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HomeMy WebLinkAboutBLD-23-002809 Qui 1 ) g12) .... , . ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department 14. h.8. ;:-"4.. "y-_ 1146 Route 28, South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508-398-0836 ,, 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 Only 4M Building Permit Number: 8 0 _,2 3 -660 Date Applied: ,..) R E C E _ V E („- r,s <-, __ h\A- . NOV 18 2022 9 Building Official(Print Name) Signature Date 3 SECTION 1:SITE INFORMATION {{{ BUILDING DE PAZTME.N'1 1.1{Pro er �A es : 1.2 Assessorsap&Parcel Num�ersr---- 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Proper Dimensions: sire rhM l 3 I2. .�,� Zoning District Propose Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided . 0 6 q-- I g 117 _ C 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Private 0 Zone: Outside Flood Zone? Municipal 0 On site disposal system X Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' R2J Owner'of Record:‘ - C I 17 / pg C9 ... 2? h i ( rent) City,State,ZIP 568.-....x:y4 ._gtor j� lori -glie/0a c-i-P- /4 .-t/z/V1// h o.and Street Telephone ,i(A#Id'rt '4' SECTION 3:DESCRIPTION OF PROPOSED WORK'-(check all that apply) New Construction 0 Existing Building Owner-Occupied 0 Repairs(s)( Alteration(s) 0 Addition. Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work:A77 p 6x /k �a� (;C ;/-k L/7,6, SECTION 4: ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $�j/ e CO 1. Building Permit Fee:$ 6�, Indicate how fee is determined: U V t k7 Standard City/Town Application Fee 2.Electrical $ c .6( 0 Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ (,pQ.O0 4.Mechanical (HVAC) Si 2,,/ 0 U0 List: L/ 3 6.5 5.Mechanical (Fire (*)i Suppression) $ Total All Fees:$ (�\ Yir Check No. Check Amount: Cash is: .t: V 6.Total Project Cost: i 'Oa' ❑Paid in Full I�Outstanding Balance • rue: 0/0 A i SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor Licensee_ (CSL) 1 /,t W ii^/ -z� ��J`�/e�` Lice Expiration Date K,. � Name o CSL older v �La to n n U� List CSL Type(see below) V No„...and Street (/ � Type Description 4� n 4 0jrC/) �`'�}i 0' 'j U Unrestricted(Buildings up to 35,000 Cu.ft.) /v�/ /// �a% V `7 ✓ R Restricted I&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I 1 Insulation Telephone Email address. D Demolition 5.2 Re iredome Im eme~,actor(HIC) ) �� ��/z mil" HI Registration Number Expiration Date Ndmp ee 1ia9/ :iriNp ` ifru t/e 079 �/�1 �77�,ftg. Email address City/Town°, State,LIP - 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 X No 0 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 true and accurate to the best of my knowledge and understanding. lacK �cL"1taSZV•t4 /1/5 v2 Print Owner's or Authorized Agent's Name(Electronic 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 HIC Program can be found at wtivw.mass.gov/oca 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" I z� re, The Commonwealth of Massachusetts i Department oflndustrialAccidetzts 1 Gongresc Street, Suite 100 f La rs.' �' 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 Name (Business/Organization/Individual): ' A4011 /L� �tv Address: /-W i �k v, i& /9 City/State/Zip 6Y2fW Phone #: o--1z-Z- 171 f ...----- Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. ❑New construction 2. (am a sole proprietor or partnership and have no employees working for me in anycapacity. 8. D Remodeling (No workers'comp. insurance required.] 3.E I am a homeowner doing all work myself. (No workers'comp. insurance required.]t 9 C Demolition /27h 4.]I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition /2e ensure that all contractors either have workers'compensation insurance or are sole 11.XElectrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑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.t 13.❑Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. I4. Other 4/V/117 152,§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. 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 certify ztn ain pen lties of perjury that the information provided above is true and correct. Signature: C� Date: Phone#: 6 G�E z� -LTc/ 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#: 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 ( &27.- P Work Address Is to be disposed of at the following location: Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. Signature of Applicant Date Permit No. i. a lrAR TO\1,N OF\'ARZtOUTi I k ,0 WATER DEPARTMENT 05`'`i .;�4 �1�7 Buck Island Read �c �.+-r+rmc 1\==stN.atrmuuth \1AO21-1 i-lc, 'tom, 1,8 `1•-9 2 I • Fa‘: 608 —1--998 BUILDING PERMIT APPLICATION FOR WATER DEPARTMENT SIGN OFF TRANSMITTAL FORM BUILDING SITE LOCATION: j,",-- . --PROPOSED WORK: fr('Tt,C✓ ! '� : _.... ... z APPLICANT: _ A � t ADI}RESS: rd _.. RESIDE:' TTI AL AND OR COMMERCIAL BUILDING Water Department: Determine Compliance of Water;1v ailahiiit) and or existing location 1-sgineerin_,Department: Determine,('umpliance for Parking and Drainage ('onsenanon Connmsattm: Ikterminc,Compliance to Wetlands \ct: i e. If(oils)border any t.pe of "eil;n ds.streams.ponds.riser:.ocean, hogs.hoys.marshland. ETC... I kith It Department: I)ciermines Compliance to State and I 011 n Regulations.i.e. requirement,Iiir Septage Disposal and other Public Health Acti‘ites I'ire Department: I ktermines Compliance to State and I`on n Requirements for Personal Sa Property Protections,i.c..Smoke Detcctory,Sprinkler Systems,eic 1/ - , 2- -- .4P1. ',1\T SIGNATURE I).1 FE OFFICE: USE:COMM.„NT;S ON PE RMI"I APPROVAL OR IWNIAI. Ed1'6— RE IF1f C DI1ISION(SIGNATURE)A DATE 12/7/22,3:17 PM Mail-Sears,Tim-Outlook 15 West Rd Sears, Tim <tsears@yarmouth.ma.us> Wed 12/7/2022 3:17 PM To:ralphcrossen@comcast.net <ralphcrossen@comcast.net> Cc:Water Department <WaterDept@yarmouth.ma.us> Ralph, I have reviewed your application and you are going to need Health &Water Department sign offs. Thank you Timothy Sears CB0 Deputy Building Commissioner Town of Yarmouth 508-398-2231 Ext. 1259 mailto:tsearsjyarmouth.ma.us https://outlook.office.com/mail/sentitems/id/AAQkADE3MDQ5NWZmLTkOYzItNDIwNi1 iMDQxLWNkMGQyNmE4NzE5NAAQAA7gu%2Bjtsy1 FgFdyXvF... 1/1 Commonwealth of Massachusetts St Division of Occupational Licensure Board of Building Re ulations and Standards Constoite0 revisor 4' J - tv CS-070029 ' _ __ _,mo ires: 11/15/2024 RALPH M C S' , 3 HERRING N.li 3 , EAST SANDV�IIC • k.14, �y` 0I.Lddil'33 ` Commissioner Li>etai-.4f'. 5%f THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affsliis4 Business Regulation HOME IMPROVE 17 t ONTRACTOR piPE rarer . I,j do fit 1 .-1 RALPH CROSSEN + z D/B/A RALPH CROSSEN1---tr-L,- . RALPH M.CROSSEN t 'J'4 .? 18 WOODRIDGE RD : ' a'( E.SANDWICH,MA 02537 ,. :- , 5.. 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Y..A f:A1041 7.AJ .A.'A. t,f1/45 SERVICE NO. a NAME 2/hiae dj De tiLe'.de STREET /5 Z1147.57 - /L da cf !ff lt/ir0bsldcn,._ VILLAGE 42571 (- az/17,06.1- X METER NO.fiagiggftbW ig f("--"ROag-igtErie j2eied i \ I a • 3 / / TM%\OF'ARZ1001 t 1 ,,o WATER DEPARTMENT 0 t. . `'34.• 9c) Buck Island Road r �••-r aces k\,.>t 1 irmuuth ,\AA 026 3 I..It uor=.t a n -1-'92I • Fis.: (W8 """I-''1')h BUILDING PERMIT APPLICATION FOR NVATER DEPARTMENT SIGN OFF TRANSMITTAL FORM BUILDING SITE LOCATION: ig' , PROPOSED WORK: fVPrOt 1 © _.. G'g z .. APPI,IC'ANT: 6Z A I) C leZ6/454/1 i-f-e -if RESIDUNTI\L AND OR CO\1\II-RC'IAI BUILDING Water Department: Determines Compliance of Water;1t ailahilit} and or existing location I-it:g neenng I) panment: Determines Compliance for Parking and Drainage Con enauon Commtssttm Determines Compliance to Wetlands \et: i c. If lot(sl border any type of tretl;uuls.streams.ponds.ricer.,.ocean. hag.boys.marshland.ETC... I leahh Department: I)eicrmines Compliance to State and '1 on n Regulation;.i.e. requirements for Septage Disposal and other Public I leafth Ac1it itcs I'ire I kpartment: I ktermines Compliance to Stale and"ton n Requirements for Personal Sa,G; Property Protections,Le,Smoke Detectors, Sprinkler Systems,elc Il l z- .... ,V14"1 '.-#\T SIGNATURE: I)t'fE OFFICE USE:COMMENTS ON PE R\II'I APPROVAL OR I)I IAI. `. 7 " / ).2 2 c L 2- REV! .` '1`F.D V�i A R DIVISION(SIGNATURE) DATE • • 1 0.�.3‘3 SERVICE NO. � 4-, 2/Lr1Qt"/ ) NAME • . LP-Ie .e _ STREET / G�J. 57 /Co ad 71 AkIgkeldcn VILLAGE 42 1 (7,472/r7Ocz-IX METER NO. IQ X /I ‘....-R 72e1g / • €. V t l q i. Sc !I/ MQ