ®Standard City/Town Application Fee 1.Building x 0 Total Project Costa (Item x multiplier _ 2. Other Fees: $ � .� C ;.Plumbing ListINSISIMIMMIM : ,n ' al (Fire Total All Fees:$_ Cash Amount: � ' 5.Mechanic MilliCheck Amount: 6.Totalsion) Check No. ,_ hlr,r7 , 0 Paid in Full Outstanding Balance Due ___3/ (�/ Project Cost: I I 6. TOWN OF YARMOUTH t'+ BUILDING DEPARTMENT �� . �''sC 4; 0 1 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261 HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DA IE: JOB LOCATION: NAME STREET ADDRESS SECTION OF TOWN "HOMFOWNER" NAME HOME PHONE WORK PHONE PRESENT MAILING ADDRESS CITY OR TOWN STA'1'P; 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 lie/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 acceptable to the building official,that he/she shall be responsible for all such work performed under the buildingpermit. (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 Ii 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: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 9 ,comer C-c-p-tc , Work Address Is to be disposed of at the following location: S-f--3 �zX 5- () nLS Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. fic-eJ /4/3/71 za Signature of Applicant Date Permit No. r ' d • Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual,partnership, association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states`Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and,if necessary, supply sub-contractor(s)name(s), address(es) and phone number(s)along with their certificate(s) of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retuned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents, Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license, number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write "all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia Commonwealth of Massachusetts i at Division of Professional Licensure ‘*9- Board of Building Re ulations and Standards Cons n'SiSpprvisor .- .".• ires:11/10/2022 CS-040398 ,,i, !I #ra PAUL C LEAVii :.1 -;,.1, - ,.k; PO BOX 130b',� kt r.-� ORLEANS M 02653 UIS.i•40t . f*,. Commissioner diaeca K. gEkn THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:lnliv dual , Realst X11411 1% 10/OFYq • 181479 r PAUL LEACH c'r -.t 6/2024` • 1r1 PAUL C. res: ,, •-•., 1 ` • GG 24 CAPTAIN DOANES WAY - - r Undersecretary • ORLEANS,MA 02653 • • • 1 •• r fry , , ONE or TWO FAMILY— BULDING PERMIT APPLICATION REGULATORY APPROVALS NOTICE Address of Proposed Work: g CAP7AlM *ors ,e„c,415 S_ Mr-mourn Scope of Proposed Work: L3 qi© UorM cs- Tut CA, 'Y'cx., /Y'C.') T ,Espi4N0 F..x/57// 4. r3,4T44 To .i.& LW,/l/Gt/e,.6C)0677r4i< l/fat<Ws4y V 4.?c6gall.4 boor CAFE--i& (LD.SQr SPg Date: /Oil 41.6.X0,.. Based on the scope of work described above, the applicant is required to obtain approval sign- offs from the following departments as checked-of below: /✓!i Health Dept. —508-398-2231 ext. 1241 NA Conservation —508-398-2231 ext. 1288 p+1,4 Water Dept. —99 Buck Island Road, 508-771-7921 'A Old Kings HWY. Hist. Comm. —508-398-22631 ext. 1292 PI Engineering Dept. —508-398-2231 ext. 1250 01 Fire Dept.—Kevin Huck/Matt Bearse, 96 Old Main Street, SY . Note: Please call Fire Department for an appointment. 508-398-2212 Other Appropriate plans and/or application shall be provided to each departments checked-off above. Each of these regulatory authorities has their own requirements outside the jurisdiction of the Building Department. All applicable approvals shall be obtained prior to submitting a building permit application to the Building Dept. Thank you for your cooperation. Receipt Ack nowt dgement: i-,./../A..1 4/70-Pda Applicant's ignature Date Rev. March 2022